The role of gel-infused translabial ultrasound as a new modality in evaluation of female urethral stricture.

Introduction: To investigate the role of trans-labial ultrasound study in detection of female urethral stenosis (FUS) compared to former cysto-urethroscopy as the currently available definitive diagnostic modality. Material and methods: In this cross-sectional study, 60 consecutive patients with bladder outlet obstruction diagnosed by clinical symptoms and urodynamic study, were included from 2019 to 2022. For additional assessment, all these patients underwent gel-Infused trans-labial ultrasound (GITLUS) and cystourethroscopy. Trans-labial real-time ultrasonography was performed following the insertion of 20 ml steady stream viscous jelly into the urethral meatus to assess the length of the urethra and exact location and length of the probable narrowing, as well as the presence of peri-urethral fibrosis (PUF). Results: In GITLUS evaluation, urethral stricture was found in 27 patients. Mean urethral length and stricture length were 35.63 ±4.78 and 17.04 ±10.59, respectively. All these stenosis were confirmed via cysto-urethroscopy. PUF was found in 20 of 27 patients. In cysto-urethroscopy, urethral stricture was confirmed in 40 patients: 13 in urethral meatus and 27 in other parts or pan-urethra. GITLUS could not reveal urethral stricture in 13 patients with meatal stenosis, confirmed with cystoscopy. GITLUS detected FUS less accurately when it involves pure distal urethra compared to other parts of urethra or pan-urethral stenosis (p value = 0.002). Conclusions: GITLUS is a safe, non-invasive, and valuable technique for detecting FUS. The location and the length of the stricture and probable peri-urethral fibrosis can be identified by this method. However, in meatal or pure short-length distal urethral strictures, this method should be used with caution.

Female Urethral Cavernous Hemangioma: Introducing Treatment and Follow-Up Course of Three Cases.

Cavernous hemangioma is a benign vascular tumor occurring in all parts of the urinary system, including the kidney, bladder, prostate, ureter, and rarely urethra. Urethral cavernous hemangiomas are mostly seen in male patients, and only a few cases of female urethral hemangiomas are reported. Herein, we present the management and follow-up course of 3 cases of female urethral cavernous hemangioma. All 3 cases were menopause women complaining of lower urinary tract symptoms. Definitive diagnosis is made by histopathologic evaluation. In case of large or pedunculated masses, initial surgical resection is highly recommended. Regular follow-up of patients in order to prevent any recurrence is suggested.

Correlation between trans-perineal ultra-sonography, urodynamic study and physical examination findings in female patients with stress urinary incontinence: Single center experience.

BACKGROUND: To evaluate the efficacy of Trans-perineal ultrasonography (TPUS) in assessment of stress urinary incontinence (SUI) and its correlation with urodynamic study (UDS) and physical examination in women with SUI. METHODS: The study enrolled a total of 91 females including 66 women with SUI and 25 women with no history of urinary incontinence as control group. The α and ß angles (anterior urethral and posterior urethro-vesical angle respectively) were recorded both at rest and at straining, using TPUS. The differences between these angles at rest and during the straining were considered as the rotational angles (Rα and Rß). Urethral length and caliber, bladder neck funneling, and pubo-urethral distance were measured as well. RESULTS: The mean (SD) α angle at rest of the SUI group was 49.0 (±14.3)°, which was higher than the same parameter in the control group: 47.6 (±9.7)°. Similarly, the α angle at straining was significantly higher in the SUI group versus the control group, 61.0 (±15.4)° versus 55.8 (±15.8)°. The mean (SD) ß angle in the SUI group at rest was 124.6 (±28.5)°, which was significantly higher than that of the control group at 114.0 (±22.5)°. The mean (SD) ß angle at straining was also higher in the SUI group versus the control group: 151.8 (±90.6) versus 136.0 (±27)°. Moreover, higher Rα and Rß angels were documented in the SUI group. CONCLUSION: Our data suggest that TPUS can be considered as a non-invasive, easily conducted, and accurate modality in early diagnosis of female SUI. It may reduce the need for performing relatively invasive UDS. However, the role of TPUS in assessment of SUI severity remains to be studied probably with a larger sample size.

Achieving a one-year-tumor-free survival in a female with primary large cell neuroendocrine carcinoma of the urinary bladder and liver metastasis; a case report.

