Contrast-Enhanced Ultrasound: A Real-Time, Noninvasive, Radiation-Free Method for Intraoperative Male Urethral Fistula Assessment.

OBJECTIVES: To evaluate the feasibility of intraoperative transurethral contrast-enhanced ultrasound for the assessment of male urethral fistulas. METHODS: Patients in a prospective database who underwent intraoperative two-dimensional ultrasound, transurethral saline-enhanced ultrasound, and contrast-enhanced ultrasound between January 2017 and July 2022 were included. All patients were clinically diagnosed with urethral fistulae (UF) in the outpatient setting based on clinical presentations, traditional two-dimensional ultrasound, and/or other imaging modalities and confirmed during surgical repair. Dynamic videos of the scans were independently analyzed by two experienced ultrasonologists. RESULTS: Thirty-nine patients with an average age of 51 years were included. The UF were located in the anterior urethra in 22 (56.4%) patients and in the bulbar urethra in 14 (63.6%) patients. UF were located in the posterior urethra in 17 (436%) patients and in the prostatic urethra in 13 (76.5%) patients. Contrast-enhanced ultrasonography revealed UF in all patients. In patients with anterior UF, saline-enhanced ultrasound images did not show a UF in 15 (68.2%, 15/22) patients, 13 (86.7%, 13/15) of whom had fistulae with diameters <3 mm. Saline-enhanced ultrasound images did not reveal posterior UF in 13 (76.5%, 13/17) patients. The fistula diameters in eight (61.5%, 8/13) patients were <3 mm. The duration for contrast-enhanced ultrasonography was approximately 3 minutes. The duration for surgical repair was approximately 2 hours. CONCLUSIONS: Transurethral contrast-enhanced ultrasound is a real-time, noninvasive, and radiation-free method that allows intraoperative imaging and accurate assessment of male UF. Its sensitivity is higher than that of both two-dimensional ultrasound and transurethral saline-enhanced ultrasound. The location, size, and course of the fistulae can be clearly seen due to greater contrast during contrast-enhanced ultrasound.

Long-term ileoanal pouch survival after pouch urinary tract fistulae.

BACKGROUND: Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS: Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS: Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION: Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications.

INTRODUCTION AND HYPOTHESIS: The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification. METHODS: We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005-2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF. RESULTS: Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types. CONCLUSIONS: Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

Association between cystoscopy at the time of hysterectomy performed by a gynecologic oncologist and delayed urinary tract injury.

OBJECTIVE: Guidance regarding the use of cystoscopy at the time of hysterectomy is lacking in gynecologic oncology. We compare the rate of delayed urinary tract injury in women who underwent cystoscopy at the time of hysterectomy performed by a gynecologic oncologist for benign or malignant indication with those who did not. METHODS: This was a retrospective cohort study of patients who had a hysterectomy performed by a gynecologic oncologist recorded in the National Surgical Quality Improvement Program between January 2014 and December 2017. The primary outcome was delayed urinary tract injury in the 30-day post-operative period. Secondary outcomes were operative time and urinary tract infection rate. The exposure of interest was cystoscopy at the time of hysterectomy and bivariable tests were used to examine associations. RESULTS: We identified 33 355 women who underwent hysterectomy for benign (41%; n=13 621) or malignant (59%; n=19 734) indications performed by a gynecologic oncologist. Surgical approach was open (39%; n=12 974), laparoscopic or robotic-assisted laparoscopic (55%; n=18 272), and vaginal or vaginally-assisted (6%; n=2109). Overall, 12% of women (n=3873) underwent cystoscopy at the time of surgery; cystoscopy was more commonly performed in laparoscopic (15%; n=2829) and vaginal (12%; n=243) approaches than with open hysterectomy (6%; n=801) (p<0.001). There was no difference in the rate of delayed urinary tract injury in patients who underwent cystoscopy at the time of surgery compared with those who did not (0.4% vs 0.3%, p=0.32). However, patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (3% vs 2%, RR 1.3, 95% CI 1.1 to 1.6). In cases where cystoscopy was performed, median operative time was increased by 9 min (137 vs 128 min, p<0.001). CONCLUSION: Cystoscopy at the time of hysterectomy performed by a gynecologic oncologist does not result in a lower rate of delayed urinary tract injury compared with no cystoscopy.

