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Aims: To compare the 30-day postoperative complications of robotic radical cystectomy (RRC) vs open radical cystectomy (ORC) in obese patients (body mass index ≥30) with bladder cancer (BC). Methods: The National Surgical Quality Improvement Program database was queried to identify obese BC patients who underwent RRC or ORC between 2005 and 2016. Patient demographics, postoperative mortality rate, morbidity, operating time (OPTIME), length of stay (LOS), readmission, and reoperation rates were recorded and compared between the two groups. Each RRC patient was matched with three ORC patients using a propensity score approach. Results: Four hundred forty-two RRC patients were matched with 1326 ORC patients. No difference in early postoperative mortality rate between RRC and ORC (0.7% vs 1.3%, relative risk, RR [95% confidence interval CI]: 0.27 [0.07–1.02]). Compared with ORC, the RRC group showed shorter mean OPTIME (364.7 [standard deviation, SD = 133.4] vs 387.8 [SD = 129.7] minutes, p = 0.001) and mean LOS (7.1 [SD = 5.6] vs 10.6 [SD = 6.6] days, p < 0.001). Compared with ORC, the RR of developing the following events in RRC group was lower: 30-day postoperative any complication (45%), any wound occurrence (64%), blood transfusion (70%), superficial surgical-site infection (78%), and wound disruption (77%). There was no difference in the RR of any-cause readmission (RR [95% CI]: 0.77 [0.57–1.05]) and reoperation (RR [95% CI]: 0.48 [0.22–1.04]) between the two groups. Conclusions: The study revealed that RRC for obese BC patients is associated with shorter OPTIME, shorter LOS, and lower risk of early postoperative complications when compared with a matched group of patients who received ORC. In addition, no difference in early postoperative mortality rate between RRC and ORC was observed. [ABSTRACT FROM AUTHOR]

The authors compared the age and referral patterns of pediatric patients undergoing surgical intervention for cryptorchidism at a rural, West Virginia University, versus urban, Johns Hopkins University, tertiary center. A retrospective review of patients undergoing surgical evaluation for cryptorchidism was performed. Patients treated for reasons unrelated to cryptorchidism or referred for multiple urologic diagnoses were excluded. The patients at each institution were then divided into four groups based on their corrected gestational age at time of surgery. Referral times and provider specialties were also obtained. A total of 131 cases at the urban center and 100 cases at the rural center were identified. At the rural center, the average age of referral and surgery were 48.3 and 53.8 months, respectively, compared to 59.6 and 65.2 months at the urban center. Only 40% of patients at the rural site and 29% at the urban institution underwent intervention at less than 18 months of age. There was no significant difference in time of referral to surgery between the institutions. The majority of referrals were made by private practice pediatricians.Conclusion: In this study, a pattern of delayed referral and intervention was observed at both institutions despite differing geographic regions and heterogeneous patient populations. It is important that referring providers realize that scrotal U/S does not change management of UDT and should not delay prompt referral. What is known: • Significant referral delay is a challenging issue in the management of cryptorchidism. • Ultrasound is not a valid method for the detection of cryptorchidism. What is new: • The rural and urban management of cryptorchidism is not that different. • More emphasis should be put on the detection management of cryptorchidism. [ABSTRACT FROM AUTHOR]

Pyocystis, empyema cystis, vesical empyema are all terms that describe the purulent filled bladder that may develop in patients with defunctionalized bladders such as after supravesical urinary diversion without cystectomy or in patients with end-stage renal disease with anuria. It is a severe form of lower urinary tract infection. In addition to the local symptoms of suprapubic pain and malodorous discharge, the condition can be more serious with bacterial dissemination into the blood stream and ensuing sepsis and even mortality. The current review will discuss the pathogenesis, risk factors and management of this commonly forgotten complication of urinary diversion. [ABSTRACT FROM AUTHOR]

