Ultrasound for the evaluation of the urethra in pediatric patients

Urethral lesions in pediatric patients can be visualized using ultrasonography. Therefore, sonographers and physicians should be familiar with the technique.

Prediction of anorectal malformations with bladder-neck/urethral-prostatic fistula using classification and regression tree analysis

BACKGROUND

The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula.

METHODS

A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample.

RESULTS

All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005).

CONCLUSIONS

A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula.

What urethrogram sees and a surgeon does not

INTRODUCTION

Urethrorrhagia is an infrequent sign in childhood. It should be distinguished from hematuria, since they have a different etiology.

CLINICAL CASE

11-year-old male patient with significant urethrorrhagia. Urinary sediment analysis: red blood cells++. Pelvic ultrasonography: fusiform anechoic image in the corpus spongiosum of the penile root. Retrograde urethrogram: normal anterior urethra, extraluminal contrast passage in the ventral aspect of the bulbar urethra. Cystoscopy: no pathological findings in the urethra or the bladder. Control retrograde urethrogram: cystic dilatation of Cowper's gland duct; Maizels' type 3 perforated syringocele.

DISCUSSION

Cowper's syringocele is a rare pathology. It can occur at any stage of childhood in the form of urinary infection, obstructive voiding symptoms, or urethrorrhagia. Urethrogram is key for diagnostic purposes, since most Cowper's syringoceles are detected following urethrogram or cystoscopy. Cases with functional repercussions for the urinary system require surgical treatment. Otherwise, a wait-and-see approach is feasible.

Bladder Agenesis and Bilateral Ectopic Ureters in an Infant Male With Cystic Renal Dysplasia, Imperforate Anus, and Penoscrotal Transposition

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients.¹ Commonly associated with other fatal malformations, the condition is often incompatible with life.² Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule.^3,4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia.

Are anterior urethral valve and anterior urethral diverticulum two separate entities: A radiological and endoscopic review

BACKGROUND

Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized.

OBJECTIVE

This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD.

STUDY DESIGN

A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management.

RESULTS

A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy.

DISCUSSION

AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management.

CONCLUSION

Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.

Ultrasonography and Surgical Treatment of an Unusual Case of Urethral Calculus in an Arabian Horse

This case report records an obstructive urolithiasis due to a large calcium carbonate urethral stone in an 11-year-old Arabian stallion. The stallion had colicky pain, anuria, and reduction in food and water intakes. Palpation of the penis revealed rhythmic contractions of the urethra, a hard mass in the penile urethra at the level of the ischial arch, and a dilated urethra proximal to the mass. Rectal examination revealed a distended and turgid urinary bladder. Passing a urethral catheter revealed a complete urethral obstruction at the level of the ischial arch. Ultrasonography revealed a calculus that appeared as an irregular, hyperechoic arch-like thick line with acoustic shadowing. Subischial urethrotomy was conducted under epidural anesthesia. Uneventful recovery was seen with no recurrence or complications for 12 months of available follow-up. In conclusion, clinical, rectal, and ultrasound examinations are valuable for definite diagnosis of urethral calculi in horses and the subischial urethrotomy appears to be successful in correcting this condition in horses.

Ultrasonographic Imaging Features of Female Urethral and Peri-urethral Masses: A Retrospective Study of 95 Patients

The aim of this study was to assess the imaging features of urethral and peri-urethral masses on transvaginal or transperineal ultrasound (US) in a cohort of 95 women. In this retrospective study, medical records of 95 female patients with 98 asymptomatic or symptomatic urethral and peri-urethral masses were retrospectively reviewed. Data regarding patient demographic characteristics, symptoms, signs, imaging features on 2-D and 3-D transvaginal or transperineal US, diagnostic tests and physical and intra-operative findings were extracted. The US imaging features and clinicopathologic characteristics of each urethral or peri-urethral mass were compared. On ultrasound, 39 masses (in 39 patients) were diagnosed as urethral diverticula, which manifested mostly as complex cystic masses (24/39, 61.5%); 35 masses (in 33 patients) were diagnosed as para-urethral cysts, which manifested mostly as simple cystic masses (19/35, 54.3%); 13 hypo-echoic solid masses (in 12 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral leiomyomas; hypo-echoic or heterogeneous solid masses (in 8 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral caruncles, including one complicated by malignant transformation; solid masses with mixed echogenicity (in 2 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral squamous cell carcinoma or adenocarcinoma, and a hypoechoic solid mass (in one patient) with blood-flow signals on color Doppler imaging was diagnosed as urethral condyloma associated with human papillomavirus infection. This study confirmed transvaginal or transperineal 2-D and 3-D ultrasonography to be a valid, non-invasive, cost-effective diagnostic modality for the differential diagnosis of urethral and periurethral masses.

