Laparoscopically assisted anorectoplasty (LAARP) for recto-bulbar urethral fistula (RBUF) has not become standard practice because of the risk of urethral injury and incomplete fistula removal in the deep pelvic space. We herein report an effective technique for treating recto-bulbar fistula, called "Reverse needle driving via umbilical trocar" in LAARP. The patient was diagnosed with RUBF by distal colostogram, and LAARP was planned to be performed. A 5-mm trocar was inserted at the umbilicus and three additional trocars were inserted. The surgeon stands on the right side of the patient and performs anorectoplasty. The RUBF was ligated with a trans-fixing suture of 4-0 absorbable monofilament that passed through the fistula tract using reverse needle driving with the surgeon's left hand. Since the surgeon's left-hand forceps are inserted through the umbilical trocar, which is located in the midline, the suture could be reliably placed just below the urethra by performing reverse left needle driving in a straight line through the umbilical trocar, confirmed with a urethroscope. After transection of the fistula, the rectum was pulled through and the stump was sutured to the perineal skin to construct the neo-anus. Postoperative imaging revealed complete fistula closure, without complications. This technique addresses the traditional challenges of urethral injury risk and incomplete fistula removal by utilizing strategic umbilical trocar positioning combined with flexible urethroscope confirmation. This robust RUBF technique represents an effective and safe approach for treating RUBF in LAARP.

Pubic osteomyelitis complicated by a rectus abdominis abscess and urethral fistula: a rare case report.

Aims: Several surgical techniques have been described for distal penile hypospadias (DPH) repair, including MAGPI, TIP, Mathieu, and glandular urethral disassembly (GUD). TIP is widely performed but has notable complications such as urethrocutaneous fistula and meatal stenosis, particularly with narrow glans or urethral plate. Urethral mobilization, first described by Beck (1898) and popularized by Koff (1981), avoids urethroplasty and reduces fistula risk, but traditional methods mobilize the urethra up to 1.5 cm. The GUD technique emphasizes minimal urethral mobilization with wide glandular dissection. This study aimed to evaluate the outcomes of the GUD technique in different types of DPH. Methods: This prospective study was conducted at Zazazig University Hospitals from April 2022 to April 2023. Thirty patients with primary or recurrent DPH, or urethral fistula, underwent repair using urethral mobilization. Patients with severe chordee, mid-penile, or proximal hypospadias were excluded. Operative details, complications, and follow-up findings were analyzed. Results: The mean age at surgery was 2.7 years, mean operative time 38.1 minutes, mean hospital stay 12.8 hours, and mean catheter duration 4.6 days. Follow-up averaged 3.6 months. Types included 10 (33.3%) coronal, 7 (23.3%) recurrent DPH, 6 (20%) subcoronal, 3 (10%) glandular, 2 (6.6%) urethral fistula, and 2 (6.6%) megameatus intact prepuce. Complications occurred in 5 patients (16.6%): meatal stenosis (6.6%), dehiscence (3.3%), meatal retraction (3.3%), and fistula (3.3%). No bleeding, infection, or iatrogenic chordee occurred. Conclusion: The GUD technique with minimal urethral mobilization is a simple, safe, and effective approach for selected DPH cases, yielding low complication rates.

A rare high anorectal malformation with recto-prostatic urethral fistula in a 1-year-old male: diagnostic and surgical management challenges in a resource-constrained setting: a case report

The Current Practice of Laparoscopically Assisted Anorectoplasty for Male Patients - An International Pediatric Endosurgery Group Survey.

