Cecoureterocele Presenting as a Urethral Mass in an Infant Female: A Rare Case Report

Is a protocol that combines in vitro maturation of germinal vesicle-stage oocytes and their vitrification with freezing of cortical ovarian tissue feasible for use in fertility preservation for both chemotherapy-naive paediatric patients as well as patients after initiation of cancer therapy? Follicle-containing ovarian tissue as well as oocytes that can undergo maturation in vitro can be obtained from paediatric patients (including prepubertal girls) both before and after cancer therapy. Anticancer therapy reduces the number of follicles/oocytes but this effect is less severe in young patients, particularly the paediatric age group. Autotransplantation of ovarian tissue has yielded to date 60 live births, including one from tissue that was cryostored in adolescence. However, it is assumed that autografting cryopreserved-thawed ovarian cortical tissue poses a risk of reseeding the malignancy. Immature oocytes can be collected from very young girls without hormonal stimulation and then matured in vitro and vitrified. We have previously shown that there is no difference in the number of ovarian cortical follicles between paediatric patients before and after chemotherapy. A prospective study was conducted in a cohort of 42 paediatric females with cancer (before and after therapy initiation) who underwent fertility preservation procedures in 2007-2014 at a single tertiary medical centre. The study group included girls and adolescent females with cancer: 22 before and 20 after chemotherapy. Following partial or complete oophorectomy, immature oocytes were either aspirated manually ex vivo from visible small antral follicles or filtered from spent media. Oocytes were incubated in oocyte maturation medium, and those that matured at 24 or 48 h were vitrified. Ovarian cortical tissue was cut and prepared for slow-gradual cryopreservation. Anti-Mullerian hormone (AMH) levels were measured in serum before and after oophorectomy. Ovarian tissue was successfully collected from 78.7% of the 42 patients. Oocytes were obtained from 20 patients before chemotherapy and 13 after chemotherapy. The youngest patients from whom oocytes were retrieved were aged 2 years (two atretic follicles) and 3 years. Of the 395 oocytes collected, ∼30% were atretic (29.6% in the pre-chemotherapy group, 37% in the post-chemotherapy group). One hundred twenty-one oocytes (31%) were matured in vitro and vitrified: 67.8% from patients before chemotherapy, the rest after chemotherapy. Mature oocytes suitable for vitrification were obtained from 16/20 patients before chemotherapy and from 12/13 patients after chemotherapy (maturation rate, 32 and 26.4%, respectively). There were significant correlations of the number of vitrified oocytes with patient age (more matured oocytes with older age) (P = 0.001) and with pre-oophorectomy AMH levels (P = 0.038 pre-chemotherapy group, P = 0.029 post-chemotherapy group). Oocytes suitable for vitrification were obtained both by manual aspiration of antral follicles (45%) and from rinse solutions after dissection. There were significantly more matured oocytes in the pre-chemotherapy group from aspiration than in the post-chemotherapy group after both aspiration (P < 0.033) and retrieval from rinsing fluids (P < 0.044). The number of pre-antral follicles per histological section did not differ in the pre- versus post-chemotherapy. AMH levels dropped by approximately 50% after ovarian removal in both groups, with a significant correlation between pre- and post-oophorectomy levels (P = 0.002 pre-chemotherapy group, P = 0.001 post-chemotherapy group). There were no patients between 5 years and 10 years old in the post-chemotherapy group, which might have affected some results and correlations. Oocytes from patients soon after chemotherapy might be damaged, and caution is advised when using them for fertility-restoration purposes. The viability, development capability and fertilization potential of oocytes from paediatric patients, especially prepubertal and after chemotherapy, are unknown, in particular oocytes recovered from the media after the tissue dissection step. Although more oocytes were collected and matured from chemotherapy-naïve paediatric patients, ovarian tissue and immature oocytes were also retrieved from young girls in whom cancer therapy has already been initiated. Our centre has established a protocol for potential maximal fertility preservation in paediatric female patients with cancer. Vitrified-in vitro-matured oocytes may serve as an important gamete source in paediatric female patients with cancer because the risk of reseeding the disease is avoided. Further studies are needed on the fertility-restoring potential of oocytes from paediatric and prepubertal patients, especially after exposure to chemotherapy. The study was conducted as part of the routine procedures for fertility preservation at our IVF unit. No funding outside of the IVF laboratory was received. Funding for the AMH measurements was obtained by a research grant from the Israel Science Foundation (to B.-A.I., ISF 13-1873). None of the authors have competing interests. N/A.

Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients

To assess the value of video-urodynamic study (VUD) in the identification of lower urinary tract voiding dysfunction in female. A total of 126 female patients with sign and symptoms of lower urinary tract voiding dysfunction underwent VUD from December 2008 to January 2011 in Beijing Chaoyang Hospital. The causes of voiding dysfunction were analyzed based on VUD findings. Neurogenic voiding dysfunction was found in 30 patients (23.8%), non-neurogenic voiding dysfunction was found in 96 patients (76.2%). The 72 patients suffered from recurrent urinary tract infection (57.1%) and 23 patients suffered from hydronephrosis (18.3%). Based on special characteristics of video-urodynamic study, a total of 126 patients were classified as: (1) Bladder outlet obstruction (BOO) was found in 65 patients. Of them, bladder neck obstruction in 40 patients (61.5%), their VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck did not open in a funnel shape and no contrast was found in urethra. Distal urethral stricture in 22 patients (33.8%), VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck open in a funnel shape, proximal urethra dilated and no contrast was found in distal urethral. Urethral sphincter obstruction in 3 patients (including detrusor-sphincter dyssynergia in 1 and sphincterismus in 2 patients), VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck open in a funnel shape, sphincteric urethra did not open, proximal urethra dilated and no contrast was found in distal urethral. (2) Detrusor areflexia (DA) was found in 39 patients (2 patients with hydronephrosis), the VUD finding was: no voluntary detrusor contraction in voiding phase, and abdominal pressure voiding pattern. (3) OAB was found in 3 patients, which VUD findings was frequent involuntary detrusor contraction at storage period with or without urine leakage. (4) Low compliance bladder was found in 17 patients (13.5%), 16 patients with hydronephrosis, the VUD showed that increased bladder storage pressure with significantly decreased bladder safe capacity and compliance, appearance of the bladder as "Christmas tree", with or without ureteral reflux. (5) And stress urinary incontinence (SUI) was in 2. The main causes of female BOO may be non-neurogenic conditions or organic obstruction. VUD would offer valuable information for confirmed diagnosis of voiding dysfunction in female patients.

Objective To explore the relationship between congenital vesical ureteral reflux(VUR) and bladder dysfunction in children through videourodynamic examination. Methods Sixty-seven children with congenital VUR in the First Affiliated Hospital of Zhengzhou University from Apr.2011 to Jul.2013 were included, and their clinical information of urinary tract infection, detrusor activity, dysfunctional voiding and grade of VUR were recorded.All the children were categorized as normal, isolated detrusor overactivity (DO)and dysfunctional voiding (DV)(with or without DO) according to the manifestation of urodynamic patterns, who were also divided into groups of low grade(Ⅰ-Ⅱ) VUR or high grade(Ⅲ-Ⅴ) VUR.Data of video-urodynamic examination, urinalysis, and voiding cystourethrogram were collected to investigate the relationship between bladder dysfunction, sides and grade of VUR and urinary tract infection. Results Totally 73.1%(49/67 cases) of children with VUR were found having bladder dysfunction, which consisted of 49.3%(33/49 cases) of DO, 23.8%(16/49 cases) of DV.Children with isolated DO tended to manifest unilateral, low grade reflux(grade Ⅰ-Ⅱ) with less urinary infection.However, children with DV, isolated or combined with DO manifest bilateral, high grade reflux(grade Ⅲ-Ⅳ), and often with urinary infection. Conclusions Video urodynamic study is useful for evaluation of bladder function in children with VUR, which is important in ma-nagement of VUR. Key words: Video urodynamic study; Vesical ureteral reflux; Bladder Dysfunction; Child

