Giant urethral stone with diverticulum; a case report

Urethral calculi are rare and represent 1-2% of all urinary stone diseases. Rarely, calculus grows to large size and are labeled as a "giant urethral calculus". A 75-year-old male came to the OPD of Madinah Teaching Hospital Faisalabad with a chief complaint of suprapubic pain, penile pain, and hard mass on the left side of the scrotum and anterior perineum. The patient had a significant history of undergoing debridement for Meleney's and Fournier's gangrene, along with suprapubic cystostomy done about 1.5 years back. Physical examination revealed a solid mass with dimensions 6x7 cm on the left side of the scrotum and anterior perineum (left periurethral area). Open surgery was performed. A huge stone, 6x6cm, was removed. Diverticulae were excised, and urethroplasty was performed. A catheter was removed on the 21st postoperative with a satisfactory urinary stream.

A Rare Case of Complex Hernia Causing Urethral Obstruction

Abdominal wall hernias rarely cause obstruction of the urinary tract. We present the case of a patient undergoing regular smooth dilatations for urethral stricture since 8 years who developed right inguinoscrotal swelling and narrowing of urinary stream since 2 years of age. There was a growing difficulty in dilatation due to path distortion of urethra by the hernia. He had a history of open suprapubic cystostomy (SPC) 8 years ago. The patient refused surgery till he landed with an inability to pass dilators and difficulty in passing urine. He was taken up for right inguinal exploration with internal optic urethrotomy (IOU). Intraoperatively, he was found to have right inguinal hernia with incisional hernia at the site of SPC which was repaired and a cystoscopy revealed urethral deviation with anterior urethral stricture for which IOU was done. Postoperatively, the patient's urethral tract straightened and his urinary complaints resolved. A complex hernia can cause urethral deviation and obstruction due to pressure effects of its contents and should be repaired at an early stage.

A Paraurethral Vaginal Mass in Rural Setting: A Case Report

Paraurethral vaginal leiomyoma is the infrequent case to be described. Approximately 300 cases have been described so far. Imaging modalities aid in identifying the morphological, structural characteristics of the mass and its relationship to the surrounding structures. Thirty-six years old married women presented with a vulvar mass of (3x5) cm2. Her associated complaints were left shift of the urinary stream and dyspareunia. Ultrasonography and cystography revealed a mass with no relationship with bladder or uterine structure. Surgical excision was performed. The histopathological report confirmed the diagnosis of paraurethral vaginal leiomyoma. Surgical excision is the treatment of choice and diagnosis is confirmed by histopathological examination.

Optimal clamping time in meatotomy procedure for children with meatal stenosis: Experience with 120 cases

Objective: During meatotomy procedure for children with meatal stenosis (MS), a straight clamp used as a hemostat on the ventrum of the meatus before incised with scissors for clamping and holding bleeding from the site of operation. The aim of this study was to evaluate the optimum clamping time for meatotomy in children with MS. Materials and methods: All the patients with MS between 2014 to 2019 were enrolled in this retrospective study. Patients with uncircumcised penis, traumatic catheterization, any kind of penile abnormality such as hypospadias or penile curvature, and active urinary tract infection (UTI) were excluded. The indication of meatotomy was a pinpoint meatus that develops with dorsal or lateral deflection of the urinary stream and high-velocity urine flow. During meatotomy procedure, clamping time was examined in different groups such as 2, 3, and 4 minutes. The main symptoms of presentation and ultrasonography (US) findings were recorded and compared between groups. To assess the optimum time clamping, postoperative bleeding was noted carefully in all groups. The success rate was recorded at onemonth postoperative follow-up in the clinic. Results: Of the 120 patients with MS who underwent a meatotomy procedure, there were 40 (33.3%) participants in each group. The main symptoms were painful urination and urine stream deviation that represented in 54 (46%) patients. Bladder wall thickness was the main pre-operation finding in the US which was observed in 67 (55.8%) patients. In comparison between the groups related to clamping time, bleeding was observed and required suturing when clamping was applied for 2 minutes in 4 (3.3%) patients (p = 0.016). With a minimum follow-up of 12 months, no recurrent meatal stenosis was reported. Conclusions: Clamping time for more than 2 minutes may prevent bleeding during and after meatotomy.

