Effects of a selective androgen receptor modulator (SARM), GSK2849466A, on stress urinary incontinence and bladder activity in rats with ovariectomy-induced oestrogen deficiency

OBJECTIVES

To report the effect of a selective androgen receptor modulators (SARMs) on the urethral continence mechanisms in a rat model of stress urinary incontinence (SUI) induced by bilateral ovariectomy (OVX).

MATERIALS AND METHODS

Female Sprague-Dawley rats with bilateral OVX were used. Rats were divided into five groups; sham operated, vehicle-treated OVX, low-dose SARM-treated OVX (GSK2849466A: 0.005 mg/kg/day, per os [p.o.]), high-dose SARM-treated OVX (GSK2849466A: 0.03 mg/kg/day, p.o.) and dihydrotestosterone (DHT)-treated OVX (1 mg/kg/day, subcutaneous) groups. After 4 weeks of SARM treatments or 3 weeks of DHT treatment (6 weeks after OVX), rats were subjected to evaluation of the sneeze-induced continence reflex using microtransducer-tipped catheter methods, sneeze-induced leak-point pressure, and continuous cystometry measurements, followed by histological analyses of urethral tissues.

RESULTS

(i) OVX significantly impaired urethral continence function after 6 weeks to induce SUI during sneezing. (ii) Low-dose SARM treatment restored urethral baseline pressure (UBP) without affecting the amplitude of urethral response during sneezing (A-URS), partially reversing OVX-induced SUI during sneezing. (iii) High-dose SARM treatment reversed decreases in both UBP and A-URS, more effectively preventing SUI during sneezing. (iv) DHT treatment only restored A-URS without affecting UBP, partially preventing OVX-induced SUI during sneezing. (v) The high-dose SARM treatment induced hypertrophy of the striated and smooth muscle around the urethra. (vi) SARM treatment did not affect bladder function in sham or OVX rats.

CONCLUSION

Treatment with SARMs could be a more effective modality for the treatment of SUI than DHT, without affecting bladder function, by enhancing smooth- and striated muscle-mediated urethral function under stress conditions such as sneezing.

Complete Urethral Duplication: Case Report and Literature Review

Urethral duplication (UD) is a rare-congenital anomaly that can affect the genito-urinary system. The aim of this case report is to show our experience in this case, including the investigation and operative techniques that we utilized. In the literature review, we will show that different types of duplication, radiological investigations, and surgical techniques have been used to treat this condition.

The Urethral Microbiota: A Missing Link in the Female Urinary Microbiota

PURPOSE

We examined the urethral microbiota, determined if it differs from the bladder urinary microbiota, and assessed if its composition differs based on patient demographic factors and presence of lower urinary tract symptoms.

MATERIALS AND METHODS

Patients presenting to our urogynecology clinic were enrolled in the study. Demographic information and responses to the Pelvic Floor Distress Inventory questionnaire were collected. All participants provided midstream voided urine, periurethral swab, transurethral swab and catheterized urine samples, which were analyzed by Expanded Quantitative Urine Culture and MALDI-TOF mass spectrometry. Bray-Curtis dissimilarity analysis assessed diversity between sample types for each participant. Kruskal-Wallis, chi-square, McNemar, Wilcoxon signed rank and Fisher's exact tests tested for significance.

RESULTS

A total of 49 patients participated in the study. Bladder microbiota were dissimilar to urethral, periurethral and voided urine microbiota (p <0.0001). Urethral and periurethral microbiota were similar (p >0.05), but the urethral microbiota were dissimilar to voided urine microbiota (p=0.001) while the periurethral microbiota were not (p >0.05). Women less than 55 years old were more likely to be sexually active, premenopausal and Hispanic compared to women 55 years old or older. Women in the younger cohort had Lactobacillus and Gardnerella cultured from urethral samples more frequently and more abundantly than women in the older cohort. There was no significant association between lower urinary tract symptoms and the frequency or abundance of urethral bacteria species.

CONCLUSIONS

Niches of microbiota along the female lower urinary tract may be influenced by age, menopausal status and sexual activity. More research is needed to determine the function and clinical significance of the urethral microbiome.

Urine as a Main Effector in Urological Tissue Engineering-A Double-Edged Sword

In order to reconstruct injured urinary tract tissues, biodegradable scaffolds with autologous seeded cells are explored in this work. However, when cells are obtained via biopsy from individuals who have damaged organs due to infection, congenital disorders, or cancer, this can result in unhealthy engineered cells and donor site morbidity. Thus, neo-organ construction through an alternative cell source might be useful. Significant advancements in the isolation and utilization of urine-derived stem cells have provided opportunities for this less invasive, limitless, and versatile source of cells to be employed in urologic tissue-engineered replacement. These cells have a high potential to differentiate into urothelial and smooth muscle cells. However, urinary tract reconstruction via tissue engineering is peculiar as it takes place in a milieu of urine that imposes certain risks on the implanted cells and scaffolds as a result of the highly cytotoxic nature of urine and its detrimental effect on both growth and differentiation of these cells. Both of these projections should be tackled thoughtfully when designing a suitable approach for repairing urinary tract defects and applying the needful precautions is vital.

Discrete Hedgehog Factor Expression and Action in the Developing Phallus

Hypospadias is a failure of urethral closure within the penis occurring in 1 in 125 boys at birth and is increasing in frequency. While paracrine hedgehog signalling is implicated in the process of urethral closure, how these factors act on a tissue level to execute closure itself is unknown. This study aimed to understand the role of different hedgehog signalling members in urethral closure. The tammar wallaby (Macropus eugenii) provides a unique system to understand urethral closure as it allows direct treatment of developing offspring because mothers give birth to young before urethral closure begins. Wallaby pouch young were treated with vehicle or oestradiol (known to induce hypospadias in males) and samples subjected to RNAseq for differential expression and gene ontology analyses. Localisation of Sonic Hedgehog (SHH) and Indian Hedgehog (IHH), as well as the transcription factor SOX9, were assessed in normal phallus tissue using immunofluorescence. Normal tissue culture explants were treated with SHH or IHH and analysed for AR, ESR1, PTCH1, GLI2, SOX9, IHH and SHH expression by qPCR. Gene ontology analysis showed enrichment for bone differentiation terms in male samples compared with either female samples or males treated with oestradiol. Expression of SHH and IHH localised to specific tissue areas during development, akin to their compartmentalised expression in developing bone. Treatment of phallus explants with SHH or IHH induced factor-specific expression of genes associated with bone differentiation. This reveals a potential developmental interaction involved in urethral closure that mimics bone differentiation and incorporates discrete hedgehog activity within the developing phallus and phallic urethra.

Influence of body position on dynamics of the pelvic floor measured with transperineal ultrasound imaging in men

AIMS

This paper aims to evaluate the feasibility of transperineal ultrasound imaging (TPUS) for visualizing the motion of pelvic landmarks associated with striated pelvic floor muscle contraction in men in standing; to compare the locations of pelvic landmarks between sitting and standing; and to compare the effects of different body positions on measures of pelvic floor muscle contraction.

METHODS

Thirty-five men awaiting prostatectomy volunteered to participate. Participants performed three repetitions of submaximal pelvic floor contraction in sitting and again in standing. Movement of pelvic landmarks with contraction was recorded using an ultrasound imaging transducer placed on the perineum.

RESULTS

The feasibility of TPUS in men in standing was demonstrated through the visualization of three out of four pelvic landmarks in more than 95% of images in the standing position. Analysis of pelvic landmarks and their respective relationships with muscle shortening demonstrated that the anorectal junction and urethrovesical junction were lower and the estimated length of puborectalis was shorter in standing than sitting. The mid-urethra (striated urethral sphincter) and anorectal junction (puborectalis) landmark displaced further cranially in standing than sitting.