Gender-affirming surgery (GAS) has witnessed a worldwide surge in demand due to societal and medical advances. Despite improved access, postoperative urogynecologic complications remain underrecognized and poorly documented. This review aims to classify complication patterns by surgical type, discuss their management, and highlight critical knowledge gaps to improve care for transgender and non-binary (TGNB) individuals. A literature review was conducted using PubMed, Embase, Cochrane, and Web of Science. After screening the articles for relevance, data were synthesized to present a narrative review to evaluate the patterns, management, and knowledge gaps surrounding urogynecologic complications following GAS, with a focus on TGNB populations. Transfeminine vaginoplasty frequently leads to urethral stricture (10-18%), meatal stenosis (5-10%), neovaginal stenosis (up to 30%), and dyspareunia (20-40%). Transmasculine procedures such as phalloplasty and metoidioplasty are associated with urethral fistulas (15-60% and 10-25%, respectively), strictures (25-58% and ~ 20%), and urinary retention (25-58% and 15-25%). Lower urinary tract symptoms are also common. Pelvic floor dysfunction (PFD) affects up to 94.1% of transgender men, impacting urinary and sexual function. Pelvic floor physical therapy (PFPT) before and after surgery can significantly reduce dysfunction rates. Urogynecology complications after GAS are prevalent and significantly impact quality of life, contributing to dysphoria and distress. Major evidence gaps remain, including inconsistent complication definitions, a lack of TGNB-specific patient-reported outcome measures (PROMs), and limited longitudinal data. Addressing these gaps and expanding access to trauma-informed, specialized rehabilitation are essential to improving long-term outcomes for TGNB individuals.

There are scant pooled data on transgender individuals regarding pelvic floor dysfunction, with or without gender-affirming surgery (GAS). A scoping review following PRISMA-ScR guidelines was carried out using PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and Lilacs in June 2024. The following pelvic floor disorders were investigated: urinary and anorectal dysfunctions, pelvic organ prolapse (POP), sexual dysfunction and pelvic floor disorders after GAS. Of 1284 studies, 35 remained for full-text analysis and data extraction. Urinary dysfunction was seen within 10 studies and prevalence of urinary incontinence (UI) varied from 15.4 to 53%, with age, BMI, and depression identified as factors in these studies. Anorectal dysfunction was found in four studies and constipation was the most frequent complaint, varying from 22 to 45%. Constipation was the main anorectal complaint (22%-45.6%). POP rate after neovaginoplasty ranged between 4% and 7.5%. Regarding sexual dysfunction, the Female Sexual Function Index, was the most commonly used questionnaire. Sexual desire appears to be affected by gender-affirming hormone therapy, whereas lubrication and pain were altered in trans women (TW) patients. Sexual dysfunction rates in trans men (TM) were high (54%-87.8%). Regarding complications, most common findings were vaginal stenosis in TW and urethral strictures and fistulas in TM. There is a high prevalence of pelvic floor dysfunction among the transgender population. Future cohort studies with better defined instruments and standardized pelvic examinations are recommended.

To evaluate the feasibility and clinical effectiveness of urethroplasty using a perineum-based scrotal flap (PBSF) for complex bulbomembranous urethral strictures (BMUS ≥ 5cm with severe scarring). We retrospectively analyzed 26 patients with complex BMUS treated at Shanghai Sixth People's Hospital between January 2015 and June 2024. The median stricture length was 7.0cm (IQR: 5.8-8.5). The preoperative maximum urinary flow rate (Qmax) was 2.8 ± 2.5ml/s. Standard posterior urethroplasty steps were performed, and when tension-free anastomosis was not possible, a full-thickness pedicled perineal flap was harvested and tubularized to bridge the defect. A silicone catheter was left in place for 4 weeks. All patients underwent uroflowmetry, retrograde urethrography (RUG) and voiding cystourethrography (VCUG) to determine the stricture length, location and recurrence. Erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5). Postoperative Qmax significantly improved to 18.1 ± 11.3ml/s (P < 0.001). Nineteen patients (73.1%) achieved both anatomical and functional success. Seven patients experienced Clavien-Dindo grade III complications (26.9%). Anastomotic strictures (4 patients, 15.4%): two treated with internal urethrotomy, two underwent cystostomy). Hair growth with stone formation (2 patients, 7.7%): Both experienced recurrence after endoscopic lithotripsy. Urethral skin fistula (1 patient, 3.8%): successfully managed with re-urethroplasty. No significant change in erectile function was observed (P = 0.396). PBSF urethroplasty provides well-vascularized tissue, flexible dimensions, and reliable tubularization. It is a viable option for long-segment BMUS, especially in patients with hairless perineal skin and when end-to-end anastomosis is not feasible.

Advanced Phalloplasty: Management of Complications and Techniques for Revision.

