Urethral Research Articles

Diagnostic tools for female urethral diverticulum: Current perspectives

Although once considered quite a rare condition in the past, female urethral diverticulum (UD) would now appear to have a higher frequency, perhaps due to greater attention from physicians. To date, there is no agreement on which is the best method for diagnosis of female UD. Traditionally, the approach was based on quite invasive techniques, such as voiding cystourethrography, and double-balloon urethrography, with satisfactory results but relevant limitations. More recent high-resolution imaging techniques, such as 2D-3D ultrasonography (US) and magnetic resonance imaging (MRI) have also been applied in the study of the abnormalities of the female urethra. US had the advantage of the outpatient setting, non-invasiveness and absence of contrast medium use; MRI, is characterized by high sensitivity thanks to multiplanar capability, with an optimal characterization of periurethral diseases or its abnormalities, and lack of ionizing radiation. A real innovation is represented by computer tomography-voiding cystourethrography, a rapid technique that allows for high quality simultaneous 2D and 3D images of the urethra, well correlated to MRI and consequently with surgical results. Here, we report and comment the available tools in the diagnosis of female UD, focusing particularly on pros and contra of different methods.

Causual analysis of liquid leakage from the urethral meatus and nursing intervention in patients indwelled with urinary catheter after transurethral resection of the prostate

Objective To investigate the causes of liquid leakage from the urethral meatus in patients indewelled with urinary catheter after transurethral resection of the prostate(TURP), and provide the basis for improving the nursing quality. Methods A retrospective study was conducted in 179 patients who underwent TURP from January 2015 to February 2018. Data included in the analysis were age, IPSS, storage and voiding symptom scores (IPSS-S, IPSS-V), QoL, maximum free flow rate (Qmax), post-voided residual urine volume, first sensation of bladder filling(FS), bladder compliance(BC), BC grade, maxmium cystometric capacity(MCC), MCC grade, maximum detrusor pressure, detrusor pressure at Qmax, obstruction grade, detrusor overactivity(DO) and detrusor underactivity(DUA). Acorrding to the status of liquid leakage from the urethral meatus after TURP, patients were divided into leakage positive (LP) and negative(LN) groups. The above mentioned parameters were compared between the two groups and these with statistical significance were further analyzed in the Logistic regression model. Results There were 76 and 103 patients in LP and LN groups, respectively. There were significant differences in age, IPSS score, IPSS-S score, BC score, BC grade, FS score, MCC score, MCC grade, Qmax and the prevalence of DO between LP and LN groups [(72.9±7.1)years old vs. (67.9±6.8)years old, (23.7±5.7)vs. (20.9±6.7), (11.4±2.9)vs.(8.8±3.3), 10.5 (5.6, 16.4) ml/cmH2O vs.37.0 (24.3, 57.3) ml/cmH2O, (3.6±3.3)vs. (9.4±5.0), (85.2±53.2)ml vs.(130.8±69.7)ml, (161.6±97.5) ml vs. (323.7±163.6)ml, (3.8±2.0)vs.(6.7±2.5), (6.1±2.8)ml/s vs.(7.4±3.3)ml/s, 57.9% (44/76) vs.17.4% (18/103)] (P<0.05 for each). Logistic regression analysis showed that high IPSS-S (OR=1.617, P=0.001), DO (OR=3.615, P=0.024), MCC (OR=0.591, P=0.002) and BC grades (OR=0.745, P=0.001) were risk and protective factors of liquid leakage from the urethral meatus after TURP. Conclusion When indwelled with urinary catheter, the patients with high IPSS-S, low MCC, low BC, and DO have high risks of liquid leakage from the urethral meatus after TURP. For these patients, we should give psychological guidance, and inform them of disease condition preoperatively; and after surgery we should take appropriate measures to improve nursing quality. Key words: Transurethral resection of prostate; Urethra; Nursing care; Leakage

Effects of WeChat online support system on continued nursing care for patients receiving enteral bladder augmentation