The Effect of Pre-Incision Urethral Plate Width and Glanular Width on the Outcome of Tubularized Incised Urethral Plate Repair Surgery in Distal Penile Hypospadias, A Prospective Study

Background: To determine the outcomes of hypospadias repair according to the width of the urethral plate & glanular width. Materials and methods A prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) & glans width (GW) of the patients were measured preoperatively using standard calipers. The urethral plate width was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of repair. All patients were managed via the same technique using Snodgrass tubularized incised plate repair (TIP). All intraoperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans without stenosis, fistula or diverticulum. Results: All 38 patients were evaluated at 6 months and 1 year follow up. The mean age at surgery was 4.5 ± 2.1 years. We categorized the patients into two groups:- (Group A) had a urethral plate width of less than 8 mm, they were 24 patients (63.15 %). (Group B) had a urethral plate width greater or equal to 8 mm. (group B) had a urethral plate width greater or equal to 8 mm, they are 14 patients (36.8 %) Overall, the mean ± of UPW was 10.92 ± 1.24 mm while the mean ± SD of GW was 9.52 ± 1.56 mm. Success was documented in 36/38 patients (94.7%). The documented complication was Fistula in two patient (5.2 %), glans dehiscensce in three patients (7.9%). Success rate was not statistically different in correlation of UPW and GW (p=0.5). The urinary stream was straight in 32 boys and sprayed in 6. Overall, mean ± SD HOPE score was 39.1 ± 8.83. The only statistically significant difference between all patients was a longer operative time in the patients with deficient urethral plate compared to others with adequate urethral plate (p= 0.005). A significant correlation found between the cosmetic outcome of the two groups and HOPE score (p = 0.06). Conclusions: The pre-incision urethral plate width and glanular width was not correlated with the TIP outcome. A better HOPE score is associated with wide urethral plate.

Long-Term Undesirable Consequences of Penile Skin Island Flap to Correct Penoescrotal Transposition: A Case Report and Review of Literature

Hypospadias is a congenital malformation of the male lower urinary tract, consisting of a ventral urethral opening proximal to the glans penis. This condition is corrected surgically in the paediatric age, with a great variety of techniques available. Traditionally, a tubularized genital skin was used for one- or two-stage repairs. Nowadays, the tendency is to use preputial or oral mucosa grafts, dorsally located, to avoid diverticula formation and prevent hair growth in the neourethra. We present a case of a patient born with proximal hypospadias with penoscrotal transposition, surgically corrected in his childhood, using dorsal penile skin island flap. The patient is referred to urology consultation in his adulthood for a weak urinary stream, recurrent infections, and a large amount of hair exiting through the urethral meatus.

The effect of pre-incision urethral plate width and glanular width on the outcome of Tubularized Incised Urethral plate repair surgery in distal penile Hypospadias, A prospective study

Objective:To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate in addition to granular width and configuration.Materials and methodsThe study was a prospective evaluation of patients operated for hypospadias after approval of ethical committee a formal consent were taken from parents. The urethral plate width (UPW) and glans width (GW) of the patients were measured preoperatively using standard calipers. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair.All patients were managed via the same technique using Snodgrass tubularized incised plate repair (TIP). All operations were performed by a single surgeon. All intaoperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum.Results:All 38 patients were evaluated at 6 months and 1 year follow up. The mean age at surgery was 4.5 ± 2.1 years. Overall, the mean ± SD of UPW was 10.92 ± 1.24 mm. a 24 patients (61.5 %) (Group A) had a urethral plate width of less than 8 mm while 14 patients (35.9 %) (group B) had a urethral plate width greater or equal to 8 mm. the mean ± SD of GW was 9.52 ± 1.56 mm. Success was documented in 36/38 patients (94.3%).The only complication was Fistula in two patient (6.7 %), glans dehiscensce in three patients (10%). Success rate was not statistically different in correlation of UPW and GW (p=0.5).The only statistically significant difference between all patients was a longer operative time in the patients with deficient urethral plate compared to others with adequate urethral plate (p= 0.005). The urinary stream was straight in 32 boys and sprayed in 6. Overall, mean ± SD HOPE score was 39.1 ± 8.83. A significant correlation found between the cosmetic outcome of the two groups and HOPE score (p = 0.06).Conclusions:The pre-incision urethral plate width and glanular width was not correlated with the TIP outcome. A better HOPE score is associated with wide urethral plate.