Objective To investigate the feasibility of a new approach for cystoplasty using autologous smooth muscle cell ( SMC) sheet and scaffold-less bladder tissue engineering with the main focus on histological outcomes in a rabbit model. Materials and Methods In all, 24 rabbits were randomly divided into two groups. In the experimental group, SMCs were obtained from the bladder muscular layer, labelled with PKH-26, and seeded on temperature-responsive culture dishes. Contiguous cell sheets were noninvasively harvested by reducing the temperature and triple-layer cell-dense tissues were constructed. After partial detrusorectomy, the engineered tissue was transplanted onto the urothelial diverticulum. The control group underwent partial detrusorectomy followed by peritoneal fat coverage. At 2, 4, and 12 weeks the rabbits were humanely killed and haematoxylin and eosin, Masson's trichrome, cluster of differentiation 34 ( CD34), CD31, CD3, CD68, α-smooth muscle actin (α- SMA), picrosirius red, and pentachrome staining were used to evaluate bladder reconstruction. Results At 2 weeks after SMC-sheet grafting, PKH-26 labelled SMCs were evident in the muscular layer. At 4 weeks, 79.1% of the cells in the muscular layer were PKH-positive cells. The portion of the muscular layer increased in the experimental group during the follow-up and was similar to normal bladder tissue after 12 weeks. α- SMA staining showed well organised muscle at 4 and 12 weeks. CD34+ endothelial progenitor cells and CD31+ microvessels increased continuously and peaked 4 and 12 weeks after grafting, respectively. Conclusion In the present study, we show that autologous SMC-sheet grafting has the potential for reliable bladder reconstruction and is technically feasible with a favourable evolution over the 12 weeks following implantation. Our findings could pave the way toward future bladder tissue engineering using the SMC-sheet technique. [ABSTRACT FROM AUTHOR]

Background: To introduce the role of fibrin sealant and preputial acellular matrix (PAM) as a new source of inert collagen matrix for urethral reconstruction. Methods: A ventral urethral segmental defect was created in 24 male rabbits divided into four groups. In group 1 (G1), urethrotomy was closed in layers. In group 2 (G2), closure was followed by applying fibrin sealant. In groups 3 (G3) and 4 (G4), urethroplasty was performed with a patch graft of PAM, and in G4, fibrin sealant was also applied. Serial urethrography was performed before and after the operation. Then, the animals were euthanized, and their urethra was excised 1, 3, and 9 months postoperatively for further electron microscopic examination, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) technique, and immunohistochemical (IHC) staining with CD34, CD31, desmin, SMA, and α-actin. Results: In G1 and G2, the fistula repair failed in all the time points. In G3 and G4, serial urethrography confirmed the maintenance of a wide urethral caliber without signs of strictures or extravasations. Satisfactory vascularity was observed in G3 and G4 during the whole study, which was more significant in G4 after 9 months of follow-up. The presence of a complete transitional cell layer was confirmed over the graft in G3 and G4 in all time points. IHC staining confirmed the effectiveness of fistula repair in G3 and G4, 3 months postoperatively. Conclusion: This rabbit model showed that PAM combined with fibrin sealant may herald a reliable option for repairing segmental urethral defects. [ABSTRACT FROM AUTHOR]

Objectives: To report the results of a novel technique of sub-urothelial polyp enucleation resection (SUPER) and urothelial auto-augmentation cystoplasty (UAAC) in patients with bladder exstrophy and polyposis plate. Methods: Twenty-eight patients with bladder exstrophy covered by plate polyposis were referred for further management. From these, 12 patients had undergone SUPER, UAAC technique, and subsequent bladder closure. In this technique, the urothelium covering the polyps was utilized as tissue for auto-augmentation cystoplasty. Sixteen patients had been operated by simple polyps' excision and bladder closure. Biopsies of polyps were obtained in both groups at the time of closure for pathological evaluations. The bladder plate was measured pre-and post-bladder plate augmentation. The patients were evaluated every 3 months for 1 year and biannually thereafter for urinary continence and social dryness. Dry period of >3 h during the day with or without nocturnal incontinence was defined as social dryness. Results: All patients experienced an uneventful postoperative period. No sign of metaplasia or dysplasia was observed in the histological and cystoscopy evaluations. These findings suggest that neither polyp recurrence nor bladder tumor development has occurred in any of the groups. The urinary continence improved significantly in the polyp's urothelial coverage augmentation cystoplasty technique (66.7 %), while 31.3 % of patients in simple closure technique achieved continence. Significantly higher mean bladder capacity was obtained in the augmentation group (190 ± 38 ml) and (119 ± 21 ml), respectively. Postoperative mild hydronephrosis and vesicoureteral reflux were significantly lower in auto-augmentation technique. Conclusion: The final clinical outcome of children with bladder exstrophy polyposis is promising. The combined SUPER and UAAC technique is feasible, safe and reproducible option for bladder exstrophy-epispadias complex (BEEC) patients with bladder plate polyposis. However, it will add one supplementary operation to the single or staged bladder reconstruction. These patients may warrant further surveillance with histopathological evaluations during the adult life. [ABSTRACT FROM AUTHOR]

