The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence.

OBJECTIVE: To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair. METHODS: We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported. RESULTS AND DISCUSSION: In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations. CONCLUSION: A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

Functional outcomes of vaginal surgery for urethral extrusion of mid-urethral tape in women.

INTRODUCTION AND HYPOTHESIS: We aim to determine the presentation of and immediate and longer-term outcomes of vaginal surgical excision of urethral extrusion of mid-urethral tape (MUT). METHODS: We performed a retrospective analysis of all patients with urethral extrusion of MUT having vaginal surgical excision between 2007 and 2018. The MUT was removed either partially (via vaginal approach) or completely (via combined vaginal and laparoscopic approach). Functional outcomes and any re-interventions are described. RESULTS: Thirty-four patients of median age 53 (range 34-82) years were identified. Preoperative symptomatic recurrent/persistent urinary incontinence was present in 29/34(85%) with 24/34(71%) women having recurrent/persistent stress urinary incontinence (SUI) or stress predominant mixed urinary incontinence (s-MUI) on urodynamics. Vaginal surgical excision was performed alone in 33/34(97%) women and in combination with laparoscopic removal of abdominopelvic MUT in 1/34(3%) woman. In the longer term vaginal/urethral pain resolved or improved in all 15/15(100%) patients presenting with this complaint whilst patient reported poor flow resolved in 8/9 (89%) women. Twenty-eight of 34 women (82%) had persistent/recurrent SUI or s-MUI following MUT excision. Twenty-four of 34 women (71%) had further SUI surgery with cure or improvement of SUI in 20/24 (83%) patients. CONCLUSIONS: The outcome of vaginal surgical excision of the MUT was cure or improvement of pain in 100% and resolution of poor flow in 89% women. Recurrent/persistent SUI or s-MUI was present in 82% following removal as compared to 71% women prior to removal. Of the 71% of women electing to have further surgery for recurrent/persistent SUI/s-MUI, 83% were dry or improved afterwards.

Intravesical onabotulinumtoxinA injections in patients on antiplatelet and anticoagulation therapy.

AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.

Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which Technique Is Best? A Systematic Review.

CONTEXT: Four techniques for graft placement in one-stage bulbar urethroplasty have been reported: dorsal onlay (DO), ventral onlay (VO), dorsolateral onlay (DLO), and dorsal inlay (DI). There is currently no systematic review in the literature comparing these techniques. OBJECTIVE: To assess if stricture recurrence and secondary outcomes vary between the four techniques and to assess if one technique is superior to any other. EVIDENCE ACQUISITION: The EMBASE, MEDLINE, and Cochrane Systematic Reviews-Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED) databases and ClinicalTrials.gov were searched for publications in English from 1996 onwards. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), observational studies (cohort, case-control/comparative, single-arm), and case series with ≥20 adult male participants were included. EVIDENCE SYNTHESIS: A total of 41 studies were included involving 3683 patients from one RCT, four NRCSs, and 36 case series. Owing to the overall low quality of the evidence, a narrative synthesis was performed. CONCLUSIONS: No single technique appears to be superior to another for bulbar free graft urethroplasty. Both DO and VO are suitable for bulbar augmentation urethroplasty, with a ≤20% recurrence rate over medium-term follow-up. No recommendations can be made regarding DI or DLO techniques owing to the paucity of evidence. Secondary outcomes including sexual function, and complications are infrequently reported. Recurrence rates deteriorate in the long term for both DO and VO procedures. PATIENT SUMMARY: We reviewed the evidence for four different skin-graft techniques used to repair narrowing of a section of the urethra (bulbar urethra, under the scrotum and perineum) in men. Two of the techniques seem to give consistent results, with recurrence rates lower than 20%. Recurrence rates increase over time, so patients should continue to monitor their symptoms. There is poorer reporting of other outcomes such as sexual function, urinary symptoms, and complications, and it is possible that these occur more frequently than the current data suggest.

A comparison of flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms: can flow rate curve shape predict female bladder outflow obstruction or detrusor underactivity?

