Female Urethroplasty with a Buccal Mucosa Graft using a Supraurethral Approach.

INTRODUCTION AND HYPOTHESIS: In the setting of recurrent female urethral stricture, urethroplasty offer the best chance of cure. However, which approach (dorsal or ventral) and which tissue (buccal mucosa, vaginal graft, vaginal flap) remain areas of controversy. In this article and accompanying video, we describe female urethroplasty with a supraurethral approach using a buccal mucosa graft. METHODS: A stricture of 3 cm in length was observed in the mid urethra. A supraurethral semi-lunar incision was made and dissection was performed up to the stricture. A dorsal urethrotomy was performed and a 3 × 2 cm oral mucosal graft was harvested from the left cheek. The mucosal graft was anastomosed to both urethral edges with running sutures. The graft was fixed to the supraurethral tissue with quilting sutures. A urethral catheter and a suprapubic catheter were left in place for 3 weeks. RESULTS: Following removal of the catheters, the patient was able to void satisfactorily with no incontinence. No complications were observed in the urethral area or at the graft harvest site. CONCLUSIONS: Buccal mucosa graft urethroplasty with a supraurethral approach is a reliable method in the treatment of female urethral stricture.

The role of intravesical prostatic protrusion (IPP) in the evaluation and treatment of bladder outlet obstruction (BOO).

AIMS: Intravesical prostatic protrusion (IPP) may be an underutilized modality for the assessment of bladder outlet obstruction (BOO). Pressure flow studies or urodynamics have long been the gold standard for the evaluation of lower urinary tract symptoms (LUTS) in men but are invasive, time-consuming and costly. Potentially, IPP may be a useful adjunct prior to performing urodynamics. METHODS: Measurement of IPP is taken in the sagittal view, using the transabdominal ultrasound. It is the vertical height from the tip of the protrusion to the base of the prostate. This technique was previously described. We reviewed previous publications that studied the accuracy, positive predictive value and clinical use of IPP. In addition, we noted the comments regarding the challenges of using this technique. RESULTS: IPP has been shown to have a positive predictive value of 72% for BOO. It has been calculated to have an area under curve (AUC) value of 0.71 and 0.84 in some stuies. Clinically, it may be used to predict the outcome of a trial without catheter following acute retention of urine. Patients with higher IPP grade were noted to have a higher risk of clinical progression. Studies have also shown that men with higher IPP are poorer responders to medical treatment such as α-blockers. CONCLUSIONS: Compared to other modalities, the advantage of IPP in assessing BOO may be its easy applicability and non-invasive nature. Therefore, there is a consideration for a larger role of IPP in bedside assessment and management of BOO in daily practice. Neurourol. Urodynam. 35:535-537, 2016. © 2015 Wiley Periodicals, Inc.

Pelvic floor spasm as a cause of voiding dysfunction.

PURPOSE OF REVIEW: Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction. RECENT FINDINGS: To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms. SUMMARY: Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.

Development and Validation of a Deep Learning System for Sound-based Prediction of Urinary Flow.