Haematogenous dissemination of undiagnosed urinary tuberculosis after performing extracorporeal shock-wave lithotripsy (ESWL) is extremely rare. Herein, we report a 41-year-old male who presented with urosepsis to the emergency room; catheterization was performed and retention resolved. He had a tattoo on his left arm and a five-year history of intravenous drug use. Blood tests indicated anaemia, leukocytosis, elevated CRP and ESR and mild hyponatraemia; haematuria, moderate bacteriuria and 2+ proteinuria on urinanalysis were observed. Chest X-ray revealed lesions suggestive of miliary tuberculosis, which was confirmed by chest CT scan. Brain CT and MRI suggested brain involvement in the setting of tuberculosis. On further investigations, HIV infection and hepatitis C seropositivity were detected and the patient remained in a coma for five days with a Glasgow Coma Scale of 6/15. Finally, the diagnosis of haematogenous dissemination of tuberculosis following lithotripsy was established. Anti-tuberculosis and anti-retroviral therapy were prescribed and monthly follow-up visits were scheduled. In conclusion, in a patient diagnosed with ureterolithiasis, a thorough history and physical examination, with specific attention to HIV and tuberculosis predisposing factors, should be carried out and preoperative screening tests considering the possibility of urinary tuberculosis are required. Finally, if urinary tuberculosis is detected, ESWL must be postponed until after appropriate treatment of tuberculosis. [ABSTRACT FROM PUBLISHER]

Aims To determine which method of intermittent urinary catheterization, sterile with a catheterization-set or the no-touch method, offers the most advantages for caregivers in a hospital setting Background The no-touch catheter is assumed to decrease the risk for infection and increase the comfort for caregivers due to its construction, however, evidence is lacking Design A cross-over experimental study was carried out from October until December 2009, 100 nurses and 71 nursing students participated. Method Every participant had to catheterize as well according to the no-touch method as to the standard intermittent catheterization method. A randomization programme determined whether the subjects had to catheterize a male or female simulation model. Findings Multiple regression analysis shows that nurses and nursing students appear to make on average two more errors with the sterile intermittent catheterization method with set than with the no-touch method. The duration of the no-touch method is 92 seconds less than the classical catheterization method. On a scale with 10 points for comfort, the classical sterile method with set scored on average two points lower than the no-touch method, as well for the nurses as for the students. Conclusions Compared with the classical method, both students and nurses spend less time on performing the no-touch method, less sterility errors are made and a higher score is assigned to the no-touch method. Also classical catheterization of men implies higher costs compared with the no-touch method. No-touch intermittent catheterization is thus expected to be preferred above the gold standard catheterization method. [ABSTRACT FROM AUTHOR]

Purpose: We prospectively evaluated the impact of transurethral resection of the prostate (TURP) versus superselective α-adrenergic blocker treatment on health-related quality of life (HRQOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH).Patients and Methods: A total of 219 patients with lower urinary tract symptoms (LUTS) caused by BPH were recruited in this study. Treatment modalities consisted of standard TURP (n = 104) and tamsulosin medical treatment (n = 115). HRQOL was assessed by SF-36-Item Health Survey 1.0. LUTS were estimated by The International Prostate Symptom Score. Patients' outcome 4 weeks after treatment was compared to pre-treatment status and to that of the other group. Statistically significant changes in each HRQOL scale from baseline to follow-up period were investigated.Results: Baseline characteristics were similar in both groups except for the duration of disease before treatment that was longer in TURP group. Both treatments resulted in statistically significant improvements from pre-treatment in all scales of QOL after 4 weeks, with no significant differences observed between the two groups. In medical treatment group, there was a significant association between higher educational level and better QOL in all 8 scales. Our outcomes revealed a significant decrease in the IPSS in both groups but this improvement was more evident in TURP group.Conclusion: All scales concerning HRQOL were favorably improved 4 weeks after both surgical and medical treatment, and no significant differences were observed between these two treatment modalities for patients with symptomatic BPH. This information may aid patients when deciding which treatment option to take. [ABSTRACT FROM AUTHOR]