CONCLUSIONS

TPUS can be used to visualize three pelvic landmarks in men with cancerous prostates. Puborectalis is shorter at rest in standing than sitting, and elevation of the mid-urethra and the anorectal junction is more in standing than sitting. Together these findings indicate that feedback for pelvic floor muscle training is possible in both positions, but the position needs to be standardized for a comparative assessment.

Involuntary cough is superior to voluntary cough for identifying stress urinary incontinence

Introduction

Voluntary cough (VC) and the laryngeal expiration reflex (LER) provoke stress urinary incontinence (SUI). The aim of this article is to analyze the effectiveness of these stimuli on the timing of urinary leaks.

Material and methods

Urodynamic testing using pressure catheters was performed on 123 subjects with history of SUI. The LER was triggered using the induced reflex cough test (iRCT). Each subject was tested with VC and LER and leaked with one or both stimuli. The occurrence and timing of leaks were recorded.

Results

The peak and average intra-abdominal pressures were 16-19% greater for LER compared to VC. Of the 123 subjects, LER caused leak in 118 (96%), VC in 71 (58%) and both in 66 (54%). For LER compared to VC, leak was more likely to occur during or immediately after the first expiratory effort. The electromyogram for VC and LER were similar.

Conclusions

The iRCT reliably initiated the LER and triggered SUI more effectively than VC. During VC, the smooth muscle of the internal urethral sphincter (IUS) starts to contract during inspiration, and constriction of the IUS continues into the expiratory phase; this increased urethral tonicity would lessen the likelihood of SUI. We refer to this as the inspiration closure reflex (ICR). With LER the inspiration would not take place, and the first expiratory effort would be against a non-constricted IUS, making leak more likely. Our findings disprove the pressure transmission theory. The internal and external urethral sphincters may both increase urethral closure pressure and resistance.

The risk of urinary tract infection in vegetarians and non-vegetarians: a prospective study

Urinary tract infection (UTI) is caused principally by ascending Escherichia coli infection via an intestine-stool-urethra route. Recent studies found that the strains of E. coli causing UTIs, called extra-intestinal pathogenic E. coli (ExPEC), were distinct from the intestinal pathogenic strains and normal commensal strains. Further analysis found the meat including poultry and pork is the major reservoir for ExPECs. Vegetarians avoid meat and should theoretically have less exposure to ExPEC. However, no study thus far has examined whether vegetarian diets reduce the risk of UTI. Our aim was to examine the association between vegetarian diet and UTI risk in a Taiwanese Buddhist population. We prospectively followed 9724 Buddhists free of UTI from 2005 to 2014. During the 10-year follow-up, 661 incident UTI cases were confirmed. Diet was assessed through a food frequency questionnaire. Cox regression was used to evaluate the prospective association between a vegetarian diet on risk of UTI while adjusting for age, sex, educational level, alcohol-drinking, smoking, hypertension, diabetes mellitus, hyperlipidemia, and disease conditions predisposing to UTIs. Overall, vegetarian diet was associated with 16% lower hazards (hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.71-0.99). In subgroup analysis, the protective association between vegetarian diet and UTI is observed mainly in the female (HR: 0.82, 95% CI: 0.69-0.99), never smokers (HR: 0.80, 95% CI: 0.67-0.95), and for uncomplicated UTI (HR: 0.81, 95% CI: 0.68-0.98).

[Urethral prolapse in a girl with urogenital bleeding]

Urethral prolapse is an uncommon condition that involves the distal urethra. It occurs most often in prepuberal black girls and in postmenopausal women. The reason for consultation is usually genital bleeding and/or dysuria. The treatment includes from conservative therapy to surgical interventions. We present the case of an 11-year-old white girl who came to the Emergency Room due to vaginal discharge for 6 days and genital bleeding for 3 days that was accompanied by stabbing pain in genital region, with occasional dysuria. A circular eversion of the urethral mucosa was observed, so the patient was surgically intervened, performing a prolapse resection with clinical resolution.

Contribution of Cav1.2 Ca2+ channels and store-operated Ca2+ entry to pig urethral smooth muscle contraction

Urethral smooth muscle (USM) generates tone to prevent urine leakage from the bladder during filling. USM tone has been thought to be a voltage-dependent process, relying on Ca²⁺ influx via voltage-dependent Ca²⁺ channels in USM cells, modulated by the activation of Ca²⁺-activated Cl^- channels encoded by Ano1. However, recent findings in the mouse have suggested that USM tone is voltage independent, relying on Ca²⁺ influx through Orai channels via store-operated Ca²⁺ entry (SOCE). We explored if this pathway also occurred in the pig using isometric tension recordings of USM tone. Pig USM strips generated myogenic tone, which was nearly abolished by the Ca_v1.2 channel antagonist nifedipine and the ATP-dependent K⁺ channel agonist pinacidil. Pig USM tone was reduced by the Orai channel blocker GSK-7975A. Electrical field stimulation (EFS) led to phentolamine-sensitive contractions of USM strips. Contractions of pig USM were also induced by phenylephrine. Phenylephrine-evoked and EFS-evoked contractions of pig USM were reduced by ~50-75% by nifedipine and ~30% by GSK-7975A. Inhibition of Ano1 channels had no effect on tone or EFS-evoked contractions of pig USM. In conclusion, unlike the mouse, pig USM exhibited voltage-dependent tone and agonist/EFS-evoked contractions. Whereas SOCE plays a role in generating tone and agonist/neural-evoked contractions in both species, this dominates in the mouse. Tone and agonist/EFS-evoked contractions of pig USM are the result of Ca²⁺ influx primarily through Ca_v1.2 channels, and no evidence was found supporting a role of Ano1 channels in modulating these mechanisms.

Retrospective analysis of diagnoses and outcomes of 45 cats with micturition disorders presenting as urinary incontinence

Background

In contrast to dogs, the causes and outcomes of urinary incontinence (UI) in cats are largely unknown.

Objectives

To determine the causes, identify comorbid conditions, and assess outcomes of cats with micturition disorders presenting as UI.

Animals

Forty‐five cats with UI.

Methods

Retrospective study. Medical records of cats presented from January 2006 to December 2017 were searched using 45 keywords related to UI. History, presenting complaint, and physical examination findings were used to confirm a diagnosis. Cases were categorized based on functional and anatomic localizations.

Results

Forty‐five cats met inclusion criteria. Spinal cord disease was the most common cause of UI (n = 18), followed by urethral (n = 17), bladder (n = 9), and ureteral (n = 1) disorders. Proportions of voiding and storage phase disorders were similar (53% and 47%, respectively). However, voiding‐phase disorders were observed more frequently in males and younger‐aged cats (P < .03). Urinary tract infection was detected in 11 of 28 (39%) cats. Outcomes were available in 38/45 cases; 16 cats (42%) regained continence, 3 (8%) improved with treatment, and 19 (50%) remained incontinent or were euthanized. Multiple variable logistic regressions indicated that spinal cord disease was significantly more likely to be associated with poor outcomes compared to bladder or urethral disorders (P < .04).

Conclusions and Clinical Importance

Urinary incontinence in cats was associated with a variety of congenital and acquired disorders that affected both phases of micturition with similar frequency. Incontinent cats with spinal cord disorders were common and warrant a more guarded prognosis than do cats with bladder or urethral disorders.

