A Randomized Clinical Trial Evaluating Indigo Carmine as a Visualization Aid for Evaluating Ureteral Patency.

OBJECTIVE: To determine whether intravenous indigo carmine provides a visualization advantage compared to saline in the evaluation of ureteral patency in a randomized, controlled clinical trial. METHODS: Patients undergoing urological or gynecological surgical procedures in which the patency of the ureter was to be assessed received a saline injection and were randomized to receive 2.5 mL or 5.0 mL of indigo carmine. Blinded video assessments were conducted by independent reviewers using a conspicuity scale ranked 1 (poorest) to 5 (best), and subjects with scores ≥3 and at least a + 1-point difference from saline were considered responders. Time to visualization was recorded for indigo carmine. A responder analysis evaluated whether indigo carmine showed improved visualization. RESULTS: There were 96 ureters evaluated with the 5.0 mL dose of indigo carmine, 92 with the 2.5 mL dose, and 180 with saline. Most ureters were scored a 4 or higher on the conspicuity scale following indigo carmine; both doses were significantly better than saline (P < .0001). Overall, 92.3% of patients were rated as a responder for either ureter. The median time to visualization of blue color was not significantly different (6.0 minutes in the 5.0 mL group and 5.9 minutes in the 2.5 mL group). There were no adverse events related to indigo carmine use. CONCLUSION: Both dose levels of indigo carmine were significantly better than saline as a visualization aid for ureter patency.

Safety of Xiaflex® (Collagenase Clostridium histolyticum) Treatment for Adult Anterior Urethral Stricture Disease.

Male urethral stricture disease is highly prevalent and difficult to treat due to potential complications. Minimally invasive treatments tend to have high recurrence rates, keeping urethroplasty as the gold standard. Collagenase Clostridium histolyticum (CCH) has been used in humans to treat fibrosis in a minimally invasive manner. Herein, we present the preliminary results from treatments of three males with urethral stricture as a feasibility and safety evaluation of the first-in-human CCH treatment for male urethral stricture disease.

Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE).

PURPOSE: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications. MATERIALS AND METHODS: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for ∼24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. RESULTS: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. CONCLUSIONS: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

Efficacy of Pudendal Nerve Blocks and Ultrasound-Guided Superior Hypogastric Plexus Blocks for the Management of Refractory Interstitial Cystitis: A Case Series.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by chronic pelvic, perineal, or bladder pain in addition to lower urinary tract symptoms. The etiology of this condition is not fully understood, which presents a challenge for effective therapeutic intervention. Current treatment guidelines recommend the use of multimodal pain management strategies including behavioral/non-pharmacologic, oral medications, bladder instillations, procedures, and major surgery. However, the safety and efficacy of these modalities vary, and there is currently no optimal treatment for the management of IC/BPS. The pudendal nerves and superior hypogastric plexus, which together mediate visceral pelvic pain and bladder control, are not addressed in the current guidelines but may serve as a therapeutic target. Here, we report improvements in pain, urinary symptoms, and functionality following bilateral pudendal nerve blocks and/or ultrasound-guided superior hypogastric plexus blocks in three patients with refractory IC/BPS. Our findings provide support for the use of these interventions in patients with IC/BPS unresponsive to prior conservative management.

Ureteral reconstruction for complex strictures: a review of the current literature.

PURPOSE: Frequently employed procedures for ureteral reconstruction include balloon dilation, pyeloplasty and ureteral re-implants. However, these procedures do not work for complex ureteral disease. The goal of this literature review is to report on techniques and success rates for the following techniques: buccal graft ureteroplasty, appendiceal interposition, transureteroureterostomy, ileal ureter and autotransplantation. METHODS: A comprehensive literature search for English-language original and review articles was conducted using PubMed. The following terms were queried: "ureteral reconstruction", "buccal graft", "appendiceal interposition", "ileal ureter", "transureteroureterostomy", "autotransplantation". RESULTS: Procedures involving the buccal mucosa or appendix offer minimally invasive techniques and low morbidity with good short-term success. Drawbacks to appendiceal interposition include the availability and length of appendix, and 10-20% of patients may have insufficient appendix upon intra-operative assessment. Transureteroureterostomy is typically limited to extensive exonerations due to concerns of injury to the contralateral kidney, even with reported success rates > 90%. Ileal ureter may carry a risk of metabolic acidosis in patients with renal insufficiency along with bowel-related complications. Ileal ureter and autotransplantation are reserved for the most severe cases due to their high morbidity but do offer options for the complex patient. CONCLUSION: Ureteral stricture disease not amenable to pyeloplasty, ureteroureterostomy or ureteroneocystostomy offers a challenge to urologist. Careful patient selection with pre-operative assessment of renal and bladder is vital to a successful operation with minimal complications.

