Complications in adulthood for patients with paediatric genitourinary reconstruction.

BACKGROUND: Caring for adults with prior paediatric genitourinary reconstruction remains a challenge for adult providers. Reconstructions typically have occurred decades before; surgical records are not always available and patients and families may be unable to convey procedures performed. Spina bifida (SB) patients are vulnerable to cognitive decline which may compound these challenges. Changes in patient body habitus and loss of function may contribute to problems with previous reconstructions. METHODS: This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on the evaluation and management of complications arising from genitourinary reconstruction in congenital neurogenic bladder patients. RESULTS: Common complications experienced by congenital neurogenic bladder patients include recurrent urinary tract infection, incontinence of catheterizable channel and urinary reservoir as well as malignancy as this population ages. Preservation of renal function and prevention of urinary tract infection while optimizing continence are essential guiding principles in the care of these patients. Many of the recommendations, however, are gleaned from available data in the adult spinal cord patient (a more commonly studied population) or the paediatric urologic literature due to limited studies in adult management of such patients. CONCLUSION: Close follow-up and vigilance is warranted to monitor for infectious, mechanical and malignant complications while optimizing preservation of the upper urinary tracts and patient quality of life.

[Ectopic seminal tract opening in enlarged prostatic utricle: A report of 22 cases].

OBJECTIVE: To explore the diagnosis, classification and treatment of ectopic seminal tract opening in enlarged prostatic utricle (EPU). METHODS: We retrospectively analyzed the clinical data on 22 cases of ectopic seminal tract opening in EPU confirmed by spermography, EPU open cannula angiography or intraoperative puncture of the vas deferens and treated by transurethral incision of EPU, cold-knife incision or electric incision of EPU, full drainage of the anteriorwal, and open or laparoscopic surgery from October 1985 to October 2017. RESULTS: Five of the patients were diagnosed with ectopic opening of the vas deferens and the other 17 with ectopic opening of the ejaculatory duct in EPU. During the 3－48 months of postoperative follow-up, symptoms disappeared in all the cases, semen quality was improved in those with infertility, and 2 of the infertile patients achieved pregnancy via ICSI. CONCLUSIONS: Ectopic seminal tract opening in EPU is rare clinically. Spermography is a reliable method for the diagnosis of the disease, and its treatment should be aimed at restoring the smooth flow of semen based on proper classification and typing of the disease.

Machine learning in the optimization of robotics in the operative field.

PURPOSE OF REVIEW: The increasing use of robotics in urologic surgery facilitates collection of 'big data'. Machine learning enables computers to infer patterns from large datasets. This review aims to highlight recent findings and applications of machine learning in robotic-assisted urologic surgery. RECENT FINDINGS: Machine learning has been used in surgical performance assessment and skill training, surgical candidate selection, and autonomous surgery. Autonomous segmentation and classification of surgical data have been explored, which serves as the stepping-stone for providing real-time surgical assessment and ultimately, improve surgical safety and quality. Predictive machine learning models have been created to guide appropriate surgical candidate selection, whereas intraoperative machine learning algorithms have been designed to provide 3-D augmented reality and real-time surgical margin checks. Reinforcement-learning strategies have been utilized in autonomous robotic surgery, and the combination of expert demonstrations and trial-and-error learning by the robot itself is a promising approach towards autonomy. SUMMARY: Robot-assisted urologic surgery coupled with machine learning is a burgeoning area of study that demonstrates exciting potential. However, further validation and clinical trials are required to ensure the safety and efficacy of incorporating machine learning into surgical practice.

Evaluation of genitourinary fistulas in pelvic malignancies with etiopathologic correlation: role of cross sectional imaging in detection and management.

