Evaluation of the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence mechanism using dynamic MRI.

INTRODUCTION: Treatment of pelvic organ prolapse (POP) associated with stress urinary incontinence (SUI) is a surgical challenge. Surgeons may perform combined prolapse and incontinence surgery or may correct prolapse first and evaluate incontinence afterwards. We present a prospective study to evaluate the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence using dynamic magnetic resonance imaging (MRI). METHODS: Twenty females with concomitant apical prolapse and SUI due to urethral hypermobility were included. Patients with intrinsic sphincteric deficiency (ISD) were excluded. All patients underwent ASC operation as a sole treatment without anti-incontinence procedure. Patients were informed they may need anti-incontinence procedure afterwards. Symptom-specific questionnaires assessing prolapse, incontinence, sexual function and quality of life (QoL), dynamic MRI and pressure flow urodynamic study were administered before and after surgery. RESULTS: Mean age was 53 years. All patients had apical prolapse; four with cystocele, and five with rectocele. Urethral hypermobility was positive in all patients. After performing ASC, all patients reported significant improvement of all prolapse and incontinence questionnaires as well as QoL and sexual function. Significant improvement of incontinence parameters on dynamic MRI (bladder neck descent, posterior urethrovesical angle and urethral inclination angle) was observed after ASC. Similarly, significant change in the position of the leading edge of prolapse and anorectal junction was observed. CONCLUSIONS: In patients with prolapse and urethral hypermobility, ASC may return bladder neck and urethral anatomy towards normal as proved by dynamic MRI. However, further studies on larger number of patients with longer follow-up period are required.

Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience.

INTRODUCTION AND HYPOTHESIS: Laparoscopic repair of different female genitourinary fistulae has been recently reported, including both conventional and laparoendoscopic single-site surgery (LESS). We present our 10-year single-center experience of the laparoscopic repair of different types of female genitourinary fistulae. METHODS: A retrospective analysis of our records over the last 10 years was performed. Type of fistula, etiology, laparoscopic approach, operative data, postoperative outcome, and follow-up were recorded. RESULTS: Overall, 46 patients with laparoscopic repair of genitourinary fistulae were reported: 25 had vesicovaginal fistulae (VVF), 14 had vesicouterine fistulae (VUF), and 7 had ureterovaginal fistulae (UVF). Thirty-three patients had conventional laparoscopic repair, whereas 7 VVF and 6 VUF had LESS repair. In all patients with VVF and VUF, extravesical repair was carried out by excising the fistulous tract and closing both the bladder and the vagina or the uterus with interposing tissue in-between. In patients with UVF, extravesical ureteric re-implantation was performed. Mean operative time was 176 ± 25 min. Mean blood loss was 105 ± 25 cc. No intraoperative or postoperative complications occurred. None was converted to open surgery. Mean postoperative hospital stay was 3.2 ± 1.2 days. After a mean follow-up of 6.3 ± 3.1 years, all patients had undergone successful repair, except for one patient with complex VVF. CONCLUSIONS: Laparoscopic repair of VVF, VUF, and UVF is a feasible procedure with a high success rate and low morbidity. LESS repair of VVF and VUF has a comparable success rate to conventional laparoscopy, but with a shorter hospital stay and fewer analgesic requirements.

A prototype non-invasive urodynamic test to estimate voiding reserve in normal adult males.

