Posterior Urethra Research Articles

Isolated penile corporeal cavernosal injury accompanying pelvic fracture after motor vehicle accident

Pelvic fracture is a common cause of traumatic injury of the bladder and posterior urethra; however, isolated corporal injury is rare. We present a case of pelvic fracture associated with proximal injury of the penile corpora cavernosa sparing the urethra and bladder, together with a literature review of erectile dysfunction post–pelvic fracture.

EDITORIAL COMMENT

Reconstruction of the posterior urethra following prostate cancer therapies such as radical prostatectomy or radiotherapy has traditionally been discouraged due to difficulties achieving an anastomosis, significant morbidity, including hemorrhage, rectal injury, ureteral injury and low success rates. However, there has been a growing experience of successful reconstruction of the posterior urethra using open, perineal, and abdominal perineal techniques.1 More recently the Trauma and Urologic Reconstructive Network of Surgeons reported encouraging results with the use of the robotic platform for reconstruction for vesicourethral anastomotic stenosis (VUAS) and recalcitrant bladder neck stenosis (BNS).

How We Made Exstrophy Bladder Continent and Preserved the Renal Functions.

Crucial requirement of exstrophy bladder repair is to make patients continent as well as to preserve kidney functions. We analyzed our patients' data retrospectively to study their continence and to find out the justification behind continence and preservation of renal functions. We selected files of 18 fully continent patients from 52 patients operated. Eleven out of 18 patients were presented from beginning and 7 were referred after around 8 to 14 years, as incontinent bladder following good repair of bladder neck and posterior urethra. Eleven were operated with complete primary repair of exstrophy along with pubic osteotomy minimal and were kept on cystostomy track (CT) till augmentation to vent out vesical pressure. In seven patients, we did reduction of caliber of posterior urethra and bladder neck along with CT followed by augmentation after 6 months. All 18 patients are maintaining dry period for 24 h. Two patients had enuresis but are manageable with partial fluid restriction from evening. Seventeen out of 18 patients are maintaining their renal functions. No tension abdominal wall closure with rectus muscle apposition is essential to preserve repaired bladder exstrophy. Osteotomy prevents lateral drag to overcome failure of whole reconstruction. Increased "systolic" vesical pressure from contraction of small bladder might destroy the mechanism of continence and renal functions. Hence, venting of vesical pressure through CT is obligatory till augmentation which is of necessity to be done as early as possible to create a low-pressure continent system.

Are There Prognostic Factors for Failure of Surgical Treatment of Post-Traumatic Posterior Ureteral Stenosis? About 30 Cases and Review of the Literature

Introduction: The management of post-traumatic stenosis of the posterior urethra is divided between early endoscopic realignment and delayed surgery. In the latter case, several techniques are used taking into account several factors. Our objective was therefore to investigate the possible prognostic factors of failure of this surgical management. Material and Methods: We conducted a retrospective study from January 2006 to December 2017 on patients admitted to the Urology Department of the Mohammed 6 University Hospital of Marrakech for management of post-traumatic posterior urethral stenosis. The parameters studied were age, medical and surgical history, causes, characteristics of the stenosis (location, number, length), associated lesions, surgical technique used, and evolution. The descriptive analysis consisted of calculation of absolute and relative frequencies for the qualitative variables, and of position and dispersion parameters for the quantitative variables (mean, standard deviation). In bivariate analysis, the comparison of categorical variables used Pearson’s Chi-square statistical test and Fisher’s test if necessary. The significance threshold was set at p < 0.05. Results: A total of 30 cases were selected. The age of our patients varied between 18 and 68 years, with an average of 38.33 years (16 - 80 years); the most affected age group was between 20 and 39 years. The mode of revelation of urethral damage was dominated by acute retention of urine present in 76% of patients, followed by dysuria (33%). The stenosis extended over 21.91 mm on average (14 - 40 mm). It was accompanied by bone involvement in 15 patients (53.3%). Erectile dysfunction was present in 23 patients (23%). Terminal urethrogram was the main surgical technique used, followed by internal urethrotomy (60% and 30% respectively). 15 patients had a recurrence, with an average of 1-second operation. Statistical analysis of the different factors studied showed no correlation with the occurrence of recurrence after surgical treatment. Conclusion: The medium and long term results of anastomotic repair of the posterior urethra do not seem to depend on the lesion parameters of the stenosis (site, number, extent, presence of associated bony lesions or erectile disorders).

