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Objectives To analyse the results of the stress urinary incontinence (SUI) audit conducted by the British Association of Urological Surgeons (BAUS), and to present UK urologists' contemporary management of SUI. Patients and methods The BAUS audit tool is an online resource, to which all UK urologists performing procedures for SUI are invited to submit data. The data entries for procedures performed during 2014-2016 were collated and analysed. Results Over the 3-year period analysed, 2917 procedures were reported by 109 surgeons, with a median of 20 procedures reported per surgeon. A total of 2 366 procedures (81.1%) were recorded as a primary surgery, with 548 procedures (18.8%) performed for recurrent SUI. Within the time period analysed, changes were noted in the frequency of all procedures performed, with a trend towards a reduction in the use of synthetic mid-urethral tapes, and a commensurate increase in the use of urethral bulking agents and autologous fascial slings. A total of 107 (3.9% of patients) peri-operative complications were recorded, with no association identified with patient age, BMI or surgeon volume. Follow-up data were available on 1832 patients (62.8%) at a median of 100 days postoperatively. Reduced pad use was reported in 1311 of patients (84.5%) with follow-up data available and 86.3% reported a pad use of one or less per day. In all, 375 patients (85%) reported being satisfied or very satisfied with the outcome of their procedure at follow-up, although data entry for this domain was poor. De novo overactive bladder (OAB) symptoms were reported by 15.2% of patients (263/1727), and this was the most commonly reported postoperative complication. For those reporting pre-existing OAB prior to their SUI surgery, 28.7% (307/1069) of patients reported they got better after their procedure, whilst 61.9% (662/1069) of patients reported no change and 9.4% of patients (100/1 069) got worse. Conclusions This review identified that, despite urological surgeons undertaking a relatively low volume of procedures per year, SUI surgery by UK urologists is associated with excellent short-term surgeon- and patient-reported outcomes and low numbers of low grade complications. Complications do not appear to be associated with surgeon volume, nor do they appear higher in those undergoing mesh surgery. Shortfalls in data collection have been identified, and a longer follow-up period is required to comment adequately on long-term complications, such as chronic pain and tape extrusion/erosion rates.

Objective To assess the presenting features and medium-term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition. Patients and Methods We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as postoperative outcomes. Results In all, 70 women with a mean (range) age of 46.5 (24–77) years underwent excision of urethral diverticulum with MLFP interposition. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%), and dysuria (57%). Pre-existing stress urinary incontinence (SUI) was present in 41% (29) of the women. After surgery, at a mean (SD) of 18.9 (16.4) months follow-up (median 14 months), complete excision of urethral diverticulum was achieved in all the women, with resolution of urethral mass, dysuria and dyspareunia in all, and urethral pain in 81%. Immediately after surgery, 10 (24%) patients reported de novo SUI, which resolved with time and pelvic floor muscle training such that at 12 months only five (12%) reported continued SUI. There was one symptomatic diverticulum recurrence (1.4%). Conclusions The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with MLFP interposition results in complete resolution of symptoms in most women. The incidence of persistent de novo SUI in an expert high-volume centre is 12%.

Objective To present our outcomes of ventral-onlay buccal mucosa graft substitution urethroplasty (VOBMGSU) in treating female urethral stricture (FUS). Patients and Methods A review of a prospectively collected database of 22 consecutive women (median age 50 years, range 34-72) with urethral stricture having VOBMGSU since June 2012 and a minimum follow up of 6 months (median 21.5, range 6-51). Data was analysed for stricture recurrence, change in median peak free flow rate (Qmax) and median post-void residuals (PVR). Statistical analysis was performed with the Wilcoxon signed rank test, Students T Test and Mann-Whitney U Test. Results Freedom from stricture recurrence was achieved in 21/22 (95.5%) women. Median Qmax significantly improved from 7 ml/s (range 3.5-11) to 18 ml/s (range 5-37) (p < 0.05). Median PVR significantly reduced from 100mls (range 0-300) to 15 mls (range 0-150) (p < 0.05). Short and longer-term complication rates were low. One patient developed mild de novo stress urinary incontinence, which settled with conservative measures by 6 months. Conclusions Early and medium term results indicate that VOBMGSU is an excellent treatment for female urethral stricture that can avoid the need for repeat procedures regularly required after traditional endoscopic management. This article is protected by copyright. All rights reserved.