Novel measurement tool and model for aberrant urinary stream in 3D printed urethras derived from human tissue

Background An estimated 10% of male adults have split or dribbled stream leading to poor hygiene, embarrassment, and inconvenience. There is no current metric that measures male stream deviation. Objective To develop a novel method to measure spray in normal and abnormal anatomical conformations. Design, setting, and participants We developed a novel platform to reliably describe spray. We used cadaveric tissues and 3D Printed models to study the impact of meatal shape on the urinary stream. Cadaveric penile tissue and 3D printed models were affixed to a fluid pump and used to simulate micturition. Dye captured on fabric allowed for spray detection. Outcome measurements and statistical analysis Spray pattern area, deviation from normal location, and flowrates were recorded. Computational fluid dynamic models were created to study fluid vorticity. Results and limitations Obstructions at the penile tip worsened spray dynamics and reduced flow. Ventral meatotomy improved flowrate (p<0.05) and reduced spray (p<0.05) compared to tips obstructed ventrally, dorsally or in the fossa navicularis. 3D models do not fully reproduce parameters of their parent cadaver material. The average flowrate from 3D model was 10ml/sec less than that of the penis from which it was derived (p = 0.03). Nonetheless, as in cadavers, increasing obstruction in 3D models leads to the same pattern of reduced flowrate and worse spray. Dynamic modeling revealed increasing distal obstruction was correlated to higher relative vorticity observed at the urethral tip. Conclusions We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the urethra and corrective surgeries on the urine stream that would not be feasible in patients. These novel methods require further validation, but offer promise as a research and clinical tool.

Comparison of Bracka I versus Blair-Byar’s technique in chordee correction.

To compare the outcome of the Bracka I Graft Technique versus Blair-Byar’s Flap technique in orthoplasty for urethral plate in terms of procedure time, hospital stay and urine stream after removal of Foley catheter. Objectives: There are multiple types of procedures to correct the chordee in hypospadias with chordee cases. We planned to perform study to discuss the differences between Bracka I where Graft is used for the plate of urethra and Blair-Byar’s flap technique in term of procedure time hospital stay and urine stream after removal of Foley catheter. Study Design: Randomized Control Trial study. Setting: Pediatric Urology Department, Children Hospital Faisalabad (CHF). Period: 1 year and 9 months, from April 2016 to December 2018. Material & Methods: Total 80 patients were taken with Non probability consecutive sampling technique was adopted with inclusion criteria with more than 2 years of age and hypospadias with chordee while, exclusion criteria of patients were previous surgery of chordee correction and any other associated anomalies. Results: In the patients with Bracka I procedure, n=37 patients (92.5%) have uneventful uptake of graft, where two (5%) patients have failure of uptake of graft while one (2.5%) of them had wound infection and adequate urinary stream after removal of Foley was found in all 40 patients. In Blair-Byar’s technique procedure had uneventful uptake of graft in n= 36 patients (90%) where two (5%) patients have failure of uptake of graft while two (5%) of them have wound infection. Cosmetically acceptance was in 39 patients (97.5%) by the parents and feasibility to do the second stage. While among Blair-Byar’s technique cosmetically acceptance was in 35 patients (87.5%) by the parents and feasibility to do the second stage. Conclusion: Bracka I (graft) Orthoplasty and Blair-Byar’s (flap) Orthoplasty has equivocal results in terms of tissue uptake and uneventful recovery, urinary stream post operatively, post-operative meatal diameter while cosmetically Bracka 1 is superior to Blair-Byar’s technique while feasibility of the availability of local tissue to make tube for urethroplasty in stage II.