Newer Insights into Prostatic Utricle in Proximal Hypospadias.

Introduction:Prostatic utricles (PUs) are the remnants of Mullerian ducts found in the male posterior urethra. Enlarged symptomatic utricles are known to be associated with hypospadias. There is a dearth of literature defining an enlarged utricle and also its clinical significance.Aims:The aim of this study was to describe anatomical difference of PUs of cases with severe hypospadias and also to find their clinical significance if any.Materials and Methods:A prospective study was carried out, and all patients with proximal hypospadias were enrolled. Cystoscopy was performed in all cases. Symptomatology, size, and location of PU were recorded. PU of >0.5 cm was considered enlarged.Results:In the present series, a total of 70 cases were included over a period of 2 years. Enlarged utricle was found in 47/70 (67.14%) on cystoscopy. They were wide-mouthed and negotiated 9 Fr/11 Fr cystoscope with ease. Recurrent epididymo-orchitis, recurrent urinary tract infection, and obstructive features were the most common complications requiring intervention.Conclusions:PUs in boys with hypospadias are enlarged as well as wide-mouthed. Most of these remain asymptomatic, but few of them carry the potential of complications. Cystoscopy helps in direct visualization of utricular anatomy, so it should be a preferred investigating modality for investigating a PU.

Laser vs optical urethrotomy for urethral stricture

A urethral stricture is a scar of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen. As the constriction increases, obstruction occurs and leads to symptoms which may be related to the obstruction or secondary to it(1). (Figure 1). The term stricture usually used for constrictions of the anterior urethra. Otherwise in the posterior urethra the terms stenosis or contracture are applied(2). The site and the age of the patient may give a hint about the cause of the stricture. For example, Meatal strictures may be caused by lichen sclerosis (the most common identifiable cause of anterior urethral stricture in young adults), and instrumentation or poor hygiene at any age(2) A urethral stricture is a scar of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen. As the constriction increases, obstruction occurs and leads to symptoms which may be related to the obstruction or secondary to it(1). (Figure 1). The term stricture usually used for constrictions of the anterior urethra. Otherwise in the posterior urethra the terms stenosis or contracture are applied(2). The site and the age of the patient may give a hint about the cause of the stricture. For example, Meatal strictures may be caused by lichen sclerosis (the most common identifiable cause of anterior urethral stricture in young adults), and instrumentation or poor hygiene at any age(2).

Extra-peritoneal Laparoscopic Resection of Benign Prostate Adenoma >150 CC with preservation of posterior wall of prostatic urethra: Dundee Technique and early outcomes.

There are limited options for men with large benign prostates (>150cc) and bladder outflow obstruction due to benign prostatic hyperplasia (BPH). Management options include surgery (open or minimal access) and endoscopic procedures. There is a paucity of literature on outcomes for prostates >150cc. In this case series we describe a step-by-step, illustrated, modified extra-peritoneal technique of laparoscopic prostatectomy with preservation of the posterior prostatic urethra. This involves creation of extra-peritoneal space, transverse incision of prostate capsule, progressive adenoma dissection, resection, and closure of the capsule. Ten patients underwent this procedure between 2015 and 2019. The mean age was 72.4 years and mean prostate size was 215.5cc. Mean procedure duration was 200 min and there were no intraoperative complications. Most patients were discharged on postoperative day 1. Mean intraoperative blood loss was 120 ml with no patient requiring blood transfusion. At follow up (mean 37 months) no patients had residual symptoms of BPH. We describe a novel extraperitoneal laparoscopic technique for benign prostates of >150cc with very good outcomes. The transferability of this technique to centres with laparoscopic expertise at minimal extra cost and future adaptability in the robotic setting are some of the advantages of this technique.

Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life.

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1–8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients’ quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Retrograde urethrography, sonouretrography and magnetic resonance urethrography in evaluation of male urethral strictures. Should the novel methods become the new standard in radiological diagnosis of urethral stricture disease?

PurposeTo verify which of the diagnostic modalities: Voiding cystouretrography (VCUG), Sonouretrography (SUG) or Magnetic resonance uretrography (MRU) is the most accurate in the assessment of urethral strictures in males and in what cases the application of novel imaging techniques benefits most.Methods55 male patients with a diagnosis of urethral stricture, were enrolled in this prospective study. Initial diagnosis of urethral stricture was based on anamnesis, uroflowmetry and VCUG. Additional imaging procedures—SUG and MRU were performed before the surgery. Virtual models and 3D printed models of the urethra with the stricture were created based on the MRU data. Exact stricture length and location were evaluated by each radiological method and accuracy was verified intraoperatively. Agreement between SUG and MRU assessments of spongiofibrosis was evaluated. MRU images were independently interpreted by two radiologists (MRU 1, MRU 2) and rater reliability was calculated.ResultsMRU was the most accurate [(95% CI 0.786–0.882), p < 0.0005] with an average overestimation of 1.145 mm (MRU 1) and 0.727 mm (MRU 2) as compared with the operative measure. VCUG was less accurate [(95% CI 0.536–0.769), p < 0.0005] with an average underestimation of 1.509 mm as compared with operative measure. SUG was the least accurate method [(95% CI 0.510–0.776), p < 0.0005] with an average overestimation of 2.127 mm as compared with the operative measure. There was almost perfect agreement of MRU interpretations between the radiologists.ConclusionsVCUG is still considered as a ‘gold standard’ in diagnosing urethral stricture disease despite its limitations. SUG and MRU provide extra guidance in preoperative planning and should be considered as supplemental for diagnosing urethral stricture. Combination of VCUG and SUG may be an optimal set of radiological tools for diagnosing patients with urethral strictures located in the penile urethra. MRU is the most accurate method and should particularly be considered in cases of post-traumatic or multiple strictures and strictures located in the posterior urethra.

Comparing spatiotemporal gait parameters between overground walking and self-paced treadmill walking in persons after stroke

A 21-year-old male presented to our hospital for life-threatening pelvic fracture, mandating emergent transarterial embolization of the right internal pudendal artery. At five-month post-injury, penile arterial flow was severely impaired, thus penile revascularization surgery were planned, before attempting urethroplasty for a 2-cm gap in the posterior urethra. However, reevaluation angiography results obtained two months later revealed spontaneous recovery of penile arterial flow. Excision and primary anastomosis urethroplasty was successfully performed without signs of bulbar ischemia. This case suggests that the timing of urethroplasty following pelvic injury should be tailored according to recovery of penile arterial flow.

Можливості використання ендоскопічного обладнання в лікуванні коротких посттравматичних стриктур уретри в дітей