Bladder outlet obstruction (BOO) in women includes functional and anatomic etiologies. Primary bladder neck obstruction (PBNO), Fowler's syndrome (FS), and dysfunctional voiding (DV) are some examples of functional obstructions, whereas pelvic organ prolapse (POP), periurethral masses, and intragenic causes are some of the anatomic causes. This literature review describes the etiologies of female BOO, unique aspects of the workup and diagnosis, and the data for the standard surgical treatments and newer surgical techniques to treat women. Urethral stenosis and sling-related obstruction are treated in the other articles of this series. Where possible the focus is the efficacy and outcomes. Treatment of PBNO using a transurethral incision of the bladder neck and injection of botulinum toxin in the bladder neck decreases the BOO. After the failure of conservative approaches, sacral neuromodulation (SNM) is effective for FS, while DV may benefit from SNM or botulinum toxin injections. Concerning POP, most surgeries have been reported to significantly improve a pre-existent BOO but the level of evidence is low. Benign urethral and periurethral masses may provoke BOO, and surgical excision usually resolves this condition. Although most surgical treatments of BOO for functional and benign anatomical etiologies in women seem to be effective, data are scarce even for more common conditions like POP. Further studies are required to give better advice on the choice of surgical technique for these patients.

Managing voiding dysfunction in young men

Vaginal reflux: A common cause of urinary incontinence

Purpose: Vesicovaginal fistula (VVF) is a pathological connection between the bladder and vagina, primarily caused by gynaecological surgery, obstructed labour, and cesarean section. VVF significantly impairs quality of life and is prevalent in developing countries, with Africa seeing up to 130,000 new cases annually. Surgical repair, especially transvaginal approaches, remains the primary treatment. Paediatric cases of VVF, often linked to congenital anomalies like ectopic ureter, are rare and complex to manage. Methodology: We report a case of a 3-year-old female with continuous urinary leakage since birth, initially flagged for renal anomalies via prenatal imaging. Clinical examination was normal with no distress or developmental issues. Diagnostic assessments, including abdominal ultrasound and micturating cystourethrogram (MCUG), revealed left hydronephrosis, hydroureter, and a definitive vesicovaginal fistula. A CT Urogram confirmed the diagnosis, showing contrast leakage into the vagina. Findings: Diagnostic cystoscopy revealed a normally positioned right ureteric orifice, while the left was aberrantly positioned near the bladder neck. Culposcopy identified a ureterocele in the posterior fornix of the vagina. During laparotomy, a dilated left distal ureter was observed entering the vagina, indicating true ureter duplication. The surgical intervention involved left ureteric reimplantation using the antireflux method, successfully resolving the anomaly. Post-operative recovery was smooth, with significant improvement in urinary symptoms and no recurrence or complications noted during follow-up. Unique contribution to theory, policy and practice: VVF secondary to ectopic ureter in paediatric patients is rare but manageable with early diagnosis and tailored surgical intervention. Our case underscores the importance of a multidisciplinary approach and the efficacy of ureteral reimplantation in treating complex congenital anomalies, leading to favourable outcomes and symptom resolution.

