Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men.

OBJECTIVES: To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS: A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS: The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION: The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.

Critical Analysis of Outcome Between Ventral and Dorsal Onlay Urethroplasty In Female Urethral Stricture.

OBJECTIVES: To evaluate and compare the 2 surgical approaches of urethral reconstruction for management of refractory female urethral strictures (FUS) in a prospective randomized setting. Early surgical reconstruction is becoming the preferred management strategy for recurrent FUS. Reconstructive techniques have been described as using either dorsal (12-o'clock) or ventral approach (6-o'clock), each with their own advantages. To our best knowledge, a direct comparison between the 2 techniques to prospectively compare outcomes hasn't been made. METHODS: We performed a prospective randomized study in a single tertiary care center on a total of 24 patients, randomizing them into 2 groups of 12 patients each. One group underwent dorsal onlay and other underwent ventral onlay urethroplasty. Preoperative, intraoperative and postoperative outcomes were evaluated and compared for the 2 approaches. RESULTS: There was high success rate (91%) with significant but comparable improvements in flow rates, post void residue and symptomatic outcomes without any major complication. There was 1 recurrence of stricture each in both groups. Important technical differences were noted with easier meatus preservation, lesser bleeding and wider operative field in the ventral approach, while the dorsal approach proving better in distal urethral strictures requiring meatal reconstruction. CONCLUSION: Both approaches of urethroplasty present a very promising modality of management of FUS with comparable outcomes but with important technical differences which must be considered to best tailor the approach for each patient.

Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes.

PURPOSE: To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture. METHODS: Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively). CONCLUSIONS: EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed.

Medical Management of Penile and Urethral Lichen Sclerosus with Topical Clobetasol Improves Long-Term Voiding Symptoms and Quality of Life.

PURPOSE: We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery. MATERIALS AND METHODS: We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively. RESULTS: We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4). CONCLUSIONS: Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.

Female bladder neck dysfunction-A video-urodynamic diagnosis among women with voiding dysfunction.

OBJECTIVE: To investigate bladder neck dysfunction (BND) in women with voiding dysfunction by video-urodynamic study (VUDS) and to examine the therapeutic results of different BND subtypes. MATERIALS AND METHODS: We retrospectively reviewed consecutive women who had undergone VUDS for investigation of voiding dysfunction at our institution. The diagnosis of BND was made based on a nonfunneling bladder neck with or without high voiding detrusor pressure. Patients diagnosed as BND were retrieved, and the urodynamic parameters were compared with patients with dysfunctional voiding (DV) and other bladder outlet obstructions (BOO). RESULTS: Among 810 women with bladder outlet dysfunction, BND was noted in 100 (12.3%), poor pelvic floor relaxation in 336 (41.5%), DV in 325 (40.1%), cystocele in 19 (2%), and urethral stricture in 30 (4%). Compared with the normal tracing group, BND patients had a significantly smaller volume of bladder filling sensation (included first sensation of filling, full sensation and cystometric bladder capaicity) and a greater BOO index (BOOI) (all P < .05). Detrusor overactivity was noted in 46 (46%) BND patients. These urodynamic parameters in BND were not significantly different from patients with DV or other BOO. High-pressure BND had a greater BOOI, but low-pressure BND had a lower voiding efficiency. Both alpha-blocker therapy and transurethral incision of the bladder neck improved uroflow parameters in BND patients. CONCLUSIONS: BND includes 12.3% of women with bladder outlet dysfunction. High-pressure BND can cause anatomical BOO, whereas low-pressure BND is likely to affect micturition through inhibiting detrusor contractility. VUDS is the mainstay diagnostic tool to diagnose BND in women.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction.

AIM: Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. METHODS: The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. RESULTS: The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. CONCLUSIONS: All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Comparison of Urethral Dilation with Amplatz Dilators and Internal Urethrotomy Techniques for the Treatment of Urethral Strictures.