Актуальність. Пошкодження уретри при пошкодженні кісток таза в дітей відмічається рідше, ніж у дорослих (менше 1 %) (Tarman G.J. et al., 2002). Посттравматична стриктура уретри в дітей є досить рідкісною та складною урологічною патологією. З урахуванням анатомічних особливостей лікування стриктури уретри в дітей відрізняється від її лікування в дорослих (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). М.М. Koraitim (2012) описав досвід лікування 20 хворих з ускладненнями після трансперинеальної пластики уретри. Автор відмітив, що у разі відсутності необхідності реконструкції шийки сечового міхура достатньо ефективним є ендоскопічне розсічення стриктури уретри. Т.Е. Helmy, А.Т. Hafez (2013) теж описали результати успішного застосування ендоскопічного обладнання (пряма візуальна уретротомія) після відкритих уретропластик. Важливим моментом, що спонукає до пошуку ефективних малоінвазивних методів лікування посттравматичних стриктур уретри в дітей, є розвиток еректильної дисфункції у подальшому, що, за даними деяких авторів (Koraitim M.M., 2014), становить до 47 %. Мета дослідження: на основі доступних літературних даних і власних результатів лікування дітей із стриктурами задньої уретри установити роль ендоскопічного лікування вказаної складної патології як методу профілактики та лікування нервово-м’язової дисфункції сечового міхура. Матеріали та методи. На базі хірургічних відділень Житомирської обласної дитячої клінічної лікарні широко впроваджені малоінвазивні ендоскопічні методи діагностики та лікування патології нижніх сечових шляхів. Наявне обладнання дає можливість проводити діагностичні процедури, починаючи з місячного віку. Виконується цілий ряд ендоскопічних оперативних втручань на нижніх сечових шляхах, а саме: видалення конкрементів, розсічення клапанів та стриктур задньої уретри, розсічення кіст уретри та ектопічних уретероцеле тощо. Також у 2010 році вперше виконано спробу за допомогою черезшкірної трипортової цистоскопії видалити вклинений у рубцево-змінену задню уретру конкремент. З 2013 року розпочато лікування посттравматичних стриктур задньої уретри під ендоскопічним контролем. Результати. Подано результати успішного малоінвазивного лікування із застосуванням сучасного ендоскопічного обладнання у двох хворих із посттравматичними стриктурами задньої уретри. Особливо наголошено на ефективності методу в діагностиці та лікуванні нервово-м’язової дисфункції сечового міхура в даної категорії хворих. Висновки. Отже, застосування сучасного малоінвазивного обладнання не лише дає можливість ефективно діагностувати пошкодження нижніх сечових шляхів, а й може бути дієвим механізмом малотравматичного хірургічного лікування при коротких посттравматичних стриктурах уретри в дитячому віці. Своєчасне якісне лікування рубцевих стриктур уретри в дітей зведе до мінімуму розвиток інфравезикальної обструкції та порушення евакуаторної функції сечового міхура із розвитком його нервово-м’язової дисфункції.

Bladder outlet obstruction

Bladder outlet obstruction

Ectopic prostatic tissue presenting as a urinary bladder polyp in a young male

Ectopic prostatic polyps are uncommon lesions, sometimes found in the lower urinary tract, particularly the posterior urethra. Ectopic prostatic tissue in the bladder is very uncommon. Until now, only 43 cases of this lesion have been reported in the English literature. Clinically and endoscopically these lesions are often mistaken for malignancy. We report a case of ectopic prostatic tissue at the bladder neck in a young male. Histopathology and immunohistochemistry confirmed the prostatic nature of the tissue. Since the entity is benign and unlikely to recur, we emphasize that urologists and pathologists need to be familiar with this to avoid misdiagnosis and unnecessary overtreatment.

Diagnostics of anatomical obstruction of the lower urinary tract using uroflowmetry with a pharmacourodynamic test