Incised urethral diversion reduces the rate of fistula after one-stage hypospadias repair: a single-center retrospective controlled study.

OBJECTIVE: Urethrocutaneous fistula is the most prevalent complication after hypospadias repair. The aim of this study was to evaluate whether incised urethral diversion was superior to traditional transurethral diversion in minimizing complications. PATIENTS AND METHODS: We retrospectively collected and analyzed 113 cases with proximal penile or penoscrotal hypospadias that were repaired by one-stage transverse preputial island flap urethroplasty between January 2016 and January 2020. Of those cases, 60 used incised urethral diversion (group A), whereas the remaining 53 were managed by transurethral diversion (group B) for urinary drainage after surgery. Postoperative complications in both groups were assessed for fistula, urethral diverticulum, meatal stenosis, wound infection, and distal urethral breakdown. RESULTS: Fistula was reported in 2 patients (3.3%) in group A, while it was observed in 15 patients (28.3%) in group B (p < 0.001). Wound infection occurred in one patient (1.7%) in group A, compared with six patients (11.3%) in group B (p < 0.05). The incidence rates of distal urethral breakdown were 1.7% (1/60) and 11.3% (6/53) for group A and group B, respectively (p < 0.05). One patient (1.7%) in group A and three patients (5.7%) in group B had a meatal stenosis (p > 0.05). There were two patients who developed urethral diverticulum in either group (p > 0.05). CONCLUSIONS: The use of incised urethral diversion for urinary drainage had an advantage over transurethral diversion in one-stage hypospadias repair with respect to the post-operational fistula occurrence, wound infection, and distal urethral breakdown.

Percutaneous embolization of contained iatrogenic vesicourethral fistula using Amplatzer vascular plug and N-butyl-2-cyanoacrylate: a case report.

PURPOSE: Reports on percutaneous embolization of vesicourethral anastomotic fistula are limited. CASE PRESENTATION: A 59-year-old male presented with persistent contained vesicourethral fistula following low anterior resection and radical retropubic prostectomy for rectal cancer. A contained fistula with urinary leakage of 350 ml/day through a Jackson-Pratt (JP) tube was found at the posterior aspect of the vesicourethral anastomotic site on cystography. After 1 month of failed conventional urinary drainage manoeuvre, percutaneous embolization of the contained fistula was successfully performed through the JP tube. An Amplatzer vascular plug (AVP) was used to block the fistula and N-butyl-2-cyanoacrylate (NBCA) was used to obliterate the urinoma cavity. Computed tomography scans at 1-month and 1-year follow-ups showed stable AVP position and complete obliteration of the cavity by NBCA. CONCLUSIONS: The contained vesicourethral anastomotic fistula was successfully managed with AVP and NBCA via a JP drainage tube. It is expected that AVP will block the fistula and NBCA will obliterate the urinoma cavity effectively.

Vesicouterine Fistula and Fetus in Bladder: A Case Report.

BACKGROUND: Vesicouterine fistulas are the rarest of all urogenital fistulas, with most cases occurring after cesarean section. CASE: A 38-year-old woman in rural Zimbabwe presented at 20 weeks gestation with a suspected fetus in the urinary bladder by transabdominal ultrasonography. This finding was confirmed intraoperatively together with a vesicouterine fistula. Cesarean section 20 years earlier was the only risk factor. Diagnosis was delayed for lack of access to appropriate imaging and a tertiary facility. CONCLUSION: A vesicouterine fistula is a rare presentation in the context of an advanced health care system. To our knowledge, this is the fourth case report of a fetus in the bladder secondary to vesicouterine fistula. Patient morbidity in this case possibly could have been avoided with earlier diagnosis and access to care.

Management of urinary-tract fistulas using reversible balloon nephrostomy: a single-center retrospective analysis of 56 patients.