OBJECTIVE: Genitourinary fistulas in pelvic malignancies are abnormal communications occurring due to either locally advanced tumours invading the surrounding organs or post-therapeutic complications of malignancies. In this article we review and describe the role of cross-sectional imaging findings in the management of genitourinary fistulas in pelvic malignancies. METHODS: A retrospective study, for the period January 2012 to December 2018, was undertaken in patients with pelvic malignancies having genitourinary fistulas. The cross-sectional (CT and MRI) imaging findings in various types of fistulas were reviewed and correlated with the primary malignancy and the underlying etiopathology. RESULTS: Genitourinary fistulas were observed in 71 patients (6 males, 65 females). 11 types of fistulas were identified in carcinomas of cervix, rectum, ovary, urinary bladder, sigmoid colon, vault, endometrium and prostate. The commonest were rectovaginal and vesicovaginal fistulas. 13 patients had multiple fistulas. The sensitivity, specificity, positive and negative predictive values of CT and MRI are 98%, 100%, 66%, 98% and 95%, 25%, 88% and 50% respectively. Contrast-enhanced CT with oral and rectal contrast is more sensitive and specific than MRI in the evaluation of genitourinary fistulas. CONCLUSION: Imaging findings significantly influence the management and outcome of genitourinary fistulas in pelvic malignancies. Contrast-enhanced CT is the imaging modality of choice in the evaluation of pelvic fistulas associated with malignancies and MRI is complimentary to it. ADVANCES IN KNOWLEDGE: To our knowledge, this study is the first of its kind wherein the mean duration of occurrence of fistulas in pelvic malignancies is correlated with the underlying etiopathology.

Ectopic seminal tract opening in enlarged prostatic utricle: A report of 22 cases / 中华男科学杂志

Objective@#To explore the diagnosis, classification and treatment of ectopic seminal tract opening in enlarged prostatic utricle (EPU).@*METHODS@#We retrospectively analyzed the clinical data on 22 cases of ectopic seminal tract opening in EPU confirmed by spermography, EPU open cannula angiography or intraoperative puncture of the vas deferens and treated by transurethral incision of EPU, cold-knife incision or electric incision of EPU, full drainage of the anteriorwal, and open or laparoscopic surgery from October 1985 to October 2017.@*RESULTS@#Five of the patients were diagnosed with ectopic opening of the vas deferens and the other 17 with ectopic opening of the ejaculatory duct in EPU. During the 3－48 months of postoperative follow-up, symptoms disappeared in all the cases, semen quality was improved in those with infertility, and 2 of the infertile patients achieved pregnancy via ICSI.@*CONCLUSIONS@#Ectopic seminal tract opening in EPU is rare clinically. Spermography is a reliable method for the diagnosis of the disease, and its treatment should be aimed at restoring the smooth flow of semen based on proper classification and typing of the disease.

The surgical burden of disease and perioperative mortality in patients admitted to hospitals in Victoria, Australia: a population-level observational study.

OBJECTIVES: Comprehensive reporting of surgical disease burden and outcomes are vital components of resilient health systems but remain under-reported. The primary objective was to identify the Victorian surgical burden of disease necessitating treatment in a hospital or day centre, including a thorough epidemiology of surgical procedures and their respective perioperative mortality rates (POMR). DESIGN: Retrospective population-level observational study. SETTING: The study was conducted in Victoria, Australia. Access to data from the Victorian Admitted Episodes Dataset was obtained using the Dr Foster Quality Investigator tool. The study included public and private facilities, including day-case facilities. PARTICIPANTS: From January 2014 to December 2016, all admissions with an International Statistical Classification of Diseases-10 code matched to the Global Health Estimates (GHE) disease categories were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Admissions were assigned a primary disease category according to the 23 GHE disease categories. Surgical procedures during hospitalisations were identified using the Australian Refined Diagnosis Related Groups (AR-DRG). POMR were calculated for GHE disease categories and AR-DRG procedures. RESULTS: A total of 4 865 226 admitted episodes were identified over the 3-year period. 1 715 862 (35.3%) of these required a surgical procedure. The mortality rate for those undergoing a procedure was 0.42%, and 1.47% for those without. The top five procedures performed per GHE category were lens procedures (162 835 cases, POMR 0.001%), caesarean delivery (76 032 cases, POMR 0.01%), abortion with operating room procedure (65 451 cases, POMR 0%), hernia procedures (52 499 cases, POMR 0.05%) and other knee procedures (47 181 cases, POMR 0.004%). CONCLUSIONS: Conditions requiring surgery were responsible for 35.3% of the hospital admitted disease burden in Victoria, a rate higher than previously published from Sweden, New Zealand and the USA. POMR is comparable to other studies reporting individual procedures and conditions, but has been reported comprehensively across all GHE disease categories for the first time.