Effect of Early Oxybutynin Treatment on Posterior Urethral Valve Outcomes in Infants: A Randomized Controlled Trial

PURPOSE

We studied the effect of oxybutynin on bladder and upper urinary tract outcomes in infants following posterior urethral valve ablation.

MATERIALS AND METHODS

Patients younger than 12 months old who had undergone primary endoscopic valve ablation for posterior urethral valves were screened for eligibility. Patients who had undergone urinary diversion or had other conditions that could affect lower urinary tract function were excluded. Study patients were randomized to either oxybutynin (0.2 mg/kg 3 times daily) until toilet training or active observation. The study end points were serum creatinine, estimated glomerular filtration rate, hydronephrosis improvement, vesicoureteral reflux resolution, febrile urinary tract infection and toilet training.

RESULTS

A total of 49 infants (24 receiving oxybutynin and 25 undergoing observation) were enrolled between December 2013 and September 2015 and completed at least 1 year of followup. Oxybutynin was discontinued before toilet training in 5 patients due to facial flushing in 2, bladder and upper tract dilatation in 2, and cognitive changes in 1. After a median followup of 44.2 months (range 12 to 57.6) median serum creatinine and estimated glomerular filtration rate were not significantly different between the groups (p=0.823 and p=0.722, respectively). Renal units in the oxybutynin group had a greater likelihood of hydronephrosis improvement (61.9% vs 34.8%, p=0.011) and resolution of vesicoureteral reflux (62.5% vs 25%, p=0.023). Febrile urinary tract infection (29.2% vs 40%, p=0.404), completion of toilet training (70.8% vs 76%, p=0.748) and age at toilet training (p=0.247) did not differ significantly between the oxybutynin and observation groups.

CONCLUSIONS

Oxybutynin enhances hydronephrosis improvement and vesicoureteral reflux resolution following primary endoscopic valve ablation in infants but periodic monitoring is warranted.

Smooth muscle of the male pelvic floor: An anatomic study

Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and innervation of the smooth muscle (SM) of the whole pelvic floor using male fetuses. We removed en-bloc the entire pelvis of three male fetuses. The specimens were serially sectioned before being stained with Masson's trichrome and hematoxylin and eosin, and immunostained for SMs, and somatic, adrenergic, sensory and nitrergic nerve fibers. Slides were digitized for three-dimensional reconstruction. We individualized a middle compartment that contains SM cells. This compartment is in close relation with the levator ani muscle (LAM), rectum, and urethra. We describe a posterior part of the middle compartment posterior to the rectal wall and an anterior part anterior to the rectal wall. The anterior part is split into (1) a centro-levator area of SM cells localized between the right and left LAM, (2) an endo-levator area that upholsters the internal aspect of the LAM, and (3) an infra-levator area below the LAM. All these areas are innervated by autonomic nerves coming from the inferior hypogastric plexus. The core and the infra-levator area receive the cavernous nerve and nerves supplying the urethra. We thus demonstrate that these muscular structures are smooth and under autonomic influence. These findings are relevant for the pelvic surgeon, and especially the urologist, during radical prostatectomy, abdominoperineal resection and intersphincteric resection. Clin. Anat., 2019. © 2019 Wiley Periodicals, Inc.

Which molecular targets do we need to focus on to improve lower urinary tract dysfunction? ICI-RS 2017

AIMS

Update on some molecular targets for new drugs to improve lower urinary tract (LUT) dysfunction.

METHODS

Using PubMed, a search for literature on molecular targets in the LUT was performed to identify relevant clinical and animal studies. Keywords were entered as Medical Subject Headings (MeSH) or as text words. The Mesh terms were used in various combinations and usually included the terms lower urinary AND pharmacology. Other Mesh term included: bladder, urethra, CNS, physiology, afferent activity, ATP, prostanoids, cannabinoids, fibrosis. Search results were assessed for their overall relevance to this review.

RESULTS

In a normal bladder, ATP contributes little to detrusor contraction, but in a diseased bladder ATP may contribute to OAB. Selective decrease of ATP release via adenosine A1 receptor stimulation offers a potential treatment possibility. Candidates for relaxation of the smooth muscle of the urethra can be found among, for example, the receptor subtypes of PGE₂ , and PGD₂ . Drugs for relaxation of the striated sphincter can target the muscle directly or the spinal sphincter control. Fibrosis is a major problem in LUT dysfunction and agents with an inhibitory effect on the TGFβ pathway, for example relaxin and BMP7, may be promising avenues. Available drugs with a CNS site of action are often limited by low efficacy or adverse effects. Inhibitors of the glycine receptor Gly-T2 or antagonists of the adenosine A2 receptor may be new alternatives.

CONCLUSION

New molecular targets for drugs aiming at improvement of voiding function can be identified, but their translational impact remains to be established.

Lower urinary tract transitional cell carcinoma in cats: Clinical findings, treatments, and outcomes in 118 cases

Background

Lower urinary tract transitional cell carcinoma (TCC) is an important but rarely described disease of cats.

Objectives

To report the clinical characteristics, treatments, and outcomes in a cohort of cats with lower urinary tract TCC and to test identified variables for prognostic relevance.

Animals

One‐hundred eighteen client‐owned cats with lower urinary tract carcinoma.

Methods

Medical records were retrospectively reviewed to obtain information regarding clinical characteristics, treatments, and outcomes. Recorded variables were analyzed statistically.

Results

Median age of affected cats was 15 years (range, 5.0‐20.8 years) and median duration of clinical signs was 30 days (range, 0‐730 days). The trigone was the most common tumor location (32/118; 27.1%) as assessed by ultrasound examination, cystoscopy, or both. Treatment was carried out in 73 of 118 (61.9%) cats. Metastatic disease was documented in 25 of 118 (21.2%) cats. Median progression‐free survival and survival time for all cats were 113 days (95% confidence interval [CI], 69‐153) and 155 days (95% CI, 110‐222), respectively. Survival increased significantly (P < .001) when comparing cats across the ordered treatment groups: no treatment, treatment without partial cystectomy, and treatment with partial cystectomy. Partial cystectomy (hazard ratio [HR], 0.31; 95% CI, 0.17‐0.87) and treatment with nonsteroidal anti‐inflammatory drugs (HR, 0.55; 95% CI, 0.33‐0.93) were significantly associated with longer survival times.

Conclusions and Clinical Importance

The results support treatment using partial cystectomy and NSAIDs in cats with TCC.

Penile ring entrapment - A true urologic emergency: Grading, approach, and management

Penile rings are used to sustain erection in order to enhance sexual pleasure. They work by reducing the outflow of blood from the cavernosal tissue. However, if left for extended periods of time severe edema, urethral fistula, gangrene, and even complete loss of the distal penis can ensue, this is known as penile ring entrapment (PRE). Management poses particular challenges due to its rarity. Herein, we report our experience with three patients from our institution that presented with PRE and include a review of the approaches others have taken. We also propose a simpler and more effective grading scale to allow for easier communication between providers, as the current grading scales do not do so.

[Mucosal melanoma primary and metastatic cases with urogenital localization in our department]

INTRODUCTION

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.

MATERIALS AND METHOD

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.

RESULTS

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.

CONCLUSION

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.

