UrethroNAV: the aetiology and extent of idiopathic urethral stricture in an Australian population.

Background: Lichen sclerosus (LS) is considered a causative factor in 10% of cases of idiopathic urethral stricture disease (IUSD), which is important for determining management strategies due to the underlying pathophysiology. Traditional excision urethroplasty may not be effective as inflammation often extends beyond the macroscopic stricture. This pilot study aims to answer two research questions: is LS an underlying cause of some idiopathic cause of strictures, and, if there is histological evidence suggesting predisposition of the surrounding tissue to strictures. Methods: Biopsies were taken from the stricture site as well as 1 and 2 cm proximal and distal in patients with IUSD. Histological features, including macroscopic and microscopic findings, were reported, including the presence of LS, hyperkeratosis, epidermal changes, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was used to aid in locating damaged urothelium. Patients were prospectively followed up after urethroplasty. Results: From 109 urethroplasties performed between 2019 to 2022, 15 male patients were enrolled after meeting specific inclusion criteria. These criteria included a diagnosis of IUSD and the absence of any evidence of trauma, macroscopic inflammatory disease, or previous endoscopic instrumentation of the urethra. Patients had to be at least 16 years old and medically suitable for undergoing urethroplasty. The study was approved by the hospitals ethics committees. None had macroscopic evidence of LS. One patient had microscopic evidence of LS at the 2 cm proximal biopsy only. A total of 93% of patients had scarring proximal and distal to the stricture, while 20-40% had inflammatory change. The patient with microscopic LS and two inflammatory change patients had stricture recurrence after urethroplasty. Additionally, one patient with inflammatory changes was diagnosed with penile intraepithelial neoplasia (PeIN) and underwent partial penectomy. Conclusions: Findings suggest that an underlying cause of IUSD could be LS. Additionally, the pathophysiology may involve scarring and inflammation beyond the limits of the stricture with extension distal from the stricture site. Careful evaluation for concomitant urethral pathology should be considered in cases of inflammatory changes. These findings should be considered in the surgical management of IUSD and warrant further research into the role of routine biopsy and drug targets in USD.

A curious case: Concurrent collecting duct renal cell carcinoma and upper tract urothelial carcinoma.

A 71-year-old male presented to Urology with three weeks of overt haematuria and increasing lethargy. Contrast-enhanced CT scans revealed an 8 × 6cm partially exophytic lesion in the left kidney's upper pole, extending beyond the capsule and invading the superior cortical vein, accompanied by abnormal retrocrural lymph nodes. Signs of paraneoplastic syndrome prompted a left radical nephrectomy for symptom relief. Histological analysis identified high-grade collecting duct renal carcinoma and invasive urothelial cell carcinoma. Post-surgery, he was referred for oncological treatment but passed away within two months of the initial diagnosis.

Catheter-associated meatal pressure injuries (CAMPI) in patients with long-term urethral catheters-a cross-sectional study of 200 patients.

Background: Indwelling urethral catheters (IDC) are ubiquitous to healthcare settings, and are associated with many familiar risks like haematuria, infections, bladder spasms and stones. However, a less known complication is catheter-associated meatal pressure injury (CAMPI), especially in those with long-term IDCs. The objective of this study was to explore the prevalence, associated features and management of CAMPI in adults with a long-term IDC. Methods: A cross-sectional multi-centre study was undertaken of 200 adults with a long-term IDC across regional south-west Queensland, Australia between June 2019 to June 2021. The prevalence of CAMPI was determined by clinical examination, voluntary surveys completed by participants and documentation in medical records. Key IDC statistics included total duration of IDC, location of IDC changes, IDC size, type and fixation. Results: Out of 200 adults with a long-term IDC, 9% (18/200) had a CAMPI. There was a higher prevalence of male CAMPI (17/169, 10%) compared to female CAMPI (1/31, 3%). The median time to identification of a CAMPI after initial IDC insertion was 12 weeks (2-136 weeks), but occurred as soon as 2 weeks. CAMPI formation was associated with IDC changes in the community, impaired mobility and congestive cardiac failure (CCF). CAMPI were mostly treated by conservative means given the frailty of the population. Conclusions: Poor mobility, community-managed IDCs, and CCF were all found to have statistically significant associations with the development of CAMPI. CAMPI represents an important and underserved iatrogenic complication within urology practice, and greater awareness is needed to prevent it in vulnerable patients with long-term IDCs.