Surgical management of genitourinary lichen sclerosus et atrophicus in boys in England: A 10-year review of practices and outcomes.

INTRODUCTION: Circumcision has long been the mainstay of management for genitourinary lichen sclerosus et atrophicus (LS); however, there has been growing interest in surgical techniques that preserve the foreskin. OBJECTIVE: The aim of this study was to assess population-based surgical management of LS in England and determine surgical outcomes. STUDY DESIGN: Cases of LS treated in English NHS trusts (2002-2011) were extracted from the Hospital Episode Statistics (HES) Database. Cases were identified by both an ICD-10 code for LS and either an OPCS4.6 code for circumcision or preputioplasty (with/without injection of steroid). Subsequent admissions were analysed for related complications/procedures. Data are presented as median (interquartile range) unless otherwise stated. RESULTS: 7893 patients had surgery for LS, of whom 7567 (95.8%) underwent circumcision (Table). Primary preputioplasty was performed in 326 (4.1%) in 44/130 centres; of these 151/326 had concomitant injection of steroid. Age at surgical intervention was 9 (6-11) years. There were no postoperative bleeds following preputioplasty. Of those treated with preputioplasty, 74 (22%) had subsequent circumcision at a median of 677 (277-1203) days post operation. Concomitant steroid injection reduced the risk of subsequent circumcision (21/151 (14%) vs. 53/175 (30%), p < 0.001). More children underwent a second operative procedure following preputioplasty than those having had a primary circumcision (27.9% vs. 7.9%, p < 0.001). CONCLUSION: Although circumcision is the predominant treatment for LS, these data suggest that preputioplasty is a valid option in management, albeit with a higher re-intervention rate. Selection bias may play a role and a randomized controlled trial is needed. Preputioplasty combined with steroid injection appears to reduce the chance of completion circumcision.

Endogenous Fungal Endophthalmitis Associated with Genitourinary Procedures.

Purpose: To summarize the characteristics of endogenous fungal endophthalmitis (EFE) after genitourinary procedures. Methods: Medical records of patients diagnosed with EFE after genitourinary procedures from a single center during a 6-year period were reviewed. Results: Nineteen eyes of 15 patients were included. The interval time between procedure to symptom was 3.6 ± 3.6 weeks. As the initial treatment, 9/19 eyes underwent primary vitrectomy and 10/19 eyes underwent intravitreal antifungal injection . Candida albicans was the pathogen in 15 of 19 eyes. Systemic treatment with itraconazole was used in all patients. LogMAR best corrected visual acuity improved from 2.2 ± 0.9 to 0.9 ± 1.2 after treatment (p = 0.002) in 15 eyes that were followed-up for an average of 4.9 ± 2.1 years. Conclusion: Genitourinary procedure is a predisposing factor for EFE. Candida albicans is the predominant pathogen. Normative systemic and local antifungal treatments improved the final visual outcome.

Nonclinical Barriers to Care for Neurogenic Patients Undergoing Complex Urologic Reconstruction.

OBJECTIVE: To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction. METHODS: Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried. RESULTS: Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates. CONCLUSION: Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them.

Fertility Issues in Pediatric Urology.