Prenatal diagnosis of complete penoscrotal transposition with normal scrotum: Two case reports and review of the literature

Complete penoscrotal transposition is an extremely rare congenital anomaly and is usually associated with other urinary system abnormalities. Prenatal diagnosis is feasible by demonstrating perineal anatomy and its relation with scrotum and phallus. We describe two prenatal cases presenting with oligohydramniosis and megacystis due to lower urinary tract obstruction. Postnatal diagnosis was confirmed in both cases. Considering the dismal perinatal outcome, an accurate prenatal diagnosis is required for counseling the parents and preparing for postnatal care.

Ultrasonographic assessment of male anterior urethra. Description of the technique of examination and presentation of major pathologies

During the last years the role of sonourethrography (SUG) in the assessment of anterior male urethra pathologies, has significantly increased. The investigation is easily performed, not time consuming and should be considered the imaging technique of choice for preliminary diagnosis, without exposing the patient to X-rays. In this paper we present the technique of examination and the most common pathologies in which SUG is indicated.

Serial voiding urosonography in posterior urethral valve diagnosis and management in pediatric patients

OBJECTIVES

Report our experience with the use of contrast-enhanced serial voiding urosonography (SVU) for posterior urethral valve (PUV) patient diagnosis and management.

MATERIAL AND METHODS

Descriptive retrospective study in 0- to 14-year-old patients with suspected PUV at SVU performed as a first contrast-enhanced urinary tract test with subsequent cystoscopic study. Variables were analyzed using SPSSv22.

RESULTS

18 patients were studied (median age: 6 months). Most patients (15) presented posterior urethral dilatation (mean diameter: 9.56 mm) and a >2 mm gap between proximal and distal urethra. 13 cases had bladder thickening and 9 had VUR. 15 PUV cases, 1 case of distal urethral mucocele, and 1 case of bladder diverticulum obstructing the urethra were diagnosed. Complete PUV resection was performed in 10 patients (66.6%) at the first cystoscopy. The control SVU detected one case of recurrence due to persistence of posterior urethral dilatation. The recurrence case and the 5 incomplete resection cases were treated with a second cystoscopy and resection. The youngest patients required a third resection and cutting balloon dilatation due to residual stenosis. Mean creatinine levels at diagnosis were 0.28 mg/dl.

CONCLUSIONS

Serial voiding urosonography (SVU) is a useful complementary test in pediatric patients with posterior urethral valve. Its dynamic nature and its advantages - absence of irradiation, safety, and high sensitivity - make it an ideal imaging test for PUV diagnosis and follow-up.

Multimodality imaging of the male urethra: trauma, infection, neoplasm, and common surgical repairs

OBJECTIVE

The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction.

RESULTS

Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG.

CONCLUSIONS

Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

Preoperative Transurethral Contrast-Enhanced Ultrasonography in the Diagnosis of Female Urethral Diverticula

OBJECTIVES

To explore the value of transurethral contrast-enhanced ultrasonography (CEUS) in the diagnosis and evaluation of female urethral diverticula.

METHODS

This study prospectively enrolled 35 women with periurethral cystic lesions, who underwent preoperative transurethral CEUS at our single center between April 2015 and May 2017. The diagnosis of a urethral diverticulum was made by the detection of microbubbles inside the lesion. Data regarding the structure and ostia of the diverticula were collected and then compared with intraoperative findings.

