Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1–8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients’ quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Efficacy of Mitomycin C Combined with Direct Vision Internal Urethrotomy for Urethral Strictures: A Systematic Review and Meta-Analysis

<b><i>Background:</i></b> The high recurrence of a urethral stricture after direct vision internal urethrotomy (DVIU) has been a problem for years. Mitomycin C (MMC) is an excellent antifibrosis antigen that has been used in many fields, but its effect on a urethral stricture remains controversial. The purpose of this review was to investigate the effectiveness of MMC in reducing the recurrence rate of a urethral stricture after the first urethrotomy. <b><i>Methods:</i></b> Common databases were searched for publications prior to November 30, 2020. Randomized controlled and cohort trials were all included. Recurrence and success rates after the first urethrotomy of the posterior urethra were the main outcomes. Revman 5.3 was used for statistical analysis. Two evaluation systems, the Cochrane risk of bias tool and the Newcastle Ottawa Scale, were used to examine the risk of bias for RCTs and all studies. The quality of evidence was assessed by the Grading of Recommendations, Assessment, Development, and Evaluation standard. <b><i>Results:</i></b> Sixteen trials were included, the reporting quality of which was generally poor, and the evidence level was very low to moderate. The addition of MMC could significantly reduce the recurrence rate of urethral strictures (risk ratio [RR] = 0.42; 95% confidence interval [CI]: 0.26, 0.67; <i>p</i> = 0.0002; 9 trials; 550 participants). The results of the subgroup analysis suggested that the effect of MMC combined with DVIU was significant in short (≤2 cm) anterior urethral strictures (RR = 0.39; 95% CI: 0.20, 0.78; <i>p</i> = 0.008), &#x3e;12-month follow-up (RR = 0.45; 95% CI: 0.26, 0.76; <i>p</i> = 0.003). It also increased the success rate of the first urethrotomy procedure for posterior urethral contracture (RR = 0.74; 95% CI: 0.65, 0.84; <i>p</i> &#x3c; 0.00001; 7 trials; 342 participants). Low-dose local injection of MMC was the most commonly used method. <b><i>Conclusion:</i></b> MMC combined with DVIU is a promising way to reduce the long-term recurrence rate of a short-segment anterior urethral stricture. It also increases the success rate of the first urethrotomy of the posterior urethra. However, more high-quality randomized controlled trials are needed.

Ectopic prostatic tissue presenting as a urinary bladder polyp in a young male

Ectopic prostatic polyps are uncommon lesions, sometimes found in the lower urinary tract, particularly the posterior urethra. Ectopic prostatic tissue in the bladder is very uncommon. Until now, only 43 cases of this lesion have been reported in the English literature. Clinically and endoscopically these lesions are often mistaken for malignancy. We report a case of ectopic prostatic tissue at the bladder neck in a young male. Histopathology and immunohistochemistry confirmed the prostatic nature of the tissue. Since the entity is benign and unlikely to recur, we emphasize that urologists and pathologists need to be familiar with this to avoid misdiagnosis and unnecessary overtreatment.