Uroflowmetry is an effective, non-invasive method for detecting lower urinary tract obstruction. However, by the nature of the uroflowgram, it is impossible to distinguish between the anatomical and functional obstruction of the urethra. The aim of the study was to develop a screening non-invasive method for the diagnosis of anatomical urethral obstruction using uroflowmetry with a pharmacourodynamic test with selective alpha-1-blocker silodosin. The study involved 235 patients aged 66.2±1.8 years (from 30 to 76 years) with symptoms of the lower urinary tract (LUTS). Uroflowmetry was performed using a “Flow-K” uroflowmeter. Ultrasound examinations of the kidneys, prostate and bladder with determination of residual urine were performed using a HONDA HS-2000 ultrasound machine. All patients underwent a pharmacourodynamic test: repeated uroflowmetry 2.5-3 hours after a single dose of 8 mg of silodosin, taking into account the pharmacodynamics of the drug. During the pharmacourodynamic test, 15 patients with obstructive or obstructive-interrupted uroflowgram had no reaction to silodosin, which was considered a positive test for anatomical (mechanical) urethral obstruction. Аn increase the maximum and average volumetric flow rate of urine during urination by 25-30%, respectively from 9.02±0.24 ml/s up to 11.69±0.32 ml/s and from 5.64±0.21 ml/s to 7.03±0.25 ml/s, were noted in 220 patients with obstructive, obstructive-interrupted obstructive-intermittent or intermittent type of uroflowgram when conducting a pharmacaurodynamic test. Such results were considered negative for anatomical (mechanical) urethral obstruction. They testified to functional obstruction of the urethra, which was subsequently successfully corrected with prescribing selective alpha-1-blockers. Patients with a positive pharmacourodynamic test were prescribed further examination using such methods as ureteroscopy, urethrocystoscopy, retrograde urethrography, to confirm the violation of the patency of the urethra or bladder neck. Urethral stricture was diagnosed in 10 patients, a calculus of the posterior urethra in 2 patients, a median lobe of the prostate gland in 3 patients with BPH. In the presence of obstructive or obstructive-interrupted uroflowgram in patients with LUTS, the pharmacourodynamic test with silodosin can be used as a screening non-invasive test to detect anatomical obstruction of the lower urinary tract.

Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta-analysis.

Lower urinary tract obstruction (LUTO) is a rare but critical fetal diagnosis. Different ultrasound markers have been reported with varying sensitivity and specificity. The objective of this systematic review and meta-analysis was to identify the diagnostic accuracy of ultrasound markers for LUTO. We performed a systematic literature review of studies reporting on fetuses with hydronephrosis or a prenatally suspected and/or postnatally confirmed diagnosis of LUTO. Bayesian bivariate random effects meta-analytic models were fitted, and we calculated posterior means and 95% credible intervals for the pooled diagnostic odds ratio (DOR). A total of 36,189 studies were identified; 636 studies were available for full text review and a total of 42 studies were included in the Bayesian meta-analysis. Among the ultrasound signs assessed, megacystis (DOR 49.15, [15.28, 177.44]), bilateral hydroureteronephrosis (DOR 41.33, [13.36,164.83]), bladder thickening (DOR 13.73, [1.23, 115.20]), bilateral hydronephrosis (DOR 8.36 [3.17, 21.91]), male sex (DOR 8.08 [3.05, 22.82]), oligo- or anhydramnios (DOR 7.75 [4.23, 14.46]), and urinoma (DOR 7.47 [1.14, 33.18]) were found to be predictive of LUTO (Table 1). The predictive sensitivities and specificities however are low and wide study heterogeneity existed. Classically, LUTO is suspected in the presence of prenatally detected megacystis with a dilated posterior urethra (i.e., the keyhole sign), and bilateral hydroureteronephrosis. However, keyhole sign has been found to have modest diagnostic performance in predicting the presence of LUTO in the literature which we confirmed in our analysis. The surprisingly low specificity may be influenced by several factors, including the degree of obstruction, and the diligence of the sonographer at searching for and documenting it during the scan. As a result, providers should consider this when establishing the differential for a fetus with hydronephrosis as the presence or absence of keyhole sign does not reliably rule in or rule out LUTO. Megacystis, bilateral hydroureteronephrosis and bladder wall thickening are the most accurate predictors of LUTO. Given the significant consequences of a missed LUTO diagnosis, clinicians providing counselling for prenatal hydronephrosis should maintain a low threshold for considering LUTO as part of the differential diagnosis.

Role of tadalafil in enhancing visualization of posterior urethra prior to combined voiding cystourethrogram and retrograde urethrogram: a retrospective analysis.