RESULTS

The median (interquartile range) age of the 35 patients was 43 (34-48) years. The most common manifestations were dysuria (43%) and palpable masses (40%). On transurethral CEUS, 20 patients were found to have urethral diverticula. The diverticula involved the proximal, mid, and distal urethra with different sizes. The shapes of the diverticula were simple in 4 patients (20%), U shaped in 8 patients (40%), and circumferential in 8 patients (40%). A total of 23 ostia were identified. Seventeen women (85%) had 1 ostium, and 3 women (15%) had 2 ostia. Twenty-one diverticular ostia (91%) were located from the 3- to 9-o'clock positions. The median (interquartile range) distance from the diverticular ostia to the bladder neck was 20 (9-31) mm. During surgery, all US presentations correlated well with surgical findings, and 21 patients were confirmed to have urethral diverticula. The transurethral CEUS had sensitivity of 95% and specificity of 100%.

CONCLUSIONS

Transurethral CEUS is an effective method for identifying the structure and ostium of female urethral diverticula. It may have a potential role in preoperative planning and surgical management.

Fluoroscopic Evaluation of Adult Male Urethral Abnormalities

Retrograde urethrograms and voiding cystourethrograms provide clinicians with important information to determine treatment options and surgical interventions for patients with urethral abnormalities. This article discusses the elements with which radiologic technologists should be familiar, including urethra anatomy, the pathology of urethral abnormalities, imaging techniques, and special considerations for preoperative and postoperative patients.

Congenital Posterior Urethral Fistulae: Literature Review and Case Report

Congenital posterior urethral-perineal fistula is an abnormal communication extending from the posterior urethra to the perineal skin. We present the case of an 11-year-old boy who had recurrent febrile urinary tract infections and abnormal dribbling of urine from the perineum. Fistulogram showed a paraescrotal fistula tract, which was then surgically excised. During the 10 months of follow-up, the patient remained asymptomatic without recurrence of urinary pathology.

Endoscopic treatment of urethrodeferential reflux in children

INTRODUCTION

Urethrodeferential reflux is an underdiagnosed condition, and there is no consensus on its treatment. Our objective is to show our experience in the minimally invasive treatment of this disease using endoscopy.

MATERIAL AND METHODS

We present 8 patients with recurrent suppurative orchitis due to urethrodeferential reflux treated endoscopically during the period 2008-2013. All patients presented unilateral orchitis. The minimum number of episodes of orchitis per patient prior to the operation was 3. The endoscopic treatment consists of ureteroscopy, locating the ejaculatory orifices and conducting an intraoperative contrast study to demonstrate the urethrodeferential reflux. Subejaculatory dextranomer/hyaluronic acid was subsequently injected in all the cases.

RESULTS

The mean surgical time was 15min, and the procedure was outpatient for all patients. There were no postoperative complications, and the patients had good clinical progression. Only one case required a second injection of dextranomer/hyaluronic acid. The follow-up of these patients showed a complete resolution of the epididymitis and good testicular development, with a follow-up longer than 4 years in all cases.

CONCLUSION

We propose this form of treatment as a minimally invasive, easily reproducible alternative that shows good long-term results in our small series of patients.

Application of dermoscopy image analysis technique in diagnosing urethral condylomata acuminata

BACKGROUND

In this study, cases with suspected urethral condylomata acuminata were examined by dermoscopy, in order to explore an effective method for clinical.

OBJECTIVE

To study the application of dermoscopy image analysis technique in clinical diagnosis of urethral condylomata acuminata.

METHODS

A total of 220 suspected urethral condylomata acuminata were clinically diagnosed first with the naked eyes, and then by using dermoscopy image analysis technique. Afterwards, a comparative analysis was made for the two diagnostic methods.

RESULTS

Among the 220 suspected urethral condylomata acuminata, there was a higher positive rate by dermoscopy examination than visual observation.

STUDY LIMITATIONS

Dermoscopy examination technique is still restricted by its inapplicability in deep urethral orifice and skin wrinkles, and concordance between different clinicians may also vary.

CONCLUSION

Dermoscopy image analysis technique features a high sensitivity, quick and accurate diagnosis and is non-invasive, and we recommend its use.