Genital reconstruction and urethral plasty after FournierÓ?s gangrene and urethral fistula

To investigate the clinical effect of transposition of gracilis muscle flap in repairing urethral perineal fistula after Miles operation. The clinical data of 3 patients with urethral perineal fistula treated in the Second Affiliated Hospital of Zhejiang University from September 2023 to November 2024 were analyzed retrospectively. All patients were male, aged from 59 to 68 years (mean 63 years). All patients underwent Miles operation because of low rectal cancer. Urethral perineal fistula occurred after 2 months to 13 years of the operation. The underlying comorbidities included diabetes (2/3), preoperative chemoradiotherapy (1/3), and chemotherapy alone (1/3). The endourethral fistula was located in the apical and membranous part of the prostate, with a diameter of 1.5-2.0 cm and a mean of 1.7 cm. Suprapubic cystostomy was performed one month before operation. In all 3 cases, perineal inverted "Y" incision was taken under general anesthesia to expose urethral fistula, cut off necrotic tissue and suture urethral fistula. The gracilis muscle of the right thigh was taken and turned through the perineal subcutaneous tunnel. and 6 stitches were suture at the urethral fistula. The operations of all 3 patients were completed successfully. The follow-up period ranged from 2 months to 12 months, with an average of 8 months. There was no case of urinary incontinence after removal of catheter 3 weeks after operation. In two patients, urethrography was reviewed 1 month after surgery to show no fistula residue and urethral stenosis, and the fistula was removed. In one patient with a history of radiotherapy, urethrography was reviewed 1 month after surgery to show a small amount of contrast overflow around the urethra, and urethrography was reviewed again 3 months after surgery to show no contrast overflow around the urethra. All the 3 patients had no disturbance of movement of the right lower limb, and the pain of different degrees of thigh incision was acceptable and basically relieved half a month after operation. Gracilis muscle flap is one of the effective methods for repairing urethral perineal fistula after Miles operation，which has a precise surgical result and few complications.

Foreskin circumcision is the oldest surgical procedure that has become part of Muslim and Jewish cultures and has been performed on healthy boys and men since ancient times. In addition, circumcision is a surgical method of treating phimosis, balanitis and balanoposthitis, which is used regardless of religion. A review of the literature showed that surgical and medical factors of foreskin circumcision sometimes lead to local complications such as penile ischemia and amputation, wound infection, bleeding, meatal stenosis, cutaneous urethral fistula, urethral erosion, iatrogenic hypospadias, bruising after injection, inflammation, necrosis and abscess. These complications worsen the aesthetic outcome of circumcision, the mood of patients and their relatives, and increase the costs of the healthcare system associated with the treatment of complications. In this regard, the current priority is to improve the safety of surgical procedures and medicinal solutions of the following pharmacological groups: anesthetics (drugs for intravenous anesthesia), local anesthetics, detergents (disinfectants), antiseptic and anti-inflammatory drugs. The fact is that it is these medicinal solutions that are most often used in circumcision. In recent years, targeted changes in local temperature have become very relevant, since hypothermia inhibits the intensity of local complications, increases the viability of damaged, ischemic and excised tissues and hyperthermia potentiates the disinfecting effect of antiseptics and helps stop bleeding. It has been shown that the risk of local complications during circumcision can be reduced by infrared monitoring of the local temperature of the penis and skin at the injection sites, as this ensures early detection of local hyperthermia in inflammation and local hypothermia in ischemia. It has been shown that the risk of ischemic soft tissue injury and amputation can be reduced by therapeutic hypothermia, as cooling increases tissue resistance to ischemia. It has been reported that the risk of wound infection in phimosis, paraphimosis, balanitis and balanoposthitis can be reduced by the use of antiseptic pyolytics, which are warm alkaline hydrogen peroxide solutions, and the risk of post-injection necrosis and abscesses can be reduced by pre-diluting drug solutions with water for injection by 2 or more times.