PURPOSE: To establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). METHODS: A retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. RESULTS: A total of 250 women with LUTS, with a mean age 48 years (range 18-83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. CONCLUSION: Flow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE: To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection. METHODS: We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre. RESULTS: Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25). CONCLUSION: Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Pad weight gain in asymptomatic continent women is far less than the current ICS definition.

AIMS: To investigate typical pad weight gain (PWG) in asymptomatic women who have never reported any episodes of urinary incontinence. METHODS: An observational study was performed by measuring the increase in weight of small sanitary pads worn by 35 healthy, female volunteers of a median age 36 (range, 23-56) years. Each pad was worn for a minimum of 5 h which is the typical maximum duration of an ambulatory urodynamics study. RESULTS: The median duration of pad wear was 6 h (interquartile range [IQR], 5-8). The median PWG was 0.111 g (IQR, 0.047-0.255). The maximum recorded PWG was 0.621 g and the minimum was 0.012 g. PWG was not significantly affected by age, parity, years since last delivery, body mass index, or menopausal status. CONCLUSIONS: PWG over a median duration of 6 h (IQR, 5-8) is typically <0.7 g in women who are asymptomatic of urinary incontinence. Therefore, PWGs in excess of 0.7 g over a 5-h ambulatory urodynamics study in symptomatic women are likely to be diagnostic of urinary incontinence.

The efficacy of onabotulinumtoxinA in patients with previous failed augmentation cystoplasty: Cohort series and literature review.

AIMS: To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO). METHODS: A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above. RESULTS: Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months). CONCLUSIONS: Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.

Ureteric reimplantation via vaginal route: a new surgical technique.

Vesicovaginal fistulae (VVF) and ureteric reimplantation are two rare complications of obstetric surgery. VVF can be repaired via a vaginal approach utilizing Martius fat pad interposition to minimize urethral complications and improve surgical outcomes, while ureteric reimplantation into the bladder classically necessitates an abdominal or laparoscopic approach. We present a new technique of ureteric reimplantation via vaginal approach with concomitant repair of a 5-cm VVF in a 25-year-old woman after an emergency caesarean section with bladder injury and ureteric transection. Good drainage was confirmed on MAG3 and successful vaginal birth (albeit preterm) was subsequently achieved.

Urethral diverticula in women are associated with increased urethra-sphincter complex volumes: A potential role for high-tone nonrelaxing sphincter in their etiology?

AIMS: Functional obstruction secondary to a high-tone nonrelaxing sphincter (HTNRS) may lead to the formation of a proximal-to-mid-urethral diverticulum (pmUD) in patients without a history of anatomical obstruction, vaginal delivery, vaginal and/or urethral surgery, or periurethral gland infection, that is, a functional pmUD (fpmUD). We used measurements of the urethra-sphincter complex volume (USCv) as a proxy for the maximal urethral closure pressure to evaluate this potential etiological factor. METHODS: We compared 17 consecutive women with fpmUD (mean age ± SD of 49.4 ± 13.2 years) with a control group consisting of 24 age-matched women (mean age: 50.8 ± 11.2 years) with no previous urological symptoms having MRI for posthysterectomy vesicovaginal fistula, and in all 71 women (mean age: 48.1 ± 11.6 years) with classical urethral diverticulum (cpmUD) referred in the same time period. The urethra-sphincter complex was measured using T2-weighted MRI and OsiriX© was then used to determine the USCv. RESULTS: The mean USCv of the fpmUD group was 10.01 ± 6.97 cm3 . The mean USCv of the cpmUD was 5.19 ± 1.19 cm 3 and for the control group was 3.92 ± 1.60 cm 3 . There was a high statistically significant (P = .01) difference between the USCv in the fpmUD group and the USCv of both the cpmUD and the control groups. CONCLUSIONS: Women with fpmUD demonstrated USCv that were significantly higher than those in women with cpmUD and the control group. These findings suggest that high pressure in the proximal urethra during voiding secondary to a HTNRS may contribute to the formation of urethral diverticula.

Appendix or Ileum-Which is the Best Material for Mitrofanoff Channel Formation in Adults?