Objective: To propose a prototype non-invasive test to estimate voiding reserve in normal adult men; identifying its feasibility, limitations, and initial results. Subjects and methods: In all, 30 adult healthy male volunteers aged <40 years were included in the study. Initial free uroflowmetry was done with post-void residual urine volume (PVR) assessment using ultrasonography. The men were later asked to void into a uroflowmeter through a condom catheter attached to the glans penis and connected to an outflow tube with specific vertical heights (10, 20, 30, 40, 50 and 60 cm) on different days. The mean maximum urinary flow rate (Qmax) and PVR at each height were compared with the Qmax and PVR at the initial free uroflowmetry. The maximum height at which the Qmax and PVR remained normal was considered the normal voiding reserve for that age group. Results: All the men completed the study without any complications. At zero level, the mean Qmax was 27.6 mL/s, which then dropped gradually to reach 17.8 mL/s at 60 cm, where still 83% of the men had a normal Qmax. The PVR was nil at zero level and started to exceed the normal range at 50 and 60 cm height (58 and 65.7 mL, respectively). So, the maximum height resistance at which the men could have a normal Qmax and normal PVR was 40 cm. Conclusions: The use of the tube height-resistance test to assess voiding reserve is feasible, non-invasive and has no complications. A 40-cm height resistance can be considered a reference level that a young adult male should be tested against to estimate his voiding reserve. Abbreviations: NPV: negative predictive value; PdetQmax: maximum detrusor pressure at maximum urinary flow; PPV: positive predictive value; PVR: post-void residual urine volume; ROC: receiver operating characteristic.

Remineralization potential of grape seed extract hydrogels on bleached enamel compared to fluoride gel: An in vitro study.

BACKGROUND: Remineralizing of bleached enamel is a common procedure that aims to compensate enamel mineral lose. This study aimed to evaluate the remineralization effectiveness of experimentally prepared grape seed extract hydrogels (GSE) compared to fluoride gel on bleached enamel. MATERIAL AND METHODS: Thirty extracted maxillary incisor were bleached using white smile bleaching agent. Bleached specimens were divided into three groups (10/group) according to the remineralizing agents tested: [GSE 6%, GSE 10%, or fluoride gel]. After bleaching and remineralization procedure, the specimens were stored in artificial saliva at 37°C. Micro-hardness and Energy-Dispersive X-ray and ultra-morphological evaluation were tested at baseline, after bleaching and after remineralization. RESULTS: Statistical significant decrease on mean micro-hardness values had resulted after bleaching procedure compared to baseline, followed by a significant increase in GSE (10%) and fluoride groups. GSE (6%) application showed the least statistical significant mean micro-hardness, which was statistically insignificant different compared to bleaching procedure. Elemental analysis results revealed a statistical significant decrease on Ca, and Ca/P ratios (At%) values after bleaching compared to baseline, followed by a significant increase after treatment with all tested remineralizing gels. SEM photomicrograph of sound enamel shows smooth uniform appearance with few pores. Bleached enamel showed irregular pitted disorganized enamel surface. Bleached enamel exposed to GSE and fluoride gel showed occlusion of enamel surface porosities and precipitates of different sizes. CONCLUSIONS: The specially prepared GSE hydrogels has positive effects on the remineralization process of bleached enamel making it an effective natural agent with remineralizing potential. Key words:Remineralization, bleaching, grape seed extract, fluoride, enamel.

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics.

INTRODUCTION AND AIM: Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics. PATIENTS AND METHODS: In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart. RESULTS: Mean age was 8.3 ±â€¯3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ±â€¯1.54 to 10.17 ±â€¯1.76, p = 0.00), rectal diameter (decreased from 34.83 ±â€¯5.91 to 27.90 ±â€¯5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ±â€¯24.95 to 30 ±â€¯17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ±â€¯45.69 to 155.17 ±â€¯39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively). CONCLUSION: Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.

Outcome of rolled fortified vaginal flap operation on female patients with intrinsic sphincteric deficiency: 2-year follow-up.

INTRODUCTION AND HYPOTHESIS: We evaluate the 2-year outcome of the rolled fortified vaginal flap (RFVF) operation for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincteric deficiency (ISD). METHODS: A prospective study of 20 women suffering from SUI due to ISD was conducted. All patients were subjected to history-taking, clinical examination, cough stress test, and urodynamics. Symptom severity and quality of life (QoL) were assessed using the Arabic version of the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF). All studied women were followed up for 24 months to detect success rate, any postoperative complications, and reveal changes in the quality of life. RESULTS: Mean age was 53 ± 8 years. Preoperative Valsalva leak point pressure was 50.1 ± 11.3 cmH2O. After a follow-up period of 24 months, only 2 patients (10%) showed mild stress incontinence with mean VLPP 80± 3 cm H2O. Postoperative mean maximum flow rate (Q-max) and mean Pdet-Qmax showed no significant difference from the preoperative results (P = 0.115 and 0.187 respectively). The quality of life domain of the ICIQ-UI-SF decreased significantly from 73.5 ± 12.1% (preoperatively) to 2.6 ± 8.1% (after a 1-year follow-up), P < 0.001 and then showed a slight increase to 4.5 ± 10.6 at 24 months' follow-up. CONCLUSION: The RFVF operation has a success rate of 90% after a 24-month follow-up. It significantly improved the quality of life of women with SUI due to ISD.

Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study.

OBJECTIVES: To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies. PATIENTS AND METHODS: Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics, and visual analog pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS). RESULTS: Sixty patients were randomized into two equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy, and repair of retrocaval ureter. Operative time was 167 ± 24 and 145 ± 39 minutes in LESS and ML groups, respectively (p = 0.09). Estimated blood loss was 59 ± 34 and 43 ± 42 mL in both groups, respectively (p = 0.2). VAS was 1.7 ± 0.6 and 2.8 ± 0.5 in both groups, respectively (p = 0.02). PSAS and OSAS were 5.9 ± 0.85 and 10.6 ± 1.98 vs 8.9 ± 0.9 and 13.5 ± 6.3 in both groups, respectively (p > 0.05). There were no intraoperative complications, conversions to open surgery, or conventional laparoscopy in both groups. Mean postoperative Diclofenac Na was 151.7 ± 35.6 and 169.7 ± 47.3 mg in both groups, respectively (p = 0.04). Postoperative complications rate and hospital stay were comparable between both groups. CONCLUSION: Both LESS and ML have comparable operative time, blood loss, complication rate, and hospital stay in treatment of upper urinary tract pathologies. However, LESS is associated with less analgesic requirement and better cosmetic outcome.

Factors determining the amount of residual urine in men with bladder outlet obstruction: Could it be a predictor for bladder contractility?

OBJECTIVE: To determine from urodynamic data what causes an increased postvoid residual urine volume (PVR) in men with bladder outlet obstruction (BOO), urethral resistance or bladder failure, and to determine how to predict bladder contractility from the PVR. PATIENTS AND METHODS: We analysed retrospectively the pressure-flow studies (PFS) of 90 men with BOO. Nine patients could not void and the remaining 81 were divided into three groups, i.e. A (30 men, PVR < 100 mL), B (30 men, PVR 100-450 mL) and C (21 men, PVR > 450 mL). The division was made according to a receiver operating characteristic curve, showing that using a threshold PVR of 450 mL had the best sensitivity and specificity for detecting the start of bladder failure. RESULTS: The filling phase showed an increase in bladder capacity with the increase in PVR and a significantly lower incidence of detrusor overactivity in group C. The voiding phase showed a significant decrease in voided volume and maximum urinary flow rate (Q max) as the PVR increased, while the urethral resistance factor (URF) increased from group A to B to C. The detrusor pressure at Q max (PdetQ max) and opening pressure were significantly higher in group B, which had the highest bladder contractility index (BCI) and longest duration of contraction. Group C had the lowest BCI and the lowest PdetQ max. CONCLUSIONS: In men with BOO, PVR results from increasing outlet resistance at the start and up to a PVR of 450 mL, where the bladder reaches its maximum compensation. At volumes of >450 mL, both the outlet resistance and bladder failure are working together, leading to detrusor decompensation.

Laparoendoscopic single-site surgery (LESS) and conventional laparoscopic extravesical repair of vesicouterine fistula: single-center experience.