Objective To establish a WeChat online system supporting continued nursing care for patients receiving enteral bladder augmentation and to evaluate its effects on continued nursing care for patients with neurogenic bladder in spinal cord injury who received enteral bladder augmentation. Methods Totally 60 patients with low-compliant neurogenic bladder in spinal cord injury who received enteral bladder augmentation and were discharged from Zhejiang Provincial People's Hospital between March 2016 and March 2018 were selected by convenient sampling, and divided into the observation group (n=30) and the control group (n=30) according to the random number table. Patients in the control group received conventional nursing care after discharge, while patients in the observation group received nursing care after discharge via the WeChat online support system. The follow-up duration was 3 months. Bladder self-management compliance, urinary catheter-associated complications, bladder function, quality of life and negative emotions at discharge and 3 months after discharge were compared between the two groups. Results The score of bladder self-management compliance, anxiety score, depression score, and scores of physical function, role function, emotional function and social function in quality of life in the observation group were better than those in the control group 3 months after discharge (P<0.05) ; the rates of urinary tract infection and urethral injury of the observation group were 3.3% and 6.7%, while those of the control group were 26.7% and 33.3%, respectively; the incidence rate of urinary catheter-associated complications of the observation group was lower than that of the control group (P<0.05) ; and the parameters of bladder function such as bladder volume, bladder compliance, residual urine volume and maximum detrusor pressure of the observation group were better than those of the control group (P<0.05) . Conclusions The WeChat online support system can improve patients' bladder self-management compliance, reduce the urinary catheter-associated complications, enable the recovery of bladder function, ameliorate their negative emotions, and improve their quality of life. Key words: Spinal cord injury; Neurogenic bladder; WeChat; Bladder augmentation; Continued nursing care

SUN-205 A Case of 46XY Mixed Gonadal Dysgenesis Presenting with Unilateral Gonad and Hemiuterus: Family History Dictates Sex Assignment

Background: Disorders of sex differentiation (DSDs) result from an atypical congenital development of chromosomal, gonadal, or anatomical sex. Mixed gonadal dysgenesis, a rare DSD, is the presence of both ovarian and testicular tissue. Early sex assignment is challenging due to the variable clinical, cytogenetic, and histopathological presentations. Clinical Case: A 1-day-old born from an uncomplicated pregnancy at 36+4/7 weeks gestation (birth weight 3.7 kg) was noted to have ambiguous genitalia. Upon examination, external genitalia was a bifid scrotum with palpable right scrotal and non-palpable left gonad; no hyperpigmentation. Phallus length was 2.5 cm and width was 1.3 cm with chordee (Prader Stage 3 hypospadias) and a single proximal urogenital sinus (anogenital ratio 1.3). Family history included a paternal uncle and two paternal cousins with ambiguous genitalia requiring surgy. The paternal uncle had two healthy daughters without fertility interventions. Also, three paternal aunts are significantly taller and infertile. Father has gynecomastia. No consanguinity. The initial investigation found normal electrolytes, LH 2.1 mIU/ml, and FSH 3.1 mIU/ml. Anti-Mullerian hormone (AMH, 20.47 ng/mL) and testosterone levels (42.6 ng/dL) were low for a male. High-resolution karyotype showed 46, XY with no mosaicism and a positive FISH SRY. Chromosomal microarray analysis was unremarkable for small deletions or duplications. A high-dose (150 mcg) ACTH stimulation test ruled out adrenal steroid biosynthesis defects. Renin and aldosterone were unremarkable. An hCG stimulation test showed appropriate rise in testosterone (443.1 ng/dL), androstenedione (112 ng/dL), and 5-alpha-dihydrotestosterone (1027.2 pg/mL). Ultrasound showed a single right testicle (~3 mL volume) within the hemiscrotum, a left inguinal hernia containing mesentery, and a left hemiuterus with no ovaries. A genitogram showed a urogenital sinus with a normal-appearing vaginal canal and elongated female urethra. No vesicoureteral reflux or other perineal orifices. The low AMH with an appropriate rise in testosterone following hCG stimulation and the presence of male and female reproductive organs in an undervirulized XY suggests mixed gonadal dysgenesis. Sex assignment was deferred by the medical team until further evaluation, but the parents chose to raise as a male based on their family history. Extended family studies are in process. Conclusion: The wide clinical and molecular variation in mixed gonadal dysgenesis constitutes a challenge for sex assignment. A multi-disciplinary team approach before sex assignment is crucial, including accurate assessment of external and internal genitalia, biochemical gonadal function, and cytogenetic testing. Among the multiple genetic variants known to cause mixed gonadal dysgenesis, highest on our differential is DMRT1.