Histology Atlas of the Developing Mouse Urinary System With Emphasis on Prenatal Days E10.5-E18.5

Congenital abnormalities of the urinary tract are some of the most common human developmental abnormalities. Several genetically engineered mouse models have been developed to mimic these abnormalities and aim to better understand the molecular mechanisms of disease. This atlas has been developed as an aid to pathologists and other biomedical scientists for identification of abnormalities in the developing murine urinary tract by cataloguing normal structures at each stage of development. Hematoxylin and eosin- and immunohistochemical-stained sections are provided, with a focus on E10.5-E18.5, as well as a brief discussion of postnatal events in urinary tract development. A section on abnormalities in the development of the urinary tract is also provided, and molecular mechanisms are presented as supplementary material. Additionally, overviews of the 2 key processes of kidney development, branching morphogenesis and nephrogenesis, are provided to aid in the understanding of the complex organogenesis of the kidney. One of the key findings of this atlas is the histological identification of the ureteric bud at E10.5, as previous literature has provided conflicting reports on the initial point of budding. Furthermore, attention is paid to points where murine development is significantly distinct from human development, namely, in the cessation of nephrogenesis.

Canadian Experience with the Adjustable Transobturator Male System for Post-Prostatectomy Incontinence: A Multicenter Study

PURPOSE

We assessed the efficacy and safety profile of the ATOMS® (Adjustable Transobturator Male System) for post-prostatectomy incontinence in a multicenter North American setting.

MATERIALS AND METHODS

We reviewed outcomes from 8 centers in men who underwent treatment of post-prostatectomy incontinence with an ATOMS. Primary study outcomes were pad changes and continence, defined as requiring 1.0 or 0 pad postoperatively in patients who required 2.0 or more pads preoperatively and 0 pad in those who required more than 1.0 or 2.0 pads preoperatively. Secondary outcomes included improvement, 90-day complications and patient satisfaction.

RESULTS

A total of 160 patients were enrolled in study with a median followup of 9.0 months. Preoperative median pad use was 4 per day (IQR 3-5). Of the patients 36.3% reported severe preoperative incontinence, 31.3% received prior radiotherapy and 16.3% underwent previous incontinence surgery. Median postoperative pad use after adjustments was 0.5 per day (IQR 0-1, p <0.001). The overall continence rate was 80.0% with improvement in 87.8% of cases. Of the patients 70.1% underwent a mean ± SD of 2.4 ± 2.7 adjustments (IQR 0-16). The patient satisfaction rate was 86.3%, 22.3% experienced 90-day complications of any grade and 7 (4.4%) experienced Clavien III complications primarily related to the injection port. Patients with a history of radiotherapy were less likely to be continent (62.5% vs 87.9%, p=0.002), improved (77.1% vs 92.6%, p=0.02) or satisfied (69.8% vs 93.2%, p=0.001). Similarly patients with previous incontinence surgery had lower rates of continence, improvement and satisfaction (57.7%, 73.1% and 69.6%, respectively).

CONCLUSIONS

In the short term the ATOMS is a safe and efficacious device to treat post-prostatectomy incontinence. Patients with concurrent radiotherapy and previous incontinence surgery respond to treatment but are less likely to be continent, improved or satisfied.

Analysis of a 7-year national online audit of the management of open reconstructive urethral surgery in men

OBJECTIVE

To conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK.

METHODS

Between 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform. Surgeon-entered information was collected in 95 fields regarding the stricture aetiology, prior management, mode of presentation, type of surgery and outcomes, with a potential 283 variable responses in the 95 fields. Data were analysed to compare UK practice with that reported in the contemporary literature and with guidelines.

RESULTS

Data on 4809 men were entered by 39 centres and 50 surgeons. Field completeness was 70.7%, 74.3% and 53.7% for preoperative, operative and follow-up data, respectively. Referral for stricture reconstruction frequently followed two prior endoscopic procedures and the stricture was not always assessed anatomically before surgery. Urinary retention was a common symptom in men awaiting reconstruction. Short unifocal strictures of the anterior urethra were the commonest reason for referral, whilst lichen sclerosus and hypospadias generated a significant volume of revisional stricture surgery. Lower numbers of very complex interventions are required for the management of posterior urethral pathology. Although precise criteria for determining success are not clear, management of urethral reconstruction in the UK was found to have a low risk of Clavien-Dindo grade 3 or higher complications, and was associated with outcomes similar to those reported in contemporary series except in the management of posterior urethral fistulae.

CONCLUSIONS

Online databases can provide volume data on the management of reconstructive urethral surgery across a multiplicity of centres in one country. They can also indicate compliance with accepted standards of, and expected outcomes from, this tertiary practice.

Urethral fistula after resection of a penile fibropapilloma in a Holstein Friesian bull

INTRODUCTION

A 2-year-old Holstein Friesian bull with a penile tumour was referred to the University of Veterinary Medicine Hannover, Foundation, Germany, where the tumour was resected and diagnosed as a fibropapilloma. A urethral fistula was diagnosed eight days postoperatively and was present nine months later, although the bull had normal copulation behaviour and satisfactory fertility. Surgical removal of fibropapillomas in close proximity to the urethra is an effective treatment. A urethral fistula, which may occur as a postsurgical complication, did not have an adverse effect on copulation capacity and fertility of the bull.

An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence

Introduction

Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model.

Material and methods

Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups.

Results

The median LPPs for the control group were: LPP – preT: 35.6 (29.8–44.8) cmH₂O, LPP – postT: 14.6 (5.8–19.0) cmH₂O, LPP – 1 month: 27.3 (19.2–33.8) cmH₂O, LPP – 2 months: 29.0 (27.0–34.0) cmH₂O, whereas for the PRP group were: LPP-preT: 40.5 (33.2–46.3) cmH₂O, LPP – postT: 15.7 (3.0–24.0) cmH₂O, LPP – 1month: 31.6 (24.8–37.4) cmH₂O, LPP – 2 months: 36.8 (32.5–45.4) cmH₂O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH₂O vs. 27.3 cmH₂O, p = .043]. This effect was confirmed at two months [36.8 cmH₂O vs. 29.0 cmH₂O, p <.001].

Conclusions

Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice.

Urethro-vaginal reflux during micturition: An underestimated cause of urinary incontinence in adult women

AIMS

To evaluate if urethrovaginal reflux (UVR) is an underestimated cause of insensible or postmicturition incontinence in adult women.

METHODS

An observational and retrospective study was carried out on the computerized records of a neuro-urology department. Female patients who had insensible or postmicturition incontinence were investigated. Retrograde and voiding urethrocystography (UCG), urodynamic evaluation, urethral pressure profilometry, and anamnestic and clinical examination had to be available.

RESULTS

Among the 79 adult female patients with insensible or postmicturition incontinence in whom the whole set of required evaluations was achieved, 16 had a UVR (mean age 47 ± 15 years). There were no urethral diverticula, urethrocele, vesicovaginal, or urethrovaginal fistula on their UCG. All of them also had a cystoscopy and a CT urography which did not establish any abnormality.

CONCLUSIONS

UVR is not an exclusive pathology of children. This mechanism seems to be an underestimated cause of urinary incontinence in adult women. Retrograde and voiding UCG appears to be the gold standard to confirm the intravaginal reflux.