Voiding urosonography with second-generation contrast as a main tool for examining the upper and lower urinary tract in children. Pilot Study

INTRODUCTION

In this series, we analyse the diagnostic efficacy of serial voiding urosonography (VUS) with second-generation contrast, combined harmoniously and specifically with contrast technology, in the examination of the urinary tract in children. This examination includes the diagnosis and follow-up for vesicoureteral reflux (VUR) and urethral disorders, mainly those of the posterior urethral valve (PUV).

PATIENTS AND METHODS

After obtaining informed consent, a prospective study was conducted using urosonography with second-generation contrast (sulphur hexafluoride microbubbles, SonoVue®) from November 2014 to October 2015 (1 year) in paediatric patients with suspected VUR or PUV impairment. For patients with a high suspicion of VUR and in cases of PUV, we also conducted simultaneous voiding cystourethrography (VCUG).

RESULTS

We studied 40 patients (80 renal units) between the ages of 2 months and 13 years (median age, 14 months). The indication for the test was a suspected VUR (36 patients, group A) and PUV follow-up (4 patients, group B). The test was correlated with VCUG in 16 patients (12 cases with high suspicion of VUR in group A and with 4 cases of PUV in group B). The visualisation of the urethra was appropriate in cases of dilation or urethral stricture. For 3 of these patients with bilateral VUR demonstrated in the serial VUS, the VCUG showed only unilateral VUR in 2 of the patients and no VUR in 1 of the patients (κ=.73).

DISCUSSION

We have shown that the visualisation of the urethra is no longer a limitation and that serial VUS can be superior to conventional VCUG in diagnosing VUR.

Urethral diverticulum in the female: a meta-analysis of modern series

INTRODUCTION

Urethral diverticula are a complex problem for the female pelvic surgeon. Given the rarity of the condition most published series are small and single institutional. This is a review article and a meta-analysis including all case series of female urethral diverticulum from the year 2000 to 2015 including only those case series with a minimum of ten subjects.

EVIDENCE ACQUISITION

Twenty-five articles were included and data was sufficient to perform a meta-analysis on patient age, symptoms at presentation, physical exam findings, location of diverticulum, diverticular size, radiological findings, pathology, complications, and recurrence rates.

EVIDENCE SYNTHESIS

Urethral diverticulum have variable symptom presentation and can mimic many other common conditions, but often present with a palpable urethral mass. Surgical diverticulectomy is the most commonly performed procedure, but does put the patient at risk for de novo stress incontinence and recurrent diverticula are not rare. Patients with pre-existing stress incontinence can be safely offered concomitant autologous pubovaginal sling at the time of diverticulectomy.

CONCLUSIONS

Pathology is benign 97% of the time but one must have a high degree of suspicion in the case of a firm mass or if MRI indicates a mass within the diverticula. Physicians need to have a high degree of suspicion particularly in those patients whose symptoms do not resolve with standard treatment and pelvic MRI is the investigation of choice.

Congenital anterior urethrocutaneous fistula at the penoscrotal junction with proximal penile megalourethra: A case report

Congenital anterior urethrocutaneous fistula and megalourethra are both rare anomalies. These anomalies are commonly associated with other anorectal or genitourinary anomalies and evaluated with voiding cystourethrography. We examined a 34-month-old boy who presented with a fistula at the penoscrotal junction. A voiding cystourethrogram showed a jet of urine coming through the fistula and proximal saccular dilatation of the penile urethra. We present the imaging findings of the first case of an association between a congenital anterior urethrocutaneous fistula at the penoscrotal junction and a proximal penile megalourethra. We also discuss the etiology, management, and differential diagnosis of this entity, and review the literature.

Female urethral diverticulum containing a giant calculus: a CARE-compliant case report

Urethral diverticula with calculi have a low incidence as reported in the literature. Diverticulum of female urethra is rare, often discovered due to associated complications. We report a case of diverticulum of the female urethra containing giant calculi in a 62-year-old multiparous woman. She consulted with our office due to dysuria and a hard, painful periurethral mass in the anterior vagina wall. The diverticulum was approached surgically by a vaginal route, and local extraction of the calculi and subsequent diverticulectomy successfully treated the condition.Diagnosis of a complicated diverticulum can be easily achieved if one possesses a high degree of clinical symptoms.

Fetal intervention for severe lower urinary tract obstruction: a multicenter case-control study comparing fetal cystoscopy with vesicoamniotic shunting

OBJECTIVE

To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO).