PURPOSE: The most common option for the management of urethral stricture (US) is direct visual internal urethrotomy (DVIU), because it is an easy and minimally invasive technique but the low success and high recurrence rates of this technique make urologists research for different types of therapeutic alternatives in stricture treatment. In this study we aimed to compare the internal urethrotomy with amplatz dilation for the treatment of male US. MATERIALS AND METHODS: A total of sixty patients, who have been operated due to urethral stricture were enrolled into this study. Group 1 was treated with amplatz renal dilators and the group 2 was treated with cold knife urethrotomy. All patients were evaluated for Qmax preoperatively and at the first, 3rd, 9th and 12th months postoperatively. RESULTS: In the 3 month uroflowmetry results, mean Q max values were 15.6±2 ml/sec in amplatz group and 15.5±1.6 ml/sec in DVIU group. There was no statisticaly difference between the two groups. However the Q max values in the postoperative 9 and 12 months were significantly decreased in the DVIU group. In the DVIU group 9 recurrences (36%) appeared and 2 of these reccurrences were in the first 3 months, whereas in the amplatz group no recurrences appeared in the first 3 months. The urethral stricture recurrence rate up to the 12 month follow up was statistically significant for group 1 when it is compared with group 2. Conclusions: In our experience, amplatz dilation is a good option as the initial treatment for urethral stricture.

Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture.

OBJECTIVES: The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. METHODS: Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. RESULTS: Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. CONCLUSIONS: Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

Primary Repair of Extensive Rectal Injury during Urethroplasty in Children Without Bowel Preparation: Report of Two Cases.

Today, there are several methods to repair colon and rectal injury such as primary repair, stoma, resection with anastomosis and damage control only. To our best knowledge, there is no definite method published in literature about iatrogenic rectal injury during perineal urethroplasty in children. Here, we explain two 10 and 12-year old boys with iatrogenic rectal injury during perineal urethroplasty who  underwent primary repair. Based on our experience, primary repair of rectum in such condition is feasible, successful and  can be a good choice to avoid placing colostomy and secondary repair.Keywords: complication; rectal injury; perineal urethroplasty; primary repair.

Long-term follow-up of urethral reconstruction for blunt urethral injury at a young age: urinary and sexual quality of life outcomes.

INTRODUCTION: Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma. OBJECTIVE: The purpose was to evaluate long-term urinary outcomes, sexual function, and quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood. STUDY DESIGN: After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires. RESULTS: Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4-18), 17 (5-20), and 19 (13.5-21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6-2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were 'very satisfied' and 20% were 'satisfied' with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8-12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5-2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5-24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13-14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5-8). CONCLUSIONS: Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.

Comparison of Multipulse Laser Vaporesection versus Plasmakinetic Resection for Treatment of Benign Prostate Obstruction.

We aimed to compare the efficacy and safety of Multipulse laser vaporesection of the prostate (MPVP) versus plasmakinetic resection of the prostate (PKRP) for treatment of patients with benign prostate obstruction (BPO) in a prospective trial. From January 2016 to April 2017, a total of 144 patients were included in the cohort study, of whom 73 patients underwent MPVP and 71 underwent PKRP. All patients received pre-operative evaluation and followed up at 1, 3, 6 and 12 months postoperatively. Baseline characteristics, perioperative data and postoperative outcomes were compared. Early (within 30 days postoperatively) and late complications were also recorded. Preoperative data, including age, prostate volume, international prostate symptom score (IPSS), International Index of Erectile Function Questionnaires (IIEF-5), the rate of anticoagulants use, Charlson comorbidity index were similar in two groups. Peri-operative parameters, including the rate of transfusion, and decrease in hemoglobin level were comparable. The operative time, the duration of catheterization and length of hospital stay were significantly shorter in the MPVP group. The voiding parameters and the quality-of-life scores (QoL) improved significantly in both groups postoperatively. There was a significantly difference in QoL at 1-year in the MPVP group (p < 0.001), under mixed model analysis with random effect and Bonferroni correction. There were no significant differences in improvement of IPSS, Qmax, IIEF-5, residual prostate volume ratio and PSA level reduction at the 1-year follow-up. MPVP was significantly superior to PKRP in terms of a reduction in overall complication rate (21.9% vs 45.0%, p = 0.004). Both treatments led to comparable symptomatic improvements. MPVP demonstrates satisfactory efficiency, shorter catheterization time and shorter hospital stay. Our data revealed that MPVP may be a promising technique which is safe and favorable alternative for patients with BPO.

Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease.