Therapeutic Effects of Botulinum Toxin A, via Urethral Sphincter Injection on Voiding Dysfunction Due to Different Bladder and Urethral Sphincter Dysfunctions

Botulinum toxin A (BoNT-A) urethral sphincter injections have been applied in treating voiding dysfunction but the treatment outcome is not consistent. This study analyzed treatment outcomes between patients with different bladder and urethral sphincter dysfunctions. Patients with refractory voiding dysfunction due to neurogenic or non-neurogenic etiology were treated with urethral sphincter 100 U BoNT-A injections. The treatment outcomes were assessed by a global response assessment one month after treatment. The bladder neck opening and urodynamic parameters in preoperative videourodynamic study were compared between successful and failed treatment groups. A total of 80 non-neurogenic and 75 neurogenic patients were included. A successful outcome was noted in 92 (59.4%) patients and a failed outcome in 63 (40.6%). The treatment outcome was not affected by the gender, voiding dysfunction subtype, bladder dysfunction, or sphincter dysfunction subtypes. Except an open bladder neck and higher maximum flow rate, no significant difference was noted in the other variables between groups. Non-neurogenic patients with successful outcomes had a significantly higher detrusor pressure, and patients with neurogenic voiding dysfunction with successful results had higher maximum flow rates and smaller post-void residuals than those who failed the treatment. However, increased urinary incontinence was reported in 12 (13%) patients. BoNT-A urethral sphincter injection is effective in about 60% of either neurogenic or non-neurogenic patients with voiding dysfunction. An open bladder neck during voiding and a higher maximum flow rate indicate a successful treatment outcome.

The Natural History and Composition of Urinary Catheter Biofilms: Early Uropathogen Colonization with Intraluminal and Distal Predominance

PURPOSE

We sought to determine the composition and initiation site of bacterial biofilm on indwelling urinary catheters and to track biofilm progression with time.

MATERIALS AND METHODS

Indwelling urinary catheters were collected from 2 tertiary care centers following removal from patients. Indwelling time was noted and catheters were de-identified. Catheters were sectioned, stained for biofilms and analyzed by spectrophotometry and visualization. Biofilm colonization patterns were analyzed using descriptive statistical analysis and bacterial composition was determined using next generation sequencing.

RESULTS

We collected and analyzed a total of 33 catheters from 26 males and 7 females with indwelling time ranging from 15 minutes to 43 days. Biofilm colonization was consistently high on the region of the balloon for all indwelling times. After week 1 the distal third of the catheter had higher biofilm colonization than the proximal third (week 2 p=0.034). At all indwelling times the intraluminal surface of the catheter had greater biofilm colonization than the outer surface. Next generation sequencing detected potential uropathogenic bacteria in all 10 analyzed samples.

CONCLUSIONS

The catheter balloon, its distal aspect and its lumen were the predominant locations of biofilm comprising uropathogenic bacteria. Strategies to prevent or treat biofilm should be targeted to these areas.

Isolated Rare Urethral Metastasis From Primary Lung Adenocarcinoma: Case Report and Literature Review

Background: Lung adenocarcinoma is a common respiratory malignancy, however urethral metastasis of lung adenocarcinoma has not yet been reported. This study aims to present a rare case of isolated urethral metastasis in a male patient with a history of primary lung adenocarcinoma.

Case Presentation: A 69 year-old male patient was admitted complaining of dysuria and nocturia for 3 months, with a history of lung adenocarcinoma after surgery. The patient was diagnosed as benign prostatic hyperplasia (BPH) and received holmium laser enucleation of the prostate, an effective transurethral procedure to treat bladder outflow obstruction due to BPH. Four months after surgery for BPH, the patient had no improvement in symptoms and continued to complain of dysuria and perineum pain. An MRI of the pelvis indicated posterior urethral mass without any regional lymphadenopathy or other sites of lesion. Urethrocystoscopy found the mass in the membranous urethra near the verumontanum, and pathology combined with immunohistochemical staining confirmed the isolated urethral metastasis of lung adenocarcinoma. The further therapeutic regimen consisting of chemotherapy (pemetrexed combined with nedaplatin) and bevacizumab was well-tolerated, and obviously relieved the patient from dysuria and perineum pain.

Conclusion: This study reported the first case of isolated rare urethral metastasis from primary lung adenocarcinoma and underlined the necessity for clinicians to remain vigilant to metastasis during follow-up of primary cancer.

Self-insertion of an odd urethral foreign body that led to Fournier's gangrene

Self-inserted urethral foreign bodies (FBs) are rare. Neither reported case was the self-inflicted FB due to a lack of financial resources nor was either case complicated by Fournier's gangrene. We present a 54-year-old male who inserted a household pipe to relieve his urine retention. Unfortunately, the FB became stuck inside, perforated the urethra, and required perineal exploration. After it was removed, the urethra was closed over a 16F urethral catheter. The wound was complicated by severe infection and resulting Fournier's gangrene. This required an additional surgery for debridement and urine diversion. Retrospectively, it would have been better if the urethra had been left open with SP tube only. We are sharing a clinical lesson learned by the practicing urologist and surgeons. Conclusively, self-inserted FBs in the urethra may lead to a series of complications. Patients with limited financial resources need more attention and care because they may hurt themselves unintentionally.

Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series

PURPOSE

We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies.

MATERIALS AND METHODS

We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization.

RESULTS

Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%.

CONCLUSIONS

Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.

The Role of Magnetic Resonance Imaging in the Diagnosis of Penile Fracture in Real-Life Emergency Settings: Comparative Analysis with Intraoperative Findings

PURPOSE

We evaluated the role of magnetic resonance imaging of the penis in the diagnosis of penile fracture and/or concomitant urethral lesions in real-life emergency settings compared with intraoperative findings.

MATERIALS AND METHODS

A total of 43 patients presented with suspicion of penile fracture between January 2006 and December 2016. Magnetic resonance imaging was performed in 28 patients prior to surgical treatment in the emergency setting. Surgery was done in all patients via a subcoronal, circumferential degloving approach. We calculated sensitivity, specificity, and positive and negative predictive values as well as likelihood ratios of the positive and negative results of the agreement between magnetic resonance imaging and intraoperative findings.

RESULTS

Intraoperatively penile fracture was confirmed in 19 of 28 patients (67.9%) and a concomitant urethral lesion was observed in 5 of 28 (17.9%). Magnetic resonance imaging findings were highly associated with intraoperative findings of tunical rupture, including 100% sensitivity (95% CI 98.5-100), 77.8% specificity (95% CI 50.6-100), 90.5% positive predictive value (95% CI 78-100), 100% negative predictive value (95% CI 97.6-100) and a positive result likelihood ratio of 4.5. Magnetic resonance imaging had lower accuracy for urethral lesions with 60% sensitivity (95% CI 17.1-100), 78.3% specificity (95% CI 61.5-95.1), 37.5% positive predictive value (95% CI 4-71), 90% negative predictive value (95% CI 76.9-100) and a positive result likelihood ratio of 2.76.

CONCLUSIONS

Magnetic resonance imaging may be applicable in the emergency setting if the goal is to treat all men who warrant intervention. It has high sensitivity and negative predictive value for tunical rupture and concomitant urethral lesions. Therefore, it could help avoid unnecessary surgery by excluding the diagnosis. However, solitary magnetic resonance imaging is not sufficient for diagnosis and it should not replace clinical assessment or delay surgical exploration.

Antegrade and retrograde CT urethrography with virtual urethroscopy in a dog with urethral narrowing after bilateral triple pelvic osteotomy

An 8-month-old, castrated male Golden Retriever was unable to urinate without catheterization after a single-session bilateral triple pelvic osteotomy. To determine the cause, a retrograde urethrography was performed, but the results were equivocal. Antegrade (voiding by abdominal compression with heavy material) and retrograde CT urethrography were performed with virtual urethroscopy and revealed that the urethral diameter was narrowed near the pubic bone remnants due to pelvic canal narrowing. After corrective surgery, the patient was able to urinate normally. A combination of antegrade and retrograde CT urethrography with virtual urethroscopy was helpful for guiding surgical decision-making in this patient.