Robotic surgery education in Australia and New Zealand: primetime for a curriculum.

BACKGROUND: Globally, robotic surgery (RS) has witnessed remarkable growth, yet Australia and New Zealand (ANZ) lack dedicated RS training programs, creating a workforce gap. This narrative review synthesises international research to explore trends and challenges in robotic education. METHODS: We conducted a comprehensive literature review, searching PubMed, Google Scholar, and MEDLINE using keywords like 'robotic surgery', 'surgical education', 'robotic surgery training', and 'robotic surgery curriculum'. We selected studies contributing to understanding current curricula, training tools, and issues in robotic education, utilising the international experience and how it might apply to the ANZ context. RESULTS: RS in ANZ has grown significantly over two decades, but formal curricula for trainees are absent. North America and Europe employ diverse training tools and curricula. Barriers include cost, access, time constraints, equipment complexity, changing training environments, and competition from emerging robotic surgical systems. Balancing the curriculum's demands with trainees' existing requirements is essential. CONCLUSION: Developing a tailored RS curriculum within ANZ's surgical training is crucial for RS to become the primary surgical approach in the future. By working towards a national curriculum we can prepare skilled trainees in robotics to meet the rising demand. The most significant barrier is the lack of robotics in public hospital where trainees are based. This curriculum should encompass online teaching modules, bedside assistance, surgical simulation, dual console mentoring, and primary operator experience.

A transparent synthetic peptide hydrogel as a haemostatic agent in athermal nerve sparing robot-assisted radical prostatectomy: an observational study.

Background: PuraStat® is a new synthetic haemostatic agent constituting peptides that self-assemble into sheets when exposed to ionic charges. The objective of this submission is to assess the perioperative, functional and user-reported outcomes of PuraStat® as an athermal topical haemostatic agent for use on the neurovascular bundle (NVB) in robot-assisted radical prostatectomy (RARP), and to inform further research into this developing field. Methods: Demographic and disease data for 29 consecutive patients undergoing RARP were recorded. PuraStat® was used as the primary haemostatic agent to the NVB, without thermal or suture haemostasis, unless necessary. Preoperative, 1-h postoperative and 24-h postoperative haemoglobin (Hb) were measured. Operative data including postoperative complications up to 30 days were noted. Urinary function, continence and erectile function (EF) were measured pre- and postoperatively with the International Prostate Symptom Score (IPSS), patient reporting of pad usage, and International Index of Erectile Function (IIEF)-5 respectively. A qualitative assessment of PuraStat® was made intraoperatively by the surgical assistant in the following categories: transparency, haemostatic efficacy, ready-to-use, handling, and overall satisfaction. Results: Twenty-nine males aged between 49 and 75 years underwent a nerve-sparing RARP under a single surgeon for clinically significant prostate cancer with PuraStat® used as the primary haemostatic agent at the NVB. One patient required an additional haemostatic suture. The median prostate volume was 36 mL. Mean blood loss was 363 mL. The mean Hb at 1 and 24 h postoperative was 135.2 and 125.1 mg/dL. Median Hb change from 1-24 h postoperative was 11 mg/dL. No transfusions were required, and there were no postoperative complications. Urinary function and continence were preserved. EF in our series was lower than published data. Conclusions: Our observational study suggests that PuraStat® is a safe haemostatic agent in RARP with similar perioperative bleeding outcomes, comparable long-term urinary outcomes and a high level of intraoperative user satisfaction. The effects on EF requires further investigation. PuraStat® appears to be a useful therapeutic tool for the urologist performing RARPs.