PRESENTATION, MANAGEMENT, AND OUTCOME OF POSTERIOR URETHRAL VALVES IN WESTERN RAJASTHAN

Introduction: Posterior urethral valve (PUV) is the most common cause of bladder outlet obstruction and renal insufciency in male children. The aim of this study was to evaluate the presentation, management, challenges, and outcome of the disease in a Western Rajasthan tertiary health institution. Methods: In a retro-prospective study, 26 male children were included from November 2017 to March 2020 at Dr. S.N.Medical college, Jodhpur. Diagnosis was conrmed by voiding cysto-urethrography (VCUG). Results: A total of 26 patients were managed for PUV.The mean age of presentation was 3.45 years with 65.8% of the patients presenting after 1 year. Voiding dysfunction noted in 23(88.4%) patients was the most common presentation. Most common nding on physical examination was palpable bladder 15(57.6%) while UTI noted in 15 (57.6%) patients was most common complication. Abdominal sonography revealed dilated posterior urethra in 10(38.4%) cases, while VCUG revealed a dilated posterior urethra in 19 (75%) cases.The creatinine value at presentation ranged from 0.4-4.5 mg/dl with a mean of 1.10 ± 0.95 mg/dl. Valve ablation with a diathermy bugbee electrode & holmium laser provided relief of obstructions in the 23 (88.4%) patients who underwent the procedure without immediate complication. The period of follow-up ranged between 1 weeks to 2 years with a mean of 8.2 months. There was sustained improvement in urine stream, reduction in the mean creatinine concentration and incidence of UTI during follow-up. Conclusion: Many patients with PUVpresented late within the reviewed period. Valve ablation provided relief of obstruction in most of the cases. Efforts at improving awareness among general population and early diagnosis and referral among the health team should be encouraged. There is a need to counsel parents on the need for long-term follow-up

Patent urachus and bladder outflow obstruction—chance or consequence? A study of a cohort of patients with complete patent urachus presenting to a tertiary urological center and a review of literature

Background To explore the association between patent urachus and bladder outflow obstruction (BOO). A retrospective review of patient records over a 35-year period (1983–2018) with complete patent urachus was performed. Antenatal ultrasound findings were noted, and postnatal investigations included ultrasound (US), micturating cystourethrogram (MCUG), functional nuclear medicine scans (MAG3, DTPA, and DMSA), and serum creatinine. Associated anomalies and management in all patients were analyzed. Results Sixty-six patients with all types of urachal remnants were identified of whom only 16 had a patent urachus. All presented clinically with a discharging umbilicus, 10/16 confirmed on MCUG and 4 had umbilical cord cysts on antenatal US. Twenty-five percent had associated bladder outlet obstruction (BOO): etiologies included atresia of posterior urethra, congenital urethral hypoplasia, urethral atresia with prune belly syndrome, and sacrococcygeal teratoma. Vesicoureteral reflux (VUR) was confirmed in 37%, and four of them had bladder outlet obstruction (BOO). Conclusion With patent urachus, bladder outflow obstruction occurs in the minority. Based on our findings, we commend US and cystogram to document VUR. The isolated PU should be treated nonoperatively up to a year of age. Renal function should be checked with the finding of VUR. The etiopathogenesis of the condition remains uncertain.

Evaluation of transperineal ultrasound in diagnosis and grading of female genuine urinary stress incontinence

Stress urinary incontinence (SUI) has an observed prevalence of between 4%and 35%. Purpose: To determine the role of transperineal ultrasound in diagnosing stress incontinence, its degree and the possible cause by: Measuring the BN descent, urethral hypermobility, funneling of BN or proximal urethra, urethral diameter, posterior urethra vesical angle, associated cystocele Using color Doppler to detect escape of urine through the urethra. Methods: 52 female patients diagnosed to have genuine stress incontinence using 3 day voiding diary, simple questionnaire and confirmed by standard urodynamics. Classification of stress incontinence into mild, moderate and severe using Valsalva leak point pressure during urodynamic study. Transperineal ultrasound for evaluation of the anterior pelvic compartment regarding: bladder neck descent, urethralhy permobility, Funneling of the BN, posterior urethrovesical angle ,urethral diameter, associatedcystocele, and finally the Doppler detection of urinary escape both at rest and with Valsalva maneuvers. Results: 28/52 cases (53.8%) of SUI didn’t show clinical evidence of cystocele; 11 cases (21.2%) showed grade 1 cystocele and 13cases (25%) showed grade 2 cystocele. The presence or absence of cystocele and also the grade of cystocele did not show a statistically significant relation to the degree of SUI; p=0.089 and 0.086 respectively Conclusion: We came to conclusion that transperineal ultrasound can be used in accurate diagnosis and grading of female urinary stress incontinence with our given cutoff values for bladder displacement, α angle, β angle and urethral diameters and from this grading by transperineal ultrasound comes the novelity of our research.