Large anterior congenital urethral diverticulum in an infant: a case report.

Introduction: A Urethral diverticulum can be defined as sac-like dilation lined with epithelial tissue, which may be congenital or acquired. It usually develops in the penoscrotal angle region but can also be observed in the penile urethra. It usually occurs in female teenagers. This report aims to discuss a male infant with a large urethral diverticulum. Case presentation: A 5-month-old male presented to the urological department at Sulaimani Teaching Hospital with a penile swelling that had been noticeable since birth. Clinical examination revealed a ventral cystic penile shaft swelling, which would fill with fluid during urination. A urethrocystoscopy was performed and showed a wide cystic ventral diverticulum. Diverticulectomy was performed as a surgical approach to remove the diverticulum. Discussion: Congenital anterior urethral diverticulum is an uncommon condition that typically begins in early life. It can manifest with various symptoms, like recurrent infections of the urinary tract, painful urination, and post-void urine dribbling. Diagnosis involves imaging, with urethrocystoscopy, to rule out other potential diagnoses. Different surgical techniques exist that show promising results in preventing recurrence. The current case involved diverticulectomy and multi-layered wound closure with a dartos flap. Conclusion: Large anterior diverticulum in early infancy is rare but possible; operation is the preferred intervention method.

Seeking clinical consensus on risk assessment in anatomical infravesical obstruction of boys - A Delphi study.

INTRODUCTION: Infravesical obstruction (IO) is a common urological condition in young boys. Patients may present with various signs and symptoms at different ages, with severity depending to a large extent on the degree of obstruction. Consensus concerning accurate and objective modalities to diagnose IO and to differentiate between an anatomical or functional cause is still lacking. OBJECTIVE: This study aimed to reach consensus on the diagnostic determinants that are important to assess the likelihood of anatomical IO in boys and differentiate between an anatomical or functional cause. STUDY DESIGN: A Delphi method was used to establish a list of diagnostic determinants that can be utilized in order to diagnose anatomical IO in boys. An international and interdisciplinary panel of experts was recruited to reach consensus using three sequential rounds of electronic questionnaires. Data were collected using the online survey platform Qualtrics. Rounds one and two were used to define diagnostic determinants. Round three was used to stratify key determinants according to age. RESULTS: All rounds received a response rate of 100%. In round one, consensus was achieved on 44 of a total 79 items. In round two, consensus was achieved on 19 of a total 51 items. Round three identified a variation in key determinants per age group. DISCUSSION: To create an effective tool for assessing IO in boys, key determinants identified in this study will need to be validated in a prospective clinical trial. Due to a large number of determinants and sections, this will not be a trivial task. In addition, since a Delphi study is based on expert opinion, any consensus achieved remains subjective. Diagnostic determinants identified in this study will need to be validated using prospective clinical data. Artificial Intelligence provides techniques for uncovering complex associations that cannot easily be reduced to equations. It may therefore play a pivotal role in the future development of robust IO risk assessment tools. CONCLUSION: An international group of experts agreed that a risk assessment tool for IO in boys would be beneficial for both clinical practice and research purposes. Using a Delphi study methodology, consensus was reached on a set of diagnostic determinants that were considered important to assess the likelihood of IO and differentiate between an anatomical or functional cause. This study paves the way for further research on IO in boys. Eventually this could lead to an accurate and standardized assessment tool for IO.

[New Sk2 guideline idiopathic posterior urethritis : Discussion of the current guideline using a case study]. / Neue Sk2-Leitlinie Urethritis posterior : Diskussion der aktuellen neuen Leitlinie anhand eines Fallbeispiels.

Posterior urethritis is diagnosed in prepubertal or pubertal boys mainly with terminal asymptomatic haematuria or postmicturition blood spotting on the meatus or in the underwear. It presents with typical changes in the bulbar urethra (hyperaemia, oedema and denuded mucosa) without laboratory or radiological findings. The pathology is self-limiting with a very good prognosis. This condition is most likely caused by dysfunctional voiding and urotherapy with biofeedback therapy offers good treatment results. Although urethrocystoscopy is the only way to confirm the diagnosis, the patient should be prevented from having a (usually unnecessary) urethrocystoscopy and the relatives should be reassured.