Improved understanding of the pathogenesis and natural history of many urologic disorders, as well as advances in fertility preservation techniques, has increased the awareness of and options for management of fertility threats in pediatric patients. In children, fertility may be altered by oncologic conditions, by differences in sexual differentiation, by gonadotoxic drugs and other side effects of treatment for nonurologic disorders, and by urologic conditions, such as varicocele and cryptorchidism. Although fertility concerns are best addressed in a multidisciplinary setting, pediatric urologists should be aware of the underlying pathophysiology and management options to properly counsel and advocate for patients.

Urethral lichen sclerosus under the microscope: a survey of academic pathologists.

INTRODUCTION: Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist. MATERIALS AND METHODS: All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease. RESULTS: There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007). CONCLUSIONS: There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.

Tratamiento de la lesión uretral cistoscópica iatrogénica asociada a secuela de la erosión del manguito en un paciente después de la implantación previa de AMS 800. Técnica de un solo paso con revisión, sin explantación del manguito / Management of iatrogenic cystoscopic urethral lesion associated with sequela of cuff erosion in a patient after previous AMS 800 implantation. One-step technique with revision, without cuff explantation

Introducción: La lesión uretral iatrogénica con posterior erosión del manguito durante la cistoscopia es una complicación poco frecuente. Se presentará la estrategia quirúrgica alternativa con uretroplastia in situ manteniendo el manguito abierto in situ. Materiales y métodos: Los autores describen 3 casos de lesión uretral iatrogénica con erosión del manguito durante la evaluación cistoscópica para excluir la estenosis o la erosión del manguito debido a la reaparición de síntomas obstructivos del tracto urinario inferior. Todos los pacientes tenían antecedentes de implantación de AMS 800 por incontinencia posprostatectomía. Se realizó una cistoscopia rígida, que no reveló alteraciones; sin embargo, se identificó una pequeña lesión uretral iatrogénica durante la extirpación del cistoscopio en la proyección del manguito. Resultados: Se realizó uretroplastia in situ y el manguito se dejó abierto in situ. Además, se colocó una solapa de grasa protectora alrededor de la uretra desde la cara dorsolateral, separando el manguito y la uretra del contacto directo entre sí. Después de 6 semanas el defecto uretral se curó completamente y a través de una incisión perineal primaria el manguito fue readaptado y cerrado. El dispositivo estaba funcionando sin ningún ajuste adicional. Conclusión: Nuestra modificación debe considerarse, en casos seleccionados sin infección, como parte de la estrategia de tratamiento en los casos de lesiones uretrales iatrogénicas con posterior erosión del manguito. De esta manera se puede evitar el manguito original y la preparación posiblemente difícil de la uretra durante la reoperación. Sin embargo, se deben presentar más casos en la literatura mundial para confirmar la utilidad de este principio quirúrgico

Introduction: Iatrogenic urethral lesion with subsequent cuff erosion during cystoscopy is a rare complication. The alternative surgical strategy with in situ urethroplasty while maintaining the open cuff left in situ will be presented. Materials and methods: The authors report 3 cases of iatrogenic urethral lesion with cuff erosion during cystoscopic evaluation to exclude stricture or cuff erosion due to new onset of obstructive lower urinary tract symptoms. All patients had a history of a AMS 800 implantation due to posprostatectomy incontinence. Rigid cystoscopy was performed, which revelaed no pathologies; however, iatrogenic small urethral lesion was identified during the removal of the cystoscope at the projection of the cuff. Results: In situ urethroplasty was performed, and the cuff was left open in situ. Additionally a protection fat flap was placed around the urethra from the dorsolateral aspect, separating the cuff and urethra from the direct contact with each other. After 6 weeks the urethral defect was completely healed and via a primary perineal incision the cuff was readapted and closed. The device was fully functioning without any additional adjustments. Conclusion: Our modification should be considered in select cases with absence of infection as part of management strategy for cases of iatrogenic urethral lesions with subsequent cuff erosion. Thereby the original cuff can be spared and the possibly difficult preparation of the urethra during reoperation can be avoided. However, additional more cases should be presented in the world-wide literature, to confirm the utility of this surgical principle