Female urethral strictures are rare. Guidelines on how to diagnose and treat these strictures are lacking. At present, only expert opinion is available to guide clinical practice. Once the diagnosis is suspected based on obstructive voiding symptoms and uroflowmetry, most clinicians will use in addition video-urodynamics (including urethrography), urethral calibration and cystourethroscopy for confirmation of the diagnosis. Clinical inspection and gynaecological examination are also important. Urethral dilation is usually the first-line treatment despite the lack of long-term success. Female urethroplasty is associated with higher success rates. A multitude of techniques are described but not one technique has shown superiority above another. This narrative review aims to provide a clinical guide for diagnosis and treatment to the urologist motivated to perform female urethroplasty.

Insights into the Pathophysiology of Urethral Stricture Disease due to Lichen Sclerosus: Comparison of Pathological Markers in Lichen Sclerosus Induced Strictures vs Nonlichen Sclerosus Induced Strictures.

PURPOSE: We evaluated the pathophysiology of lichen sclerosus and nonlichen sclerosus urethral stricture disease by comparing protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. MATERIALS AND METHODS: Tissue samples were collected from the urethral strictures of 81 patients undergoing urethroplasty. Clinical and demographic data were obtained by chart review. After identifying areas pathognomonic for lichen sclerosus a tissue microarray was created with cores from each sample and immunohistochemistry was performed. RESULTS: Patients had similar baseline demographics and comorbidities. Of the 81 strictures 58 were and 23 were not due to lichen sclerosus. Lichen sclerosus strictures were significantly longer and showed higher levels of inflammation. The proportion of T cells which stained positive for CD8 was significantly higher in strictures due to lichen sclerosus (50% vs 13%, p = 0.004). CCL-4 was expressed significantly more in strictures due to lichen sclerosus (76% vs 42%, p = 0.01). Several other inflammatory markers were only found in strictures due to lichen sclerosus. Block-like p16, a surrogate for high risk human papillomavirus infection, and varicella zoster virus were found only in lichen sclerosus urethral stricture disease samples, although both were rare. Epstein-Barr virus RNA was found in significantly more lichen sclerosus samples (37% vs 10%, p = 0.024). CONCLUSIONS: To our knowledge this is the first study to evaluate protein expression in lichen sclerosus urethral stricture disease. These strictures demonstrate increased inflammation compared to nonlichen sclerosus urethral strictures. Markers of oxidative stress, cell cycle dysregulation and the androgen receptor do not appear to be uniquely associated with lichen sclerosus urethral stricture disease. Positive staining for several viruses in samples of lichen sclerosus urethral stricture disease suggests a possible infectious etiology.

Excision and Primary Anastomosis for Bulbar Urethral Strictures Improves Functional Outcomes and Quality of Life: A Prospective Analysis from a Single Centre.

BACKGROUND: Excision and primary anastomotic (EPA) urethroplasty remains the gold standard definitive treatment for short urethral stricture disease. For patients, postoperative erectile function and quality of life are the main goals of the surgery. Patient-reported outcome measures (PROMs) are therefore of major importance. OBJECTIVE: The objective of this study was to prospectively analyse functional outcomes and patient satisfaction. DESIGN SETTINGS AND PARTICIPANTS: We prospectively evaluated 47 patients before and after EPA from August 2009 until February 2017. The first follow-up visit occurred after a median of 2.2 months (n = 47/47), with the second and third follow-ups occurring at a median of 8.5 months (n = 38/47) and 20.2 months (n = 31/47). Before surgery and at each follow-up visit, the patients received five questionnaires: the International Prostate Symptom Score (IPSS), the International Prostate Symptom Score with the Quality of Life (IPSS-QOL) score, the Urogenital Distress Inventory Short Form (UDI-6) score, the International Index of Erectile Function-5 (IIEF-5) score, and the ICIQ-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) score. SURGICAL PROCEDURE: Surgery was performed in all cases using the same standardized EPA technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Voiding symptoms, erectile dysfunction, and quality of life were analysed using paired sample t-tests, with a multiple-testing Bonferroni correction. Any requirement for instrumentation after surgery was considered treatment failure. RESULTS AND LIMITATIONS: Patients with mild or no baseline erectile dysfunction showed significant decline in erectile function at first follow-up (mean IIEF-5 of 23.27 [standard deviation; SD: 2.60] vs. 13.91 [SD: 7.50]; p=0.002), but this had recovered completely at the third follow-up (IIEF-5: 23.25 [SD: 1.91]; p=0.659). Clinically significant improvements were noted in IPSS, IPSS-QOL-score, UDI-6-score, and ICIQ-LUTS-QOL-score at the first follow-up (p<0.0001). These improvements remained significant at the second and third follow-ups (p<0.0001) for all PROMs. Three of the patients experienced stricture recurrence. The main limitations of this study were incomplete questionnaires, loss to follow-up, and low number of patients. CONCLUSIONS: EPA results in an initial decline in erectile function, but full recovery occurred at a median of 20 months. Voiding improved significantly, and a major improvement in quality of life was noted, which persisted for up to 20 months after surgery. PATIENT SUMMARY: This study showed the importance of patient-reported outcome measures in indicating the actual outcome of urethral stricture disease surgery.

