Female urethral stricture: techniques for reconstruction

Female urethral stricture (FUS) is a rare condition. It was not studied robustly for many years, but interest has grown recently in the reconstructive urology community, leading to an increase in publications. In this review, we gather the latest data regarding FUS and its different therapeutic options. Studies are summarized, split by technique. We also review the recently published European Guidelines. In addition, we share our preferred surgical technique and our views on future options. Diagnosing FUS can often be challenging and requires a high index of clinical suspicion. Its vague clinical symptoms and empiric initial treatments combine to make FUS an underdiagnosed condition. The lack of consensus on how to define FUS also compounds the problem. Appropriate diagnosis requires thorough investigation, and ancillary studies such as video urodynamics, cystoscopy, and voiding cystourethrogram may be useful. Treatment options range from conservative management to definitive procedures, although studies have shown that conservative measures such as urethral dilation have a low success rate overall. Within definitive management, augmented urethroplasty - using either flaps or grafts, has proven to be the gold standard. Both have shown excellent results over time; however, there is insufficient data available to recommend one over the other. Contemporary data has an overall poor level of evidence. Although challenging due to the rarity of the problem, a proper randomized controlled clinical trial comparing the principal surgical options and their outcomes would be beneficial and would allow for more informed decision making when considering options for women with urethral stricture.

Image-guided confirmation of a precision pull-through procedure during laparoscopically assisted anorectoplasty in an open MRI operating theater: first application in an infantile case with anorectal malformation

Background Image-guided surgery with an open magnetic resonance imaging (MRI) system is applied for brain tumors in the neurosurgery field, but has rarely been reported in pediatric surgery. We report our initial experience of intraoperative confirmation of precision rectal pull-through during laparoscopically assisted anorectoplasty (LAARP) in an open MRI operating theater for pediatric patients with anorectal malformation (ARM). Case presentation A 3.0 kg term male neonate was delivered with anorectal malformation. An invertogram revealed the intermediate type. Transverse colostomy was made on the left upper abdomen. The recto-bulbar urethral fistula (RBUF) was diagnosed by a distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. Because this was the first procedure in which the pediatric abdomen had been scanned in an open MRI operating theater in our institution, we scanned his pelvic floor under sedation 3 weeks before the operation using the open MRI system in our operation room. We performed the operation with 4 trocars. The peritoneal reflection was carefully incised and the rectum was dissected. The RBUF was resected. The center of the muscle complex was detected at the perineal skin with an electrical nerve stimulator, and a 7-mm longitudinal skin incision was made on the perineal lesion for anoplasty. The muscle complex and the pubo-rectal sling were confirmed laparoscopically using a 3.5-mm bipolar forceps connected to the electrical nerve stimulator. Anoplasty was performed between the rectal stump and perineal skin. After anoplasty, the patient was scanned with open MRI under general anesthesia. We attached the quadrature-detection (QD) head coil around the patient’s pelvis and inserted him in the gantry. A 0.45-T open MRI clearly revealed that the pulled through rectum was located in the center of the muscle complex on T2-weighted images. The postoperative course was uneventful. Oral intake was started on post-operative day 1. Postoperative dynamic urography showed no complication (e.g., leakage or residual fistula). Conclusions We successfully performed LAARP for ARM, with intraoperative confirmation of precision rectal pull-through in an open MRI operating theater. Further cases are required to evaluate the application of open MRI systems in pediatric surgery.

Accuracy of pre-operative fistula diagnostics in anorectal malformations

Background Surgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics. Methods Ethical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001–2020. Results The 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other. Conclusions Ostomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60–70%.