PURPOSE: To evaluate the effectiveness of balloon nephrostomy (BN) for treating urinary tract fistulas. MATERIALS AND METHODS: In a single-center retrospective analysis, 56 patients were treated using BN between 2003 and 2014. All causes of urinary tract fistula were included. We assessed the effectiveness of drainage, complications, and the types of reconstruction surgery used. Success was defined as fistula closure without surgery. RESULTS: The cohort consisted of 25 males (54%) and 31 females (55%) with a median age of 63 years who underwent BN for a urinary fistula secondary to surgery, i.e., urologic (40%; n = 22), gynecologic (34%; n = 19), or digestive (20%; n = 11). Of these patients, 48 (86%) had a history of cancer (49% had a tumor progression). Median drainage time was 90 days (10-583), with an average of three successive readjustments needed per patient. We obtained a 21% success rate (n = 12), morbidity was 6.5% (urinary sepsis, renal abscess, ureteral stricture), and 7% of patients developed ureteral stricture after balloon removal. There was no recurrence of any fistula within a median follow-up time of 15.2 months. CONCLUSION: This minimally invasive procedure can be used for selected urinary tract fistulas with few complications. It can also be used safely in populations that have several comorbidities.

Conservative treatment for urinary fistula following ileal conduit urinary diversion: a simple method.

BACKGROUND: The presence of urinary fistula after ileal conduit urinary diversion is a challenging complication, and this study investigated the role of the intra-conduit negative pressure system (NPS) in the presence of urinary fistula following ileal conduit (IC) urinary diversion as a conservative treatment. METHODS: Using the intra-conduit NPS, a minor drainage tube was placed within a silicon tube to suck urine from the conduit with consistent negative pressure. Patients with urinary fistula following IC from August 2012 to July 2017 were recorded, and the clinical characteristics and outcome were retrospectively analyzed. RESULTS: The intra-conduit NPS was used as a primarily conservative treatment for 13 patients who suffered from urinary fistula and presented with a large amount of abdominal/pelvic drainage without other significant morbidities. The median age was 60 years old (42-74 years), and 7patients were male. The median duration between the IC operation and the presence of urinary fistula was 15 days (2-28 days), and elevated creatinine levels were detected in the abdominal/pelvic drainage with a median level of 2114 µmol/L (636-388 µmol/L). A significant decrease in abdominal/pelvic drainage was identified in 12 patients. The median time that the NPS was used was 9 days (7-11 days). The other patient did not show any improvements after 2 days of observation and then underwent open surgery. With ureteral stenting, 2 abdominal drainage tubes and the intra-conduit NPS were placed during operation, no urine leakage was observed in the abdominal/pelvic field, and the patient was cured in 9 days. With a median follow-up of 22 months, no fistula recurrence or hydronephrosis was detected. CONCLUSION: The intra-conduit negative pressure system is a feasible and promising way to cure urinary fistula following ileal conduit urinary diversion. Because this procedure is a mini-invasive and simple approach, it might represent an alternative in selected patients.

A case report of endorectal displacement of a right ureteral stent following radiochemotherapy and Bevacizumab.

BACKGROUND: The angiogenesis inhibitor monoclonal antibody Bevacizumab is presently the standard treatment for numerous neoplasms but particular toxicities are emerging, such as hypertension, haemorrhage, thromboembolism, gastrointestinal perforation, fistulae, and delayed wound healing. The addition of Bevacizumab to radio and chemotherapy has improved the overall survival rate in patients with metastatic, persistent or recurrent cervical carcinoma. However an increased risk of enteric or urinary fistula formation has been documented, related to hypoxia which is induced by the inhibition of angiogenesis. Moreover, previous pelvic surgery, repeated ureteral stenting and radiation are additional risk factors. CASE PRESENTATION: We describe the remarkable case of a right ureteral stent displacement inside the rectum lumen in a patient treated with Bevacizumab for pelvic recurrence of cervical cancer. The patient was referred to our Urology Department with urinary sepsis and bilateral hydronephrosis. Right ureteral stent substitution was planned; at cystoscopy the distal loop of the stent was not visualized inside the bladder. The presence of the distal loop of the right ureteral inside the rectum was clearly demonstrated with a CT scan. CONCLUSIONS: Since Bevacizumab is increasingly used in the treatment of gynaecological neoplasms and indwelling ureteral stents are often required to treat or prevent ureteral compressions, similar cases are likely to be diagnosed and this complication should be considered in the management of advanced pelvic cancers.