Análisis de parámetros seminales en varones subfértiles sin y con varicocele (Pre-Postquirúrgico) / Analysis of seminal parameters in subfertile males without and with varicocele (Pre-Surgical)

Introducción: Durante años, el varicocele se ha propugnado como la causa más común de infertilidad, siendo esta patología la de mayor incidencia en los varones como factor causal (19 - 41%). Material y Métodos: Se evaluaron 228 pacientes, sexo masculino (18 y 39 años) con subfertilidad primaria con o sin varicocele. Se realizó historia clínica, examen físico, laboratorio y espermograma por duplicado. Se dividieron un grupo de 120 pacientes con subfertilidad primaria, varicocele izquierdo y por lo menos un parámetro seminal alterado en dos muestras sometidos a varicocelectomía y control seminal 6 y 9 meses post-operatorio y otro grupo 108 pacientes de iguales características pero sin varicocele. Se utilizaron criterios OMS en concentración, motilidad y morfología espermática. Estudio de casos y controles. Resultados: La mejoría en la concentración de espermatozoides tras el tratamiento quirúrgico fue de 20,06% (p‹ 0,0001) a los 6 meses y 26,31% (p‹ 0,0001) a los 9 meses. La motilidad aumentó 21,32% (p‹ 0,001) a los 6 meses y 28,28% (p‹ 0,0001) a los 9 meses y la morfología mejoró un 26,8% (p‹ 0,0001) a los 6 meses y 57,38% (p‹ 0,0001) a los 9 meses. Todas las variables resultaron estadísticamente significativas tras el tratamiento quirúrgico. No hubo diferencia estadísticamente significativa en ninguna de las variables entre el grupo pre-quirúrgico y el grupo control, y si las hubo en todas las variables estudiadas entre el grupo control comparado con el post- quirúrgico, a favor de este último. Los porcentajes de mejoras entre el grupo post-quirúrgico a los 6 meses y 9 meses de la cirugía, a favor de este último fueron 7,5% (p‹ 0,0001) en la concentración, 5,28 % (p‹ 0.0001) en la motilidad y 25,32% (p‹ 0.0001) en la morfología... Conclusiones: Los parámetros seminales evidenciaron cambios positivos luego de la varicocelectomia y más aún con el transcurrir del tiempo.

Introduction: Varicocele has been proposed for years as the most common cause of infertility, and this condition is the prevalent incidence as causal factor. (19-41%) Material and methods: 228 male patients (between 18 and 39 years old) were evaluated with primary sub fertility with or without varicocele. The records included history, physical examination and two spermogram for patient. The population was divided in two groups. The first one of 120 patients with primary subfertility, left varicocele and at least one abnormal seminal parameter in two samples, with surgical resection of varicocele and final seminal post-surgical evaluation at 6 and 9 months. The other group included 108 patients with similar characteristics but without varicocele. The WHO criteria for spermatic concentration, motility and morphology were applied. Evaluation of cases and controls. Results: The improvement in spermatozoa concentration after treatment was of 20.06% (p<0,0001). The motility improved 21,32% at 6 months (p<0,0001) and 28,28% at 9 months (p<0,0001).The morphology improved 26,8% at 6 months (p<0,0001) and 57,38% at 9 months (p<0,0001)All the parameters were statistically significant after surgery. While there were no significant differences in any parameter between the pre-surgical group and the control group, there were differences in all the parameters evaluated between the control group and the post-surgical group, with best results in the latter.The percentages of improvement in the post-surgical group were 7,5%(p < 0,0001) in concentration, 5,28% in motility and 25,32% in morphology...Conclusions: The seminal parameters showed positive changes after varicocelectomy, especially over time.