METHODS

A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively. Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention. Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention.

RESULTS

Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61. Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis. In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 1.86 (95% CI, 1.01-3.42; P = 0.048) and ARR, 1.73 (95% CI, 1.01-3.08; P = 0.04) respectively). A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 1.73 (95% CI, 0.97-3.08; P = 0.06)) but was not observed in the vesicoamniotic shunt group (ARR, 1.16 (95% CI, 0.86-1.55; P = 0.33)). In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6-month survival rate and renal function (ARR, 4.10 (95% CI, 1.75-9.62; P < 0.01) and 2.66 (95% CI, 1.25-5.70; P = 0.01) respectively) while vesicoamniotic shunting was associated only with an improvement in the 6-month survival rate (ARR, 3.76 (95% CI, 1.42-9.97; P < 0.01)) with no effect on renal function (ARR, 1.03 (95% CI, 0.49-2.17, P = 0.93)).

CONCLUSION

Fetal cystoscopy and vesicoamniotic shunting improve the 6-month survival rate in cases of severe LUTO. However, only fetal cystoscopy may prevent impairment of renal function in fetuses with posterior urethral valves. Our data support the idea of performing a subsequent randomized controlled trial to compare the effectiveness of fetal cystoscopy vs vesicoamniotic shunting for severe fetal LUTO.

Transperineal ultrasonography

Transperineal US has increased in use in the last decade. It is helpful in the evaluation of distal genitourinary structures, the rectum and overlying soft tissues. When used in conjunction with transabdominal US, transperineal US can further delineate anatomy and assess abnormalities that affect the lower pelvis. This paper describes optimal technique and common indications for transperineal US in children with examples of congenital and acquired lesions in pediatric patients.

Syringocele in adult patient. Case report

OBJECTIVE

To describe one case of syringocele in an adult patient.

METHODS/RESULTS

We report the case of a 26 year old man who presented frequency, hematuria and fever during one year, mictional cystourethrography showed a syringocele. Treatment consisted in endoscopic surgery, with good results in the follow-up.

CONCLUSIONS

The syringocele is a relatively infrequent entity, that is necessary to study in a young patient with voiding symptoms, accompanied or not of haematuria and fever. The diagnosis is based on the cystourethrography, and treatment consisted, usually, in endoscopic surgery.

Diagnosis of a female urethral diverticulum using transvaginal contrast-enhanced sonourethrography

The diagnosis of female urethral diverticulum is difficult due to its nonspecific symptoms, and invasive diagnostic procedures are often necessary. We report a case in which the diagnosis was made with contrast-enhanced transvaginal sonourethrography. The microbubble contrast agent could be seen filling the diverticular cavity via its opening.

[Using contrast inversion to extend the diagnostic value of perineal ultrasound for urethral and paraurethral pathologies]

PURPOSE

The aim of our study was to show how using contrast inversion extends the diagnostic value of perineal ultrasound, in particular with regard to paraurethral pathologies.

MATERIALS AND METHODS

To assess the practical value of contrast inversion in the daily routine, 42 women with urinary incontinence underwent perineal ultrasound examination. Pictures were converted to contrast inversion and then checked for the visibility of sonographic reference points for urogynecological measurements (urethra, meatus urethrae internus, vesical base) by two independent evaluators both in B-mode and contrast inversion. Visibility was compared using a coefficient of agreement. The results were then tested for significance. In addition, in our clinical routine we detected several paraurethral pathologies (e. g. paraurethral abscess, glandula paraurethralis, urethral diverticulum), each being presented in B-mode and contrast inversion.

RESULTS

There was no significant difference between contrast inversion and B-mode with regard to the reproducibility of visibility of the three sonographic reference points. Contrast inversion was superior for depicting paraurethral pathologies and postoperative anatomical findings.

CONCLUSION

With respect to routine evaluation, the two modes do not reveal any significant difference. For the sonographic evaluation of paraurethral pathologies, contrast inversion provides better contour sharpness than B-mode, suggesting a higher diagnostic value for ambiguous anatomical settings. The nature of contrast inversion nevertheless facilitates misinterpretations and requires frequent comparison with B-mode pictures. In conclusion, we propose contrast inversion as an initial screen and a refinement to established diagnostic methods, such as MRI and voiding cysturethrography, not as their substitute.