To show utility of tadalafil in enhancing visualization of posterior urethra in patients with urethral stricture. We retrospectively reviewed the records of adults male who failed to delineate the posterior urethra while undergoing combined voiding cystourethrogram and retrograde urethrogram (VCUG and RUG), as a part of preoperative assessment of stricture length and location before urethral reconstruction. The study was repeated 24 h later after a single dose of tadalafil 20 mg was administrated 2 h before the procedure (Tadalafil group). A control group who did not receive any medication was used for comparison (control group). This study was carried out in between March 2016 and August 2019. Thirty patients were included in the tadalafil group and equal number of patients was used as control group for comparison. The etiologies of strictures were pelvic fracture urethral distraction defect (39 patients), bulbar stricture with complete obliteration (15 patients) and post catheterization (6 patients). Success rate of opening bladder outlet on initiation of voiding was 90% in tadalafil group and 40% in the control group (P = 0.0004). None of the men reported any serious adverse events after oral administration of the drug. Almost all AEs were mild and well-tolerated. Tadalafil effectively relaxes the bladder neck and the posterior urethra prior to combined VCUG and RUG in urethral stricture patients. Tadalafil was safe with no serious adverse effects when administered prior to performing the test. This prevents the patients from undergoing further invasive or expensive diagnostic techniques, moreover, tadalafil assisted in preoperative surgical preparation and patient's counseling.

WITHDRAWN: Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy

Abstract Vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy is a narrowing of the vesicourethral anastomosis after radical prostatectomy. We aim to describe a safe re-anastomotic procedure for recurrent bladder neck contracture following radical prostatectomy (RP). This technique allows an easier access to the stenotic vesico-urethral anastomosis, a better mobilization of the bladder neck and a tension free re-anastomosis. Twelve patients suffering from VUAS after radical prostatectomy were enrolled between May 2014 and September 2018. We describe our approach to the disease. The evaluated outcomes were intra- and post-operative complications, stricture recurrence, and postoperative stress incontinence. Average operative time was 3 h. No major intraoperative complications or bleeding occurred. Patients were discharged after 72 h. At the time of catheter removal, 3 weeks after surgery, 9 out of twelve patients developed stress urinary incontinence, requiring 4 pads/day. Two patients with history of pelvic radiotherapy developed a surgical site abscess that required toilette and external urinary diversion. One recurrence occurred and was treated with internal urethrotomy before sphincter placement. No patient reported significant postoperative pain or fecal incontinence. Our approach allows direct access to the posterior urethra, and we demonstrate the advantages for treatment of VUAS to achieve a tension free anastomosis. All patients need to be informed of subsequent urinary incontinence to be treated with artificial sphincter placement. Patients with a history of pelvic radiotherapy show very poor preoperative conditions of the tissues and must be informed about the possibility of an external urinary diversion.

Partial Inferior Pubectomy in the Delayed Repair of Pelvic Fracture Urethral Injury: Adopting a Bone-nibbling Technique

Background: The use of wedge inferior pubectomy can be challenging to many urethral surgeons. Our objective was to introduce a bone-nibbling technique to accomplish a partial inferior pubectomy (PIP) in a resource-poor setting, and to report the medium- to longterm outcome of using the technique.&#x0D; Methods: Five patients were recruited (mean age: 38.8 years) who presented, over a 30-month period, with posterior urethral fibrosis from a pelvic fracture urethral injury (PFUI). One had failed a previous attempt at posterior urethral reconstruction elsewhere. The length of urethral defect was from 2 to 4 cm. We describe a bone-nibbling technique used to carry out PIP for the delayed repair of PFUI in these patients. The outcomes in the medium to long term of surgical procedures done with this technique are presented.&#x0D; Results: Immediate postoperative complications in all were essentially a Clavien–Dindo grade I. Peak flow rate assessed 12 weeks’ post operation was between 20 mL/s and 23 mL/s (mean: 21 mL/s). The longest duration of follow-up was 34 months, and all patients were voiding satisfactorily.&#x0D; Conclusions: A satisfactory and durable outcome can be obtained from nibbling at the bone from the inferior margin of the pubic bone to achieve PIP. This is of interest to lower urinary tract reconstructive surgeons who have concerns with chiseling-out wedge of the inferior pubis.&#x0D; Keywords: Bone nibbling, Partial inferior pubectomy, PFUI, Posterior urethra, Urethral anastomosis