BACKGROUND: Uroflowmetry remains an important tool for the assessment of patients with lower urinary tract symptoms (LUTS), but accuracy can be limited by within-subject variation of urinary flow rates. Voiding acoustics appear to correlate well with conventional uroflowmetry and show promise as a convenient home-based alternative for the monitoring of urinary flows. OBJECTIVE: To evaluate the ability of a sound-based deep learning algorithm (Audioflow) to predict uroflowmetry parameters and identify abnormal urinary flow patterns. DESIGN, SETTING, AND PARTICIPANTS: In this prospective open-label study, 534 male participants recruited at Singapore General Hospital between December 1, 2017 and July 1, 2019 voided into a uroflowmetry machine, and voiding acoustics were recorded using a smartphone in close proximity. The Audioflow algorithm consisted of two models-the first model for the prediction of flow parameters including maximum flow rate (Qmax), average flow rate (Qave), and voided volume (VV) was trained and validated using leave-one-out cross-validation procedures; the second model for discrimination of normal and abnormal urinary flows was trained based on a reference standard created by three senior urologists. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Lin's correlation coefficient was used to evaluate the agreement between Audioflow predictions and conventional uroflowmetry for Qmax, Qave, and VV. Accuracy of the Audioflow algorithm in the identification of abnormal urinary flows was assessed with sensitivity analyses and the area under the receiver operating curve (AUC); this algorithm was compared with an external panel of graders comprising six urology residents/general practitioners who separately graded flow patterns in the validation dataset. RESULTS AND LIMITATIONS: A total of 331 patients were included for analysis. Agreement between Audioflow and conventional uroflowmetry for Qmax, Qave, and VV was 0.77 (95% confidence interval [CI], 0.72-0.80), 0.85 (95% CI, 0.82-0.88) and 0.84 (95% CI, 0.80-0.87), respectively. For the identification of abnormal flows, Audioflow achieved a high rate of agreement of 83.8% (95% CI, 77.5-90.1%) with the reference standard, and was comparable with an external panel of six residents/general practitioners. AUC was 0.892 (95% CI, 0.834-0.951), with high sensitivity of 87.3% (95% CI, 76.8-93.7%) and specificity of 77.5% (95% CI, 61.1-88.6%). CONCLUSIONS: The results of this study suggest that a deep learning algorithm can predict uroflowmetry parameters and identify abnormal urinary voids based on voiding sounds, and shows promise as a simple home-based alternative to uroflowmetry in the management of patients with LUTS. PATIENT SUMMARY: In this study, we trained a deep learning-based algorithm to measure urinary flow rates and identify abnormal flow patterns based on voiding sounds. This may provide a convenient, home-based alternative to conventional uroflowmetry for the assessment and monitoring of patients with lower urinary tract symptoms.

A Systemic Review and Meta-analysis of Transabdominal Intravesical Prostatic Protrusion Assessment in Determining Bladder Outlet Obstruction and Unsuccessful Trial Without Catheter.

CONTEXT: Urodynamic study (UDS) provides the most objective assessment of bladder outlet obstruction (BOO) but is impractical to be recommended routinely in outpatient services. Intravesical prostatic protrusion (IPP) had been described to obstruct urinary flow by creating an anatomical ball-valve effect, but there remains a lack of pooled evidence that can objectively correlate with BOO in benign prostatic hyperplasia. OBJECTIVE: To update the current evidence on the predictive role of IPP in determining BOO and unsuccessful trial without catheter (TWOC). EVIDENCE ACQUISITION: A comprehensive literature search was performed to identify studies that evaluated IPP in diagnosing UDS-determined BOO and TWOC. The search included the PubMed/MEDLINE, EMBASE, and Cochrane Library up to January 2021. An updated systemic review and meta-analysis was performed. EVIDENCE SYNTHESIS: A total of 18 studies with 4128 patients were examined. Eleven studies with 1478 patients examined the role of IPP in UDS-determined BOO. The pooled area under the curve (AUC) was 0.83 (95% confidence interval [CI]: 0.79-0.86), and at a cut-off of >10 mm, the sensitivity (Sn) and specificity (Sp) were 0.71 (95% CI: 0.61-0.78) and 0.77 (95% CI: 0.68-0.84), respectively. The probability-modifying plot revealed positive and negative likelihood ratios of 3.34 (95% CI: 2.56-4.36) and 0.35 (95% CI: 0.26-0.45), respectively. Seven studies with 2650 patients examined IPP in predicting unsuccessful TWOC, with a pooled AUC of 0.74 (95% CI: 0.70-0.84), with Sn of 0.51 (95% CI: 0.43-0.60) and Sp of 0.79 (95% CI: 0.73-0.84) at an IPP cut-off of >10 mm. Five studies compared prostate volume (PV) and IPP and revealed a lower AUC of PV at 0.71 (95% CI: 0.67-0.75), which was an inferior parameter in diagnosing BOO (p < 0.001). CONCLUSIONS: This systemic review provided evidence that IPP is a reliable clinical parameter that correlates strongly with underlying BOO and unsuccessful TWOC. PATIENT SUMMARY: In this review, we comprehensively reviewed all the literature to date on evaluating the clinical utility of intravesical prostatic protrusion (IPP). We have demonstrated that IPP correlates strongly with urodynamic study (UDS)-determined bladder outlet obstruction and failure of trial without catheter (TWOC). Outpatient IPP measurement is a quick, inexpensive, and reproducible clinical parameter that can determine the severity of benign prostatic hyperplasia. The clinical role of IPP in predicting failure of TWOC selects patients who are best treated with aggressive surgical approaches rather than conservative medical therapies. More importantly, IPP can facilitate the discriminatory use of invasive UDS, reserved for patients with a strong suspicion of concomitant detrusor abnormalities.