Primary neuroendocrine tumor (NET) of bladder is rare. It has four subtypes, and large cell neuroendocrine carcinoma (LCNEC) is the rarest. LCNEC affects mostly men over 60. Most common symptom is gross hematuria. It has no specific treatment. Metastasis is common and once occurred, average survival would be less than three months. Herein we present diagnostic and therapeutic management of a 65-year-old female with LCNEC of bladder and concurrent high-grade urothelial carcinoma. Despite developing early liver metastasis, she achieved a one-year tumor-free survival.

Accreditation of an old surgical technique for stress urinary incontinence: long-term outcomes of modified autologous fascial pubovaginal sling.

PURPOSE: To evaluate long-term outcomes of modified autologous fascial pubovaginal sling (AFPVS) in women with stress urinary incontinence (SUI). METHODS: To evaluate long-term outcomes of modified AFPVS, we retrospectively reviewed the medical records of our patients from 2004 to 2015. From 2 decades ago, we have made modifications to classic surgical technique to make it simpler and faster. RESULTS: 199 patients were contacted with mean age of 52 years. The mean follow-up period was 107 months. According to Revised Urinary Incontinence Scale (RUIS) questionnaire, overall success rate was 83.9%. In patients with positive history for SUI surgery, success rate was 73% compared to 87% in those without it. Body mass index was negatively associated with cure rate. We did not encounter any major complications and most of the issues were managed conservatively. Recurrence of SUI occurred in 6 patients (3.5%) after initial improvement. CONCLUSION: Modified AFPVS is an effective surgical technique for treatment of SUI with high and durable success rate. At the present time with concerns regarding the use of transvaginal synthetic mesh, there is increasing interest and request for modified traditional procedures. It is likely that AFPVS may become more popular in upcoming years.

Renal mucormycosis following transurethral resection of prostate in the time of COVID-19: Unique imaging features resembling emphysematous pyelonephritis.

We report a case of isolated renal mucormycosis 2 weeks following transurethral resection of prostate. The patient also mentioned history of admission for COVID-19, two months earlier. Symptoms progressed and patient underwent urgent nephrectomy. CT scan resembled imaging features of emphysematous pyelonephritis and therefore, patient did not receive timely treatment with amphotericin B in addition to nephrectomy and succumbed to the disease.

Huge vaginal wall Mullerian cyst mimicking high stage pelvic organ prolapse.

Vaginal Mullerian cysts are usually small and asymptomatic. Occasionally, they are enlarged and mimic other anatomical disorders, such as anterior vaginal wall prolapse, middle compartment defects (enterocele, apical vaginal wall prolapse) or urethral diverticulum.  Herein we report a female case with a huge vaginal wall Mullerian cyst which was initially misdiagnosed as stage 4 cystocele. Pelvic MRI and cysto uerthroscopy revealed no communication between the cyst and adjacent structures. The cyst was completely excised through a vaginal approach. The pathologic evaluation revealed a benign Mullerian cyst lined with mucinous epithelium. Diagnostic approach to space occupying lesions in the vaginal cavity needs assessment by history, physical examination and appropriate imaging which are essential to prevent misdiagnosis and mistreatment.

Vulvar Pyogenic Granuloma in Adult Female Population: A Case Report and Review of the Literature.

Pyogenic granuloma (PG) is an uncommon lesion of unknown etiology. It may be formed following a minor injury. They result from a reactive or inflammatory process consisting of proliferating vascular channels, immature fibroblastic connective tissue, and scattered inflammatory cells rather than neoplastic process. Bleeding is the most common symptom of the lesion. They may be seen in all age groups, and there is no clear predominance of a gender. Vulvar PGs can be confused with other polypoid or sessile lesions of the genital site. There are only a few cases of female genital PGs reported in the literature. Herein, we describe the first case of vulvar (clitoral) PG in an Iranian patient and a brief review of the literature in this regard.

Primary Epidermoid Cyst of the Clitoris in Adult Female Population: Three Case Reports and Introducing a Safe Surgical Approach.

Epidermoid cyst (EPC) of the clitoris is a very rare cause of non-hormonal acquired clitoromegaly. Clitoral EPCs are extremely uncommon without prior history of genital surgery, trauma, circumcision, or piercing. Surgical removal with special care to avoid compromising neurovascular bundle of the clitoris is the preferred treatment. To our best knowledge, only three cases of adult female clitoral EPC without history of genital surgery, female circumcision, or medications including oral or implantable contraceptives have been reported. Herein, we describe three cases of primary EPC of the clitoris, their management, unique histopathology report, safe surgical approach, and their follow up course.

Female Urethral Cavernous Hemangioma, A Rare Entity: Two Case Reports and Review of The Literature.