Modified York Mason technique for repair of iatrogenic recto-urinary fistula: 20 years of the Montsouris experience.

PURPOSE: Iatrogenic recto-urinary fistulas are a disastrous complication of therapeutic interventions on the prostate. Many surgical approaches have been described to repair recto-urinary fistulas and no consensus has been reached regarding the better approach. The objective of this study is to present the results of our updated 20-year experience in the surgical management of recto-urinary fistula using a modified York Mason procedure. METHODS: We proceed to a retrospective single-institution review of surgically treated patients for iatrogenic recto-urinary fistulas between 1998 and 2017 by the modified York Mason technique. Descriptive analysis of our population was performed. Continuous and categorical variables were compared using Mann-Whitney and Fischer tests, respectively. All tests were two-sided with a significance level set at p value < 0.05. RESULTS: We included 30 consecutive patients treated for iatrogenic recto-urinary fistula. The median follow-up was 76 months (2-195). The median size of the fistula was 5 mm (2-20). Successful healing of the recto-urinary fistula was observed in 80, 97, and 100% of patients after 1, 2, or 3 York Mason procedure. During the study period, no one single case of acquired urinary incontinence or durable fecal incontinence has been observed. CONCLUSIONS: Our modified York Mason technique is a reliable and effective procedure with a 100% success rate for the repair of small iatrogenic recto-urinary fistulas in non-irradiated patients. It has a very low morbidity rate, and no case of postoperative urine or fecal incontinence has been observed.

Augmented-pressure distal colostogram: the most important diagnostic tool for planning definitive surgical repair of anorectal malformations in boys.

There is little current literature on the augmented-pressure distal colostogram, the single most important diagnostic study performed in boys with imperforate anus prior to definitive repair. Accurate understanding of the anatomy of the anorectal malformation including an associated fistulous communication between the rectum and the urogenital tract is essential for optimal surgical management. Specifically, the position of the rectal pouch and recto-urinary fistula relative to posterior sagittal structures of the perineum, especially the sacral spine, dictates the operative approach. This pictorial essay is a guide for those who encounter such children with relative infrequency to become more comfortable with the technique. We report how to perform this radiologic exam and the potential pitfalls from our experience of performing the technique in our large pediatric colorectal practice.

Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS).

PURPOSE: To characterize anterior urinary fistulae following radiotherapy for prostate cancer. METHODS: Over 10 years, 31 men were identified to have an anterior urinary fistula. A retrospective database was created to evaluate patient demographics, presentation, diagnostic procedures, operative interventions, outcomes, and complications. Comparisons between men who underwent cystectomy versus bladder-sparing surgeries were performed. RESULTS: At a median age of 73 (interquartile range (IQR) 68.5, 79) years, presenting symptoms included as follows: pubic pain (19/31, 61%), urine drainage via fistula (10/31, 32%), or a superficial wound infection (6/31, 19%). Recent instrumentation prior to diagnosis of anterior urinary fistula was reported by 18/31 (58%) at a median of 14.9 months (IQR 7.9, 103.8) after manipulation. Anterior fistula formation was either isolated to the pubic symphysis (19/31, 61%) or the thigh (12/31, 38%). Nineteen men underwent a cystectomy, whereas 12 men underwent a fistula repair. Excluding grades 1 and 2, 30- and 90-day postoperative complications were limited to four and two men, respectively, all of whom had a grade 3 complication. At 6-month follow-up, 26/31 (84%) men reported their pain had resolved. There was one fistula recurrence managed with subsequent cystectomy. CONCLUSIONS: Complex anterior urinary fistulae to the pubic symphysis and thigh are devastating yet treatable conditions. Universally, these men have a history of radiotherapy and repeated endoscopic interventions. Surgical intervention with either cystectomy or primary repair was highly successful.