Vesicovaginal fistula repair at the time of colpocleisis.

INTRODUCTION AND HYPOTHESIS: The objectives of this video are to discuss the presentation, evaluation, and surgical management of a patient with a vesicovaginal fistula at the time of colpocleisis. METHOD: We present the case of an 83-year-old woman with a history of stage IV prolapse who had had a pessary device removed. Urine had been noted to be in the vaginal vault, leading to suspicion of a vesicovaginal fistula. Following evaluation, the patient decided to proceed with surgical management. The patient underwent a vesicovaginal fistula repair with concomitant colpocleisis. A cystoscopy was performed at the conclusion of the case where the bilateral ureteral stents were removed and a strong efflux was noted at both ureteral orifices. RESULTS: At the patient's 1-month follow-up, she had no complaints of prolapse or vaginal leaking. CONCLUSION: Neglect of a vaginal pessary can lead to serious complications, indicating the importance of patient education and careful follow-up. Surgical planning is a key component in effectively managing a vesicovaginal fistula with ureteral presentation in order to preserve ureteral integrity. Concomitant vesicovaginal repair and colpocleisis can be performed safely with effective cure of a vesicovaginal fistula and stage IV prolapse.

Concomitant laparoscopic and vaginal excision of duplicated collecting system.

INTRODUCTION AND HYPOTHESIS: A duplicated collecting system is the most common birth defect related to the urinary tract and is more common in women. Approximately 0.7% of the healthy adult population and 2-4% of patients with urinary tract symptoms have duplicated ureters. This video discusses the presentation, evaluation, and treatment of duplicated urinary collecting systems, and presents a case of duplicated collecting system with ectopic ureteral implantation at the vaginal introitus. METHODS: We present the case of a 56-year-old presenting with a history of incontinence and recurrent urinary tract infections starting in adolescence and her workup for a duplicated collecting system, as well as subsequent surgical management with narrated footage. The patient was counseled that a distal ectopic ureter remnant could serve as a nidus for infection and the patient elected to undergo complete excision of the distal ectopic ureter. CONCLUSION: Duplicated urinary collecting systems are the most common birth defect related to the urinary tract and can be frequently encountered by the pelvic surgeon. Knowledge of the presentation and workup of a suspected duplicated collecting system is important in carrying out appropriate treatment.

Erectile and Ejaculatory Dysfunction After Urethroplasty.

PURPOSE OF THE REVIEW: The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty. RECENT FINDINGS: With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty.

Prostatic artery embolization for bladder outlet obstruction in the setting of prior posterior urethroplasty.

This case presents a patient with a remote history of complex posterior urethral repair related to a prior motorcycle accident who presented to the urology clinic in urinary retention with associated lower urinary tract symptoms. Due to his altered anatomy, traditional outlet procedures were deferred due to significant reported risks of post treatment urinary incontinence. Decision was made to proceed with prostatic artery embolization, and at follow up he reported resolution of his urinary retention and significant symptomatic improvement in his voiding without development of urinary incontinence.

Robotic Surgery for Urologic Deep Infiltrating Endometriosis: A Review and Case Presentations.

Urologic involvement is seen in 1.2-3.9% of women with endometriosis. The bladder (84%) is the most common location of urinary tract endometriosis and the retro-trigone and dome of the bladder are the most frequently affected sites. Ureteral involvement is commonly extrinsic and leads to compression and fibrosis of peri-ureteral tissue, leading to obstruction. Robotic-assisted laparoscopy provides additional advantages of 3D visualization, shorter learning curve compared to conventional laparoscopy, improved dissection in tight pelvic spaces, and facilitation of suturing techniques. In this review, we present the multidisciplinary management of four cases of deep infiltrating endometriosis of the urinary tract in a tertiary referral center of expertise and a review of the literature.