Introduction: Radical nephroureterectomy with excision of ipsilateral bladder cuff is the gold standard treatment for high risk upper urinary tract transitional cell carcinoma. This procedure requires two incisions. However endoscopic detachment of distal ureter and bladder cuff by transurethral incision and removal of kidney requires single abdominal incision. Though the intention is to decrease morbidity by avoiding a second lower abdominal incision, argument exists regarding oncological outcome Methods: This Quasi-Experimental study was conducted from September, 2020 to August, 2022 in the department of urology, Bangabandhu Sheikh Mujib Medical University. Here 15 patients were in Group A who underwent transurethral incision around the ureteric orifice to remove the bladder cuff (Pluck technique) with single abdominal incision for open radical nephroureterectomy and 17 patients were in Group B who underwent open extravesical approach for excision of cuff of bladder during radical nephroureterectomy making two abdominal incisions. Both techniques were compared to assess the operative and oncological outcome. Results: Operative time was longer in group B (p&lt;0.001). Post-operative pain was more in group B (p&lt;0.001), median duration of catheterization was 10 days in group A and 7 days in group B (p&lt;0.001). Median duration of hospital stay 7 days in group A and 8 days in group B (p&lt;0.069). In both group no patient had recurrence of TCC in urinary bladder at 3 months. However at 6 months 3 (20%) patients in group A and 2 (11.76%) patients in group B had recurrence of TCC in urinary bladder (p=0.645). In group A 1 (6.7%) patient had metastasis in pelvic cavity at 6 months postoperatively. But no patient in group B had metastasis in pelvic cavity (p=0.469). Conclusion: Transurethral incision around the ureteric orifice up to perivesical fat followed by extraction of distal ureter and bladder cuff by pluck technique is technically feasible and oncologically safe operation with a shorter operative time, less postoperative pain but need longer duration of catheterization and drain. Bangladesh J. Urol. 2023; 26(2): 70-77

BackgroundBladder neck transection is one of the most difficult procedures for robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. To ensure negative surgical margins and safely preserve the ureteral orifices during bladder neck transection, we propose the use of the transurethral resectoscope for making the incision in the bladder neck before initiating RALP. Thus, we developed a technique for bladder neck transection to facilitate this operation in such patients.Case presentationTwo Japanese men, aged 61 and 63 years, who were diagnosed with prostate cancer, received a transurethral marking incision of the bladder neck before starting RALP; prostate cancer developed in one patient after TUR-P and the other patient had cancer protruding into the bladder neck. A transurethral resectoscope was used to closely observe the ureteral orifices and bladder necks; the bladder necks were marked to indicate the depth from the mucosa to the muscular layer. During the RALP, the bladder necks were dissected to indicate the depth of the marking incision. The surgical margins were negative and perioperative complications did not occur. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed.ConclusionThis technique, involving the use of an ordinary transurethral resectoscope, may be an easy procedure to ensure negative surgical margins, safely preserve the ureteral orifices, avoid increasing the bladder neck diameter, and achieve a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.

To evaluate the role of video-urodynamics (VUD) in the diagnosis of lower urinary tract voiding dysfunction. From December 2008 to March 2010, 115 patients with lower urinary tract voiding dysfunction were included in our study. All patients underwent VUD studies. Neurogenic bladder was found in 37 patients, including 25 male patients and 12 female patients. Among these patients, 18 patients were detrusor areflexia (DA), 2 patients were overactive bladder (OAB), 10 patients were low compliance bladder with hydronephrosis and 7 patients were detrusor-external sphincter dyssynergia. Non-neurogenic voiding dysfunction was found in 59 patients, including 34 male patients and 25 female patients. Among these patients, bladder outlet obstruction was found in 33 patients, OAB in 4 patients, urethra stricture in 4 patients and sphincterismus in 3 patients. Seven patients receiving augmentation of bladder took second VUD examination, including 4 male patients and 3 female patients. One patient receiving Indiana pouch and one patient receiving ureter reimplantation all took VUD examination. Ten patients had basic normal bladder urethra function from VUD examination, including 6 male patients and 4 female patients. From combination of pressure-flow figure and real time image, VUD examination provides precise evidence of diagnosis and treatment for lower urinary tract voiding dysfunction.

Objective To evaluate the effect of modified transurethral bladder neck incision in treatment of female bladder neck obstruction. Methods Sixteen female patients with bladder neck obstruction from March 2008 to May 2016 in Beijing Haidian Hospital were selected, and the patients were treated with modified transurethral bladder neck incision at the 3, 6 and 9-O′clock positions. The international prostate symptom score (IPSS), quality of life (QOL) and maximum urinary flow rate (Qmax) were evaluated before surgery and 1 year after surgery respectively. Results All 16 patients underwent successful operation, and the mean operation duration was 20 min, with the blood loss<10 ml. The difficulty of urination after removing the catheter was significantly improved. Postoperative pathological results were chronic inflammatory changes with fibrous tissue proliferation. There was no complication such as urinary incontinence, vesico-vaginal fistula and urethral stricture after operation. The IPSS, QOL and Qmax after surgery were significantly improved compared with those before surgery: (6.43 ± 3.31) scores vs. (25.21 ± 4.71) scores, (1.41 ± 1.15) scores vs. (4.43 ± 1.36) scores and (15.36 ± 4.82) ml/s vs. (7.49 ± 2.27) ml/s, and there were statistical differences (P<0.01). Conclusions The modified transurethral bladder neck incision is a safe and effective therapy for female bladder neck obstruction. Key words: Urinary bladder neck obstruction; Transurethral incision of bladder neck; Female