Purpose: We prospectively evaluated the impact of transurethral resection of the prostate (TURP) versus superselective α-adrenergic blocker treatment on health-related quality of life (HRQOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH). Patients and methods: A total of 219 patients with lower urinary tract symptoms (LUTS) caused by BPH were recruited in this study. Treatment modalities consisted of standard TURP ( n = 104) and tamsulosin medical treatment ( n = 115). HRQOL was assessed by SF-36-Item Health Survey 1.0. LUTS were estimated by The International Prostate Symptom Score. Patients' outcome 4 weeks after treatment was compared to pre-treatment status and to that of the other group. Statistically significant changes in each HRQOL scale from baseline to follow-up period were investigated. Results: Baseline characteristics were similar in both groups except for the duration of disease before treatment that was longer in TURP group. Both treatments resulted in statistically significant improvements from pre-treatment in all scales of QOL after 4 weeks, with no significant differences observed between the two groups. In medical treatment group, there was a significant association between higher educational level and better QOL in all 8 scales. Our outcomes revealed a significant decrease in the IPSS in both groups but this improvement was more evident in TURP group. Conclusion: All scales concerning HRQOL were favorably improved 4 weeks after both surgical and medical treatment, and no significant differences were observed between these two treatment modalities for patients with symptomatic BPH. This information may aid patients when deciding which treatment option to take. [ABSTRACT FROM AUTHOR]

Purpose: To identify independent factors that may predict vesicoureteral reflux (VUR) resolution after endoscopic treatment using dextranomer/hyaluronic acid copolymer (Deflux) in children free of anatomical anomalies. Materials and methods: A retrospective study was conducted in our pediatric referral center from 1998 to 2011 on children with primary VUR who underwent endoscopic injection of Deflux with or without concomitant autologous blood injection (called HABIT or HIT, respectively). Children with secondary VUR or incomplete records were excluded from the study. Potential factors were divided into three categories including preoperative, intraoperative and postoperative. Success was defined as no sign of VUR on postoperative voiding cystourethrogram. Univariate and multivariate logistic regression models were constructed to identify independent factors that may predict success. Odds ratio (OR) and 95 % confidence interval (95 % CI) for prediction of success were estimated for each factor. Results: From 485 children received Deflux injection, a total of 372 with a mean age of 3.10 years (ranged from 6 months to 12 years) were included in the study and endoscopic management was successful in 322 (86.6 %) of them. Of the patients, 185 (49.7 %) underwent HIT and 187 (50.3 %) underwent HABIT technique. On univariate analysis, VUR grade from preoperative category (OR = 4.79, 95 % CI = 2.22-10.30, p = 0.000), operation technique (OR = 0.33, 95 % CI = 0.17-0.64, p = 0.001) and presence of mound on postoperative sonography (OR = 0.06, 95 % CI = 0.02-0.16, p = 0.000) were associated with success. On multivariate analysis, preoperative VUR grade (OR = 4.85, 95 % CI = 2.49-8.96, p = 0.000) and identification of mound on postoperative sonography (OR = 0.07, 95 % CI = 0.01-0.18, p = 0.000) remained as independent success predictors. Conclusion: Based on this study, successful VUR correction after the endoscopic injection of Deflux can be predicted with respect to preoperative VUR grade and presence of mound after operation. [ABSTRACT FROM AUTHOR]

Purpose: To present the results of our experience with combined endoureterotomy and endoscopic injection of dextranomer/hyaluronic acid (Deflux) for the treatment of primary obstructive refluxing megaureter (PORM). Patients and Methods: Eighteen children (12 female, 6 male; mean age-14 months) with 20 PORM units underwent concomitant endoureterotomy and endoscopic subureteral Deflux injection. All patients underwent endoureterotomy at the 6-o'clock position with insertion of a 3F Double-J ureteral stent into the obstructed segment of ureter and subureteral injection of Deflux at the 5-o'clock and 7-o'clock positions. The Double-J stent was left in place with its distal tip fixed with a single knot to the external genitalia for easy removal after 1 week. Patients with refluxing nonobstructive ureter on the contralateral side of the PORM unit (seven children) underwent simultaneous endoscopic subureteral injection of Deflux. Voiding cystourethrography (VCUG) was performed at 6 months, and ultrasonography was performed at 1 week 3, 6, and 12 months postoperatively. Results: With a mean follow-up of 30 months, the procedure was uneventful in all patients. Follow-up VCUG showed no evidence of reflux in 15 ureterorenal (75%), significant decrease in reflux grade in 2 (10%), and no change in 3 (15%) in the endoscopic treated PORM units. No evidence of reflux was observed in the treated contralateral refluxing nonobstructive ureters. Ultrasonography revealed no ureterovesical junction obstruction. In 19 ureterorenal (95%) units, there was a complete resolution or decrease in hydroureteronephrosis. Conclusions: The results of this study demonstrate that combined endoureterotomy and subureteral injection of Deflux is safe and effective in the treatment of PORM in selected patients. [ABSTRACT FROM AUTHOR]