Mirabegron causes vesical and urethral relaxation in rats with spinal cord injury

The effects of solifenacin and mirabegron on vesical and urethral function were compared in rats with or without spinal cord injury (SCI). Isovolumetric cystometry and urethral pressure recording were initially performed in intact rats. Then, the bladder neck was ligated under urethane anesthesia, after which a catheter was inserted through the bladder dome for isovolumetric cystometry and another catheter was inserted into the urethra to measure urethral pressure. Solifenacin (0.03-3 mg/kg) or mirabegron (0.03-3 mg/kg) was injected intravenously, and bladder and urethral activity were recorded. To create rats with SCI, the spinal cord was transected at the lower thoracic level under isoflurane anesthesia. After 2 weeks, a catheter was inserted through the bladder dome for single cystometry and bladder activity was recorded without anesthesia following intravenous injection of solifenacin or mirabegron. Isovolumetric cystometry revealed a larger decrease in maximum bladder contraction pressure after injection of solifenacin, whereas prolongation of the interval between bladder contractions was greater with mirabegron. In SCI rats, single cystometry showed that solifenacin and mirabegron both increased bladder volume at the first non-voiding bladder contraction and decreased the maximum bladder contraction pressure. Mirabegron also increased the voided volume and decreased the percentage residual volume without altering bladder capacity. Solifenacin and mirabegron both inhibited bladder contractility, and mirabegron possibly also induced urethral relaxation. Mirabegron may be suitable for patients with overactive bladder and residual urine.

Surgical treatment of pelvic fracture urethral distraction defects in boys: which approach is suitable?

Pelvic fracture urethral distraction defects (PFUDDs) are relatively infrequent in boys, and treatment for PFUDDs presents one of the most difficult problems in urological practice. Anastomotic urethroplasty is considered an ideal surgical procedure for PFUDDs in boys. However, various surgical approaches for anastomotic urethroplasty have been proposed, including a simple transperineal approach, a transperineal intercorporal septal separation approach, a transperineal inferior pubic approach, and a combined transpubic-perineal approach. This study aims to determine which surgical approach is best for PFUDDs in boys. We retrospectively identified 22 boys with PFUDDs aged 2-14 years who underwent anastomotic urethroplasty via different approaches between January 2008 and December 2017. Follow-up was performed in all the 22 patients for 6-123 (mean: 52.0) months. Finally, 20 of the 22 boys (90.9%) were successfully treated, including 1 of 2 patients treated with a simple transperineal approach, 3 of 3 with a transperineal approach with intercorporal septal separation, 14 of 15 with a transperineal inferior pubic approach, and 2 of 2 with a combined transpubic-perineal approach. Two patients had failed outcomes after the operation, and stenosis recurred. Based on the outcome of the 22 patients, we can draw a preliminary conclusion that most boys (20/22) can be treated with a transperineal inferior pubic approach or simpler procedures without the need of completely removing or incising the pubis. The combined transpubic-perineal approach can be used in cases of extremely long urethral distract defects.

Tadalafil, a phosphodiesterase type 5 inhibitor, restores urethra and detrusor function in the initial phase of diabetes in rats

OBJECTIVE

This study investigated the effects of tadalafil on the urethra and detrusor in the initial phase of diabetes in rats.

METHODS

Thirty-six female Sprague-Dawley rats were assigned to a non-diabetes (ND), diabetes (D), or tadalafil-treated diabetes (DT) group (n = 12 per group), with the DT group receiving oral tadalafil (2 mg/kg/d) for 7 days before the experiments. Seven weeks after diabetes induction (by a single intraperitoneal injection of streptozotocin), urethral and intravesical pressure were simultaneously recorded in vivo, whereas responses of detrusor strips to potassium chloride (30 mM), electrical field stimulation (EFS) and carbachol were measured in vitro.

RESULTS

The intravesical pressure at which the urethra started to relax was significantly lower in the DT than D group (mean [± s.d.] 18.9 ± 2.9 vs 29.1 ± 6.6 cm H₂ O; P < .05). In addition, the reduction in urethral pressure was significantly larger in the DT than D group (-10.9 ± 4.0 vs -4.0 ± 2.9 cm H₂ O; P < .05). Detrusor stimulation revealed that the mean contractile responses to EFS and carbachol were significantly lower in the ND and DT groups than in the D group (120.7 ± 26.5% and 130.8 ± 15.8% vs 200.1 ± 47.9% of the 30 mM KCl-induced contraction, respectively, in response to 50 Hz EFS [P < .05]; 211.1 ± 35.4% and 208.4 ± 25.3% vs 425.7 ± 125.0% of the 30 mM KCl-induced contraction, respectively, in response to 10^-3 M carbachol [P < .05]).

CONCLUSIONS

Tadalafil restored urethral relaxation function and detrusor responses to EFS and carbachol during the initial phase of diabetes.

Comparative ultrasonographic examination and measurements of the urethra and penis of castrated and intact male lambs

Early castration of male small ruminants is regarded as a risk factor for urolithiasis, although the underlying correlations are still unclear. One possible reason is a deferred development of the penis and the urethra after castration. Therefore, we examined the penis and urethra of castrated and intact lambs by ultrasonography to determine the correlation between urethral area and pe- nile cross-sectional area. Ultrasonography was performed in 6-month-old Lacaune crossbred lambs (early castrated, late castrated, and intact; each group, n = 11). Sectional images at 5 loca- tions (glans penis, penile urethra, distal and proximal sigmoid flexure, and ischial arch) were ob- tained to determine the urethral and penile diameters. Urethral and penile cross-sectional areas were calculated. Grey-scale analysis of ultrasound images was performed to evaluate possible differences in the penile texture between the groups. Correlation analyses between both cross-sectional areas showed a significant general correlation for location 2 in all lambs (R = 0.52; P = 0.003), for location 3 in late-castrated lambs, and for location 5 in early-castrated lambs. Statistically significant correlations between the penile and the urethral area of castrated and intact lambs were not evident. Therefore, measurement of the penile cross-sectional area alone does not allow for accurate estimation of urethral size. Statistically significant differences con- cerning the grey-scale analysis between the groups were also not detectable. Thus, simplification of the formerly presented ultrasonographic examination of the urethra is not recommended. In animals at a risk of obstructive urolithiasis, complete urethral examina- tion is essential.

Malignant melanoma of the male urethra with increased 5-S-cysteinyldopa: A case report

Introduction

We herein present a case of malignant melanoma of the male urethra with an increased serum 5‐S‐cysteinyldopa concentration.

Case presentation

A 77‐year‐old man visited our hospital complaining dysuria and a dark brown mass protruding from the external urethral meatus. His serum 5‐S‐cysteinyldopa concentration was elevated beyond the upper limit of the reference range. Biopsy of the tumor was performed, and the histological diagnosis was malignant melanoma. He underwent total penectomy, and the serum 5‐S‐cysteinyldopa concentration was normalized. He remained alive without evidence of locoregional recurrence or distant metastases for 6 months after surgery.

Conclusion

Malignant melanoma of the male urethra is uncommon. The prognosis is favorable if it is detected in its early stages. This case report suggests that measurement of the serum concentration of 5‐S‐cysteinyldopa, a melanin metabolite, is useful for early diagnosis of male urethral melanoma.

Patient Characteristics that May Influence the Effect of Urethral Injection Therapy for Female Stress Urinary Incontinence

PURPOSE

Urethral injection therapy is a well-known treatment of female stress urinary incontinence but to our knowledge the optimal group of recipients has not been established. In this study we examined which patient characteristics are associated with success after urethral injection therapy.