BackgroundThis study aims to investigate the clinical characteristics and treatment strategies for congenital anterior urethrocutaneous fistula.MethodsWe retrospectively analyzed the clinical data of patients with congenital anterior urethrocutaneous fistula who underwent surgical treatment at Anhui Children's Hospital from December 2009 to February 2023. Data collected included patient demographics, preoperative fistula characteristics, surgical details, and postoperative outcomes. Postoperative follow-up was conducted regularly to evaluate clinical outcomes.ResultsThe average age of the eight patients was 31.38 ± 18.70 months. Fistula locations included three at the coronal sulcus, three at the penile midshaft, one at the penoscrotal junction, and one on the scrotum. The mean length of the fistulas was 0.66 ± 0.28 cm. Two patients presented with associated penile curvature and scrotal raphe splitting, while one had isolated penile curvature. Seven patients underwent primary repair: for cases with fistulas at the coronal sulcus (Cases 2 and 8), the Mathieu technique was utilized due to well-developed glans and sufficient ventral subcutaneous tissue; three patients (Cases 1, 3, and 5) with well-developed urethral plates underwent the Duplay technique; for two cases (Cases 4 and 7) with narrow urethral plates, the TIP and Onlay techniques were employed, respectively. In Case 6, due to severe penile curvature, a staged approach was necessary, involving transection of the urethral plate with initial Duckett procedure and proximal urethrostomy, followed by urethrostomy closure as a secondary procedure. The mean duration of the first-stage surgery for all 8 patients was 100.75 ± 27.88 min. The urinary catheters were removed 12–14 days postoperatively for all surgeries. During a follow-up period of 15–154 months, all patients exhibited normal urination with no evidence of urethral fistula, stricture, diverticulum, or recurrent penile curvature.ConclusionsThe surgical outcomes of congenital anterior urethrocutaneous fistula are generally favorable. For patients without penile curvature, with well-developed urethral plates and sufficient surrounding fascial tissue, the Mathieu or Duplay techniques are suitable for repair. The Onlay or TIP techniques may be preferred for those with narrow urethral plates. For cases with severe penile curvature, transection of the urethral plate with staged repair may be warranted.

This article examines the bioethical aspects of ritual and prophylactic circumcision of boys (CВ). Religious, cul-tural, and social factors influence not only the decisions of many parents to have their children circumcised, but also thoseofpediatric surgeons who are asked to perform such an operation. When or under what conditions is it considered ethical to cir-cumcise the genitals of boys unless it is medically necessary? The central ethical issue at stake is that СВin infants is contrary to standard surgical principlesbecause there is no absolute medical indication for its performance. In most ordinary circum-stances, genital cutting of any individual without his or her own informed consent is a gross violation of that individual’s right to physical integrity and sexualexpression. The medical, ethical, cultural, and legal issues surrounding CВperformed without medical indications are numerous and complex, and are deeply rooted in Western civilization, which is unequivocally based onrespect for basic human rights and onthe protection of the physical and mental health of every member of society. The topic of СВis a complex paradigm for today's pluralistic, multi-ethnic and multicultural society, in which various demands, tradi-tions, rights, cultural, religious and ideological norms conflict with each other. Like any surgical operation, it carries a risk ofcomplications, which can be defined as early (bleeding, inflammation, damage to the glans and urinary retention) and late (such as phimosis, penile torsion and urethral cutaneous fistula). СВ, based on cultural and religious factors that are deeply ingrained in some segments of society, should be conducted in conditions of maximum security in specialized medical institutions and with properly trained personnel.

To evaluate whether the double cannula urethral stents (DCUS) are superior to traditional silicone Foley catheters (FC) or gastric tubes (GT) in hypospadias repair to decrease complications. This retrospective cohort study included 224 patients with hypospadias who underwent placement with DCUS (group DCUS), FC (group FC), and GT (group GT) after hypospadias repair between August 2019 and June 2023. The occurrence of early and late complications was assessed. The occurrence of complications in the three groups was compared, and the important contributing factors of urinary fistula and glans dehiscence were determined. A total of 224 patients, 86 in FC, 59 in GT, and 79 in the DCUS group, met the inclusion criteria. Postoperative early complications in the DCUS group were significantly lower than those in the FC group (P = 0.002), but there was no significant difference between the GT and FC group (P = 0.390), or between the GT and DCUS group (P = 0.065). Postoperative late complications in the DCUS group were significantly lower than those in the FC group (P = 0.040), and there was no significant difference between the GT and FC group (P = 0.422), or between the GT and DCUS group (P = 0.325). Logistic regression showed that age (p = 0.030) and stent type (p = 0.048) were important risk factors for urethral fistula, while glans width (p = 0.016) was an important risk factor for glans dehiscence. DCUS reduced the occurrence of complications compare to FC and GT after hypospadias repair, offering practical value for clinical application.