Prenatal diagnosis of penoscrotal transposition with 2- and 3-dimensional ultrasonography

OBJECTIVES

The purpose of this study was to determine the prenatal diagnostic accuracy of 2-dimensional ultrasonography (2DUS) alone versus 2DUS in combination with 3-dimensional ultrasonography (3DUS) for penoscrotal transposition.

METHODS

Fetuses suspected of having penoscrotal transposition on the basis of ultrasonographic findings or a family history were examined by 2DUS and then 3DUS.

RESULTS

Of a total of 22 fetuses, 14 had penoscrotal transposition at birth. The combination of 2DUS and 3DUS correctly identified more of the penoscrotal transposition cases than 2DUS alone (90.9% versus 63.6%; P < .05).

CONCLUSIONS

The combination of 2DUS and 3DUS improved the prenatal detection rate for penoscrotal transposition compared with 2DUS alone.

Allantoic cysts and posterior urethral valves: a case report

Allantoic cysts are a somewhat rare entity. They are identifiable on antenatal ultrasound examination but are not easily distinguishable from pseudocysts, which are often associated with a poor prognosis. Their etiology remains obscure and obstructive uropathies have been proposed to be one of the underlying mechanisms. We report on a case in which both allantoic cysts and a patent urachus were detected antenatally and turned out to be associated with posterior urethral valves (PUV). The cysts were first seen in the early second trimester, with a full fetal bladder and patent urachus. They disappeared by the 29(th) week. During the subsequent sonographic examinations, the bladder was emptying regularly. The kidneys remained normal throughout the pregnancy. It is hypothesized that the increased pressure within the urinary tract kept the urachus patent, led to the formation of allantoic cysts and, later, to their perforation; this allowed the fetus to empty his bladder and kept him from the usual complications of PUV. This case emphasizes the importance of detection and characterization of umbilical cord cysts on antenatal ultasound examination and suggests that obstructive uropathies should be included in the differential diagnosis of umbilical cord cyst communicating with the fetal bladder.

Fetal bowel calcifications: a sign of anal atresia with rectourethral fistula

Fetal bowel calcifications were observed at 24 weeks of gestation in a male fetus, suggesting an anorectal malformation (ARM) with rectourethral fistula. At birth, the newborn presented with complex ARM including anal atresia, rectourethral fistula, and esophageal atresia. The prenatal sonographic visualization of calcifications within distended bowel should raise the suspicion of ARM including anal atresia and rectourethral fistula, the presence of such calcification depending on the timing of onset of fistula formation.

Acquired male urethral diverticulum: case reports

Urethral diverticulum is a localised out pouching or fusiform dilatation of the urethra. It is an uncommon clinical entity affecting both males and females. Although, the diagnosis could be straightforward in the males, it may present as a diagnostic puzzle in the female because it often presents with non-specific symptomatology and diagnosis may not be easily made with common investigation techniques. Two cases of urethral diverticulum are presented to highlight the aetiopathogenesis of urethral diverticulum.

Transvaginal sonographic diagnosis of female urethral diverticula

PURPOSE

We report our experience with transvaginal sonography (TVUS) in the diagnosis of female urethral diverticulum (UD).

METHOD

We reviewed the TVUS examinations of 4 patients with a clinical diagnosis of UD and correlated the sonographic findings with the operative findings, especially regarding the UD's size, content, and location.

RESULTS

All UDs were demonstrated on TVUS. The size, content, and location of the UD correlated well with the operative findings.

CONCLUSION

TVUS is accurate in diagnosis and determination of the size, content, and location of female UD.

Congenital anomalies of the male urethra

The spectrum of congenital anomalies of the male urethra is presented. The embryologic basis of each anomaly, when known, is discussed. Clinical and imaging features of each entity are presented.