MATERIALS AND METHODS

This study is a post hoc analysis of a previously published, randomized, 33-center study of the hydrogel bulking agent Bulkamid® vs the collagen gel Contigen®. Regardless of the treatment women were considered cured if there were no stress incontinence episodes in the bladder diary and no stress incontinence symptoms on the ICIQ-UI-SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form), improved if there was a 50% or greater reduction in stress incontinence episodes and no effect if there was less than a 50% reduction in stress incontinence episodes 1 year after treatment.

RESULTS

Of the 345 women who were initially randomized 291 were included in this study. A total of 191 women received hydrogel and 100 received collagen. At 1 year 74 women (25%) were cured, 164 (56%) were improved and 53 (18%) showed no effect. On multivariate logistic regression analysis age 60 years or greater and fewer than 2.5 daily stress incontinence episodes were associated with cure. In this group 90% of women experienced a treatment effect and 38% were cured compared with a 13% cure rate in those younger than 60 years with 2.5 or more daily stress incontinence episodes.

CONCLUSIONS

Urethral injection therapy was more effective to treat stress urinary incontinence in women 60 years old or older with fewer than 2.5 daily stress incontinence episodes. It had a 90% success rate in these women.

Randomized Clinical Trial Using Sterile Single Use and Reused Polyvinylchloride Catheters for Intermittent Catheterization with a Clean Technique in Spina Bifida Cases: Short-Term Urinary Tract Infection Outcomes

PURPOSE

Urinary tract infections are common and severe complications in patients with spina bifida. Management includes intermittent bladder catheterization with single use or reused sterile catheters. There is insufficient evidence to set a standard among the different techniques. We determined whether single use polyvinylchloride catheters would reduce urinary tract infections compared to reused polyvinylchloride catheters in patients with neurogenic bladder due to spina bifida.

MATERIALS AND METHODS

We performed a 2-arm randomized parallel clinical trial from 2015 to 2016 with an 8-week followup at our center in patients with neurogenic bladder caused by spina bifida. Patients were divided into single use and reused polyvinylchloride catheter groups. Evaluations were done on days 0, 7, 14, 28, 42 and 56. Participants reported symptoms and urine cultures were obtained. The primary outcome was urinary tract infection frequency, defined as positive urine culture plus fever, flank pain, malaise, or cloudy or odorous urine. Study eligibility criteria were age 2 years or greater, spina bifida diagnosis with regular clean intermittent bladder catheterization and no urinary tract infection at initial evaluation.

RESULTS

The calculated sample size was 75. Of the patients 135 were screened, 83 were randomized and 75 completed followup. Mean age was 12.7 years (range 2-56) and there were 29 males and 46 females. No statistical difference was found between the single use vs reused catheter groups in the frequency of asymptomatic bacteriuria (32.4% vs 23.7%, p = 0.398) or urinary tract infections (35.2% vs 36.8%, p = 0.877).

CONCLUSIONS

Single use polyvinylchloride catheters for intermittent bladder catheterization did not decrease the incidence of urinary tract infections in our patients with neurogenic bladder compared to reused polyvinylchloride catheters. These results are consistent with the 2014 Cochrane Review.

Retropubic versus Transobturator Mid Urethral Slings in Patients at High Risk for Recurrent Stress Incontinence: A Systematic Review and Meta-Analysis

PURPOSE

The efficacy and safety of retropubic and transobturator tension-free vaginal tape mid urethral slings remain controversial in patients with stress urinary incontinence and risk factors for recurrence. We compared the techniques after initial mid urethral sling insertion in select groups, including patients with obesity, intrinsic sphincter deficiency, pelvic organ prolapse and recurrent stress urinary incontinence.

MATERIALS AND METHODS

We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement to report the methods and results of the current review. Randomized controlled trials and observational studies were included. We assessed the objective and subjective cure rates, and the complication rate using the OR with the 95% CI. The protocol of the current meta-analysis was registered on PROSPERO (No. CRD42018102233).

RESULTS

We retrieved 28 studies in a total of 2,607 patients to compare the efficacy and safety of retropubic vs transobturator tension-free vaginal tape in select groups (mean followup 26.9 months). Meta-analysis of the objective cure rate showed the significant superiority of retropubic compared to transobturator tension-free vaginal tape in patients overall (OR 3.37, 95% CI 2.55-4.43, p <0.00001, I² = 37%) and in each subpopulation. The subjective cure rate of retropubic tension-free vaginal tape was also significantly superior to that of transobturator tension-free vaginal tape in in patients overall (OR 2.01, 95% CI 1.45-2.80, p <0.0001, I² = 0%) and in those with intrinsic sphincter deficiency and recurrent stress urinary incontinence after mid urethral sling insertion. There was no significant difference in overall complications between retropubic and transobturator tension-free vaginal tape (OR 1.22, 95% CI 0.89-1.66, p = 0.21, I² = 0%).

CONCLUSIONS

The meta-analysis showed the superiority of retropubic tension-free vaginal tape over transobturator tension-free vaginal tape in terms of the objective and subjective cure rates in patients with obesity, intrinsic sphincter deficiency, pelvic organ prolapse and recurrent stress urinary incontinence after mid urethral sling insertion. Retropubic tension-free vaginal tape also has morbidity comparable to that of transobturator tension-free vaginal tape.

TRP Channels as Lower Urinary Tract Sensory Targets

Several members of the transient receptor potential (TRP) superfamily, including TRPV1, TRPV2, TRPV4, TRM4, TRPM8 and TRPA1, are expressed in the lower urinary tract (LUT), not only in neuronal fibers innervating the bladder and urethra, but also in the urothelial and muscular layers of the bladder and urethral walls. In the LUT, TRP channels are mainly involved in nociception and mechanosensory transduction. Animal studies have suggested the therapeutic potential of several TRP channels for the treatment of both bladder over- and underactivity and bladder pain disorders,; however translation of this finding to clinical application has been slow and the involvement of these channels in normal human bladder function, and in various pathologic states have not been established. The development of selective TRP channel agonists and antagonists is ongoing and the use of such agents can be expected to offer new and important information concerning both normal physiological functions and possible therapeutic applications.

Magnetic resonance imaging as an assessment tool following intervention with an AdVance XP suburethral sling for postprostatectomy urinary incontinence

AIMS

The aim of this study was to compare magnetic resonance imaging (MRI) parameters in patients with mild incontinence after radical prostatectomy, who had undergone treatment with a suburethral sling. The objective was to compare patients who had been successfully treated with unsuccessful patients.

METHODS

This observational cohort study at a single institution evaluated consecutive patients treated with an AdVance XP sling. MRI was performed using a 1.5 Tesla system. Preoperative urodynamic assessment and flexible cystoscopy were performed. The qualitative analysis was based on sling indentation (complete vs incomplete). The quantitative analysis comprised the following three parameters: the sling-pubis distance, the thickness of the proximal urethral bulb, and the sling backward distance (SBD), defined as the distance between the prolongation of a line through the major axis of the pubis (the line-segment joining the vertices of the pubis) and the sling indentation. The primary outcome was pad count at 3 months; cure as zero pads. A logistic univariate regression model was employed to assess the potential predictors of successful outcomes. An adjusted multivariate logistic regression model using the significant univariate factors was developed.

RESULTS

Of the 83 patients enrolled, the univariate analysis revealed a relationship between failure and adverse urodynamics and between success and sling indentation, thickness of the proximal bulb and SBD. Only the association with SBD persisted in the multivariate analysis.

CONCLUSIONS

MRI revealed a strong relationship between proper positioning of the sling (small SBD) and continence outcome. These data have important implications for a second surgery following initial sling failure.