Metoidioplasty is a genital-masculinization surgery for transmen with gender dysphoria that creates a small penis from a hormonally enlarged clitoris, and while standing urination is currently facilitated by urethroplasty using buccal (Belgrade method) or labia-minora (Ring method) mucosal grafts combined with a vaginal flap, these techniques involve buccal wounds and are associated with high urethral-fistula rates. This study aims to describe our vaginal-mucosal graft metoidioplasty technique and report early outcomes from a case series of seven patients, based on the hypothesis that our approach may offer advantages over existing methods by avoiding buccal wounding seen in the Belgrade method and potentially reducing urinary complications compared to the Ring method. We performed vaginal-mucosal graft metoidioplasty on seven patients who expressed a desire to undergo metoidioplasty during preoperative counseling. At our institution, metoidioplasty is performed simultaneously with hysterectomy, oophorectomy, and vaginal closure, which allows us to harvest long vaginal flaps and vaginal-mucosal grafts of various sizes. We incorporate these grafts into urethroplasty to improve surgical outcomes. Primary outcome was the incidence of urinary complications, namely, urethral fistula and stricture. Median blood loss was 1610mL. Median operative time was 4:57h:min. Median postoperative follow-up period was 5 (range 2-11) months. One patient developed urethral fistula requiring closure surgery. Another had mild urethral stricture that is still under observation. The remaining patients had no noticeable complications. Vaginal-mucosal graft metoidioplasty does not involve buccal wounding and it had similar urethral-fistula rates in our small series as the Belgrade method (14% vs. 7%-15%). The technique permits urethral reconstruction with readily available vaginal mucosa. Blood loss was high because the vaginal flap is elevated with scissors and the vaginal-mucosal graft must be harvested in a circumferential manner. However, we believe blood loss will improve with experience. Our case series also only involved seven patients and follow-up of 2-11months, and patient satisfaction regarding cosmetic, urinary, and sexual outcomes was not routinely recorded. Longer follow-up, more cases, and the use of patient-recorded outcome measures are needed to determine long-term surgical, urinary, cosmetic, and sexual outcomes. Vaginal-mucosal graft metoidioplasty provides an accessible method for urethral reconstruction and may have acceptable urinary-complication rates, although further studies are required to confirm its safety and efficacy.

Background: Hypospadias, a common congenital anomaly, is characterized by incomplete development of the urethral spongiosum and ventral prepuce. Surgical repair aims to achieve a functional penis, enabling upright urination and sexual intercourse, while also prioritizing aesthetic outcomes. Despite advancements in surgical techniques, the optimal approach for skin coverage in hypospadias repair remains debated. Methods: This study compared two skin coverage techniques in hypospadias repair: The inner preputial buttonhole flap and the Byars flap. All 40 patients underwent urethroplasty using the Snodgrass technique, with 20 patients receiving a preputial buttonhole flap and the remaining 20 receiving a Byars flap as a waterproof layer. Postoperative outcomes, including urethral fistula, meatal stenosis, and the need for repeat surgery, were evaluated over a minimum follow-up period of six months. Data were analyzed using SPSS software. Results: The mean age of the patients was 26.1 ± 8.5 months No significant differences were observed between the two techniques in terms of urethral fistula, meatal stenosis, or reoperation rates (P &gt; 0.05). Conclusions: The preputial buttonhole flap may offer advantages over the Byars flap in neourethra coverage for distal hypospadias, particularly in reducing fistula formation. However, further studies with larger sample sizes are needed to validate these findings and establish definitive recommendations.

Abstract Objectives Penile augmentation with injections of liquid paraffin and implantation of silicon beads is a common practice in some Balkan countries. Paraffinomas and siliconomas are the result of the foreign body reaction, which occur in almost every case, having a tremendous and sometimes catastrofic effect, due to serious infection and penile deformities. We present a case of paraffinoma and siliconoma after a failed penile augmentation and the oparative technique we applied for penile reconstruction. Methods A 40 year-old male presented at the ER with penile pain due to paraphimosis. The patient had underwent a penile augmentation operation with silicon beads implantation and liquid paraffin injections troughout the penile shaft, a few weeks before. Results The patient was immediately admitted and underwent an emergency radical circumscicion with extended excision of fibrotic scirrhous masses and removal of erroded silicon beads. A negative pressure drainage was placed along with a typical mummy wrap. Frequent wound changes followed, but due to foreskin necrosis at the site of sutures, subcoronally, the patient underwent a wound-freshening, 2 weeks after the operation.Patient had a well post-operative healing, without the need of further intervention, or any major complication such as a fistula formation, and 2 months after the first operation he reports a pain-free succesful intercourse. Conclusions Penile paraffinomas and siliconomas can occur after a failed penile augmentation injection of liquid paraffin and silicon beads implantation. Most of the times such interventions are performed by non-medical personnel. The choice of a plastic reconstructive treatment depends on the extent of the paraffinoma and siliconoma. If it is limited to the foreskin, a radical circumcision, excising the fibrotic tissue and any foreign body is sufficient but if it extends to the skin of the penile shaft, a plastic defect coverage with a graft, autologous or mesh, is required. If serious complications are present, such as urethral fistulas, auxiliary reconstructive procedures should be performed. Conflicts of Interest None.