Tratamiento del trauma perineal complejo. Revisión de la literatura / Treatment of complex perineal trauma. A review of the literature

El trauma perineal, aunque poco común, no es un evento raro. Puede presentarse con una amplia variedad de patrones de lesión y por esta razón necesita de una precisa evaluación diagnóstica y de tratamientos adecuados. Las lesiones traumáticas del periné pueden presentarse de manera aislada o asociarse a lesiones de otros órganos pélvicos, abdominales o de miembros inferiores. Por esta razón es importante conocer no solo la anatomía del periné y sus órganos sino también la relevancia del estado hemodinámico del paciente en el tratamiento de estas lesiones, de acuerdo con los protocolos de tratamiento del paciente politraumatizado. El propósito de esta revisión es describir las características de las lesiones traumáticas perineales, su presentación clínica y su tratamiento basado en la evidencia más reciente, para intentar definir líneas de diagnóstico y tratamiento específicas tanto en los pacientes en situación de inestabilidad como de estabilidad hemodinámica

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients

Current Status of Robot-Assisted Radical Cystectomy and Intracorporeal Urinary Diversion.

Robot-assisted surgery has become a widely used surgical approach in the management of urologic malignancies. With its initial experience in the treatment of prostate cancer, the technology rapidly expanded to other urologic malignancies including bladder cancer. Since its introduction in 2003, robot-assisted radical cystectomy has seen refinement and increased penetration over the last decade. Furthermore, urologic surgeons have expanded its use to perform urinary diversions. The concept of intracorporeal urinary diversion is still in development but continues to see increased refinement among high volume academic centers.

[Minimally invasive interventional techniques involving the urogenital tract in dogs and cats]. / Minimal-invasive interventionelle Verfahren am Urogenitaltrakt von Hund und Katze.

Minimally invasive interventional techniques are advancing fast in small animal medicine. These techniques utilize state-of-the-art diagnostic methods, including fluoroscopy, ultrasonography, endoscopy, and laparoscopy. Minimally invasive procedures are particularly attractive in the field of small animal urology because, in the past, treatment options for diseases of the urogenital tract were rather limited or associated with a high rate of complications. Most endourological interventions have a steep learning curve. With the appropriate equipment and practical training some of these procedures can be performed in most veterinary practices. However, most interventions require referral to a specialty clinic. This article summarizes the standard endourological equipment and materials as well as the different endourological interventions performed in dogs and cats with diseases of the kidneys/renal pelves, ureters, or lower urinary tract (urinary bladder and urethra).

Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas.

BACKGROUND: Urogenital fistulas are devastating complications occurring after tumors or trauma. Surgical treatment is challenging. Thus, further surgical repair options are needed for treatment of complex fistulas within the pelvic region. METHODS: Twelve patients with urogenital fistulas were surgically treated in our department from 2004 to 2012. These selected cases fulfilled eligibility criteria for continence-preserving surgery - a history of fistula recurrences with ongoing incontinence after receiving at least two surgical attempts. Five VRAM and eight gracilis flaps were used to cover up given tissue defects and to perform functional continence-preserving reconstruction with mean follow-up of 6.3 years. Data were retrospectively reviewed, and standardized survey was performed to evaluate quality of life of all living patients (n = 10). RESULTS: In all cases, final surgical treatment of the given fistulae by VRAM or gracilis flaps could be achieved, with mean operating time of 5:31 h (range: 4:50-6:48 h) for VRAM flap and 3:11 h (range: 2:04-4:42 h) for gracilis flap. Outcome measures were primarily to avoid fistula recurrence after plastic surgical treatment, and secondary quality of life and survival. All patients had their continence preserved, but two patients died during follow-up period. Postoperative assessment revealed the following: VRAM flap patients (n = 3) showed slight incontinence during the follow-up period, whereas continence was restored in all patients with gracilis flap reconstruction (n = 7). Quality-of-life assessment indicated restoration of quality of life in comparison to general population (women > men). Furthermore, key points of the two presented surgical techniques are demonstrated in detail. CONCLUSION: With preformed VRAM or gracilis flaps, complex urogenital fistulas can be successfully eradicated and continence is restored. The main focus should be the recovery of quality of life, which could be successfully regained. Nevertheless, the continence success rate has to be defined on an individual, case-by-case basis. LEVEL OF EVIDENCE: Original work, cohort study level III.