Clinical efficacy of pelvic floor reconstruction with autologous tissue in treatment of pelvic organ prolapse

One hundred and twenty nine patients with pelvic organ prolapse (stage Ⅲ to Ⅳ according to POP-Q staging) diagnosed in our hospital from January 2010 to December 2016 were enrolled, among whom 66 cases underwent vaginal hysterectomy plus vaginal anterior and posterior wall repair (TO group), 63 cases underwent vaginal hysterectomy plus pelvic floor reconstruction with autologous tissue (AT group). Clinical parameters, perioperative and postoperative complications were analyzed. There was no statistically significant difference in intraoperative blood loss, indwelling urethral catheter time, length of hospital stay, and anal exhaust time between group AT and group TO (P>0.05). The average operation time of group AT was significantly longer than that of group TO (P 0.05), while the BND at 12 months after operation in group TO was increased compared to 3 months after operation (P<0.05). There were significant differences in scores of PFIQ-7 and PISQ-12 before surgery and 12 month after surgery in both groups (P<0.05). There was no statistically significant difference between the two groups in the incidence of postoperative recurrence and pressure incontinence (P<0.05). It is suggested that the stability of pelvic floor anatomical structure after pelvic floor reconstruction with autologous tissue is better than that of the traditional surgery, especially for patients with severe pelvic organ prolapse. Key words: Uterine prolapse; Urinary incontinence, stress; Rrepair of vaginal anterior and posterior wall; Pelvic floor reconstruction surgery with autologous tissue

Genital-Sparing Cystectomy versus Standard Urethral-Sparing Cystectomy Followed with Orthotopic Neobladder in Women with Bladder Cancer: Incidence and Causes of Hypercontinence with an Ultrastructure Study of Urethral Smooth Muscles.

BACKGROUND:Bladder cancer in women is an indication for radical cystectomy (RC) when the tumour is confined muscle-invasive bladder cancer (MIBC) of T2 N0M0, or high risk progressive non-muscle invasive bladder cancer (NMIBC). Radical cystectomy is either genital-sparing cystectomy (GSC) or standard urethra-sparing cystectomy (USC) that is followed with orthotopic ileal neobladder (ONB). Post-operative chronic retention “Hypercontinence” had been reported in different series following URS or GSC and ONB. In long-term follow-up, we evaluated the functional outcome of women who developed hypercontinence after USC or GSC and ONB.AIM:An ultrastructure study of female urethral smooth muscle was done to elucidate the underlying causes of hypercontinence.MATERIAL AND METHODS:Retrospective study was conducted on 71 women who underwent RC and ONB, 45women had undergone USC, and 26 women had GSC, follow-up ranged from 5 to 15 years. Ultrastructure studies were done on 5 urethral biopsy specimens from 5 women who had hypercontinence, and 4 biopsies were from a normal control.RESULTS:Follow-up showed that women who had undergone USC and ONB, 28.88% developed hypercontinence, where in the series of GSC and ONB three women out of 26 developed hypercontinence (7.80%). Three women who had hypercontinence following USC and ONB, they developed stones in the ileal pouch. Ultrastructure study of urethral smooth muscles in women who had hypercontinence showed organized collagen fibrils, absent myelin sheath, and non-detected lymphatic vessels. Normal urethra showed collagen fibrils within the interstitial matrix, preserved myelin sheath of nerve fibres, the presence of lymphatic vessels in the matrix.CONCLUSION:The present study shoes that GSC with ONB leads to the minimal incidence of hypercontinence (7.80%), while standard USC lead to higher incidence (28.88%). Ultrastructure changes of the female urethra who had hypercontinence were fibrotic changes, loss of myelin sheath and minimal vascularity, their findings explains the underlying cause of hypercontinence and support the technique of GSC rather than the standard USC.

Study on the practicality of the semi-automatic measurement for the urogenital hiatus

