The role of transperineal ultrasound in the evaluation of stress urinary incontinence cases

ABSTRACT Purpose: To evaluate the use of transperineal ultrasonography while diagnosing stress urinary incontinence (SUI) by comparing the urethral angle (α), posterior urethrovesical angle (β), and bladder neck descent (BND) during rest and Valsalva maneuver in continent women and women with SUI. Materials and methods: This prospective observational study was conducted with 50 women with SUI and 50 continent women. Transperineal ultrasonography was performed at rest and during Valsalva maneuver. Q-tip test was performed. Results: During the Valsalva maneuver, both α and β angles were significantly higher in women with SUI (p <0.001). The difference between Valsalva and rest measurements of α and β angles (R α, R β) were also significantly higher in women with SUI (p <0.001). The cut-off point determined for the R α in the diagnosis of stress incontinence was 16° (80% sensitivity, 98% specificity). A statistically significant strong correlation was found between Q-tip test angle and R α value (p=0.000; r=0.890). Q-tip VAS pain scores were significantly higher than ultrasonography VAS pain scores (p <0.001). In relation to the bladder neck descent comparison between the two groups showed that BND was significantly higher in SUI group (p <0.001). The cut-off point determined for BND in the diagnosis of SUI was >11mm (90% sensitivity, 98% specificity). Conclusion: Transperineal ultrasonography is a practical, reliable, non-invasive and comfortable method for evaluation of SUI. It has the advantage of dynamic evaluation during the Valsalva maneuver. Rotation angles and BND have high sensitivity and specificity for detection of SUI. The change in α angle with Valsalva (Rα) can be used as an alternative to Q-tip test.

Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

ABSTRACT Introduction: The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1, 2). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1, 3, 4). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance. Material and methods: A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed. Result: Patient's postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section. Conclusion: We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.

La uretrografía como primer paso para hacer una buena reconstrucción uretral / Urethrography as a first step for good urethral reconstruction

La uretrografía es la aplicación de medio de contraste a través de la uretra, con el objetivo de "pintarla" completamente y poder ver toda su anatomía. De esta manera, se logra definir si la uretra esta sana o por el contrario, tiene áreas enfermas.[1] Hasta aquí, se podría considerar que es un estudio realmente sencillo y técnicamente fácil de realizar. Sin embargo, al llevarlo a la práctica, se trata de un estudio lleno de múltiples detalles que, si se tienen en cuenta, permitirán un mejor apoyo en la toma de decisiones en cuanto al diagnóstico y manejo de la estrechez uretral.

Urethrography is the application of contrast medium through the urethra, with the objective of "painting" it completely and being able to see all its anatomy. In this way, it is possible to define whether the urethra is healthy or, on the contrary, has diseased areas.[1] Up to this point, it could be considered a really simple study and technically easy to perform. However, when it is put into practice, it is a study full of multiple details that, if taken into account, will allow better support in making decisions regarding the diagnosis and management of urethral stricture.

Does MRI help in the pre - operative evaluation of pelvic fracture urethral distraction defect? - a pilot study

ABSTRACT Objectives To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)? Materials and Methods In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome. Results Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome. Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20). Conclusions MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED. Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.

Intraoperative breakage of Sachse's knife blade: A rare complication of optical internal urethrotomy (one case managing experience)

ABSTRACT Optical internal urethrotomy (OIU) is the most common procedure performed for short segment bulbar urethral stricture worldwide. This procedure most commonly performed using Sachse’s cold knife. Various perioperative complications of internal urethrotomy have been described in literature including bleeding, urinary tract infection, extravasation of fluid, incontinence, impotence, and recurrence of stricture. Here we report a unique complication of breakage of Sachse knife blade intraoperatively and its endoscopic management.

The long-term results of temporary urethral stent placement for the treatment of recurrent bulbar urethral stricture disease

ABSTRACT Aim: To evaluate the long term outcomes of temporary urethral stent placement for the treatment of recurrent bulbar urethral stricture. Materials and Methods: Twenty-eight patients who underwent temporary polymer coated urethral stent placement due to recurrent bulbar urethral stricture between 2010 and 2014 were enrolled in the study. The long term outcomes of the patients were analyzed. Results: The mean age of the patients was 62.3±6.4 (44–81). The overall clinical success was achieved in 18 (64.2%) of the 28 patients at a median (range) follow-up of 29 (7–46) months. No patient reported discomfort at the stent site. Stone formation was observed at the urethral stent implantation area only in one patient. Stenosis occurred in the distal end of the stents in two patients and took place in bulbar urethra in seven patients after removed the stents. The mean maximum urine flow rates were 6.24±2.81mL/sec and 19.12±4.31mL/sec before and at 3 months after the procedure, respectively. Conclusion: In this study, the success rate of temporary urethral stent placement has remained at 64.2% at a median follow-up of 29 months. Therefore, our outcomes have not achieved desired success rate for the standard treatment of recurrent bulbar urethral stricture.