Validation of laparoscopy and flexible ureteroscopy tasks in inanimate simulation training models at a large-scale conference setting.

OBJECTIVE: Simulation based training with training models is being increasingly used as a tool to help trainees mount the learning curve. However, validation studies of surgical simulators are often limited by small numbers. We aim to evaluate the feasibility of validating simulation-training tasks in laparoscopy and flexible ureteroscopy (FURS) rapidly at a large-scale conference setting for residents. METHODS: Seventy-six urology residents from various Asian countries were assessed on their laparoscopic and FURS skills during the 14th Urological Association of Asia Congress 2016. Residents performed the peg transfer task from the fundamentals of laparoscopic surgery (FLS) and completed inspection of calyces and stone retrieval using a flexible ureteroscope in an endourological model. Each participant's experience (no experience, 1-30 or >30 procedures) in laparoscopy, rigid ureteroscopy (RURS) and FURS was self-reported. RESULTS: Median time taken to complete the laparoscopic task decreased with increasing laparoscopic experience (209 s vs. 177 s vs. 145 s, p=0.008) whereas median time taken to complete the FURS tasks reduced with increasing FURS experience (405 s vs. 250 s vs. 163 s, p=0.003) but not with RURS experience (400.5 s vs. 397 s vs. 331 s, p=0.143), demonstrating construct validity. Positive educational impact of both tasks was high, with mean ratings of 4.16/5 and 4.10/5 respectively, demonstrating face validity. CONCLUSION: Our study demonstrates construct and face validities of laparoscopy and FURS simulation tasks among residents at a conference setting. Validation studies at a conference setting can be an effective avenue for evaluating simulation models and curriculum in the future.

Non-invasive evaluation of lower urinary tract symptoms (LUTS) in men.

Lower urinary tract symptoms (LUTS) are common in males over the age of 40 years old and are likely to increase with an aging population. Currently urodynamic studies are the gold standard to determine the aetiology of voiding dysfunction and LUTS. However, due to its invasive nature, a great number of non-invasive ultrasound based investigations have been developed to assess patients with symptomatic LUTS. The clinical application of non-invasive tests could potentially stratify patients who would require more invasive investigations and allow more precise patient directed treatment. A PubMed literature review was performed and we will discuss the non-invasive investigations that have been developed thus far, focusing on bladder wall and detrusor wall thickness (BWT & DWT), ultrasound estimated bladder weight (UEBW) and intravesical prostatic protrusion (IPP).

A 3D Printed Implantable Device for Voiding the Bladder Using Shape Memory Alloy (SMA) Actuators.

Underactive bladder or detrusor underactivity (DU) is defined as a reduction of contraction strength or duration of the bladder wall. Despite the serious healthcare implications of DU, there are limited solutions for affected individuals. A flexible 3D printed implantable device driven by shape memory alloys (SMA) actuators is presented here for the first time to physically contract the bladder to restore voluntary control of the bladder for individuals suffering from DU. This approach is used initially in benchtop experiments with a rubber balloon acting as a model for the rat bladder to verify its potential for voiding, and that the operating temperatures are safe for the eventual implantation of the device in a rat. The device is then implanted and tested on an anesthetized rat, and a voiding volume of more than 8% is successfully achieved for the SMA-based device without any surgical intervention or drug injection to relax the external sphincter.

Early outcome of transurethral enucleation and resection of the prostate versus transurethral resection of the prostate.