Complete transection of the urethra and corpora cavernosa: a complication after laparoscopic repair (TEP) of an inguinal hernia.

Complete transection of both corpora cavernosa and the urethra is a very rare condition in urology. We report the case of a 59-year-old man with complete transection of the corpora cavernosa and the urethra during a laparoscopic repair of a recurrent inguinal hernia.

Transurethral endoscopic treatment of seminal vesicle cysts (report of seven cases).

OBJECTIVE: Seminal vesicle cysts are a rare disorder of the male reproductive system. The goal of this report was to summarize the radiological manifestations and transurethral endoscopic treatment of large seminal vesicle cysts. MATERIALS AND METHODS: The clinical data of seven cases of giant seminal vesicle cysts, including their symptoms, radiological images, transurethral endoscopic treatment, and postoperative follow-up, were retrospectively reviewed. RESULTS: Computerized tomography and magnetic resonance imaging (MRI) demonstrated the cysts behind the bladder, above the prostate, and away from the midline. The lesions ranged in size from 8.26 cm × 7.98 cm × 4.85 cm to 9.27 cm × 8.95 cm × 8.15 cm. Two cases were associated with ipsilateral renal and ureteral agenesis and were classified as congenital malformations. The other five cases were simple seminal vesicle cysts thought to be secondary to acquired ejaculatory duct obstruction. All seven cases were successfully treated using transurethral endoscopic unroofing with cautery of the mucosa. All the seminal vesicle cysts were confirmed by pathologic examination. No malignant disease was found. All preoperative symptoms resolved after surgery. No complications were observed. No patient developed abnormalities of erection, ejaculation, or orgasm. No bladder or rectal injuries were noted. The seminal vesicle cysts were significantly decreased in size or absent 3-6 months after treatment. CONCLUSION: MRI best characterized seminal vesical cysts and their cause. Transurethral unroofing with cautery of the mucosa is an extension of well-accepted cystoscopic techniques. It is safe, easy to perform, and effective. It is the preferred method for the treatment of large seminal vesicle cysts.

Congenital bilateral absence of the vas deferens: the impact of spermatogenesis quality on intracytoplasmic sperm injection outcomes in 108 men.

In azoospermic men with congenital bilateral absence of the vas deferens (CBAVD), it is not known whether the outcomes of intracytoplasmic sperm injection (ICSI) depend on the quality of testicular spermatogenesis (as determined histopathologically). We retrospectively studied the impact of spermatogenesis quality on ICSI outcomes in 108 azoospermic men with CBAVD consulting in a university hospital's department of andrology and reproductive biology. As part of an ICSI program, sperm samples were obtained from the epididymis [by microsurgical epididymal sperm aspiration (MESA); n = 47] or the testis [by testicular sperm extraction (TESE); n = 14] or both (MESA + TESE, n = 47). In the TESE group (i.e., TESE-only and MESA + TESE), spermatogenesis was normal in 21 of the 108 men (19.4%) and hypospermatogenesis occurred in 33 (30.5%). The fertilization rate was significantly lower in the hypospermatogenic group than in the normospermatogenesis group (65.6 and 72.9%, respectively; p = 0.02); this was also true for the embryo cleavage rate (88.6 and 92.1%, respectively; p = 0.007), and the proportion of embryos with fewer than 30% of enucleate fragments (79.5 and 86.9%, respectively; p = 0.02). Our study results showed that impaired spermatogenesis had a negative impact on certain early-stage biological outcomes of ICSI. In CBAVD, male factors are likely to exert a harmful effect on the early stages of embryo development.