Genitourinary hemangiomas are very rare. To our knowledge few cases of female urethral hemangiomas have been reported and presenting cases are the first reports in Iran.They should be considered as differential diagnosis of any female patient with microscopic or gross hematuria or bloody urethral discharge, especially when other parts of urinary system are radiologically intact. Thorough physical examination of genital area is highly recommended in order not to miss any urethral lesions. Herein we report two cases of female urethral cavernous hemangioma, their management and a review of literature.

Salvage autologous fascial sling after failed anti-incontinence surgeries: Long term follow up.

OBJECTIVE: To evaluate long term outcomes of autologous pubovaginal fascial sling (AFPVS) as a salvage procedure following different types of failed anti-incontinence surgeries. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients who had undergone salvage AFPVS after any kind of anti-incontinence surgery from 2005-2015 at our medical center. Patients were contacted by telephone. Revised Urinary Incontinence Scale (RUIS) was used to determine the success rate. RESULTS: A total of 40 patients out of 51 were successfully contacted. Mean patient age was 50.8± 9.8 years (range30-75) and mean follow up was 62.6±32.4 months (range12-120). Of 40 patients, 14(35%) had pure SUI and 26(65%) complained of mixed urinary incontinence. A total of 15(37.5%) patients had a failed Burch colposuspention, 5(12.5%) TVT, 8(20%) TOT, 3 (7.5%) AFPVS and five (12.5%) patients had history of failed mini-sling procedure. Four (10%) patients had undergone more than one anti incontinence surgeries. Overall success rate was 65% in our study. New onset urge urinary incontinence was detected in 25% of patient which was negatively associated with satisfaction and recommendation.  There was no statistically significant correlation between mixed urinary incontinence, type or number of previous failed surgeries with success however presence of pure SUI had a strongCOCLUSION: Autologous pubovaginal fascial sling might be considered as a safe and efficacious salvage surgical option following failed midurethral slings, Burch colposuspention and even AFPVS itself. It will provide reasonable long term results with no major complications.

Long-term follow-up of trigonoplasty antireflux operation.

BACKGROUND: Open trigonoplasty antireflux operation has been associated with promising results. However, its success in controlling reflux has not been evaluated in the long term. METHODS: All patients who underwent trigonoplasty for vesicoureteral reflux by one surgeon from 2004 to 2014 were included. Preoperative evaluations included direct radionuclide cystography (DRNC) or voiding cystourethrography, urine analysis and culture and abdominal sonography. Urodynamic study and cystoscopy was performed in selected patients. Trigonoplasty was done by a modified Gil-Verent method. The latest available patients' DRNCs were used to judge for reflux relapse. RESULTS: Ninety-one patients, 142 refluxing units; median (range) age, 10.5 (1-45) years; M/F, (11/80) were followed for 18 to 135 months. Reflux resolution rate was 73.6% for patients and 75.4% for refluxing units. Relapse was associated with reflux grade (67% in grade V), ureteral orifice appearance (40% in golf hole/stadium), and patients with a history of pyelonephritis. Multivariable model based on the above variables had less than 10% sensitivity in predicting relapse. CONCLUSIONS: Trigonoplasty success rate can decrease with long-term follow-up.

Erectile function and dysfunction following low flow priapism: a comparison of distal and proximal shunts.

PURPOSE: To compare erectile function following low flow priapism in patients undergoing distal and proximal shunts. MATERIALS AND METHODS: From January 1995 to December 2005, we retrospectively studied 16 patients who presented to our medical center with refractory priapism. Of 16 patients, 5 underwent Winter shunt, while El-Ghorab procedure was performed for 7 patients and the remaining 4 underwent Grayhack shunt. Erectile function was assessed in a minimum follow-up of 2 years (range, 2 to 10 years) using erectile dysfunction (ED) intensity scale [Total score: 5 to 10 (severe ED); 11 to 15 (moderate ED); 16 to 20 (mild ED); and 21 to 25 (no ED)]. RESULTS: The mean patient's age was 40.62 ± 15.27 years. Mean duration of priapism was 51.12 ± 37.99 hours. Of 4 patients (25%) who underwent proximal shunt (Grayhack procedure), 2 (50%) were impotent, 1 had potency, and the other one achieved some penile erection with administration of oral sildenafil. Of 5 patients (31.25%) who underwent Winter procedure, 1 died because of metastatic bladder cancer and of 4 remainders, 2 (50%) had normal erectile function, but 1 patient suffered from recurrent priapism. Of 7 patients (43.75%) who underwent El-Ghorab procedure, 1 was lost for follow-up and of remaining 6 patients, 2 (33.3%) had normal erectile function and 4 (66.6%) were impotent. No surgical complication was seen. Median lag time from priapism till surgery for patients with and without ED was 48 and 26 hours, respectively (P = .22). CONCLUSION: Grayhack shunt is a safe surgical procedure without any major complications and with lower ED rate. Grayhack shunt might be considered as treatment of choice for refractory low flow priapism.