INTRODUCTION: Recurrent prostate adenoma is a long-term complication following transurethral resection of the prostate (TURP). Transurethral enucleation and resection of the prostate (TUERP) is more appealing, since the nodular adenoma can be completely removed through endoscopy. TUERP is also hypothesised to result in a lower frequency of recurrent adenoma. This study aimed to compare the early outcomes of TUERP and TURP, and assess the feasibility and safety of TUERP. METHODS: We compared the outcome of 81 patients who underwent TUERP with that of 85 patients who underwent TURP. International prostate symptom score, quality of life score, prostate volume, degree of intravesical prostatic protrusion, maximum flow rate, post-void residual volume and prostate-specific antigen (PSA) level were obtained pre- and postoperatively. Complications (e.g. transfusion rate, incontinence, infection and urethral stricture) were analysed. RESULTS: Operative time was significantly longer in the TUERP group compared to the TURP group (85.3 minutes vs. 51.6 minutes). After TUERP, the maximum flow rate was significantly higher (21.1 mL/s vs. 17.1 mL/s) and PSA level was significantly lower (1.2 ng/mL vs. 1.9 ng/mL) than after TURP. The rates of infection, transfusion and urethral stricture were similar for both groups, but the TUERP group had a higher rate of temporary incontinence (13.6% vs. 4.7%). CONCLUSION: The lower PSA level and better maximum flow rate achieved following TUERP suggest that prostate adenoma removal was more complete with TUERP. Long-term follow-up is required to establish whether TUERP results in fewer resections for recurrent adenoma.

The clinical presentation and diagnosis of ketamine-associated urinary tract dysfunction in Singapore.

Ketamine is a short-acting anaesthetic agent that has gained popularity as a 'club drug' due to its hallucinogenic effects. Substance abuse should be considered in young adult patients who present with severe debilitating symptoms such as lower urinary tract symptoms, even though the use of controlled substances is rare in Singapore. Although the natural history of disease varies from person to person, a relationship between symptom severity and frequency/dosage of abuse has been established. It is important to be aware of this condition and have a high degree of clinical suspicion to enable early diagnosis and immediate initiation of multidisciplinary and holistic treatment. A delayed diagnosis can lead to irreversible pathological changes and increased morbidity among ketamine abusers.

Surgical tips and tricks during urethroplasty for bulbar urethral strictures focusing on accurate localisation of the stricture: results from a tertiary centre.

BACKGROUND: There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken. OBJECTIVE: We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons. SURGICAL PROCEDURE: Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy. OUTCOME MEASURES AND STATISTICAL ANALYSIS: Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. RESULTS AND LIMITATIONS: A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence. CONCLUSIONS: Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex. PATIENT SUMMARY: We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture.

Diagnosis of prostate adenoma and the relationship between the site of prostate adenoma and bladder outlet obstruction.

INTRODUCTION: The objective of this study was to evaluate the accuracy of using intravesical prostatic protrusion (IPP) as a parameter for the diagnosis of prostate adenoma (PA), as well as to determine the relationship between the site of PA and bladder outlet obstruction. IPP was determined with the use of transabdominal ultrasonography (TAUS). METHODS: A total of 77 consecutive adult men aged 30-85 years with haematuria or undergoing checkup for bladder tumour were enrolled. International Prostate Symptom Score (IPSS), and the results of uroflowmetry, TAUS and cystourethroscopy were assessed. All cases of IPP were classified into grades 0 (no IPP), 1 (1-5 mm), 2 (6-10 mm) or 3 (> 10 mm). PA diagnosis was confirmed using flexible cystourethroscopy. The sites of PA were classified as U0 (no adenoma), U1 (lateral lobes), U2 (middle lobe) or U3 (lateral and middle lobes). RESULTS: Of the 77 patients, 11 (14.3%) had no IPP. PA was confirmed using cystourethroscopy for all patients with IPP and for 7 of the 11 patients without IPP. Of the 37 patients with prostate volume < 20 g, 29 (78.4%) had IPP. Sensitivity, specificity, as well as positive and negative predictive values for diagnosing PA using only IPP were 90.4%, 100.0%, 100.0% and 36.4%, respectively. Higher sensitivity (95.9%) and negative predictive value (50.0%) were obtained when PA was used together with peak urinary flow rate (Qmax) < 20.0 mL/s. The mean Qmax of patients classified as U1 (n = 39) was 16.0 mL/s, while the mean Qmax in those classified as U2 (n = 12) and U3 (n = 22) was 11.9 mL/s and 8.9 mL/s, respectively. CONCLUSION: All patients with IPP had PA, and PA in the middle lobe was more obstructive than those in lateral lobes. Patients without IPP may still have PA.

Does periprostatic block increase the transrectal ultrasound (TRUS) biopsy sepsis rate in men with elevated PSA?