Periurethral abscess etiology, risk factors, treatment options, and outcomes: A systematic review.

Objectives: This study aimed to describe patterns of presentation, etiology, risk factors, management, and treatment outcomes of periurethral abscesses using a systematic review framework. Materials and methods: After prospective registration on the PROSPERO database (CRD42020193063), a systematic review of Web of Science, Embase, PubMed, and Cochrane scientific databases was performed. Articles published between 1900 and 2021 were considered. Extracted data included symptoms, etiology, medical history, investigations, treatment, and outcomes. Collated data were analyzed using univariate methods. Results: Sixty articles met the inclusion criteria reporting on 270 patients (211 male, 59 female) with periurethral abscess. The most common clinical features were pain (41.5%), pyuria (41.5%), dysuria (38.5%), urinary frequency (32.3%), fever (25%), and a palpable mass (23%). Predisposing risk factors included the presence of a sexually transmitted infection or urinary tract infection (55.0%), urethral strictures (39.6%), and recent urethral instrumentation (18.7%). Management approaches included open incision and drainage (64.3%), conservative management with antibiotics (29.8%), and minimally invasive techniques (needle aspiration, endoscopic drainage). Time trend analysis of etiology revealed a decreased incidence of infection (sexually transmitted infection/urinary tract infection, human immunodeficiency virus) and higher incidence of diabetes mellitus and periurethral bulking injections in recent years. Conclusions: Periurethral abscesses may display a wide range of clinical features. Presentation, risk factors and underlying etiology vary with sex. The optimal management technique is guided by abscess size. Open incision and drainage combined with antibiotics continues to be the mainstay of management. However, minimally invasive techniques are gaining favor. To the authors' knowledge, this is the first systematic appraisal and management algorithm for periurethral abscess.

A Prospective, Randomized Controlled Multicenter Trial Comparing the Bard Inlay Optima and the Cook Universa Soft Stent.

OBJECTIVE: To determine if the Bard Inlay Optima with its anti-inflammatory pHreecoat stent coating had reduced stent-related symptoms at Week 1 (W1) and Week 3 (W3) post insertion compared to the Cook Universa Soft (CUS) using the validated Ureteral Stent Symptoms Questionnaire (USSQ). METHODS: A prospective, double-blinded, randomized controlled trial was performed on patients receiving unilateral retrograde double-J stents for urolithiasis or pelviureteric junction obstruction at three public Urology services. One hundred forty patients that met inclusion criteria were randomized in a 1:1 ratio to each stent. Primary endpoints were the mean USSQ index scores for the urinary, pain, general, and sexual health domains at W1 and W3. Secondary endpoints were responses to individual USSQ questions, early stent removal, and postoperative opioid use. RESULTS: No significant difference was found between the two stents in terms of index scores for all USSQ domains, early stent removal or postoperative opioid use. The CUS had worse symptom scores at W1 relating to self-reported urinary tract infection symptoms (3.1 ± 1.3 vs 2.6 ± 1.3, P = .05). The CUS was also associated with higher rate of representation to hospital at W1 (n = 10, 16% vs n = 1, 2%, P < .001) and W3 (n = 15, 25% vs n = 3, 5%, P < .001). This did not remain significant when adjusted to site of recruitment (W1 P = .27; W3 P = .22). CONCLUSION: The Bard Inlay Optima's anti-inflammatory pHreecoat stent coating did not translate to any significant difference in overall postoperative symptoms across urinary, pain, general, and sexual health domains.

Influence of pre-stenting on RIRS outcomes. Inferences from patients of the Global Multicentre Flexible Ureteroscopy Outcome Registry (FLEXOR).