Computational Fluid Dynamic Modeling of Urethral Strictures.

PURPOSE: Computational fluid dynamics have paradigm shifting potential in understanding the physiological flow of fluids in the human body. This translational branch of engineering has already made an important clinical impact on the study of cardiovascular disease. We evaluated the feasibility and applicability of computational fluid dynamics to model urine flow. MATERIALS AND METHODS: We prepared a computational fluid dynamics model using an idealized male genitourinary system. We created 16 hypothetical urethral stricture scenarios as a test bed. Standard parameters of urine such as pressure, temperature and viscosity were applied as well as typical assumptions germane to fluid dynamic modeling. We used ABAQUS/CAE 6.14 (Dassault Systèmes®) with a direct unsymmetrical solver with standard (FC3D8) 3D brick 8Node elements for model generation. RESULTS: The average flow rate in urethral stricture disease as measured by our model was 5.97 ml per second (IQR 2.2-10.9). The model predicted a flow rate of 2.88 ml per second for a single 5Fr stricture in the mid bulbar urethra when assuming all other variables constant. The model demonstrated that increasing stricture diameter and bladder pressure strongly impacted urine flow while stricture location and length, and the sequence of multiple strictures had a weaker impact. CONCLUSIONS: We successfully created a computational fluid dynamics model of an idealized male urethra with varied types of urethral strictures. The resultant flow rates were consistent with the literature. The accuracy of modeling increasing bladder pressure should be improved by future iterations. This technology has vast research and clinical potential.

Role of poor urethral sphincter relaxation in men with voiding dysfunction refractory to α-blocker therapy: Clinical characteristics and predictive factors.

OBJECTIVES: This study evaluates the diagnostic value of poorly relaxed external sphincter (PRES) in men with voiding dysfunction. We analyzed clinical and video-urodynamic characteristics to identify predictive factors of PRES in patients with lower urinary tract symptoms (LUTS) refractory to α-1 adrenoceptor blocker (α-blocker) therapy. METHODS: This retrospective study included 3379 men with LUTS in whom the initial 1-month α-blocker therapy failed. Clinical parameters and video-urodynamic results were analyzed. Patients with bladder outlet disorders including bladder neck obstruction (BNO), benign prostatic obstruction (BPO), urethral stricture (US), or PRES were categorized according to video-urodynamic findings. Predictive factors for PRES were analyzed. RESULTS: A total of 3379 men were included in this study. Among the patients with voiding dysfunction, 905 (43.6%) had BPO, 624 (30.0%) had BNO, 487 (23.4%) had PRES, and 62 (3.0%) had US. Patients with PRES were younger and had a higher maximum flow rate, larger bladder capacity, smaller total prostate volume (TPV) and transition zone index, and a lower rate of LUTS of urgency or urge urinary incontinence (UUI) than other groups. On multivariate analysis, only small TPV and lower urgency/UUI rate were predictive factors of PRES. A scale composed of voided volume, TPV, and urgency/UUI predicted PRES with high specificity. CONCLUSIONS: PRES was the etiology of voiding dysfunction in 23.4% of the men with LUTS refractory to α-blocker therapy. A simple scale composed of voiding volume, TPV, and urgency/UUI was useful in predicting the presence of PRES before video-urodynamic studies.

Female bladder outlet obstruction: Common symptoms masking an uncommon cause.