Evaluation of Procalcitonin Serum Levels in Children Younger than Five Years Old with Urinary Tract Infection

Background: Children with vesicoureteral reflux (VUR) are posed to the danger of recurrent pyelonephritis, kidney scar and renal failure. Nowadays, the evaluation of VUR is carried out using different imaging methods that are accompanied with different limitations. Pediatricians usually look for other evaluation methods that are feasible, easy to implement and carries the least amount of danger to the patient. Objectives: The aim of this study was to investigate the level of serum Procalcitonin (PCT) as a predictor of VUR instead of the voiding cystourethrogram (VCUG). Methods: This case-control study was conducted from 2013 to 2014. One hundred and ten children younger than five years old were divided into two groups: (i) the case group with 76 children diagnosed with urinary tract infection (UTI) using urine culture test, and (ii) the control group with 34 healthy children. Serum levels of PCT were measured by a commercial kit. Demographic data were collected using a questionnaire and analyzed by software SPSS. Results: Of the samples, 69.1% of them had no VUR, 20% and 10.9% of the samples suffered from severe unilateral VUR and severe bilateral VUR, respectively. With regard to the level of serum PCT, 61.8% of the samples were positive. One-half of those samples (38 people) who was diagnosed to be healthy had a normal level of serum PCT. However, 30 people (88.2%) of the samples diagnosed to be healthy using VCUG had increased level of serum PCT. The positive and negative predictive values of the level of serum PCT were 44% and 90%, respectively. In this respect, 50% of the samples diagnosed by using level of serum PCT were false positive and 11.8% were false negative. The kappa score for the level of serum PCT was 0.3 (P < 0.0001). The positive predictive value of the serum level of PCT for the female and male samples were 43% and 50% respectively. Conclusions: There was no statistically significant relationship between VUR and the serum level of PCT.

An insight into the management of urinary bladder diverticulum: a retrospective observational study

Background: The aim of the study is to retrospectively analyse the best mode of treatment for patients presenting with urinary bladder diverticulum. Methods: This study includes 46 patients who presented to the outpatient department between January of 2018 to March of 2020. They had lower urinary tract symptoms (LUTS) and were later found on investigations with imaging like ultrasound and voiding cystourethrogram (VCUG) as having bladder diverticulum with some cases associated with bladder outlet obstruction. Secondary causes were treated surgically or conservatively with clean intermittent catheterisation (CIC). Diverticulum was addressed with diverticulectomy when conservative management failed with recurrent LUTS or if the diverticulum was of a large size with significant post void residual urine. Results: Most of the patients with diverticulum associated with prostatomegaly or stricture urethra fared well after treatment of the underlying cause except one who underwent subsequent diverticulectomy. Four out of 5 patients with neurogenic bladder did well with CIC alone barring one who underwent diverticulectomy for a large sized diverticulum and refractory LUTS. Two patients with bladder growth involving the neck of diverticulum underwent partial cystectomy along with diverticulectomy. Four out of the remaining 8 patients with primary diverticulum were taken up for diverticulectomy directly and one underwent subsequent diverticulectomy for failed CIC. Conclusions: Not all urinary bladder diverticulum required surgical management per se. Most fared well with treatment of the underlying cause. So only those with large size, recurrent LUTS and failed management with CIC should be considered for diverticulectomy.

Prevalence of Vesicoureteral Reflux and Urinary Tract Infection in Children with and without Urolithiasis

Background: Vesicourethral reflux (VUR) is a common urinary tract disorder in children, which may be associated with urolithiasis. Objectives: The current study aimed to investigate vesicoureteral reflux in children with and without urolithiasis. Methods: In this case-control study, 130 children younger than 10 years, with a confirmed diagnosis of urinary tract infection (UTI) are investigated. The demographic information and clinical status of all participants were recorded. Ultrasonography was performed for all children, and they were divided into two groups of 65 subjects based on the results: group 1, children with UTI+stone; and group 2, children with UTI+ non-stone. All children received Voiding Cystourethrogram to evaluate Vesicourethral reflux. Results: The mean age of participants was 7.48 ± 3.2 years, and 68 (52.7%) of them were male. Also, VUR was observed in 33 (25.38%) cases. The frequency of reflux in the UTI + stone group was 21 (32.3%), which was significantly higher than the other group (12 cases, or 18.46%) (P = 0.011). However, the association between UTI and stone (P = 0.3, CC = -0.01) was not significant. Conclusions: This study demonstrated a significant correlation between urinary tract stones and VUR in children with urinary tract infections. It is recommended to investigate the presence of stone or VUR in children suffering from any of the described disorders.