Adipose-Derived Regenerative Cell Injection Therapy for Postprostatectomy Incontinence: A Phase I Clinical Study

PURPOSE: We report our initial experience with transurethral injection of autologous adipose-derived regenerative cells (ADRCs) for the treatment of urinary incontinence after radical prostatectomy. MATERIALS AND METHODS: After providing written informed consent, six men with persistent urinary incontinence after radical prostatectomy were enrolled in the study. Under general anesthesia, about 50 mL of adipose tissue was obtained from the patients by liposuction. ADRCs were obtained by separation with centrifugation using the Celution cell-processing device. A mixture of ADRCs and adipose tissue were transurethrally injected into the submucosal space of the membranous urethra. Functional and anatomical improvement was assessed using a 24-h pad test, validated patient questionnaire, urethral pressure profile, and magnetic resonance imaging (MRI) during 12-week follow-up. RESULTS: Urine leakage volume was improved with time in all patients in the 24-h pad test, with the exemption of temporal deterioration at the first 2 weeks post-injection in 2 patients. Subjective symptoms and quality of life assessed on the basis of questionnaire results showed similar improvement. The mean maximum urethral closing pressure increased from 44.0 to 63.5 cm H2O at 12 weeks after injection. MRI showed an increase in functional urethral length (from 6.1 to 8.3 mm) between the lower rim of the pubic bone and the bladder neck. Adverse events, such as pelvic pain, inflammation, or de novo urgency, were not observed in any case during follow-up. CONCLUSION: This study demonstrated that transurethral injection of autologous ADRCs can be a safe and effective treatment modality for postprostatectomy incontinence.

Perineostomy: the last oportunity

Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis. .

radiological puzzle: incidental genitography leading to peritoneal extravasation of contrast medium, during voiding cysto-urethrography, in a patient with urogenital sinus

While attempting cysto-urethrography and genitography in a nine-year-old female there was extravasation of the contrast medium to tHe peritoneal cavity during voiding cysto-urethrography [VCU] due to congenital adrenal hyperplasia [CAH]. Spillage of peritoneal contrast medium during VCU is extremely rare, even in patients with CAH and a persistent uro-genital sinus. Early fluoroscopic detection is essential, in recognizing the occurrence of spillage amid preventing further unnecessary injection of contrast medium into the peritoneal cavity

Clean intermittent catheterization with triamcinolone ointment following internal urethrotomy

Our aim was to evaluate clean intermittent catheterization [CIC] results in combination with triamcinolone ointment for lubrication of the catheter after internal urethrotomy. Seventy patients who underwent internal urethrotomy were assigned into 2 groups and performed CIC with either triamcinolone 1% ointment or a water-based gel [control] for lubrication of the catheter. They continued CIC regimen up to 6 month and were followed up for 12 months. Retrograde urethrography and urethrocystoscopy were done 6 and 12 months postoperatively. In case of obstructive symptoms or any difficulty in passing the urethral catheter, internal urethrotomy would be performed, if needed, and the same follow-up protocol would be started again. The recurrence rates after the first and second urethrotomy attempts were compared between the two groups. Thirty patients in the triamcinolone group and 34 in the control group completed the study. There were no significant differences in the baseline characteristics of the patients or the etiology of the stricture between the two groups. There was a 30.0% recurrence rate in the patients of the triamcinolone group versus 44.1% in those of the control group after the first internal urethrotomy [P = .24]. Following the second internal urethrotomy, the urethra was stabilized in 88.9% of the patients in the triamcinolone group and 60.0% those in the control group [P = .15]. Administration of triamcinolone ointment in patients on CIC regimen after internal urethrotomy only slightly decreased the stricture recurrence rate, and its possible effects should be more investigated

[Congenital obstructive anomalies of anterior urethra; diagnostic methods]

Radiological findings of ten patients with congenital obstructive anomalies of anterior urethra [eight cases with saccular diverticula, one case with globular dilatation of entire urethra, and one case with globular dilatation of distal urethra] showed that the VCUG and retrograde urethrography were diagnostic in all of patients