PRESENTATION, MANAGEMENT, AND OUTCOME OF POSTERIOR URETHRAL VALVES IN WESTERN RAJASTHAN

Introduction: Posterior urethral valve (PUV) is the most common cause of bladder outlet obstruction and renal insufciency in male children. The aim of this study was to evaluate the presentation, management, challenges, and outcome of the disease in a Western Rajasthan tertiary health institution. Methods: In a retro-prospective study, 26 male children were included from November 2017 to March 2020 at Dr. S.N.Medical college, Jodhpur. Diagnosis was conrmed by voiding cysto-urethrography (VCUG). Results: A total of 26 patients were managed for PUV.The mean age of presentation was 3.45 years with 65.8% of the patients presenting after 1 year. Voiding dysfunction noted in 23(88.4%) patients was the most common presentation. Most common nding on physical examination was palpable bladder 15(57.6%) while UTI noted in 15 (57.6%) patients was most common complication. Abdominal sonography revealed dilated posterior urethra in 10(38.4%) cases, while VCUG revealed a dilated posterior urethra in 19 (75%) cases.The creatinine value at presentation ranged from 0.4-4.5 mg/dl with a mean of 1.10 ± 0.95 mg/dl. Valve ablation with a diathermy bugbee electrode &amp; holmium laser provided relief of obstructions in the 23 (88.4%) patients who underwent the procedure without immediate complication. The period of follow-up ranged between 1 weeks to 2 years with a mean of 8.2 months. There was sustained improvement in urine stream, reduction in the mean creatinine concentration and incidence of UTI during follow-up. Conclusion: Many patients with PUVpresented late within the reviewed period. Valve ablation provided relief of obstruction in most of the cases. Efforts at improving awareness among general population and early diagnosis and referral among the health team should be encouraged. There is a need to counsel parents on the need for long-term follow-up

Surgical treatment for prostatic utricle cyst in children: A single-center report of 15 patients.

To report our single-center experience of the management of children with prostatic utricle cysts. We retrospectively analyzed 15 children who were incidentally found to have a prostatic utricle cyst and were admitted to our department between October 2013 and August 2020. Clinical characteristics and management were collected and catalogued. Recurrent genitourinary tract infections were the most frequent complaint, and two-thirds of patients also had hypospadias. A connection between the posterior urethra and the prostatic utricle cyst was found in all cases. Two patients directly had their progressively enlarging prostatic utricle cyst resected laparoscopically. Endoscopic techniques were used in 13 patients, two of whom underwent laparoscopic excision for repeated symptoms. The mean (range) follow-up period was 34.9 (2-82)months. No recurrences were observed in four patients who underwent prostatic utricle cyst excision and eight patients who received endoscopic treatment. Three patients had recurrent symptoms after endoscopic treatment and were managed by nonsurgical treatment. Prostatic utricle cyst is a rare disease which can cause recurrent genitourinary tract infections. Extra attention should be paid to evaluation for prostatic utricle cyst in children with external genital anomalies. Retrograde urethrogram and magnetic resonance imaging are useful tools with which to distinguish prostatic utricle cyst from other cystic lesions that are located in the midline pelvis in male patients. Individualized treatment is appropriate when considering fertility preservation, recurrences and malignancy. Laparoscopic excision is feasible for symptomatic and large prostatic utricle cyst. Regular long-term monitoring is recommended for all patients with prostatic utricle cyst.