PURPOSE: We report long-term data on a large cohort of adults who underwent formation of a continent catheterizable channel for various indications. We examined outcomes according to the tissue used for channel formation. MATERIALS AND METHODS: We retrospectively reviewed the case notes of 176 consecutive adult patients in whom a continent catheterizable channel was created using the Mitrofanoff principle for a broad range of indications a median of 142 months (range 54 to 386) previously. We evaluated outcomes in terms of continued use and continence for each type of material used for channel formation. RESULTS: At the time of this review 165 of the 173 patients (95.4%) included in this study were alive. We included 114 women (65.9%) and 59 men (34.1%) who underwent surgery at a median age of 42 years (range 18 to 73) with a mean followup of 78.6 months (median 60, range 2 to 365). The rate of revision for all causes was higher in the ileal group than in the group with an appendiceal channel (channel stenosis rate 22.7% vs 17.2%, p = 0.39, and channel incontinence rate 36.0% vs 19.5%, p = 0.03). Although 38.7% of patients underwent major surgical revision of the channel at some point, 75.9% of channels continued to be used, of which 90.2% were continent. CONCLUSIONS: This study provides a pragmatic overview of the outcome of these challenging cases. Mitrofanoff channel formation represents a durable technique. Appendix and ileum are each a viable choice for tissue use. Tissue selection depends on availability and individual patient factors.

Correlation of MRI features of urethral diverticulum and pre- and post-operative stress urinary incontinence.

AIMS: The complexity of urethral diverticulectomy depends on location, size, and degree of circumferential involvement. MRI features were examined to predict functional outcome after surgery for urethral diverticulum (UD). METHODS: A prospectively acquired database was of all patients who have had surgical excision of UD at a tertiary center since 2004 was reviewed. Particular focus was pre- and post-operative urodynamically proven stress urinary incontinence (USUI), and pre-operative MRI features. MRI parameters included diverticular volume, degree of circumferential involvement around the urethra, distance of the Os of UD to bladder neck and urethral length. Students t-test and Mann-Whitney U-test were used to compare rates of de novo USUI. RESULTS: There were 100 patients (mean age 45.8 yrs), who had excision of UD since 2004, with a minimum follow-up of 10 months (range 10-112 months). Full MRI data was available for 83 patients. Fourteen were of simple configuration (16.8%), 32 were horseshoe (38.6%), and 37 (44.6%) were circumferential. Twenty-five (25%) patients had pre-operative USUI, while 12 (12%) patients developed de novo USUI post-excision. While, the majority of patients with de novo USUI (67%) had >270° circumferential involvement of urethra, the pre-operative diverticular volume did not predict the likelihood of USUI developing (P = 0.3). A shorter urethral length was associated with pre-operative USUI. CONCLUSIONS: 25% of all patients had pre-op USUI, and diverticular volume and urethral length was significantly smaller in this group. The majority of patients with de novo USUI had complex diverticula configuration with higher baseline circumferential angle around urethra, with 67% of angle's between 270 and 360°.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes.

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Developing and validating a new nomogram for diagnosing bladder outlet obstruction in women.

OBJECTIVE: To develop and validate a nomogram for assessing bladder outlet obstruction (BOO) in women derived from concurrent Pdet.Qmax and Qmax based on radiographic evidence of increased urethral resistance. PATIENTS AND METHODS: Retrospective analysis of prospectively acquired video-urodynamics and clinical data of 185 women (development cohort) was performed. The Pdet.Qmax were plotted against Qmax and cluster analysis was performed to determine an axis that best divided the definitively obstructed and unobstructed. Using data from a further 350 women (validation cohort), the sensitivity and specificity of the derived criterion was calculated. Finally, the data from both groups was pooled together and using binary logistic regression analysis, a nomogram was produced. RESULTS: Of the 535 patients in the two cohorts, (122 [22.8%]) demonstrated radiographic evidence of BOO. Cluster analysis identified the axis that best separates the radiographically obstructed and unobstructed as Pdet.Qmax = 2*Qmax . Using the data from the validation cohort, the sensitivity and specificity for this was calculated as 0.94 and 0.93, respectively. A nomogram, representing the probability of BOO for concurrent Pdet.Qmax and Qmax measurements was derived by pooling data from both cohorts. Alternatively, a female BOO index (BOOIf) may be calculated mathematically using the formula BOOIf = Pdet.Qmax - 2.2*Qmax, that is, BOOIf < 0, <10% probability of obstruction, BOOIf > 5 likely obstructed (50%) and If BOOIf > 18, obstruction almost certain (>90%). CONCLUSION: A female BOO nomogram (the SG nomogram) with high sensitivity and specificity is proposed. The nomogram can be used to stratify the degree of BOO or assess response to treatment.