PURPOSE: To present for the fist time in literature laparoendoscopic single-site surgery (LESS) extravesical repair of vesicouterine fistula (VUF) and to compare this with conventional laparoscopic repair. METHODS: Eleven females with VUF were included; of them, six had conventional laparoscopic repair where 5 ports were used, while five females had LESS repair. Additional 5-mm port was inserted during suturing in LESS group and both straight and pre-bent instruments were used. Fistulous tract was excised; then, uterine rent was closed through single figure of eight suture, while urinary bladder was closed in two layers; then, an omental flap was interposed in between. Sutures were done using 3/0 vicryl. Urinary bladder was drained for 3 weeks through uretheral catheter. RESULTS: No conversion to open surgery in both groups or from LESS to conventional repair. Blood loss in conventional laparoscopic and LESS repair was 95 ± 18 and 86 ± 15 c.c., respectively. No complications were reported in both groups. Operative time for conventional laparoscopic and LESS repair was 149 ± 18 and 144 ± 16 min, respectively. Postoperative hospital stay was 3.1 ± 0.8 and 2 days for both groups, respectively. At follow-up period of 23.6 ± 8.2 and 13.4 ± 1.8 months for both groups, respectively, all were cured. CONCLUSION: Both conventional laparoscopic and LESS extravesical repair of VUF are effective and reproducible and they follow the same principles of open surgical repair. However, LESS repair of VUF seems to be less morbid than conventional laparoscopic repair.

Different urodynamic patterns in female bladder outlet obstruction: Can urodynamics alone reach the diagnosis?

OBJECTIVE: To define the different urodynamic patterns in female bladder outlet obstruction (BOO) and to assess whether urodynamics alone can be relied on for the diagnosis. PATIENTS AND METHODS: This prospective study included 60 clinically obstructed women and 27 with stress urinary incontinence as a control group. All patients had pressure-flow studies and were divided into four groups. Group A (control group, 27 patients) and group B (22) had a maximum urinary flow rate (Q max) of >15 mL/s and a detrusor pressure at Q max (P det Q max) of <30 or >30 cm H2O, respectively. Group C (20 patients) and group D (18) had a Q max of <15 mL/s and a P det Q max of >30 or <30 cm H2O, respectively. RESULTS: The mean Q max for groups A, B, C, and D were 21.8, 21.9, 10.8 and 9.9 mL/s, respectively, while the mean P det Q max was 20.8, 40.4, 48.7, and 18.7 cm H2O, respectively. The residual urine volume was <100 mL in groups A and B but >100 mL in groups C and D. When compared with group A, groups B-D had a significant difference in vesical pressure, groups B and C had a significant difference in P det Q max, while Q max, the maximum voided volume and residual urine volume were significantly different in groups C and D. Group A was obviously unobstructed, group B might have early obstruction, group C had compensated obstruction, while group D can be considered to have late de-compensated obstruction. CONCLUSIONS: BOO in females has three different urodynamic patterns, i.e. early, compensated and late obstruction. However, urodynamics should be combined with the clinical presentation and residual urine volume for an accurate diagnosis.

Refractory enuresis in children and adolescents: how can urodynamics affect management and what is the optimum test?

OBJECTIVE: After failure of medical and behavioral therapy in enuresis, the usual next step is to investigate using urodynamics. The aim of this study was to determine the actual benefit and optimal method of urodynamics in the treatment of refractory enuresis. METHODS: This prospective randomized study included 56 patients: 17 males and 39 females with an age range of 7-16 years. All had tried multiple courses of medical treatment for enuresis for at least 6 months without response. Thirty patients underwent investigation by cystometrogram, uroflowmetry and electromyogram (UFM/EMG), while 26 patients underwent pressure/flow/EMG (P/F/EMG) studies. RESULTS: Bladder filling abnormalities were found in 25 out of the 56 patients (44.6%) and included low bladder capacity in 39%, hypocompliance in 32%, and detrusor overactivity in 45%. With regard to voiding dysfunction, 70% of the UFM/EMG group had detrusor‒sphincter dyssynergia and 67% of the P/F/EMG group had bladder outlet obstruction. CONCLUSIONS: Urodynamics can help in cases of refractory enuresis by detecting dysfunctional voiding, which is present in a large percentage of these patients. This can be diagnosed by UFM/EMG, rather than P/F/EMG, as a non-invasive test. UFM alone may be misleading. Alpha adrenergic blockers may be of benefit in treating these patients.

Treatment of female stress urinary incontinence: what women find acceptable and the impact of clinical and urodynamic evaluation on their final choice.