Primary urothelial carcinoma of the male anterior urethra; A case report.

Introduction: and importance: Urethral cancer is a rare condition. It represents less than 1% of all cancers and the clinical signs are not very specific and confusing, which explains the often-late diagnosis. The prognosis can be poor. The objective of our observation is to discuss, through a review of the literature, the diagnostic and therapeutic means of tumors of the male anterior urethra. Case presentation: This is a 54-year-old patient, smoker, followed for urinary lithiasis. He initially consulted us for right nephritic colic, with an obstructive iliac ureteral stone on a CT scan. He had drainage by JJ stent followed by extracorporeal lithotripsy. After three months, it was decided to remove the JJ Stent. During urethrocystoscopy, a papillary tumor of the anterior urethra was found, measuring 0.5 cm on the long axis. Endoscopic resection of the tumor was performed. Pathological examination revealed a low-grade malignant urothelial carcinoma. No tumor recurrence was noted after one year of follow-up. Discussion: Primary urethral cancer is a rare condition. Most series in the literature show a male predominance. The main risk factors are chronic inflammation, history of urethritis, and urethral stricture. The clinical signs of urethral cancer are usually discrete and not very specific. The reference examination for positive diagnosis remains urethroscopy, which allows a more precise diagnosis thanks to a direct view of the urethral mucosa. The management of tumors of the anterior urethra consisted of aggressive excisional surgery. The main goal was to achieve satisfactory local control. conservative treatment by resection, fulguration or laser vaporization is indicated for small lesions (<1 cm). Conclusion: Tumors of the anterior urethra in men are often diagnosed late. More effort should be made to diagnose this disease earlier, especially in high-risk groups. Conservative treatment can be offered in patients with a small lesion.

Diagnostic urethrocystoscopy: A five-year review of indications and findings in a tertiary hospital in Nigeria

Background:Urethrocystoscopy is defined as endoscopic visualization of the urethra and the urinary bladder for the purpose of diagnosis or treatment of diseases of the lower urinary tract.Objective: To study the indications, diagnosis and complications of diagnostic urethrocystoscopy in our hospital.Materials and method:It was a retrospective descriptive study of all patients who had diagnostic urethrocystoscopy in our hospital between January 2016 to December 2021. Institutional ethical clearance was obtained. Particulars of the patients were collected from the operating theatre register and their medical case files were retrieved. Information about the patients'bio-data, presentation, clinical/radiologic diagnosis, urethrocystoscopic findings and its complications were extracted. The generated data was analyzed using statistical package for social sciences (SPSS) version 21 and results presented in tables, text and figures.Results:Atotal of 673 patients had urethrocystoscopy/cystoscopy during the period out of which we recovered full medical records of 592 patients whose data were analyzed.The patient's age ranges between 9 to 86years with mean age of 43.7±9.3SD years and M: F = 3.9:1. The indications for diagnostic urethrocystoscopy were lower urinary tract symptoms [LUTS] (48.8%), bladder tumour (29.2%) and haematuria (11.1%) among others. The urethrocystoscopic diagnoses were bladder tumour (37.8%), prostate enlargement (19.1%) and urethral stricture (6.9%) among others. The complications recorded were urethral/bladder bleeding (2.4%), urosepsis (1.4%) and urethral/bladder injury (0.3%).Keywords: Urethrocystoscopy, diagnosis, indicationsConclusion: Urethrocystoscopy is a necessary tool for comprehensive practice of urology owing to its vital role in the diagnosis and treatment of different kinds of lower urinary tract diseases and it is generally a safe procedure

A Large Congenital Anterior Urethral Diverticulum in a 14-Month-Old Boy.

Congenital anterior urethral diverticulum is a rare condition causing lower urinary tract obstruction in children. It usually arises from the ventral aspect of the anterior urethra, mostly located at the penoscrotal junction. We report a case of a 14-month-old baby boy who presented with a soft ventral swelling over the distal penile urethra, difficulty in passing urine, and a history of recurrent febrile urinary tract infections. A retrograde urethrogram revealed a large distal anterior urethral diverticulum. He underwent diverticulectomy and primary repair with no post-operative complications. The treatment of these depends on the size of the diverticulum and the degree of obstruction. In cases of a large anterior urethral diverticulum, open diverticulectomy and primary repair are recommended.