Does the appearance of the urethral pressure profile trace correlate with the sphincter EMG findings in women with voiding dysfunction?

AIMS: Women with functional voiding dysfunction often experience a "catching" sensation when catheterising and are in general investigated with both urethral pressure profilometry (UPP) and sphincter electromyography (EMG). It is unknown whether the pattern of the UPP trace correlates with this sensation of "catching" or with sphincter EMG findings. METHODS: We reviewed the database of all women with voiding dysfunction who had undergone both sphincter EMG and UPP to assess for any relationship between pattern of UPP trace and "catching" on catheterization and/or sphincter EMG findings. UPP traces were classified as smooth or pulsatile and the EMG was classified as normal or abnormal. Statistical analysis was by Chi squared test for pulsatile UPP trace as a predictor of abnormal EMG. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a pulsatile UPP trace for predicting abnormal EMG were also determined. These patients were asked to complete a telephone interview assessing discomfort on catheterization, particularly on catheter removal ("catching"). RESULTS: A total of 107 women of mean age 35.8 years underwent both sphincter EMG and UPP between 2011 and 2015. There was no significant association between "catching" on catheterization and pattern of UPP. There was a significant association between the presence of a pulsatile UPP and the finding of an abnormal EMG (P < 0.0001) The PPV of pulsatile UPP for abnormal EMG was 0.82 and the NPV of pulsatile UPP for abnormal EMG was 0.74. CONCLUSIONS: A pulsatile UPP trace is a sensitive predictor for abnormal EMG in patients with voiding dysfunction. There is no obvious correlation between a pulsatile UPP trace and a reported "catching" sensation on catheterization.

A systematic review of the literature on cystodistension in bladder pain syndrome.

INTRODUCTION AND HYPOTHESIS: There is significant variability in technique for cystodistension and an international discrepancy in the role in its treatment of bladder pain syndrome (BPS). The authors evaluate the evidence base for the use of cystodistension for BPS with particular reference to patient-related outcomes. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, a prospective search and evaluation protocol was prepared and registered with the PROSPERO database (ID CRD42017053710). A review of the literature was performed using the search terms cystodistension and hydrodistension of the bladder using the PubMed database on 6 October 2016. RESULTS: A total of 59 papers were reviewed, but only 17 studies contained original data available for analysis from 1975 to 2016. Ten studies evaluated the outcome of cystodistension in a single arm design or used cystodistension as the control for evaluating adjunctive treatments. Seven studies evaluated cystodistension in combination with other agents or therapies. The best symptomatic responses reported a subjective improvement in 56% of men with moderate to severe prostatitis and 57% in patients with "inflammatory cystitis" respectively. There were no studies that employed a validated outcome measure, neither a questionnaire nor an analogue scale, to assess the effect of cystodistension alone. CONCLUSIONS: Cystodistension is increasingly popular, despite a weak evidence base by current standards. The quality of available evidence falls below the level that would be expected of a new intervention. This review highlights the need for cystodistension to be further investigated with randomised control trials.

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision.

CONTEXT: Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%. AIMS: We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum. PATIENTS AND METHODS: All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram. STATISTICAL ANALYSIS USED: Statistical analysis was performed by Chi-squared and Fisher's exact. RESULTS: Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential. CONCLUSIONS: New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI - rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.

Patient treatment preferences for symptomatic refractory urodynamic idiopathic detrusor overactivity.