Imaging of the Male Urethra

For imaging of the male urethra, conventional radiographic contrast studies including retrograde urethrography are most commonly utilized. They are best suited for delineating luminal abnormalities of the urethra and thus are commonly used as the primary imaging modality for patients with various urethral abnormalities such as trauma, inflammation, and stricture. More recently, the cross-sectional imaging techniques of ultrasound, computed tomography and magnetic resonance imaging have been utilized increasingly for urethral and periurethral abnormalities. These studies are most valuable as an adjunctive tool in patients with the complex anatomical derangements such as congenital anomalies, posterior (or bulbomembranous) urethral injuries, and with urethral or periurethral tumors. These cross-sectional techniques can be performed during micturition or with retrograde injection of saline or jelly through the urethral meatus to improve visualization of the urethral luminal abnormalities. This article describes imaging techniques, anatomy, and findings of various urethral and periurethral pathology in the male including congenital anomalies, infection/inflammation, stricture, traumatic injury, fistula, tumors, and calculi.

Prenatal Diagnosis and Neonatal Management of Congenital Urethral Diverticulum

PURPOSE

We present a series of male neonates with prenatally detected anterior urethral diverticula and discuss postnatal management.

MATERIALS AND METHODS

We retrospectively reviewed 3 cases of prenatally detected anterior urethral diverticula presenting between 1998 and 2005.

RESULTS

An anterior urethral cystic mass was identified prenatally in all 3 patients. One mass spontaneously ruptured prenatally. The patient underwent diverticulectomy and urethroplasty at age 6 months. Two patients had obstructive uropathy with oligohydramnios and were delivered at 32 weeks of gestation. Both cases were managed by urethrostomy and subsequent diverticulectomy and urethroplasty at age 6 months.

CONCLUSIONS

Infravesical obstruction from a urethral diverticulum can be accurately identified and differentiated from other causes prenatally. Marsupialization is an excellent option for temporary urinary diversion when the clinical situation precludes primary excision and repair.

Fetal urinary bladder rupture and urinary ascites secondary to posterior urethral valves. A case report

Megacystis is a typical prenatal sonographic finding in cases of lower urinary tract obstruction. Urinary bladder perforation represents a rare complication in this condition. We report on a boy with in utero bladder perforation and urinary ascites secondary to posterior urethral valves. The pre- and postnatal therapy is described and the current literature is reviewed.

Complex urethral disruptions: in pursuit of a successful reconstruction

OBJECTIVES

We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions.

METHODS

The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics.

RESULTS

End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%.

CONCLUSION

Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.

Evaluation of male anterior urethral strictures by ultrasonography compared with retrograde urethrography

BACKGROUND

Abnormality of the male anterior urethra is common and is routinely assessed by contrast X-ray retrograde urethrogram (RUG). There is paucity of knowledge about the efficacy or findings at ultrasound of the anterior urethra in patients with urethral stricture in our setting.

OBJECTIVE

To compare the efficacy of ultrasound to that of RUG in male patients diagnosed as having urethral strictures

METHOD

In order to compare the efficacy of ultrasound to that of RUG thirteen male patients diagnosed as having urethral strictures were prospectively examined using high resolution sonourethrography (SUG) and X-ray retrograde urethrogram between June and November 2004.

RESULTS

The ages of the patients ranged from 32 to 66 years (with a mean of 49.8). All the 13 patients scanned showed abnormalities of the anterior urethra, 11 (84.6%) of which had strictures. Ten out of the 11 strictures were detected on both sonourethrography and RUG. One patient who was negative on RUG showed a stricture only 2.3 mm thick on SUG. The urethral mucosa, thickness of the urethral wall at the stricture level and the lengths of the strictures were well assessed on sonourethrography SUG.

CONCLUSION

Ultrasound is as efficacious as retrograde urethrogram in the assessment of the male anterior urethra in patients with urethral stricture and may be recommended in the evaluation of this disease, in view of its efficacy, non-invasiveness, ready-availability and lack of exposure to radiation. It may also serve as baseline for other similar studies in our environment.

Treatment of Refractory Urethrovaginal Fistula Using Rectus Abdominis Muscle Flap in a Six-Year-Old Girl

Urethrovaginal fistula usually occurs after urethrovaginal injury, resulting in urinary incontinence. Several modalities to treat urethrovaginal fistula have been reported. We describe a treatment in which we used a rectus abdominis muscle flap in a 6-year-old girl with refractory urethrovaginal fistula.