Female primary urethral carcinoma: A rare case report.

INTRODUCTION: Primary tumors of the female urethra are exceedingly rare and account for <0.02% of the malignant disease occurring in women. This disease usually presents late and, hence, has a poor outcome. Early diagnosis is necessary to prevent further metastasis and prevent urinary catheter-dependant. Tumors arising from the distal urethra tend to be early stage and cure rates are high, however lack of knowledge about this disease is notorious, the transmission of knowledge is made only by case reports. CASE PRESENTATION: A 76-years-old woman presented with the chief complaint of lower pelvic pain. The complaintas also accompanied by a burning sensation in the urethra and stranguria, urinary retention, and hematuria. Macroscopic observation revealed the lesion was whitish with vegetative aspect at the urethral meatus, involving the entire urethra. The fragile mass was palpable in distal urethra and external meatus urethra per vaginally and easily bleedings. Laboratory examination of blood chemistry results within normal limit. Urinalysis showed pyuria and hematuria. Urethrocystoscopy findings were whitish lesion with vegetative aspect also fragile mass along the urethra, abnormal bladder neck, and bladder mucous was hyperemis. The histopathological result showed metaplasia squamous cell carcinoma, clear cell carcinoma. She is planned on getting cystouretherectomy (anterior exenteration) later. CLINICAL DISCUSSION: The female urethral carcinoma is a disease with low prevalence with urothelial carcinoma (transitional cell) is the most common histological type (Leão et al., 2016; Adolfsson et al., 2012). Symptoms of urethral carcinoma are varied. The carcinoma spreads initially by local invasion into the periurethral tissue, vagina, and vulva and proximally spread to the bladder neck (Leão et al., 2016; Mittal et al., 2020). Distant metastasis is uncommon (Mittal et al., 2020). The most suitable method for collecting material for biopsy is the urethrocystoscopy. MRI is commonly used for staging. For post-surgical staging, the best investigation is the excretory urography (Gourtsoyianni et al., 2011; Picozzi et al., 2012). The management in vogue are surgical such as tumor excision, radical nephro-ureterectomy or anterior pelvic exenteration with radiotherapy or chemotherapy complementary. This cancer is associated with poor outcomes. Therefore, prognostic factors are important to be known. CONCLUSION: Although female urethral carcinoma is a rare disease entity, clinicians should have strong suspicion of malignancies in patients to make an exact diagnosis. Early radical surgery can achieve better outcomes, although the standard therapy remains controversial.

Are anterior urethral valve and anterior urethral diverticulum two separate entities: A radiological and endoscopic review.

BACKGROUND: Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized. OBJECTIVE: This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD. STUDY DESIGN: A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management. RESULTS: A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy. DISCUSSION: AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management. CONCLUSION: Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.

Clinical characteristics and endoscopic treatment of hematospermia with postcoital hematuria.

BACKGROUND: Recurrent hematospermia accompanied by postejaculatory hematuria is a very rare phenomenon, has not been well understood in the clinical setting, and usually leads to misdiagnosis and mistreatment. The aim of this study was to summarize the clinical characteristics, etiologic diagnosis, and endoscopic treatment of hematospermia with postcoital hematuria. METHODS: We collected the clinical data from 39 patients of hematospermia with postcoital hematuria, who were admitted to our hospital from May 2014 to October 2019. The etiologic diagnostic process and endoscopic surgery were analyzed retrospectively, and we observed and evaluated the efficacy and any complications during follow-up. RESULTS: The average age of the 39 patients was 44.1 years (range, 18-61 years), and the disease history ranged from 1 month to 20 years, with a median duration of 24 months. All of the patients were observed by urethrocystoscopy, which showed 38 cases of posterior urethral hemangioma (PUH) or abnormal varicose vessels, and 1 case of anterior urethral hemangioma. Of these, 18 patients underwent transurethral resection of urethral hemangioma, and 21 patients underwent transurethral electrocauterization. Postoperative follow-up ranged from 1 to 56 months, with a median of 16 months. The symptoms disappeared in 37 patients and recurred in 2 patients two to 3 months after the operation. The two recurrent patients were treated again by transurethral electrocauterization, and their symptoms then disappeared. CONCLUSIONS: PUH is the most common cause of hematospermia with postejaculatory hematuria. Herein, we demonstrated that transurethral resection or electrocauterization provides a safe, effective, and minimally invasive method for the treatment of PUH.