An unusual variant of Zinner syndrome with ureteral ectopia from an atrophied supernumerary kidney.

This case presents an unusual variation of Zinner syndrome with a patient found to have an ectopic ureteral insertion of the seminal vesicle from a supernumerary pelvic kidney and complete duplication of the ipsilateral, otherwise normal renal unit. The case offers an interesting variant of a previously established syndrome with successful treatment involving robotic resection of an ectopic ureter and seminal vesiculectomy, resulting in resolution of the patient's symptoms.

Urologic trauma from vaginal dilation for congenital vaginal stenosis: A newly-described and challenging complication.

Vaginal dilation is first line therapy for vaginal agenesis. No major urologic complications have even been described. We present the management and successful outcome of immediate repair for urethral trauma in a patient with history of congenital anomalies managed with vaginal dilation. Proper exposure is difficult, but urologic repair can be achieved with or without concomitant vaginal repair.

Survival Outcomes Associated With Female Primary Urethral Carcinoma: Review of a Single Institutional Experience.

BACKGROUND: Primary urethral carcinoma (PUC) is rare, and standard treatment recommendations are lacking. We examined the variation in treatments and survival outcomes of female PUC at a single, tertiary referral cancer center. METHODS: Records of women with PUC referred to our multidisciplinary genitourinary oncology service between 2003 and 2017 were reviewed. Clinical, demographic, pathologic, primary and salvage therapy details, and overall (OS) and recurrence-free survival (RFS) were recorded. Survival outcomes were analyzed for the entire cohort, and cases of locally-advanced (≥ T2 tumor), non-metastatic PUC were evaluated according to treatment intensity. Multimodal treatment (cystourethrectomy + concomitant therapy) was compared with non-multimodal therapy. Contingency analyses and Kaplan-Meier estimates were performed. RESULTS: Thirty-nine women with PUC were identified. In total, median OS was 36 months (95% confidence interval, 10.6-61.4 months). Twenty-four had T3 to T4 disease, 12 were node-positive, and 3 had distant metastases. Histology included 22 adenocarcinomas, 11 urothelial, 5 squamous, and 1 neuroendocrine. Patients with locally advanced, non-metastatic disease (n = 25) had significantly reduced OS (36 vs. 99 months; P = .016) and RFS (46 months vs. unmet; P = .011) compared with patients with locally confined tumors. Approximately one-half of locally advanced cases were managed with multimodal therapy (4 with neoadjuvant therapy + cystourethrectomy, 8 with cystourethrectomy + adjuvant therapy, and 1 with chemoradiation + consolidative cystourethrectomy). Multimodal therapy had nonsignificant longer OS (36 vs. 16 months) and RFS (58 vs. 16 months), P > .05. CONCLUSIONS: Locally advanced female PUC has relatively poor survival outcomes. Although we observed a nonsignificant interval improvement in survival with multimodality therapy, the treatment paradigm is inconsistent. Because it is a rare disease, collaborative multi-institutional studies are needed.

Pudendal nerve blocks in men undergoing urethroplasty: a case series.

The pudendal nerve block (PNB) is widely used for regional anesthesia during obstetric and anorectal procedures, but its role in urologic procedures has not been thoroughly studied. While transvaginal PNB is relatively straightforward, PNB in male patients often requires imaging guidance due to difficulty appreciating anatomic landmarks. We review the PNB and relevant sonoanatomy, and describe its analgesic efficacy in three male patients undergoing urethroplasty for urethral stricture. In this procedure, the patient was placed in lithotomy position, the ischial tuberosity was palpated, and the sacrotuberous ligament and pudendal artery were identified using ultrasound. Ropivacaine was injected medial to the pudendal artery and disappearance of muscle twitch was demonstrated. Two patients reported well-controlled pain at 24 hours postoperatively. One reported perineal pain requiring additional analgesia. All patients were discharged on postoperative day 1 without complications. Ultrasound-guided PNB provides safe and reasonably effective pain control to male patients undergoing urologic procedures.