The concomitant presence of urethral triplication and caudal duplication is extremely rare with no previous reported cases. We report a case of urethral triplication associated with bladder, sigmoid, and rectum duplication. The patient was initially referred with a history of fecaluria and recurrent urinary tract infection. Physical examination revealed 2 meatal opening on the glans penis. Further investigation revealed three distinct urinary streams, two terminating on the glans penis, and one in the rectum in voiding cystourethrography and retrograde urethrography. Computed tomography demonstrated the bladder divided into two compartments by a complete sagittal septum. The patient was managed by the excision of the rectal ending urethra and removal of the bladder sagittal septum during which, two sigmoidal and rectal segments (the right one filled with fecal) were revealed. The right sigmoid and rectum was resected. The two ventral urethras were kept intact. The postoperative course was uneventful. At his 4 month readmission for colostomy closure, the patient reported good urethral voiding with no complication and recurrence of urinary tract infection and the colostomy was closed with no major complication. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although female epispadias are considered as a rare congenital anomaly the urologist should keep the diagnosis in the back of their mind when examining a child with abnormal external genitalia or unexplained urinary incontinence in order to reach early diagnosis and subsequent prevention of bladder maldevelopment. The main goal in the management of female epispadias is satisfactory continence status with the ability of volitional micturition, together with reconstruction of cosmetically acceptable and functional external genitalia. A limitation to the previously described continence surgery in these patients is the lack of a practical intraoperative method for evaluation of the proper degree of ultimate bladder outlet resistance. For the first time, we introduced the single-stage subsymphyseal urethrogenitoplasty along with cystoscopic-guided bladder neck pliation technique as a real-time intraoperative method for objective evaluation of the bladder outlet resistance, in order to improve continence outcomes and provide a safe pressure within the upper urinary tract. Considering the promising outcomes of the present method in female epispadias, it seems reasonable to defer more invasive currently used approaches and classic continence surgeries, until the outcome from this procedure is evaluated. OBJECTIVE • To investigate the feasibility of an endoscopic technique as a guide to evaluate bladder outlet resistance during bladder neck plication (BNP) for treatment of female epispadias. PATIENTS AND METHODS • The postoperative outcomes with long-term follow-up of 10 girls with epispadias were reviewed (four had a previous history of bulking agent injection into the BN). • After taking a skin flap from the area between the crura of the bifid clitoris, subsymphyseal dissection was continued to the BN. • Under cystoscopic guidance, BNP was performed using absorbable sutures (two cases) or non-absorbable sutures (eight) aiming to attain a smooth closure of the BN during gradual withdrawal of the cystoscope. • Finally, urethrogenitoplasty was accomplished by urethral reconstruction with tubularization of the inter-clitorial flap followed by monsplasty and approximation of the two hemi-clitorises. RESULTS • The mean (range) follow-up was 9.1 (5-15) years. • After primary surgery seven of the 10 girls were continent and all could void normally. • Of the three failed cases (including two that underwent BNP using absorbable suture), two became dry after injection of bulking agent into the BN and the remaining girl underwent BN reconstruction; she was socially continent at the final follow-up. • Ultimately, all 10 girls were socially continent, including six who were completely dry. • Urodynamic studies showed an increase in mean bladder capacity ( P < 0.001) and a significant time-dependent improvement of the leak-point pressure and maximum urinary flow rate. CONCLUSIONS • The present series suggests that single-stage subsymphyseal urethrogenitoplasty together with cystoscopic-guided BNP for management of female epispadias is reliable and effective with definite advantages. • The high success rate and safety of the procedure are important factors for the introduction of this method as a valid option for treatment of this rare congenital anomaly. [ABSTRACT FROM AUTHOR]

Purpose: To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves.Patients and Methods: Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure.Results: The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory.Conclusion: Double-faced Mathieu technique seems applicable in patients with shallow urethral grooves when TIP procedure may increase the risk of complications. Unlike its predecessor, this technique eliminates the tension on glans wing sutures and the risk of subsequent neo-urethral break down. [ABSTRACT FROM AUTHOR]

Glans necrosis is a rare complication after circumcision and may occur secondary to cautery . The treatment of choice for glanular necrosis has not yet been established. The authors describe two cases of severe glanular ischemic necrosis that occurred after circumcision. The patients were successfully managed with 10 % testosterone cream for 4 wk. After completing the treatment course, the glans looked acceptable in size but the urethra sloughed partially and became hypospadic in one case. The authors hypothesize that the testosterone impact on endothelial cells and vascular endothelial growth factor expression may increase the penile blood supply and induce adequate revascularization of the glans; the effect that has been previously shown in experimental in vitro studies. [ABSTRACT FROM AUTHOR]