Voiding urethrocystoscopy: A new concept for benign prostatic obstruction characterization.

AIM: To assess the feasibility of voiding urethrocystoscopy (VUC) in males and describe the characteristics of dynamic movements of the prostatic lobes during micturition. MATERIAL AND METHODS: Patients scheduled for benign prostatic obstruction relief in a tertiary reference center were included in this prospective evaluation. During urethrocystoscopy with a small diameter flexible endoscope, the bladder was filled until desire to void. The patient was asked to void with endoscope in place facing the veru montanum. Movements of the prostatic lobes during micturition were characterized, video-recorded, and categorized based on the dynamics of the lateral lobes, the posterior lobe and the bladder neck. RESULTS: In all, 192 evaluations were conducted. In 161 cases (84%), the patient was able to void. Among these patients, 126 cases were stated as "closed" (coalescent), without opening of the initial part of the urethra and the bladder neck. In 38 cases, there was no opening of the lateral lobes (type 1A), and in 47 cases a partial opening of the distal parts of the lateral lobes was seen (type 1B). In 31 cases, a fixed posterior bladder neck was seen (type 2A) and in 10 cases a mobile median lobe, with a rolling ball effect, was seen (type 2B). In 25 cases, the lumen was completely open and equivocal in 10 cases. CONCLUSIONS: This study demonstrates the feasibility of VUC and describes for the first time the dynamics of prostatic lobes during micturition. This evaluation may lead to a new approach for understanding the mechanical aspects of benign prostatic obstruction. LEVEL OF EVIDENCE: 3.

[Narrow band imaging-assisted cystoscopy in bladder tumor follow-up: Can more tumors be identified?]. / "Narrow-band-imaging-assistierte" Zystoskopie in der Blasentumornachsorge : Sind mehr Tumoren erkennbar?

BACKGROUND: Narrow band imaging (NBI) is a new technique of urethrocystoscopy, in which only certain wavelengths [415 (blue) and 540 nm (green)] are used to detect urothelial carcinoma. The aim of the investigation was to analyze the potential benefit of NBI in the follow-up of patients with transitional cell carcinoma of the bladder. METHODS: Between August 2013 and July 2014, patients with a history of transitional cell carcinoma of the bladder, presenting for follow-up cystoscopy, were either examined via flexible white light endoscopy (WLE) plus second look WLE (n = 251, controls) or second look NBI cystoscopy alone (n = 251) in the same session. RESULTS: Rates of recurrences were similar in the two groups [NBI 68 (27.1 %); WLE 70 (27.9 %)]. NBI after WLE identified more tumors in 13 patients (5.69 vs. 3.92). In 8 patients NBI showed no vascularization in suspicious areas. In the control arm, in 8 cases more tumors (3.75 vs. 3.13) were identified in the second WLE. CONCLUSIONS: The additional use of NBI in the follow-up cystoscopy of patients after transurethral resection of nonmuscle invasive bladder cancer leads to an increased number of detected tumors; however, a part of the additionally detected tumors can be explained by the double examination. NBI appears to provide information in individual cases whether transurethral resection of bladder tumor is necessary.

High level of patient satisfaction and comfort during diagnostic urological procedures performed by urologists and residents.

OBJECTIVE: The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences. METHODS: Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologists n = 39, residents n = 45) and 138 urethrocystoscopies (UCS; urologists n = 44, residents n = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0-10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors. RESULTS: Median values for patient experiences across procedures were 10 (range 5-10) for patient satisfaction, 2 (0-9) for pain and 8 (0-10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients. CONCLUSIONS: Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position.

Late diagnosis of posterior urethral valves.