Congenital urethral anomalies in boys. Part II

In the second part of this article, congenital urethral anomalies other than posterior urethral valve were reviewed. The anomalies considered in the current review were anterior urethral valve, lacuna magna, syringocele, Cobb's collar, duplication of urethra, megalourethra, and prostatic urethral polyps. The literature was extensively reviewed concerning the presentations, diagnosis, different types of treatment modalities, morbidity, mortality, and new concepts for the above disorders. Anterior urethral valves or diverticula are the most prevalent congenital anomalies of anterior urethra. The lacuna magna is the largest depression in the dorsal aspect of the fossa navicularis. It is demonstrable on a well-performed voiding cystourethrography of the distal urethra. The dilated Cowper's gland duct is the other missed diagnosed anomaly of the urethra in boys. The congenital narrowing of the bulbar urethra with a variable clinical presentation and obstruction grade and different types of anterior urethral obstruction are the most common presentation of these anomalies. However, other symptoms or signs including, hematuria, bloody spotting on underwear, discomfort or sever pain in the vicinity of the glance, interrupted voiding, infection, bulging of anterior urethra, enuresis, and postvoiding dribbling are the only nonspecific manifestations of these disorders. All of these disorders are demonstrable on a well-performed voiding cystourethrography of the distal urethra. The urologist must be aware about these uncommon congenital anomalies and the anterior urethra should be carefully evaluated for such anomalies. Diagnosis of these entities is elusive unless the physician is looking for them. Nonspecific symptoms mentioned here besides radiographic findings can be a valuable clue for diagnosis

Extravasation of the contrast in the unused urinary bladder.

Ruptured bladder or extravasation from the bladder is almost always associated with trauma. Spontaneous extravasation is extremely rare with only a few reported cases. All those reported extravasations occurred in the patients diagnosed with end stage renal disease (ESRD) and were self limiting conditions. During the one-year period of 2001, voiding cystourethrography (VCUG) of 115 patients were performed in our institution with various indications. The authors found 3 cases with extravasation of contrast from the bladder during VCUG. All extravasations were occurred in ESRD patients and the VCUG was performed as part of the routine investigation prior to renal transplantation. The presented cases shared a similar observation of 1) no traumatic catheterization, 2) only minimal and self limiting extravasation and 3) no immediate or delayed symptom associated with extravasation. The cause and mechanism of leakage remain uncertain. Hypertonicity and mucosal changes within the unused bladder were purposed as probably the two main causes of extravasation.

Sonography in evaluation of male anterior urethra

Ultrasonography offers advantages over conventional urethrography in terms of abnormalities detected, convenience of the study and lack of ionizing radiation. Our study favours sonography to be the examination of choice for both follow up of postoperative patients and for the evaluation of patients with new symptoms. The urologist may require a "road map" before surgery and for this purpose contrast urethra-gram may be more helpful

role of an urgent urethrography in the diagnosis and optimal management of anterior urethral injury

Twenty one patients with straddle injuries [thier age ranged from 20- 45 years] underwent urgent urethrography for evaluation of urethral integrity, complete rupture bulbous urethra in 15 patients and simple urethral contusion in other 6 patients. 10 patients were managed by primary urethral reconstruction with supra pubic diversion and the other 5 patients by supra pubic cystostomy as the primary repair for rupture bulbous urethra. Two out of ten patients were managed by primary urethral reconstruction requires further procedure of urethral dilatation, while 3 patients were managed primarily by suprapubic cystostomy required gradual urethral dilatation, two of them visualised internal uretherotomy and only one patient needs surgical excision of strictured part with urethroplasty [end to end anastomosis]. Therefore urgernt urethrography provides, non invasive, simple and accurate diagnostic procedure for the extent of urethral injury, that is necessary for optimal management with the best successful outcome and least morbidity, as well it can eliminate the controversy existed about the result of primary urethral repair in comparison to suprapubic cystostomy as preliminary procedure as it clarifies the extent of urethral injury

Urethro-venous intravasation during retrograde urethrography (report of 5 cases).

Five instances of urethro-venous intravasation during retrograde urethrography are reported. Four cases were of urethral strictures and one case was of urethral hemangioma. All patients had post procedural bleeding while one patient got allergic reactions, another showed chills and rigors. Anatomy of the drainage veins is described. Factors responsible for this complication and its clinical implications are discussed. It is suggested that urethro-venous intravasation should be considered a diagnostic sign of urethral inflammation.