A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment.

Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.

Midurethral Sling Removal or Revision in Women with Chronic Pain.

OBJECTIVES: The objectives of this study are (1) to estimate the incidence of midurethral sling revision/removal in women with preexisting pain diagnoses versus those without these diagnoses and (2) to describe associations between numbers and type of pain diagnoses with revision/removal. METHODS: Women who underwent midurethral sling surgery between 2009 through 2014 were identified in the MarketScan database and tracked and December 31, 2014. Patients with preoperative chronic pain diagnoses (fibromyalgia, endometriosis, irritable bowel, dyspareunia, low back pain, temporomandibular joint syndrome, interstitial cystitis, pelvic/perineal pain) were compared with controls (those without these diagnoses) regarding mesh sling revision/removal. Logistic regression identified variables associated with mesh revision/removal, and survival analysis compared timing of mesh removal/revision. RESULTS: There were 161,459 women who underwent midurethral sling surgery (pain, 83,484; nonpain, 77,975). Pain and nonpain groups differed in age (52.1 vs 53.5 years, P < 0.01) and insurance status (P < 0.01), with the pain group more commonly living in the South or West. Mean follow-up was 42.3 months. Cumulative risk for sling revision/removal was higher in patients with 1 pain diagnosis relative to controls (relative risk, 1.54; 95% confidence interval [CI], 1.41-1.54). Risks increased with increased pain diagnoses (≥4 diagnoses; relative risk, 3.13; 95% CI, 2.81-3.47). Pelvic pain conditions had greatest odds of mesh revision/removal (dyspareunia adjusted odds ratio [aOR], 2.44; 95% CI, 2.23-2.63; interstitial cystitis aOR, 1.46; 95% CI, 1.27-1.66; pelvic/perineal pain aOR, 1.41; 95% CI, 1.33-1.48). Co-occurrence of dyspareunia and interstitial cystitis or pelvic/perineal pain had 12.7% cumulative incidence of sling revision/removal. Cox proportional hazards revealed greatest risk for those with pelvic pain conditions (hazard ratio, 2.40; 95% CI, 2.13-2.70). CONCLUSIONS: Chronic pain diagnoses increased risk of midurethral sling revision/removal; pelvic pain and numbers of diagnoses increased this risk.

Contemporary management of adult-acquired buried penis.

OBJECTIVES: To describe our buried penis repair technique that includes penile release, tissue resection, wound closure, and penile reconstruction. PATIENTS AND METHODS: In all, 73 patients were treated from 2007 to 2017. Patients can be categorised into five stages: Stage I, involves only a phimotic band; Stage 2, required excision of diseased penile skin with split-thickness skin grafting (STSG); Stage 3, requires scrotal excision; Stage 4, requires escutcheonectomy; and Stage 5, requires panniculectomy. Successful treatment hinges on adequate excision of diseased skin and de-bulking followed by replacement of deficient skin with STSG. RESULTS: In all, 36 of 73 (49%) patients had Stage 1-3 disease, whilst 37 of 73 (51%) were Stage 4-5. There were complications within the first 30 days in 44 of 73 (60%) patients. In all, 62 of 73 (85%) patients either had no complications or Clavien-Dindo grade I-II complications and nine (12%) had complications beyond 30 days. Only five of 36 (14%) patients with Stage 1-3 disease had complications. One patient developed recurrent phimosis. CONCLUSION: The buried penis is a challenging surgical entity where conservative treatment will most likely lead to failure. Surgery is the only means for a lasting cure in these patients and should be used as a first-line treatment. One should expect complications postoperatively, especially within the first 30 days; however, these are mostly limited to Clavien-Dindo grade I-II complications.

Advances in urethral stricture management.

Urethral stricture/stenosis is a narrowing of the urethral lumen. These conditions greatly impact the health and quality of life of patients. Management of urethral strictures/stenosis is complex and requires careful evaluation. The treatment options for urethral stricture vary in their success rates. Urethral dilation and internal urethrotomy are the most commonly performed procedures but carry the lowest chance for long-term success (0-9%). Urethroplasty has a much higher chance of success (85-90%) and is considered the gold-standard treatment. The most common urethroplasty techniques are excision and primary anastomosis and graft onlay urethroplasty. Anastomotic urethroplasty and graft urethroplasty have similar long-term success rates, although long-term data have yet to confirm equal efficacy. Anastomotic urethroplasty may have higher rates of sexual dysfunction. Posterior urethral stenosis is typically caused by previous urologic surgery. It is treated endoscopically with radial incisions. The use of mitomycin C may decrease recurrence. An exciting area of research is tissue engineering and scar modulation to augment stricture treatment. These include the use of acellular matrices or tissue-engineered buccal mucosa to produce grafting material for urethroplasty. Other experimental strategies aim to prevent scar formation altogether.