Objective To determine the consistency of urogenital hiatus (UH) data between the semi-automatic measurement and manual measurement using transperineal pelvic floor ultrasonography. Methods Total of 286 three-dimensional images of minimal UH dimension were obtained. And they were divided into study group (100 images) and test group (186 images) randomly. Three experts traced and created the whole profile of the UH of those images in the study group by MATLAB. Then the semi-automatic software was obtained through machine learning algorithms. In the test group, 6 parameters of UH (including anterioposterior diameter, transverse diameter, circumference, area, left and right levator urethral gap distance) were measured by two experts (D1 and D2) both manually and semi-automatically. The time experts spent on measuring was also recorded and compared. Results The time used for semi-automatic measurement was significantly shorter than that for manual measurement[ (7.49±1.51)s vs (42.42±11.08)s, (7.52±1.37)s vs (43.45±9.09)s for D1 and D2, t=-12.09, -13.64, all P=0.00]. The Pearson correlation coefficients between semi-automatic and manual measurements of 6 parameters were 0.857-0.985 (P<0.01), 0.853-0.979 (P<0.01) in D1 and D2, respectively. The interclass correlation coefficients (ICC) of six parameters were ranged from 0.846-0.985 for D1 and 0.843~0.979 for D2(all P<0.01). The Bland Altman plot also showed good agreement between two methods. Conclusions Intellectual recognition and semi-automatic measurement has simplified the process for UH measurement, and it is proved to be a reliable and timesaving method that is practical for clinical use. Key words: Ultrasonography, transperineal; Urogenital hiatus; Intelligent identification; Semi-automatic measurement; artificial intelligence

Replacing a smaller-size catheter after tubularized incised plate urethroplasty may decrease postoperative urethral complications

Objective To investigate the effect of replacing a smaller-size catheter after tubularized incised plate (TIP) urethroplasty on postoperative urethral complications. Methods The data of 116 hypospadias patients underwent TIP urethroplasty performed by the same urologist in our hospital from January 2014 to December 2017 were retrospectively analyzed. The age of patients ranged from 0.5-15.4 years, with the median age of 1.5 years. Meatal location was distal in 47(39.5%), midshaft in 62(52.1%) and proximal in 10(8.4%) patients. Unhealthy urethral plate occurred in 49(42.2%) patients. F8 catheter was used for urethroplasty in 92(79.3%) patients, F10 in 17(14.7%), and F12 in 7(6.0%). According to the pattern of urinary diversion, patients were divided into two groups. Conventional catheter group in 56 patients (group A): the catheter was chosen in as large size as possible for urethroplasty without tension. Replace a smaller-size catheter group in 60 patients (group B): replace a smaller-size catheter after urethroplasty on the basis of group A. There were no statistically significant differences in age, meatal location and catheter size between the two groups (P>0.05). Results The mean follow up was 23 months (range 6-66 months). There were 73(62.9%) cases of orifice overflow during indwelling catheterization. There were 5(4.3%) patients needed further reoperation result from postoperative urethral complications, including 4 cases of fistula and 1 case of meatal stenosis. The process of replacing a smaller-size catheter after urethroplasty in group B was simple and without adverse reactions. There were 15(26.8%) cases of orifice overflow in group A and 58(96.7%) in group B. There were statistically significant differences in orifice overflow between the two groups (P<0.05). There were 5(8.9%) cases of postoperative urethral complications in group A and 0 case in group B. There were statistically significant differences in postoperative urethral complications (P<0.05). Conclusions The process of replacing a smaller-size catheter after TIP urethroplasty in was simple and subsequently contributed to less postoperative urethral complications. The results of replacing a smaller-size catheter after TIP urethroplasty were superior to that of no replacing conventionally. Key words: Hypospadias; Tubularized incised plate urethroplasty; Catheter; Urethral complications

Open reduction and internal fixation for acetabular fractures complicated with injury to lower urinary tract: short-term outcomes

Objective To investigate the short-term outcomes and surgical timing in patients who were treated by open reduction and internal fixation (ORIF) for acetabular fractures complicated with injury to lower urinary tract. Methods A retrospective analysis was conducted of the 14 patients with acetabular fracture complicated with lower urinary tract injury who had been treated at Department of Orthopaedics, The First Affiliated Hospital to Nanjing Medical University from January 2011 to September 2017. They were 12 males and 2 females, with an average age of 40.3 years (from 30 to 56 years). According to Letournel-Judet classification, there were one anterior column, 2 transverse, 3 anterior column plus posterior hemi-transverse, one T-shaped, 5 associated both-column and 2 transverse plus posterior wall fractures. The time from injury to surgery ranged from 6.0 to 30.5 days, with an average of 13.4 days. Of the 8 patients with bladder injury undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 4, a single modified ilioinguinal approach in 3, and a Stoppa approach combined with an iliac fossa approach in one; of the 6 patients with urethral rupture undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 3, a single modified ilioinguinal approach in one, a Kocher-Langenbeck approach in one and a Stoppa approach in one. The fracture union time, outcomes and complications were recorded. Results The mean follow-up time for the 14 patients was 27.2 months (from 12 to 60 months). The fracture union time ranged from 3.0 to 4.5 months, averaging 3.5 months. According to the Majeed’s scoring, the pelvic function at the final follow-up was excellent in 7 patients, good in 4, fair in 2 and poor in one; their scores ranged from 30 to 92 points, averging 80 points. No infection or implant failure occurred during follow-ups. Heterotopic ossification at the acetabulum was observed in one patient whose Brooker grading was IV at the final follow-up. Conclusion The patients with acetabular fracture complicated with lower urethral or bladder injury should be treated with ORIF as soon as possible so that fine clinical outcomes can be achieved. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Urethra; Bladder