Partial ureterectomy for a huge primary leiomyoma of the ureter.

A case of a huge primary leiomyoma of the ureter in which only partial ureterectomy was performed is presented. The benign nature of the mass was primarily confirmed with frozen section at the time of surgery and then with immunohistochemistry (IHC). To the best of our knowledge, this case is a unique form of leiomyoma of the ureter due to its large size. There have been only ten cases of primary leiomyoma of the ureter reported since 1955 and all of them were very small in size. Our case is considered to be the eleventh.

Special characteristics of culturing mature human bladder smooth muscle cells on human amniotic membrane as a suitable matrix.

INTRODUCTION: Our aim was to evaluate the natural behavior, growth pattern, morphology, and specific features of human bladder smooth muscle cells (HBSMCs) on two different matrixes, including human amniotic membrane (HAM) and collagen. MATERIALS AND METHODS: The HBSMCs were obtained from 6 children with primary vesicoureteral reflux undergoing open antireflux surgery, and they were isolated from the anterior wall of the bladder. The specimens were cultured on a tissue culture plate of bovine dermal collagen serving as control and on decellularized HAM. Histological, transmission electron microscopy, and immunocytochemical examinations were done, thereafter. RESULTS: On HAM, very few HBSMCs slowly migrated from explant tissue on the 7th day of culture. All the cells were placed at the same direction, and in some parts, formed multilayer. After 35 to 40 days, the confluency rate was 75% and the cells were orderly arranged. On collagen, cell migration from explant culture took place as rapidly as the 3rd to 4th day of culturing. On days 30 to 40, the confluency rate was 100%. Immunocytochemical staining was positive for anti-actin and antidesmin antibodies. On transmission electron microscopy, cell organelles of HBSMCs exhibited the same features of the natural smooth muscle cells. They were tightly attached to each other and the underlying layer basement membrane. CONCLUSION: A well-designed growth pattern of HBSMCs on HAM with abundant cell-to-cell adhesions encourages us to use it as a competent tissue for reconstruction of relatively damaged or diseased bladders. Undoubtedly, further clinical studies should be performed to replicate our results.

Transperitoneal laparoscopic partial nephrectomy using a new technique.

INTRODUCTION: We report our experience with a new technique for transperitoneal laparoscopic partial nephrectomy with the kidney turned upside down intraoperatively. MATERIALS AND METHODS: Laparoscopic partial nephrectomy was performed in 10 patients with upper pole lesions through a transperitoneal approach. Once complete mobilization of the kidney was achieved, it was rotated 180 degrees around the horizontal axis, so that the upper pole was positioned inferiorly. After performing partial nephrectomy, the resection bed was sutured by 2-0 polyglactin sutures and application of Hem-o-Lok clips. Then, the kidney was returned into its normal position and fixed to the abdominal wall. RESULTS: We performed laparoscopic partial nephrectomy on 9 patients with a contrast-enhancing upper pole kidney mass and 1 patient with a nonfunctioning upper pole. The median tumor size was 58 mm (range, 41 mm to 92 mm). The median operative time was 206 minutes (range, 114 to 262 minutes) and the mean warm ischemia time was 30 minutes (range, 22 to 35 minutes). One patient underwent surgical exploration due to bleeding 6 hours after the operation. Prolonged urine leakage (more than 7 days) was observed in 1 patient, which responded to ureteral stent insertion. Surgical margins were negative in all of the patients. Renal cell carcinoma was histologically diagnosed in patients with a kidney tumor. CONCLUSION: Laparoscopic upper pole partial nephrectomy had acceptable results while the kidney was turned upside down intraoperatively, in terms of operative time and complications. This approach facilitates the procedure by achieving a better field of vision.

Renal cell carcinoma in presacral pelvic kidney.

Renal pelvic ectopia has been estimated to occur in 1 of 2100 to 3000 autopsies. Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. According to our review of literature, there are only seven reports of RCC occurrence in pelvic kidneys. We describe a patient with RCC of presacral ectopic kidney who underwent radical nephrectomy at our medical center.