BACKGROUND: Retrograde Intrarenal Surgery (RIRS) is recommended as an alternative to percutaneous nephrolithotomy for stones up to 2 cm. Pre-stenting before RIRS remains controversial with various studies differing in outcomes and recommendations. We aim to understand how pre-stenting influences surgical outcomes. METHODS: A number of 6579 patients from the TOWER group registry were divided into pre-stented (group 1) and non-pre-stented groups (group 2). Patients aged ≥18 years old, with normal calyceal anatomy were enrolled. Patients with ureteric stones, anomalous kidneys, bilateral stones, planned for ECIRS were excluded. RESULTS: Patients are homogeneously distributed in both groups (3112 vs. 3467). The predominant indication for pre-stenting was symptom relief. Overall stone size was comparable, whilst group 1 had a significantly more multiple (1419 vs. 1283, P<0.001) and lower-pole (LP) stones (1503 vs. 1411, P<0.001). The mean operative time for group 2 was significantly longer (68.17 vs. 58.92, P<0.001). Stone size, LP stones, age, recurrence and multiple stones are contributing factors for residual fragments at the multivariable analysis. The incidence of postoperative day 1 fever and sepsis was significantly higher in group 2, indicating that pre-stenting is associated with a lower risk of post-RIRS infection and a lower overall complications rate (13.62% vs. 15.89%) (P<0.001). CONCLUSIONS: RIRS without pre-stenting can be considered safe without significant morbidity. Multiple, lower-pole and large stone is a significant contributor towards residual fragments. Patients who were not pre-stented had significantly higher but low-grade complications, especially for lower pole and large volume stones. While we do not advocate routine pre-stenting, a tailored approach for these patients should include proper counselling regarding pre-stenting.

How to do a penile urethroplasty using a novel self-retaining penile retractor.

Effective retraction and clear exposure of urethral tissue is essential in reconstructive penile surgery. The Joshi-Kulkarni retractor provides stable, bloodless operative exposure via non-traumatic tissue compression at the base of penis. The self-retaining design of this retractor also improves ergonomics thereby reducing surgeon fatigue. In this article, we describe how to do a penile urethroplasty by using the Joshi-Kulkarni penile retractor.

Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To collect a multicentric database on behalf of TOWER research group to assess practice patterns and outcomes of retrograde intrarenal surgery (RIRS) for kidney stones. METHODS: Inclusion criteria: age ≥ 18 years, normal renal/calyceal system anatomy, calculi of any size, number, and position. STUDY PERIOD: January 2018 and August 2021. Stone-free status: absence of fragments > 2 mm, assessed post procedure according to the local protocol (KUB X-Ray and/or ultrasound or non-contrast CT scan). RESULTS: Twenty centers from fifteen countries enrolled 6669 patients. There were 4407 (66.2%) men. Mean age was 49.3 ± 15.59 years. Pain was the most frequent symptom indication for intervention (62.6%). 679 (10.2%) patients underwent RIRS for an incidental finding of stones. 2732 (41.0%) patients had multiple stones. Mean stone size was 10.04 ± 6.84 mm. A reusable flexible ureteroscope was used in 4803 (72.0%) procedures. A sheath-less RIRS was performed in 454 (6.8%) cases. Holmium:YAG laser was used in 4878 (73.1%) cases. A combination of dusting and fragmentation was the most common lithotripsy mode performed (64.3%). Mean operation time was 62.40 ± 17.76 min. 119 (1.8%) patients had an intraoperative injury of the ureter due to UAS insertion. Mean postoperative stay was 3.62 ± 3.47 days. At least one postoperative complication occurred in 535 (8.0%) patients. Sepsis requiring intensive care admission occurred in 84 (1.3%) patients. Residual fragments were detected in 1445 (21.7%) patients. Among the latter, 744 (51.5%) patients required a further intervention. CONCLUSION: Our database contributes real-world data to support to a better understanding of modern RIRS practice and outcomes.