Urodynamic analysis of extraperitoneal Studer orthotropic ileal neobladder following radical cystectomy

Objective To evaluate changes of the urodynamics of extraperitoneal Studer orthotropic ileal neobladder after radical cystectomy. Methods Between July 2013 and October 2017, Retrospective analysis was performed on 58 bladder cancer patients.58 patients who underwent retrograde extraperitoneal approach of radical cystectomy and Studer orthotopic ileal neobladder. The patients were comprised of 56 male and 2 female patients with average age of 62 years. There were 9 cases of T1, 26 cases of T2, 20 cases of T3, and 3 cases of T4.All operations were completed by open suprapubic extraperitoneal approach, then entered the abdominal cavity. An ileal segment 50-55 cm long was isolated which was 25 cm proximal to the ileocecum. The 35-40 cm ileal segment was detubularized along its antimesenteric border. The anterior wall was folded forward with U-shaped and the edges were sutured to formed a neobladder. The proximal 15cm was reserved for the double isoperistaltic afferent limb. The lowest part of the neobladder was anastomosed with urethral stump, the peritoneum was closed at the mesentery, and the neobladder was completely placed extraperitoneal. Upper urinary tract function was examined by renal function test, enhanced CT, IVU or cystography. Uroflowmetry, urodynamic evaluation, diurnal and nocturnal continence were performed at 3, 6, 12, 24 months following the surgery. Results After removed of the catheter, all patients were able to urinate through the urethra. The 3, 6, 12, 24 month follow-up data of urodynamic were compared. The maximum neobladder capacity was[(378±66) vs.(381±102)vs.(438±75)vs.(472±96)]ml, the maximum flow rate[(10.2±2.8)vs. (14.9±4.3) vs.(16.4±3.6)vs.(17.6±2.1)]ml/s, maximum bladder pressure during filling was[(23.0±4.6)vs. (21.7±7.1)vs.(20.6±6.4)vs.(18.8±6.3)]cmH2O, the PVR was[(68.0±33.2)vs.(36.2±10.1)vs.(30.6±11.9)vs.(14.0±9.6)]ml . There were significant differences between the 6-month and 12-month.There were no significant differences in the maximum bladder pressure during flowing[(38.6±7.4)vs.(49.2±6.8)vs.(58.4±10.5)vs.(56.8±7.4)]cmH2O. 53 cases were followed up 12 months after surgery. Excellent daytime and nighttime continence was 98%(52/53)and 83%(44/53)in the first year. Mild unilateral hydronephrosis occurred in 2 cases 1 month after surgery. Blood electrolytes and renal function were within the normal range. 1 case presented bilateral mild hydronephrosis 12 months after surgery, without bladder and ureter regurgitation. The blood electrolyte and renal function of the other patients were in normal range with no signs of ureteral stricture and upper urinary tract hydronephrosis. Conclusions Extraperitoneal Studer orthotopic ileal neobladder reduced the interference of postoperative intraperitoneal intestinal tract on neobladder function. Postoperative patients have a smooth urination, a safe pressure during the storage period. The urination period, and the function of day and night urinary control is close to normal physiological characteristics. Key words: Urinary bladder neoplasms; Extraperitoneal approach; Orthotropic ileal neobladder; Urodynamic analysis