OBJECTIVE: Bladder outlet obstruction (BOO) in women remains an underdiagnosed condition. Although diagnosed rarely in general urologic practice, its incidence in specialist centers has been reported to be up to 29%. In the present study we evaluated the incidence of female BOO in adult women referred for evaluation of lower urinary tract symptoms or urinary incontinence, assessing its etiology and correlating this with its clinical presentation. METHODS: The present study consisted of a retrospective review of a prospectively acquired videourodynamic database of 1142 consecutive women referred for evaluation of lower urinary tract symptoms (LUTS) or urinary incontinence from March 2007 to December 2012 and diagnosed with BOO. After exclusions, data from 1014 patients were analyzed. BOO was defined using a combination of radiographic evidence of obstruction during the voiding phase of the urodynamic study and pressure-flow criteria (Solomon-Greenwell nomogram). Diagnosis was confirmed by cystoscopy, maximal urethral closure pressure, and magnetic resonance imaging as clinically indicated. RESULTS: In all, 192 women (19%) were diagnosed with BOO. Functional sphincteric obstruction was diagnosed in 70 women (36%). The most common anatomical cause of BOO was previous anti-incontinence surgery, followed by urethral stricture, diagnosed in 21% and 20% of patients, respectively. The most common presenting symptoms were storage phase symptoms of daytime and night-time urinary frequency. CONCLUSIONS: BOO was present in 19% of women with LUTS. Functional sphincteric obstruction was the most common cause (36%), followed by obstruction after anti-incontinence surgery (21%). The most common presenting symptom was daytime urinary frequency. BOO should be suspected in women with refractory LUTS, especially those presenting with urinary frequency.

Uroflowmetry Before and After Meatotomy in Boys with Symptomatic Meatal Stenosis Following Neonatal Circumcision - A Long-term Prospective Study.

OBJECTIVE: To assess uroflowmetry in the long-term follow-up of symptomatic meatal stenosis patients prior to and following meatotomy. Severity of symptoms and treatment success has been defined by patient history, physical examination, and witnessed voiding. Uroflowmetry might add objective parameters for the assessment, however long-term data are lacking. METHODS: A prospective study following 25 symptomatic toilet-trained boys before and after meatotomy was performed with short and long-term follow-up after surgery. Patient history, physical examination, and uroflowmetry variables were recorded. RESULTS: Fifteen patients were fully evaluable. Mean age at operation was 6.4 years (2.5-10.5) with an average follow-up of 43 months. All patients were symptomatic before surgery; complete symptomatic resolution was achieved in all patients at short-term follow-up, and in 12 at long-term follow-up. A stenotic meatus was seen in all patients before surgery, at long-term follow-up 12 of 15 (80%) had an open appearing meatus (P = .0001). Abnormal uroflowmetry pattern was present in 8 of 15 (53%) prior to surgery and 2 of 15 (13%) at long-term follow-up (P = .02). Normal maximal flow rate as defined by ICCS were seen in 5, 11, and 12 patients before, 1 month after and at long-term follow-up (P = .06 and 0.02, respectively). PVR improved significantly at long-term follow-up (P = .0012). CONCLUSION: Symptom evaluation and physical examination should be the hallmark assessing children with meatal stenosis. Clinical assessment one month after surgery suffices and long-term follow-up is unnecessary. Uroflowmetry provides objective assessment as well as surgical success; however, it is unnecessary since it does not change the management.

Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

OBJECTIVE: To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. MATERIALS AND METHODS: Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. RESULTS: Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. CONCLUSIONS: Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.

Female urethral dilatation (bougierung): a case report.

BACKGROUND: Primary bladder neck obstruction is a rare clinical entity, reported to be responsible for 2.7-8% of lower urinary tract symptoms. It can lead to various urinary storage and voiding symptoms. The mainstay of treatment of female urethral strictures is urethral dilatation. Despite the long history of this method, it is unclear how far the female urethra should be dilated in correlation with residual urine volume. CASE PRESENTATION: A 79-year-old Caucasian woman presented to our institute with urgency (12-15 times/day), nocturia (3 times/night), and reoccurring urinary tract infections. A physical examination revealed no anatomical malformation in her genital organs, 150 mL post-void urine retention, and a significant narrowing in the mid-segment of the urethra (4 mm). After informed consent, our patient underwent urethral dilatation ranging from Ch9 (3 mm) to Ch39 (13 mm), and reported no symptoms at the 4-week follow-up, with no post-void residual urine. CONCLUSIONS: The relatively low (around 50%) success rate of urethral dilatation might be improved by the utilization of wider dilatators, and the relaxation of the pubourethral ligament, achieved by a gentle downward saggital push during the intervention, although long-term studies with a large number of participants are necessary to prove our hypothesis.