OBJECTIVES: The aim of this study was determine what women find acceptable regarding treatment modality for Stress urinary incontinence (SUI) and to assess the impact of clinical and urodynamic evaluation on their final decision. MATERIAL AND METHODS: This prospective, institutional review board-approved study included 100 consecutive women with primary SUI. All women were given a questionnaire that included the Urinary Distress Inventory (UDI-6) and the American Urologic Association Quality of Life questionnaire (AUA-QoL6). The patients were also asked to choose one of the four available treatment options, which included major surgeries, minor surgeries, office procedures and medication. Factors affecting the initial choice of treatment were studied. A Q-tip test and multichannel urodynamics were then carried out and the patients were recounseled by the urologist. The patients' final decision was compared with their initial choice and statistical analysis was performed. RESULTS: Initially, 22% patients chose major surgery, 39% minor surgery, 27% an office procedure and 12% medication. This was affected by age, symptom severity and quality of life bother. After clinical and urodynamic evaluation, 34% shifted to a different treatment modality; this correlated significantly with young age, severe symptoms, limited urethral mobility and low Valsalva leak point pressure. CONCLUSIONS: Patients' initial choice for treatment of SUI was affected by age, symptom severity and quality of life; however, the final decision was more influenced by the clinical and urodynamic evaluation. It is important to counsel the patients before definitive treatment, to achieve a better outcome.

Differential profile analysis of urinary cytokines in patients with overactive bladder.

INTRODUCTION AND HYPOTHESIS: We hypothesize that overactive bladder (OAB) can produce inflammatory cytokines due to afferent neural plasticity or urothelial dysfunction. This study aimed to detect abnormal cytokine levels in urine of patients with OAB compared to urinary tract infections (UTI) and controls. METHODS: This was a prospective, single blind study including 20 premenopausal women (control), 20 with OAB and 16 with UTI. Urine samples were collected, centrifuged, and stored (-80°C). Urinary total proteins were quantified and detected by antibody-based array chip for release of 120 human cytokines in the two groups relative to the controls. RESULTS: Majority of cytokines showed the same expression in the OAB compared with the controls. Cytokines exclusively expressed in OAB were: monocyte chemoattractant protein (MCP) 1, TARC, PARC, and Fas/TNFRSF6. MCP-2, MCP-3, tumor necrosis factor-ß, GCSF and eotaxin-3 showed a shared expression in UTI and OAB. Conversely, few of the cytokines were downregulated in OAB (IL-5, IL-6, IL-7, and GM-CSF). CONCLUSIONS: Taken together, the results suggest that a subset of inflammatory cytokines and chemokines provides a framework for development of highly optimized urinary biomarker assay for differential diagnosis and treatment of OAB.

Do women have realistic expectations of treatment for stress urinary incontinence?

AIMS: Our objective was to determine what women find acceptable regarding treatment and outcomes for treatment of stress urinary incontinence (SUI), and correlate this to age, distress and quality of life (QOL). MATERIALS AND METHODS: This prospective cross-sectional IRB-approved study evaluated women with primary SUI. One hundred sequential women (mean age, 53.8 years) answered questionnaires on initial interview, including the Urogential Distress Inventory (UDI-6), the American Urologic Association QOL questionnaire, as well as other validated questions regarding treatment options and possible outcomes. Statistical analysis was performed using Chi Squared, Fisher Exact, and t tests as well as the Wilcoxon Rank Score. RESULTS: Of the 100 women who submitted questionnaires, 22% overall expected a complete cure, 57% a good improvement, 12% to be able to cope better, and 9% expected any improvement at all. We found this to be a realistic expectation of possible outcomes of treatment, with 79% expecting a good improvement or cure for their SUI. The women were also asked what type of treatment they found acceptable for their SUI: 22% found a major surgery acceptable, 39% found a minor surgery acceptable, 32% found a clinical procedure acceptable, and 7% found medication acceptable. The majority of women (71%) found a minor surgery, like a transobturator tape, or a clinical procedure, like collagen injection, most desirable. These results were then analyzed for correlation to age, degree of distress (measured by UDI-6), and QOL (measured by AUA QOL score). CONCLUSIONS: Overall women have realistic expectations of treatment for SUI. They are willing to accept varied results depending on their distress regarding incontinence. Choices regarding treatments are influenced by age, severity and quality of life. It may be beneficial to include the UDI-6, age and QOL score as a part of the work up and planning for treatment of SUI to better meet patient's expectations.