Developmental mutant mouse models for external genitalia formation

Development of external genitalia and perineum is the subject of developmental biology as well as toxicology and teratology researches. Cloaca forms in the lower (caudal) end of endoderm. Such endodermal epithelia and surrounding mesenchyme interact with various signals to form the external genitalia. External genitalia (the anlage termed as genital tubercle: GT) formation shows prominent sexually dimorphic morphogenesis in late embryonic stages, which is an unexplored developmental research field because of many reasons. External genitalia develop adjacent to the cloaca which develops urethra and corporal bodies. Developmental regulators including growth factor signals are necessary for epithelia-mesenchyme interaction (EMI) in posterior embryos including the cloaca and urethra in the genitalia. In the case of male type urethra, formation of tubular urethra proceeds from the lower (ventral) side of external genitalia as a masculinization process in contrast to the case of female urethra. Mechanisms for its development are not elucidated yet due to the lack of suitable mutant mouse models. Because of the recent progresses of Cre (recombinase)-mediated conditional target gene modification analyses, many developmental regulatory genes become increasingly analyzed. Conditional gene knockout mouse approaches and tissue lineage approaches are expected to offer vital information for such sexually dimorphic developmental processes. This review aims to offer recent updates on the progresses of these emerging developmental processes for the research field of congenital anomalies.

Urological Injuries during Colorectal Surgery

The proximity of the colon and rectum to the organs of the urologic system virtually ensures that iatrogenic urologic injuries become a distinct possibility during complex colorectal surgical procedures. An intimate knowledge of urogenital anatomy as well as strategies for identification and repair of potential injuries is of paramount importance. Attention is mandated when operating within the narrow confines of the pelvis, as this is where these structures are most at risk. The ureters are at highest risk of injury, followed by the bladder and urethra. The nature of these injuries encompasses both functional and mechanical morbidities. Patient factors, including prior pelvic surgery, radiation, inflammatory bowel disease, infectious processes, and urogenital abnormalities all increase the risk of injury. As colorectal surgeons encounter an increasing number of patients with the above risk factors, it is important to be familiar with the various urologic injury patterns, their diagnosis, and appropriate management.

Management of male pelvic fracture urethral injuries: Review and current topics

Pelvic fractures from high-energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.

Dorsal buccal graft urethroplasty in female urethral stricture disease: a multi-center experience

Background

Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes.

Methods

We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy.

Results

Mean age was 50 (range, 29-81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons' index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7-106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence.

Conclusions

FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

Evidence for Previously Unidentified Sexual Transmission of Protozoan Parasites

Knowing the mode of transmission of a disease can affect its control and prevention. Here, we identify 5 protozoan parasites with demonstrated presence in seminal fluid, only 1 of which has been identified as a sexually transmitted disease among humans.

Nail Scissor as a Rare Foreign Body in the Urethra: Case Report

Foreign bodies in the urethra are rare in the literature. A majority of the foreign bodies administered in the urethra are because of a psychiatric disorder, senility, intoxication, and self-erotic stimulation. Clinical examination and imaging tests, such as X-ray, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have been used for the diagnosis of foreign bodies. Surgical exploration or endoscopic extraction are the main approaches to the treatment. This case report deals with a 45-year-old male patient who was admitted with urethral pain to the emergency service. A nail scissor was diagnosed in the urethra and endoscopic extraction was performed under regional anesthesia.

Hypospadias Repair in Ethiopia: A Five Year Review

Background

Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias.

Materials and Methods

This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study.

Results

A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p<0.01).

Conclusion

From our experience, we found TIP a relatively safe and reliable method of repair for distal hypospadias while TVPF single stage repair was superior in the proximal ones. The high rate of complications in our institution was associated with higher burden of severe hypospadias and older age at surgery.

The Engagement of the Pelvic Floor Muscles to the Urethra, Does Variation in Point of Action Exist?

Purpose: Lower urinary tract dysfunction (LUTD) occurs frequently in girls and may display a spinning top urethra (STU) on voiding cysto-urethrogram (VCUG) in case of dysfunctional voiding. A STU presents as a narrowing of the urethra caused by a lack of relaxation of the pelvic floor musculature during micturition and may vary in length between the proximal and the distal urethra. Although a STU has been recognized since 1960 as a pathological entity on VCUG, no reports exist on the different levels of engagement of the pelvic floor muscles to the urethra as expressed by the varying length of the phenomenon. The aim of our study is to demonstrate the wide anatomical variation in the level of engagement of the pelvic floor musculature to the urethra. Materials and Methods: Dynamic ultrasound videos of pelvic floor musculature of 40 girls with LUTD were reassessed by three observers, looking for the level of engagement of the puborectalis muscle (PRM) to the urethra during coughing, Valsalva and hold-up maneuver. Three levels were defined, for the level of engagement of the pelvic floor to the urethra, proximal, mid, and distal. Intra- and inter-rater variability was analyzed using Cohen's kappa statistics. Results: A wide range of points of action was found on the assessed ultrasound videos. Intra- and inter-rater agreement showed different levels of conformity, varying over a wide spectrum (intra-rater kappa 0.145-0.546; inter-rater kappa -0.1030.724). Throughout the assessed videos, all not-corresponding intra-rater observations differed maximal one category. Of the not-corresponding inter-rater observations, 90% differed maximal one category. Conclusion: An anatomical variation in levels of engagement of the PRM to the urethra does exist. The clinical value of this finding, whether the point of engagement influences symptomatology or treatment success of LUTD, is currently being studied.

Traumatic Posterior Urethral Strictures in Children and Adolescents

Background: Management of partial or complete traumatic urethral disruptions of the posterior urethra in children and adolescents, secondary to pelvic fracture poses a challenge. Controversy exists as to the correct acute treatment of posterior urethral injuries and delayed management of PFPUDDs. We reviewed the urological literature related to the treatment of traumatic posterior urethral injuries and delayed repair of these distraction defects in children and adolescents. Material and Methods: There are few long-term outcomes studies of patients who underwent PFPUDDs repairs in childhood; most reports included few cases with short follow up. We excluded studies in which the cohort of patients was heterogeneous in terms of stricture disease, etiology and location. Results: Primary cystostomy and delayed urethroplasty is the traditional management for PFPUIs. Immediate repair is rarely possible to perform. Realignment of posterior urethral rupture in children is indicated in special situations: (a) concomitant bladder neck tears, (b) associated rectal lacerations, (c) long disruptions of the urethral ends. Before delayed reconstruction ascending urethrography and micturating cystourethrogram along with retrograde and antegrade urethroscopy define site and length of the urethral gap. However, the most accurate evaluation of the characteristics of the distraction defect is made when surgical exposure reveals the complexity of the ruptured urethra. Partial ruptures may be managed with urethral stenting or suprapubic cystostomy, which may result in a patent urethra or a short stricture treated by optical urethrotomy. The gold standard treatment for PFPUDDs in children is deferred excision of pelvic fibrosis and bulbo-prostatic tension-free anastomosis, provided a healthy anterior urethra is present. Timing of delayed repair is at 3 to 4 months after trauma. Some urologists prefer either the perineal access or the transpubic approach to restore urethral continuity in children with PFPUDDs. Substitution urethroplasties are used in children with PFPUDDs, when anastomotic repair can't be achieved due to severe damage of the bulbar urethra. Conclusion: As evidenced in this review the progressive perineo-abdominal partial transpubic anastomotic repair has advantages over the isolated perineal anastomotic approach in patients with "complex" PFPUDD. This approach provides wider exposure and facilitates reconstruction of long or complicated posterior urethral distraction defects.