INTRODUCTION: There is a multiplicity of treatments currently available for patients with symptomatic refractory urodynamic idiopathic detrusor overactivity (SRU IDO). We have assessed patient treatment preferences and their outcomes over a 12-month period from January 1 2009 to December 31 2009. PATIENTS AND METHODS: A retrospective database of all patients with SRU IDO was reviewed for patient demographics, treatment preference, and outcome. All patients attending for treatment in the time period were offered: no further treatment, repeat bladder training ± antimuscarinic (BT ± AM), acupuncture, intravesical botulinum toxin injection, sacral neuromodulation (SNM), clam cystoplasty ± Mitrofanoff channel formation, and ileal conduit. STATISTICAL ANALYSIS USED: Statistical analysis of outcomes was done by Chi-square test, and statistical significance was determined as P < 0.05. RESULTS: A total of 217 patients with SRU IDO underwent primary treatment in this time period, with a median age of 56 years and follow-up for a minimum of 12 months' posttreatment to determine outcome. No patients opted for any further treatment or an ileal conduit. The majority of patients opted for intravesical botulinum toxin injections and SNM with similar success rates (approximately 70%). A small number of patients decided to have nonsurgical interventions (BT ± AM or acupuncture) and had a broadly similar success rate (50%). A minority opted for clam cystoplasty ± Mitrofanoff channel formation - this group reported the highest success rate at 86%. CONCLUSIONS: Treatment options in SRU IDO are diverse, with the majority of patients opting for minimally invasive surgery. Clinicians should be familiar with all treatment options for management of SRU IDO.

Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft.

BACKGROUND: Urethral stricture disease is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture under a single surgeon in a third referral centre in UK. METHODS: We conducted a retrospective review of a prospectively gathered database of 128 patients having various forms of BMG urethroplasty between 2001 and 2015. Success and failure in terms of stricture recurrence, patient demographics, stricture aetiology and anatomy, and the adverse outcomes of: post-micturition dribbling (PMD), erectile dysfunction (ED) >12 months and complications were recorded in order to determine risk factors for recurrent stricture and complications. RESULTS: The mean age of all patients was 42.8 years (range, 16-74 years). Average follow-up was 45 months (range, 3-159 months). The total re-stricture rate was 19% (24 men). PMD was reported in 16% (n=20) and ED in 12.5% (n=16). All ED was none organic and responded to oral PDE5 inhibitor treatment. Post-operative complications were reported in 16 patients (12.5%). The most frequent complications recorded were urinary fistula (n=4; 3.1%), graft contracture (n=4; 3.1%) and graft failure (n=4; 3.1%), all reported after penile urethroplasty. Univariate analysis indicated that age at surgery, stricture length, site and aetiology were all significant risk factors for stricture recurrence. On multivariate analysis penile site was the only significant independent variable for restricture. CONCLUSIONS: BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a success rate of 81% at 45 months of follow-up. Complications are more common in complex stricture of the penile urethra. On multivariate analysis penile site was the only significant independent variable for re-stricture.

Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women.

OBJECTIVE: To present our outcomes of ventral-onlay buccal mucosa graft (BMG) substitution urethroplasty in treating female urethral stricture (FUS). PATIENTS AND METHODS: We conducted a review of a prospectively collected database of 22 consecutive women (median [range] age 50 [34-72] years) with urethral stricture who underwent ventral onlay BMG substitution urethroplasty after June 2012 and who had a minimum follow-up of 6 months (median 21.5, range 6-51 months). Data were analysed for stricture recurrence, change in median maximum urinary flow rate (Qmax ) and median post-void residual urine volume (PVR). Statistical analysis was performed using the Wilcoxon signed rank test, Student's t-test and the Mann-Whitney U-test. RESULTS: Freedom from stricture recurrence was achieved in 21/22 (95.5%) women. The median (range) Qmax significantly improved, increasing from 7 (3.5-11) to 18 (5-37) mL/s (P <0.05). The median (range) PVR was significantly reduced from 100 (0-300) to 15 (0-150) mL (P < 0.05). Short- and longer-term complication rates were low. One woman developed mild de novo stress urinary incontinence, which settled with conservative management by 6 months. CONCLUSIONS: Early and medium-term results indicate that ventral onlay BMG substitution urethroplasty is an excellent treatment for FUS that can avoid the need for the repeat procedures regularly required after traditional endoscopic management.