Urogenitalis lokalizációjú mucosamelanoma primer és áttétes esetei klinikánkon

Both primary and metastatic cases of mucosal melanoma in urogenital localization are rare tumors. Only 4-5% of all primary melanomas do not arise from the skin. Extracutaneous melanomas have a complex clinical presentation, but these aggressive tumors have a poor prognosis. In our department, we found 7 patients with malignant melanoma of the genitourinary tract in the past few years. The 7 cases were: primary amelanotic melanoma of the female urethra, a primary melanoma of the bladder, two primary melanomas of the penis, a metastatic melanoma of the urethra and another to the testis and a metastatic melanoma of the bladder with melanuria. We retrospectively analyzed the available data to describe the presentation, management, and clinical outcome of the patients. In the three inoperative cases, palliative, urologic surgical procedures and systemic antitumor therapy were performed. Two of the four primary urogenital tumors were localized to the penis. In one case, local recurrence developed after surgical treatment, but with a radical, repeated surgery, the patient has been asymptomatic for a year and a half. In the other, neglected case, the penis melanoma spread through the urethra and the inguinal lymph nodes two years after radical surgery and inguinal block dissection. In the female primary urethral melanoma case, the first histological study reported a primary mesenchymal tumor, and the recurrent tumor that occurred one and a half years later showed melanoma diagnosis. Radical surgery performed because of urethral involvement resulted in a 5-year asymptomatic state, followed by local recurrence and distant metastasis. In the fourth case of a primary bladder melanoma, the rapid progression of the disease and the BRAF positivity of the tumor suggested that not the firstly diagnosed bladder melanoma was the primary tumor. The occurrence of urinary tract melanoma is very rare and its discovery happens often in a disseminated state, so the expected prognosis of the cases is also poor. The most important factors for increasing therapeutic efficacy are early diagnosis and radical surgical intervention. Tumors appearing in different localizations require different urological surgical approaches. The literature recommendations for treatment are not uniform. Their prognosis is worse compared to the cutaneous melanoma, which may be due to clinical and pathological diagnostic difficulties. The latest targeted and immunotherapeutic agents can significantly improve the survival of metastatic patients. Orv Hetil. 2019; 160(10): 378-385.

Urethral regions with differential tissular composition may underlie urinary continence and voiding function in female rats.

To analyze, in female rats, the anatomical and histological features of the urethra and its relationship with the vagina and clitoris, and its innervation. Seventeen adult female Wistar rats were used. Gross anatomy and acetylcholinesterase (AchE) histochemistry were performed to describe the urethral features, adjacent structures, and innervation. The histomorphometric characteristics of the urethra were determined in transversal, longitudinal, or coronal sections stained with Masson's Trichrome. The female rat urethra is not a homogeneous tubular organ. The pre-pelvic and pelvic regions are firmly attached to the vagina with belt-like striated fibers forming a urethra-vaginal complex. The bulbar regions have curved segments and a narrow lumen. The clitoral region is characterized by a urethra-clitoral complex surrounded by a vascular plexus. The lumen area and thickness of the urethral layers significantly varied between regions (P < 0.05). Innervation of the urethra arrives from the major pelvic ganglion, the dorsal nerve of the clitoris (DNC), and the motor branch of the sacral plexus (MBSP). Differential tissular composition of the urethra may underlie urinary continence and voiding dysfunction through different physiological mechanisms. The urethra-vagina complex seems to be the main site controlling urinary continence through active muscular mechanisms, while the bulbar urethra provides passive mechanisms and the urethra-clitoris complex seems to be crucial for distal urethral closure by means of a periurethral vascular network.

Surgical techniques and short-term outcomes of transvesical robot assisted radical prostatectomy

Objective To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP). Methods From April 2018 to August 2018, 10 patients underwent TvRARP performed by a single surgical team were retrospectively reviewed. Preoperative data of patients [aged (58.6±9.4) years, BMI (26.5±3.1) kg/m2, tPSA (19.5±4.1) ng/ml, biopsy Gleason score 6(6-7), prostate volume (33.4±15.8)ml and IIEF-5 score 12(10-16)] were collected. Preoperative study revealed 8 cases of cT1c, 1 case of cT2a and 1 case of cT2b. All patients were continent preoperatively. During the surgical procedure, the bladder was opened, and a circumferential incision was then made around the internal urethral orifice. Initially, posterior dissection of bilateral vas deferens and seminal vesicles was performed, followed by posterior dissection towards apex. Lateral dissection of neurovascular bundles was performed before anterior dissection towards apex. The exposed urethra was transected and specimen was removed. Vesicourethral anastomosis and closure of bladder was performed in a standard way. Results All 10 cases were successfully performed robotically without conversion, transfusion or other major intraoperative or postoperative complications. Postoperative pathology confirmed 6 cases of pT2a , 3 cases of pT2b and 1 case of pT2c [median Gleason score 6(6-7)]. One case was reported positive surgical margin. Operative time was (140.5±35.5) mins. Estimated blood loss was (65.5±35.5) ml. Urethral catheter was removed at 7 days postoperatively. Nine patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 1 patient returned to full continence at 2 weeks postoperatively. During a mean follow-up of 3 months (2-4 months), no biochemical recurrence was detected (tPSA 0.05). Conclusions Transvesical approach is a valid alternative of RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined by long term follow-up. Key words: Radical prostatectomy; Robot; Transvesical approach; Localized prostate cancer

Primary malignant melanotic melanoma and hypomelanotic melanoma of the female urethra: case series and a review of the literature in China.