BACKGROUND Giant hiatal hernias, whether primary or recurrent, carry substantial risks of complications, including incarceration, ischemia, and necrosis. Early diagnosis and management are essential. Endoscopic gastric decompression facilitates preoperative stabilization by relieving mediastinal compression and gastric ischemia. To prevent recurrence and complications, various techniques have been used to secure the stomach in the abdominal cavity. A combination of esophageal dissection, crural repair, and fundoplication with abdominal wall gastropexy has shown effectiveness; a novel approach - gastrojejunopexy, or the "leash maneuver" - emerged during an emergency operation. This technique demonstrates potential as a method for stomach traction. It may mitigate giant hiatal hernia recurrence, but further studies are required for validation. CASE REPORT A 65-year-old man with obesity (body mass index 33.5 kg/m²) and prior Nissen fundoplication exhibited a giant recurrent hiatal hernia complicated by mediastinal gastric incarceration. Symptoms included dysphagia, regurgitation, thoracic pain, dyspnea, hypotension, and tachycardia. After stabilization with awake endoscopic decompression and fluid/electrolyte imbalance correction, laparoscopic hiatal hernia repair was undertaken. Following crural closure and fundoplication reconstruction, gastrojejunopexy was performed by anchoring a jejunal segment near the ligament of Treitz to the stomach's greater curvature. This maneuver provided downward traction, covered ischemic areas, and reduced recurrence risk. The patient recovered uneventfully, with symptom resolution and no imaging evidence of recurrence at an 8-month follow-up. CONCLUSIONS Gastrojejunopexy appears to be a safe, effective, and technically feasible adjunct to reduce giant hiatal hernia recurrence, particularly in high-risk patients with obesity. Additional studies are necessary to confirm its long-term efficacy and safety.

Factors of transurethral incision effectiveness for ureteroceles in pediatric patients: A 28-year, single-institution retrospective review

Malacoplakia is a very rare chronic granulomatous disease. It can affect almost all organs of the urogenital system, among which the urinary bladder is most common. During cystoscopy, it may reveal sessile mass which may cause misdiagnosis as malignancy. Therefore, only histopathological examination can differentiate it from malignancy. We reported a case of a 31 years old male presented with generalised weakness, low grade fever, dysuria, frequency and urgency but no pyuria or haematuria. Diagnostic urethrocystoscopy was performed which revealed multiple sessile mass obscuring left ureteric orifice, but right ureteric orifice was identified properly and right sided URS was done &amp; soft plaque like lesion was found at distal ureter from which biopsy was taken. Then TUR of bladder mass was done resulting visualization of left ureteric orifice, followed by left sided URS in which whole of the left ureter was found dilated upto renal pelvis with no mass lesion. Microscopic examination of tissue taken by both transurethral resection and URS biopsy revealed features of malacoplakia. Postoperatively, the patient was treated with broad spectrum antibiotics and other supportive measures to prevent further deterioration of renal function. Ultimately, the patient recovers well with no more progression to obstructive nephropathy. Urologists should emphasize multifocal malacoplakia involving more than one genitourinary organ presenting with obstructive nephropathy. Early diagnosis and treatment with long term oral antimicrobial agents combined with cholinergic drugs or vitamin C, as well as full surgical excision (i.e. transurethral resection) should be done to obtain better therapeutic effect against malacoplakia. Bangladesh J. Urol. 2025; 28(1): 44-48