Prevalence and sequelae of penile lichen sclerosus in males presenting for circumcision in regional Australia: a multicentre retrospective cohort study.

Background: Lichen sclerosus (LS) in men commonly involves the external genitalia, with up to 20% of these patients developing urethral stricture disease, and a small group developing malignant transformation to penile squamous cell carcinoma (SCC). The objective of this study was to determine the prevalence of LS and its sequelae in males presenting for circumcision. Methods: A multicentre retrospective cohort study was conducted at 8 hospitals within 3 Australian regional centres. We identified males who underwent circumcision between January 2004 and November 2018 and obtained histological and clinical data. Histopathological confirmation of LS was the primary outcome. Development of urethral stricture disease and penile cancer were secondary outcomes. Results: Six hundred and eleven patients underwent circumcision, of which 313 (51.2%) had a specimen sent for histology. Of these, 199 (63.6%) had confirmed LS where the median age at diagnosis was 65 years [interquartile range (IQR), 40-77]. Even if the remainder of unsent specimens were free of LS, the prevalence would still be 32.6%. Amongst the patients with LS, 44 (22.1%) developed urethral strictures, 1 penile SCC (0.5%), and 1 penile intraepithelial neoplasia (0.5%). Conclusions: The prevalence of LS in patients undergoing circumcision where the foreskin was sent for histopathological review was 63.6%. In those with LS, the prevalence of urethral stricture disease was 22.1%.

Oncological and urinary outcomes following low-dose-rate brachytherapy with a median follow-up of 11.8 years.

OBJECTIVES: To examine the long-term oncological outcomes and urological morbidity of low-dose-rate prostate brachytherapy (LDRBT) monotherapy using live intraoperative dosimetry planning and an automated needle navigation delivery system for the treatment of men with low and intermediate-risk prostate cancer. PATIENTS AND METHODS: A prospective database of 400 consecutive patients who underwent LDRBT between July 2003 and June 2015 was retrospectively reviewed to assess urinary side-effects and biochemical progression, based on the Phoenix definition and also a definition of a prostate-specific antigen (PSA) level of ≥0.2 µg/L. RESULTS: Minimum patient follow-up was 5.5 years. The median follow-up of the entire cohort was 11.8 years. The median (range) PSA level was 6.1 (0.9-17) µg/L and the median Gleason score was 3 + 4. The biochemical relapse-free survival (RFS; freedom from biochemical recurrence) based on the Phoenix definition was 85.8% (343/400). The RFS using a 'surgical' definition of a PSA level of <0.2 µg/L was 71% (284/400). Of the 297 men followed for ≥10 years, prostate cancer-specific survival (PCSS) was 98% (291/297). Post-LDRBT urethral stricture developed in 11 men (2.8%, 11/400). For men with ≥10 years of follow-up, 22 men (7.4%, 22/297) required a pad for either stress or urge urinary incontinence (UI). UI was identified in only 2.2% (one of 46) of men who had a bladder neck incision (BNI) before LDRBT. CONCLUSION: LDRBT is associated with excellent PCSS, with a median follow-up of 11.8 years. The risk of post-implantation urethral stricture and UI is low and a pre-implantation BNI for management of bladder outflow obstruction does not increase the risk of UI or urethral stricture.

Large renal artery aneurysm masquerading as renal cell carcinoma.

Renal artery aneurysms (RAAs) are rare. Diagnosis is typically incidental with most cases asymptomatic and detected on routine imaging. Rarely large saccular RAAs may appear to extend to the neighbouring renal parenchyma. Differentiating these from renal tumours can be difficult and subsequent investigation with biopsy may result in fatal rupture. Our case describes an RAA arising from the right renal artery masquerading as renal cell carcinoma (RCC). Emphasis is placed upon thorough radiological evaluation ensuring that RAA is considered and excluded from the differential diagnosis prior to biopsy or surgical intervention. The role of multidisciplinary input is also emphasised.