Abstract Objectives To describe the long-term outcomes of urethral reconstruction in a large cohort of individuals assigned female at birth (AFAB) following phalloplasty. All patients had an integrated (tube-in-tube) urethra or staged radial artery urethroplasty (RAU). Methods Retrospective analysis of a prospectively compiled database. All patients between 2013-2017 were included. Rates of urethral fistulae and strictures were recorded. Events were recorded at the time of diagnosis, and survival analyses were used to describe the cohort following urethroplasty. Results 37.7% of the 289 patients experienced a urethral complication (56% were fistulae and 44% strictures) with a cumulative failure probability of 60.4% at 10y. 13.1% of patients had a radial artery urethroplasty (RAU) to reconstruct the urethra. The median follow-up (FU) for successful urethral constructions was 8.34y (IQR 7.43-9.19y), while the median time to urethral complications was 6.9y (IQR 0.67-8.57y). On Kaplan–Meier analysis, there was a clear increase in failure rates within the first 2y and after the first 6.5y of FU. 42.2% of the complications occurred within the first 2 years, while 51.4% occurred after 6.5 years with no difference between fistulae and strictures. Urethral reconstruction by RAU reduced urethral complications (Cox HR 0.4, p = 0.032, CI = 0.18-0.92). The overall urethroplasty failures recorded were 20.2% with a cumulative failure probability of 20.8% at 10y. The median time to failure was 1.28y with a median FU of 7.9y. At Cox regression, fistulae repair had slightly better success than strictures (72.9% vs 85.2%, Cox p = 0.111). Conclusions This is the largest study to date on a well-defined cohort of AFAB individuals following phalloplasty with urethral reconstruction and join-up. The urethral complication rate was 37.7% despite contemporary reconstructive techniques. Most of the complications were diagnosed within the first 2y and after 6.5y. RAU reduced urethral complications. The cumulative success probability of urethroplasty was ~80%. The Kaplan Meier curve representing events after repair of the first urethral complication may be biased by the time the complication was repaired, and failed repairs could potentially happen earlier than were recorded. Conflicts of Interest none.

This study aimed to compare the efficacy and complication rates of urethral-plate longitudinal incision combined with Mathieu repair versus tubularized incised plate (TIP) in the reoperation of hypospadias. This study retrospectively analyzed 46 patients with subcoronal urethral fistula and glans dehiscence after hypospadias operation in our hospital from February 2021 to March 2023. It has been 6-56 months since the initial operation. For the selected patients with subcoronal fistula, the tissues from the fistula to the urethral orifice were cut in the membranous or skin bridge shape. Meanwhile, all patients were divided into two groups, including group A and group B. Group A (n = 19) received the urethral-plate longitudinal incision combined with Mathieu repair. Group B (n = 27) adopted conventional TIP repair. The complication rate and urethral orifice shape were compared between the two groups. In terms of postoperative follow-up, there were three cases with complications in group A and 12 in group B, and the difference was statistically significant (p = 0.041). With regard to urethral orifice, no case in group A and seven cases in group B had urethral orifice, and the difference was statistically significant (p = 0.036). Except for glans dehiscence, all cases with urethral orifice in both groups had a fissured appearance. As an effective approach to repair glans dehiscence and subcoronal fistula after hypospadias operation, urethral-plate longitudinal incision combined with Mathieu helps to further expand the urethral orifice and form a reasonable vertical fissured urethral orifice. Institutional Reviewer Board: IRB:EYLL-2023-006.