The incidence of primary malignant melanoma (MM) of female urethra is extremely low, leading to paucity of recommendations on management. The objectives of our study were to gain more insight into the clinical features, diagnosis, treatment, and prognosis of this rare type of tumor. We carried out a retrospective analysis of all four cases who underwent an operation in our hospital since 1980. Moreover, other 32 cases of MM that have been reported in Chinese papers were also included for further review. The age of the patients ranged from 38 to 81 years. A mass in the urethral meatus and hematuria are common presentations. The final diagnosis depends on histopathological examination. After surgery alone or combined with chemotherapy/radiotherapy/immunotherapy, all cases were followed for 1-151 months, whereas only one lived for more than 4 years after receiving the diagnosis. A timely and accurate diagnosis of MM is critical, especially for hypomelanotic and amelanotic cases. Immunohistochemical staining and electron microscopy are necessary for a precise diagnosis in some cases. Extensive resection, early chemotherapy, and immunotherapy may help to improve survival.

Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture.

The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

The protective effect of non-transecting urethroplasty on erectile function in patients with posterior urethral stricture

Objective To explore the erectile function preservational mechanism of Non-transecting urethroplasty(NTU)for posterior urethral stricture. Methods From May 2012 to September 2016, 62 patients with posterior urethral stricture, who were treated with NTU, were enrolled in this study. The mean age was 37.5 years old, ranging 18-48 years old. The causes were pelvic fracture urethral injury in 53 cases and iatrogenic injury in 9 cases. Preoperative urethrography and urethroscopy revealed the strictures located in posterior urethra, which was at the distal of verumontanum. The mean length of stricture was 2.1 cm, ranging 0.5-2.5 cm. The average period between trauma and surgery was 6.4 months, ranging 3 months-2 years. All patients had no previous history of urethroplasty. Their sexual hormones were in normal level. Among those patients, the IIEF-5 scores were more than 12 and number of events during NPT test were more than twice. Finally, 43 cases were underwent NTU and 19 cases accepted inferior pubectomy (IP)+NTU. All patients had a general anesthesia. The bulbar urethra was mobilized dorsally from the tunica albuginea of the corpora cavernosa and then extended proximally up toward the perineal membrane. Scar tissue surrounding the urethra was excised and inferior pubectomy (IP) was performed as a supplemental technique to keep the suturing position without tension. The ventral hemi-circumference was then sutured with interrupted 4-0 polyglycolic sutures with tension-free anastomosis. The 18-Fr indwelling catheter was inserted. Result Average follow-up was 20.2 months, ranged from 12 to 36 months. In NTU group, NPT test revealed no significant difference in number of events(2.7±0.7 vs. 3.0±1.0, P>0.05), duration of best episode [(16.4±3.5)min vs. (16.4±3.8)min, P>0.05)] or tip rigidity[(31.2±4.7)% vs. (30.8±3.5)%, P>0.05)] between pre- and post-operation, respectively. The IIEF-5 score(19.7±1.9 vs.20.4±2.1, P<0.05 )and Qmax [(8.7±4.0)ml/s vs. (25.5±4.7)ml/s, P<0.05)] increased significant pre- and post-operation, respectively. In IP+NTU group, Qmax [(8.4±4.4)ml/s vs. (23.1±3.5)ml/s, P<0.05)] increased significant pre and post operation. The NPT test revealed slight decrease in number of events(2.3±0.6 vs. 1.6±1.0, P<0.05), duration of best episode [(15.6±2.4)min vs. (14.5±2.4)min, P<0.05)] or tip rigidity [(29.8±3.0)% vs. (25.6±7.1)%, P<0.05)] between pre- and post-operation, respectively. However, the IIEF-5 scores(17.3±1.6 vs.16.5±2.1, P<0.05) didn't show significant difference pre- and post-operation. Stricture recurrence occurred in 3 patients, the success rate was 95.2%(59/62) during 12 months following. Conclusion NTU is not only a safe and promising procedure for posterior urethral stricture less than 2.5cm, but also a new minimally invasive approach to preserve erectile function. Key words: Posterior urethral stricture; Non-transecting corpus spongiosum; Erectile function