INTRODUCTION: Periprostatic nerve block (PPNB) is a common local anaesthetic technique in transrectal ultrasound-guided (TRUS) prostate biopsy, but concerns remain over the increased theoretical risks of urinary tract infection (UTI) and sepsis from the additional transrectal needle punctures. This study reviewed our biopsy data to assess this risk. MATERIALS AND METHODS: Retrospective data collected from 177 men who underwent TRUS biopsy between July 2007 and December 2009 in a single institution were analysed. PPNB was administered using 1% xylocaine at the prostatic base and apex and repeated on the contralateral side under ultrasound guidance. Complications, including UTI sepsis, bleeding per rectum and acute retention of urine (ARU) were noted. Every patient was tracked for the first 2 weeks for complications until his clinic review. Demographic profi le, biopsy parameters and histological fi ndings were reviewed. Univariate and multivariate analysis of possible risk factors for development of sepsis after TRUS biopsy were performed. Statistical analysis was performed using SPSS 17.0. RESULTS: Ninety (51%) men received PPNB and 87 (49%) did not. The groups were matched in age (PPNB: mean 62.7 ± 5.8 years; without PPNB: mean 64.4 ± 5.7 years) and prebiopsy prostate specific antigen (PSA) levels (PPNB: mean 8.2 ± 3.9 ng/mL; without PPNB: mean 8.3 ± 3.7 ng/mL). The PPNB group had a larger prostate volume, with more cores taken (P <0.05). On univariate and multivariate analysis controlling for age, PSA, prostate volume, number of cores taken and histological prostatitis, PPNB was not a significant risk factor for sepsis. Sepsis rates were 5.6% in the PPNB group and 5.7% in the other group (P = 0.956). Overall prostate cancer detection rate was 33.3%. CONCLUSION: The risk of sepsis was not increased in patients who received PPNB, even though this group had larger gland volumes and more biopsy cores taken.

Outcome of laparoscopic live donor nephrectomy and impact of double renal arteries: results from two transplant centres.

OBJECTIVE: Live donor kidney transplantation is consistently superior to deceased donor kidney transplantation. Laparoscopic donor nephrectomy (LDN) is increasingly accepted as a safe and preferred surgical option. To evaluate the outcome of LDN and the impact of multiple arteries, a retrospective review was conducted on patients in two transplant centres. METHODS: Fifty patients including eight with double vessels were studied. Standard left transperitoneal LDN was performed. Grafts including those with double vessels were prepared using the bench technique. Postoperative outcomes (up to 1 year) for donors and recipients were studied. The outcomes of recipients of a single or double vessel graft were compared. RESULTS: All donors had an eventful recovery. No difference was found between the single and multiple vessels groups for operating time (168.21 ± 5.712 minutes vs. 197.50 ± 15.755 minutes) or hospital stay (3.21±0.165 days vs. 4.13±0.789 days). The recipient outcomes including hospital stay (10.17±0.596 days vs. 12.13 ± 1.797 days) and creatinine levels at day 7 (106.53 ± 5.583 µmol/L vs. 107.13 ± 11.857 µmol/L) and 1 year (120.21 ± 6.562 µmol/L vs. 124.75 ± 11.857 µmol/L) were similar. No ureteric stricture or graft loss was noted at 1-year follow-up. Recipient complications included lymphocoele (n = 2), haematoma (n = 3 with 2 requiring exploration), sepsis (n = 1), renal artery stenosis (n = 2 with 1 stented), repeated anastomosis (n = 1), and incisional hernia (n = 1). No differences were noted between the two groups. CONCLUSION: Our results showed that overall donor morbidity rate was low, as reflected by the short hospital stay. Also, the overall parameters of the recipients were good. In particular, no ureteric stricture was noted, and graft survival was 100% at 1 year. The outcomes of the reconstructed group, despite the technical challenge, were similar to those of the single-vessel group.

Xanthogranulomatous inflammation of urachus mimicking urachal carcinoma.

Urachal xanthogranuloma is rare. In this case, the patient presented with a lower abdominal mass and elevated inflammatory markers. The computed tomography findings of xanthogranulomatous urachitis resemble those of urachal carcinoma and, although rare, this entity should be included in the differential diagnosis of urachal masses.