Lichen sclerosus presenting as an isolated bulbar urethral stricture.

Lichen sclerosus (LS) is a chronic inflammatory condition of the anogenital skin that can cause significant urinary and sexual dysfunction in men, particularly by means of destructive urethral disease. LS is traditionally thought to progress from the meatus with migration along the urethra proximally, however we present a case describing an isolated bulbar urethral stricture secondary to LS. To our knowledge, this has only been reported in the literature in one previous study. Clinician recognition of LS as a potential cause of isolated bulbar urethral stricture disease is important as this has ramifications on follow up and successful management.

Two-year safety and efficacy of Indigenous Abluminus Sirolimus Eluting Stent. Does it differ amongst diabetics? - Data from en-ABLe- REGISTRY.

Introduction: To evaluate the efficacy/safety profile of the Abluminus DES+ over 2-years follow-up in the "real-world" scenario in diabetics as compared to non-diabetics. Methods: In prospective, all-comers, open-label registry conducted at 31 sites, patients were analyzed for 1 & 2-year outcomes with the primary endpoint defined as 3P-MACE of CV death, target vessel related myocardial infarction (TV-MI), ischemia-driven target lesion revascularization (TLR)/target vessel revascularization (TVR) apart from Stent thrombosis (ST). Results: Of 2500 patients of PCI with 3286 Abluminus-DES+, 1641 (65.64%) were non-diabetics while859 (34.36%) were diabetics. The 3-P MACE for the cohort at 1 & 2 years were 2.9%, and 3.16%; TLR/TVR - 1.4% at both the intervals for 2493 patients at 2 yrs. follow-up. TV-MI & ST were 0.36% and0.56% at 1st and 2nd year respectively. The 3P-MACE was lower in non-diabetics at 1 & 2 years (2.3%vs 4.2%; 2.4% vs 4.7% respectively). For components of MACE, CV mortality (0.9 vs 1.9% at 1 yr ; 1.0vs 2.1% at 2 years) was significant (P < 0.05) while TLR (1.1 vs 1.9% at 1 yr. & 1.1 vs 2.1% at 2 yrs.) and TV-MI (0.9 vs 1.9% at 1 yr. & 1 vs 2.1% at 2 years) were similar for diabetics and non-diabetics so was ST (P > 0.05). Conclusion: Abluminus-DES+ showed excellent 2-year safety and efficacy with low 3-P MACE which was higher in diabetics driven by higher CV death but similar TLR, TV-MI and ST.

Management of paediatric recurrent urinary tract infections and challenges in special patient populations.

BACKGROUND: Urinary tract infections (UTIs) affect up to 8.4% of girls and 1.7% of boys within their first six years of life. The rate of recurrence is as high as 30%, with the effects carrying long-term morbidity. Concomitant pathology such as vesicoureteric reflux (VUR) or bowel and bladder dysfunction (BBD) can pose further diagnostic and management challenges in the primary care setting. OBJECTIVE: The aim of this article is to discuss the approach to diagnosis and management of recurrence and strategies to prevent it, with additional information regarding patients with VUR and BBD. DISCUSSION: Management of recurrent UTIs requires family-centred care, with conservative, pharmacological and surgical options effective across different patient groups. In situations that exceed the capacity of local services, referral to paediatric subspecialties should be considered to assist in further investigation of recurrent cystitis-like symptoms.

Targeting "diabetic" coronary artery disease merging the properties of sirolimus coated balloon with sirolimus eluting stent.