CLINICAL PROBLEM: We diagnosed 8 patients with late-stage posterior urethral valves (PUV) between 1 and 14 years of age. Five patients complained of symptoms related to voiding dysfunction. The other 3 patients required urethrocystoscopy for other reasons (hypospadias fistulae, difficulty with catheterisation and high-grade vesicoureteral reflux [VUR]). A second review of the first 2 patients' medical history showed voiding dysfunction symptoms. All patients underwent preoperative ultrasonography: 3 patients had normal results and 5 had renal or vesical disorders. The diagnosis was reached through voiding cystourethrogram (VCUG), and 4 patients underwent urodynamic studies. The diagnosis was confirmed by urethrocystoscopy, performing valve electrofulguration. We performed urethrocystoscopy during the check-ups at 3-6 weeks and observed no stenosis. The symptoms disappeared for all patients after 20 months of follow-up. The patient with VUR was cured. The ultrasounds showed no progression of the renal involvement and showed improvement in the vesical involvement. The velocimetries during check-ups presented curves within normal ranges. DISCUSSION: Most children with PUV are diagnosed through ultrasound during the neonatal period. Some patients present PUV at later ages with diverse symptoms, which impedes its diagnosis. We should suspect PUV in male patients with symptoms of voiding dysfunction, either when they have normal or pathological results from ultrasounds or VCUG. We recommend performing urethrocystoscopy to rule out urethral obstruction.

[Bilateral renal sclerotherapy as a treatment option in a mixed breed male dog with idiopathic renal haematuria]. / Bilaterale Sklerotherapie zur Behandlung der idiopathischen renalen Hämaturie bei einem Mischlingsrüden.

A 2-year-old male castrated German Shepherd dog mix was presented with chronic macroscopic haematuria. Further diagnostics included abdominal ultrasound and urethrocystoscopy and led to a diagnosis of severe bilateral idiopathic renal haematuria (IRH). Medical treatment with Yunnan Baiyao was unsuccessful. Bilateral renal-sparing sclerotherapy was performed and, despite distal migration of both ureteral stents within 12 days, permanently resolved the macroscopic haematuria.

Outpatient flexible urethrocystoscopy - initial experience at university of ilorin teaching hospital.

BACKGROUND: Endourology has revolutionized urological practices worldwide. This is not so in many urological centers in the West African sub-region. Although, some centers have made progress in the level of urological services that they offer; many of such centers provide rigid urethrocystoscopy services and only a few centers provide flexible urethrocystoscopy services. Flexible urethrocystoscopy has the advantage of being convenient as daycare procedure with no requirement for invasive forms of anaesthesia or the need for lithotomy position. In addition, skill transfer and acquisition is good. AIM & OBJECTIVES: We present our 2 year experience with outpatient flexible cystoscopy at the University of Ilorin Teaching Hospital, Ilorin. PATIENTS & METHODS: A review of the records of patients who had flexible cystoscopy at our outpatient endoscopy unit over a 2 year period was carried out. RESULTS: There were 39 patients (36 males and 3 females) with the age range of 25 -84 years and a mean of 58.5 years. The indications were both diagnostic and therapeutic. All the procedures were done under topical anesthesia. There were no complications noted. Consultants performed 80% of the cases while the remaining was performed by a senior registrar. The year 2 registrars from surgery and Obstetrics & Gyneacology assisted in most cases. CONCLUSION: Outpatient flexible urethrocystoscopy has positively improved endourological services in this centre with less invasive anesthesia, less morbidity and improved patient satisfaction. It has also enhanced training of residents doctors in lower urinary tract endoscopy.

ABC of flexible cystoscopy for junior trainee and general practitioner.

INTRODUCTION: Flexible cystoscopy is a diagnostic procedure usually performed under local anesthesia and has been used in the outpatient setting since the 1980s. METHODS: We performed an electronic search of MEDLINE(®) and the Cochrane Central Search Library between 1990 and 2010. Duplicate references were removed. One reviewer extracted the publications relevant to general clinical practice. RESULTS: MEDLINE search using the MeSH (Medical Subject Headings) words "flexible" and "cystoscopy" revealed 274 titles, and there were 42 titles in the Cochrane Central Search Library. However, interestingly, only 13 published papers addressing the clinical practice of flexible cystoscopy in the English literature were identified. CONCLUSIONS: Flexible cystoscopy is a real revolution in the field of diagnostic urology.