The outcome of transobturator cystocele repair using biocompatible porcine dermis graft: our experience with 32 cases.

This study aims to evaluate the outcome of cystocele repair using Perigee with biocompatible matrix (InteXen). After IRB approval, a retrospective chart review of patients who underwent Perigee/InteXen repair was done. Success was defined as a postoperative anatomical stage 0 or I using POP-Q system. Thirty two patients were included with 14 (43.75%) who had failed previous repair. Preoperatively, eight patients (25%) had stage II cystocele, 21 (65.6%) had stage III, and three (9.4%) had stage IV. Twenty six patients (81.25%) were available for a median follow up of 8.72 (6-31) months that showed success in 25 patients (96%) with 14 (54%) having stage 0 and 11 (42%) having stage I. Complications included bladder perforation (n = 1), incidental cystotomy (n = 1), mesh erosion (n = 1), and wound dehiscence (n = 1). This study suggests cystocele repair using Perigee with InteXen has a high short-term success with lower morbidity.

Recurrent stress urinary incontinence after dislodged screws in patient with bone-anchored suburethral sling.

This is the first reported case of recurrent stress urinary incontinence secondary to dislodged bone-anchoring screws. A 71-year-old man who had undergone successful bone-anchored sling placement for post-prostatectomy incontinence, presented with recurrent stress urinary incontinence after a bout of coughing. Pelvic radiography revealed three screws had been dislodged. The mesh was left in place, with replacement of the dislodged screws and the addition of one extra screw. The findings of this case suggest that dislodged screws can be a possible cause of sling failure. Preoperative bone scanning and postoperative pelvic radiography should be a part of the routine workup for patients with bone-anchored slings.

Transperineal repair of complex rectourethral fistula using gracilis muscle flap interposition--can urinary and bowel functions be preserved?

PURPOSE: Rectourethral fistula developing after prostate cancer treatment is usually complex and difficult to repair. We present our experience with 25 cases of complex rectourethral fistula using gracilis muscle interposition, addressing the efficacy of this technique as well as the postoperative urinary and fecal outcome. MATERIALS AND METHODS: After receiving institutional review board approval we performed a retrospective chart review of patients with prostate cancer who had undergone gracilis muscle interposition for complex rectourethral fistula. A 1-page questionnaire was then mailed to all patients to assess urinary and bowel function. RESULTS: At mean followup of 28 months all patients had successful fistula closure with no recurrence. Of the 18 patients (72%) with urinary continence 5 were continent after artificial urinary sphincter implantation. Three patients (12%) were totally incontinent and lost to followup. Four patients (16%) had permanent urinary diversion due to a devastated urinary outlet, while a urethral stricture was found in 5 and bladder neck contracture was noted in 3. Regarding bowel control, 19 patients (76%) were continent, 2 (8%) had fecal incontinence and 4 (16%) required permanent colostomy due to a devastated fecal outlet. A total of 17 patients replied to the mailed questionnaire for a 68% response rate and all had significant improvement in all parameters. Factors predisposing to a suboptimal outcome were large fistula size, surgery followed by radiation and cryotherapy. CONCLUSIONS: Gracilis muscle transposition is an excellent procedure for treating complex rectourethral fistula. Several other local factors may affect the postoperative urinary and fecal outcome. The collaboration of colorectal and urological surgeons is necessary to achieve optimal results.

Urethral diverticulum after tension-free vaginal tape procedure: case report.

This study presents the third case in the literature of a urethral diverticulum after the tension-free vaginal tape (TVT) procedure, with an additional finding of the diverticulum developing distal to the tape. A 54-year-old woman, with 3 years' status post-TVT, presented with urinary tract infection and infravesical obstruction. Urethrocystoscopy revealed a urethral diverticulum just distal to the sling site. Transvaginal diverticulectomy and excision of the sling was done, with improvement of symptoms at 1-year follow-up.