Feasibility research of remifentanil combined with propofol on ureteral stent removal under patient's sober state

Objective To investigate feasibility of remifentanil combined with propofol on ureteral stent removal under outpatient's sober state. Methods From October 2015 to April 2017, 60 outpatients with ureteral stent removal were selected in hospital(considering urethral physiologic characteristics of male patients, the research selected all patients as male), who were randomly divided into two groups, 30 cases in each group. Group A was remifentanil-propofol-lidocaine group. Group B was local infiltration anesthesia group. Changes of vital signs during the operation in two groups were observed, such as heart rate (HR), mean arterial pressure (MAP) , oxygen saturation (SPO2) at different time points of pre-anaesthesia (T1), post injection (T2), cystoscopy (T3), double-J tube (T4), 3 minutes after operation (T5). Operation time, postoperative left ventricular time, anesthesia effect, visual analogue score of pain, postoperative patients' satisfaction were compared between two groups. Results Patients in two groups were able to remove ureteral stent successfully. Hemodynamics in group A were more stable than group B. Anesthesia effect in group A was better than group B. VAS score in group A was lower than group B(P 0.05). There was no significant difference in operation time between two groups(P>0.05). Conclusions Remifentanil-propofol-lidocaine compound solution can be used safely in ureteral stent removal of outpatients, which has great clinical value. Key words: Ureter; Stents; Fentanyl; Propofol

Treatment of upper urinary calculi after urinary reconstruction (report of 8 cases)

Objective To investigate the treatment methods and effectiveness of upper urinary calculi after urinary reconstruction. Methods Retrospective analysis of 8 patients with different reasons for prior upper urinary calculi after urinary reconstruction (total intravesical ileum cystectomy for bladder cancer, total cystectomy in situ cystectomy for bladder cancer, ureteral reimplantation for ureteral stricture, renal transplantation for renal failure, ileum ureterostomy for ureteral stricture) was performed, including 2 cases of renal calculus, 5 cases of ureteral calculi, 1 case of renal calculi associated with ureteral calculi, who got distinctive and individual treatment: 2 cases of extracorporeal shock wave lithotripsy (ESWL), 1case of percutaneous nephrolithotomy, 1 case of bilateral percutaneous nephrostomy in phase 1 and ureteroscopy combined with cystoscope for ureteral stent in phase 2, two cases of retrograde ureteroscopic lithotripsy, 1 case of percutaneous ureteroscopic lithotripsy by percutaneous ureteral ureteroscopy. One case was under active observation and follow-up. Results All of the investigated patients (7 cases) had no significant residual calculi after operation except the one with follow-up. Two patients got postoperative pyrexia, 1 patient got systemic inflammatory reaction and improved after anti inflammatory treatment. Conclusions The individualized treatment is adopted in patients with upper urinary calculi with different characteristics after ureteral reconstruction contributed to the good clinical effects. Key words: Urinary Calculi; Urethra

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective.

IntroductionPreserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.Material and methodsA PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.ResultsModifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.ConclusionsThere is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Diverticular Fistula of the Female Urethra on Lithiasis at the District Health Center (CSREF) in Communeii, Bamako, Mali

The diverticulum of the female urethra or sub-urethral pouch is in the form of a cul-de-sac lined with mucous membrane through the muscular layer of the urethra. Thus, it is a site of stasis, urinary infection, formation of calculus or even malignant tumor. The diverticula of the urethra or sub-urethral pouches in women have a prevalence of 0.5% to 6% depending on the series. We report the case of a 61-year-old patient operated for a diverticulum on fistulized urethra complicated lithiasis. Our patient had five pregnancies and five births when she consulted for dysuria, urinary burns evolving since a year. The urogenital examination revealed a partially stenotic urethral meatus and a 3-cm large fistulized intravaginal peri-urethral mass allowing urine leak. The mass was painful and hard at palpation. We performed transvaginal diverticulectomy. The follow-up was simple and the probe was removed two weeks after the surgery. An atomo-pathological examination of the resected diverticulum concluded an aspect compatible with lithiasis urethritis.