[Modified Snodgrass technique for hypospadias].

OBJECTIVE: To investigate the clinical effect of modified Snodgrass surgical technique in the treatment of hypospadias. METHODS: We retrospectively analyzed the clinical data about 212 cases of hypospadias treated by urethroplasty from January 2008 to October 2016, 94 with the modified Snodgrass technique, namely with a silk line in addition to the urethral suture to make easier postoperative removal of the suture (group A), and the other 118 with the conventional Snodgrass technique (group B). The urethral suture was removed at 10 days after surgery for the patients in group A. We compared the success rate of surgery and incidence of postoperative complications between the two groups. RESULTS: Compared with group B, group A showed a significantly higher success rate of surgery (81.36% vs 91.49%, P <0.05) but lower incidence rates of postoperative incisional infection (12.71% vs 4.26%, P <0.05) and urinary fistula (16.10% vs 6.38%, P <0.05). No statistically significant difference was found in the incidence of urethral stenosis between the two groups (2.54% vs 2.13%, P >0.05). CONCLUSIONS: The modified Snodgrass technique can improve the success rate of surgery and reduce the incidence rates of incisional infection and urinary fistula, which deserves wide clinical application.

Postoperative drainage does not prevent complications after robotic partial nephrectomy.

OBJECTIVES: We aimed to assess the impact of a postoperative drainage after RPN. METHODS: A retrospective multicentric study included RPN performed at eight centers between 2010 and 2014. Three centers stopped using postoperative drainage early in their RPN experience, whereas other institutions systematically left a drain. Preoperative characteristics, complication rates, need for postoperative imaging or procedure (surgical or radiological) and length of hospital stay were compared between the two groups [drainage (D) and no drainage (ND)]. RESULTS: Among 636 RPNs, 140 were done without drainage (22 %). In the ND group, surgeons were more experienced (>50 cases: 55.7 vs. 15.1 %; p < 0.0001), and tumors were more complex (RENAL score: 7.6 vs. 6.5; p < 0.0001). Complication rates were similar in both groups (21.9 vs. 20.2 %; p = 0.67). The omission of postoperative drainage did not increase requirement of CT scan (RR = 1.03; 95 % CI 0.64-1.67). Length of hospital stay was shorter in the ND group (4.5 vs. 5.5 days; p = 0.007). There were six urinary fistulas: four in the D group (0.8 %) and two in the ND group (1.4 %; p = 0.49). A CT scan was done to confirm the diagnosis of fistula in every case. In multivariate analysis, the omission of drainage was not associated with increased need of postoperative CT scan or major complications but was a predictor of decreased length of stay. CONCLUSION: The omission of postoperative drainage does not seem to increase the risk of postoperative complications and could safely be omitted after RPN.

Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women.

AIM: We present the surgical management and outcomes of patients who underwent transvaginal neo-bladder vaginal fistula (NBVF) repair at our institution. METHODS: Between 2002 and 2012, eight patients underwent transvaginal NBVF repair. The surgical management entailed placing a Foley catheter into the fistula tract. A circumferential incision was made around the fistula tract after which a plane between the serosa of the neobladder and the vaginal epithelium was created. Interrupted polyglycolic acid sutures were used to close the fistula. An additional layer of vaginal wall, Martius, or omental flap was interposed before vaginal wall closure. A urethral catheter was placed for a minimum of 14 days and removed after a negative cystogram and pelvic exam with retrograde neobladder filling without leakage. RESULTS: All patients presented with a fistula following radical cystectomy with orthotopic ileal neobladder. Two patients had failed two prior transvaginal fistula repairs. A unilateral Martius flap was used in five patients and an omental flap was used in one patient. The surgery was successful in all patients. After a mean follow up of 33 months [4-117], five patients underwent or are waiting to undergo management of stress urinary incontinence with bulking agents. No patient had a recurrent fistula. CONCLUSIONS: Management of NBVF is challenging but cure is possible using a transvaginal approach. Most patients will suffer from incontinence after the repair because of a short and incompetent urethra. Patients should be counseled about the high probability of requiring a secondary procedure to achieve continence.