BACKGROUND: Patients with diabetes mellitus (DM) represents a challenging subset of population as they experience worse outcomes after percutaneous coronary intervention than patients without diabetes. We evaluated the 2-year efficacy and safety profile of the Abluminus DES+ in patients with diabetes within the population enrolled in the large multicenter en-ABL e-registry. METHODS: Multicenter, prospective, all-comers registry performed in 31 centers in India. We analyze patients according to the diagnosis of DM and insulin dependency (ID or Non-ID): non-DM (1641 patients), NIDDM (721 patients), IDDM (138 patients). The primary endpoint was a composite of device-oriented major adverse cardiac events (MACE): cardiac death, target vessel-related myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR)/ target vessel revascularization (TVR) at 2-year. Stent thrombosis (ST) at any time point was also recorded. RESULTS: The MACE rate at 2-year follow-up was 3.0% in the overall population with DM patients showing a higher rate of primary endpoint compared to non-DM (4.4% vs. 2.4%, P=0.025). Rate of cardiac death was actually low and consistent between the 2 groups (1.7% vs. 0.9%, P=0.100). At 2-year follow-up, the rate of ST was 0.9% in DM patients versus 0.5% in non-DM, P=0.213. CONCLUSIONS: At 2-year follow-up, the Abluminus DES+ technology that merges the features of a sirolimus coated balloon with those of a bioresorbable polymer drug eluting stent appears to be safe and effective. This safety/efficacy profile was consistent in patients with or without DM.

Narrowing in on urethral strictures.

BACKGROUND: Urethral strictures have affected men for millennia, and they are commonly iatrogenic, idiopathic or traumatic in nature. When left untreated, urethral strictures can devastate the health and function of the urinary tract. For centuries, simple urethral dilation and endoscopic urethrotomy have provided temporary relief. However, in only the past 20 years, urethroplasty has emerged as a curative treatment. OBJECTIVE: The aims of this article are to review the aetiology and clinical manifestations of urethral strictures, evaluate the traditional but temporising treatments for urethral strictures, highlight the relatively recent evolution of urethroplasty and promote awareness of the success of urethroplasty in curing urethral strictures. DISCUSSION: Urethral strictures are an important, but often overlooked, cause of bothersome urinary symptoms in men. In this article, the authors provide a summary of the aetiology, clinical manifestations and recent trends in the management of urethral strictures.

Magnetic resonance imaging procedure for pelvic fracture urethral injuries and recto urethral fistulas: A simplified protocol.

OBJECTIVE: The urethral gap in pelvic fracture urethral injury (PFUI) is traditionally assessed using voiding cystourethrogram (VCUG) and retrograde urethrogram (RGU). Magnetic resonance imaging (MRI) is performed in complex cases. We assessed the refined "Joshi" MRI protocol to evaluate complex urethral defects after PFUI. MATERIAL AND METHODS: A prospective study was conducted at our center from January 2018 to January 2020, involving patients aged >18 years with PFUI, suitable for MRI, and those who gave consent to perform standard RGU, VCUG, and MRI using standard and "Joshi" protocol. Forty men were included in the study. Distance between urethral/prostatic stumps was measured. Image quality was scored by four radiologists and four urologists. The surgical approach and type of PFUI repair were noted. We also established the need for inferior pubectomy by assessing the position of the posterior urethra (membranous) in relation to a horizontal line drawn from the lower edge of the pubic bone anteriorly to the rectum posteriorly in a sagittal image. RESULTS: The mean age was 30 years (SD, 5.25; range, 21-43), and the time from injury to imaging was 4 months (3-10 months); 40% of the men underwent crural separation, 57.5%, inferior pubectomy, and 2.5%, crural rerouting. There was a difference of 0.3 to 1.1 cm in the urethral gap measurements between MR images using the standard versus "Joshi" technique. MRI identified complex injuries such as rectourethral fistula, the need for inferior pubectomy, and the orientation of the posterior urethra. Urologists' and radiologists' satisfaction scores for the MR images were satisfactory to excellent. If the posterior urethra was over the defined mark, there was a 100% likelihood of inferior pubectomy (23/40 patients). CONCLUSION: MR image acquisition using the "Joshi" protocol provided high-quality anatomical information in PFUI cases to assist with surgical planning.