Objective To assess the long-term efficacy of polydimethylsiloxane (Macroplastique®) injection (MPI) in the treatment of Mitrofanoff leakage secondary to valve incompetence. Patients and Methods Between 1995 and 2012, the records of 24 consecutive patients who underwent MPI for Mitrofanoff urinary leakage after continent cutaneous urinary diversion (CCUD) surgery were examined. All patients had a valve deemed of sufficient length (>2 cm) to attempt Macroplastique coaptation. Treatment outcomes were divided into three categories based on physician assessment: success (dry), partial success (>50% reduction in incontinence pads) and failure. Success rates were assessed according to the type of reservoir and conduit channel. Results The mean (range) follow-up was 30 (6–96) months. One patient had initial difficulty catheterising, and subsequently required major revision surgery. In all, 12 patients (50%) failed the treatment and subsequently underwent operative revision to the channel. Three patients (12.5%) achieved complete success; one patient had an appendix channel through native bladder and the remaining two had Monti channels through colon. Nine patients (37.5%) had partial success; success rates were higher with appendix channels (four of six) and colonic reservoirs (six of seven) when compared with Monti channels (eight of 18, 44%) and ileal reservoirs (zero of two). Five of the nine patients with partial success eventually required further surgical revision for deteriorating continence at a mean (range) of 41 (14–96) months, whilst the other four have maintained sufficient continence with MPI alone. Conclusion Macroplastique bulking cured only 12.5% patients, but leakage was substantially improved in a further 37.5% allowing major surgery to be avoided or postponed in one half of the cohort. Appendix Mitrofanoffs do better than the Monti Mitrofanoff, with channels through colonic segments generally doing better than those through ileal bladders. MPI should be considered as a less invasive alternative to avoid or delay major reconstructive surgery.

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

Urethral diverticula are rare but underdiagnosed entities that may cause a variety of urinary and pelvic symptoms in women.They are best demonstrated by magnetic resonance imaging and micturating cysto-urethrography prior to transvaginal surgical excision. Although unlikely, the possibility of malignant transformation should not be forgotten.

OBJECTIVETo evaluate screening cystoscopy as the long-term follow up in patients with an enterocystoplasty for >= 10 years.PATIENTS AND METHODSWe performed a prospective analysis of 92 consecutive patients who attended our endoscopy suite for regular check cystoscopy as per standard follow-up. This is performed for all patients with cystoplasty performed at our institute after 10 years. The data were recorded on patient demographics, original diagnosis and type of cystoplasty. In all, 53 of these patients consented to undergo bladder biopsies at the same time.RESULTSThe median (range) follow-up was 15 (10-33) years. No cancer was identified with either surveillance cystoscopy or on routine biopsies. Chronic inflammation was identified in 25 biopsies (27%). Villous atrophy was present in 12 (55%) ileal patch and three (12.5%) colonic patch biopsies. During this study, the first and only case of malignancy in a cystoplasty at our institution was diagnosed in a symptomatic patient. She had intermittent haematuria and recurrent urinary tract infections (UTIs). She previously had a normal surveillance cystoscopy.CONCLUSIONSWe feel that it is not necessary to perform yearly check cystoscopies in patients with augmented bladders at least in the first 15 years, as cancer has not yet been detected with surveillance cystoscopy in this patient group. However, if the patient develops haematuria or other worrisome symptoms including suprapubic pain and recurrent unexplained UTIs a full evaluation, including cystoscopy and computerized tomography should be undertaken.

OBJECTIVE To review the outcomes of consecutive patients referred with urethral diverticula to a tertiary centre; to investigate the diagnostic, imaging and surgical factors relevant to success. PATIENTS AND METHODS A retrospective case note review of 30 consecutive patients treated between January 1999-2007 was performed and data retrieved on demographics, presenting symptoms, preoperative imaging, surgical technique, outcomes and need for further intervention. RESULTS All patients were tertiary referrals, four after failed local repairs. The mean (range) interval between initial presentation and repair was 48 (1-264) months. Only seven patients (23%) had all three symptoms of the classical triad of dysuria, dyspareunia and dribble, whilst 23% did not have any of these symptoms. Transvaginal ultrasonography showed the diverticulum in six of nine patients, voiding cysto-urethrography (VCUG) in 13 of 18 patients (72%) and magnetic resonance imaging (MRI) in all 11 patients assessed. MRI accurately imaged diverticular configuration, whilst VCUG assessed detrusor and sphincteric function. Twenty-nine (97%) patients were cured of their diverticulum; all 19 patients with simple diverticula were cured at first attempt, whilst 17 procedures were performed on the 11 patients with complex diverticula. Twenty of 24 (83%) repairs were successful using three-layered closure, 9 of 11 using Martius interposition, and one using bulbospongiosus muscle interposition. There were three primary repair failures; two circumferential diverticula repaired with Martius interposition and one partial horseshoe diverticulum repaired without interposition had partial recurrences. Both were subsequently repaired successfully. One patient with chronic urethral pain from multiple, infected recurrences was eventually diverted. A pubovaginal sling procedure was required in only one (3.3%) patient with persistent pre-existing stress urinary incontinence (SUI). CONCLUSIONS The presentation of urethral diverticula is diverse and diagnosis frequently delayed. The most useful preoperative imaging is MRI and VCUG to assess diverticular anatomy and detrusor/urethral function, respectively. In simple cases, transvaginal excision with three-layer closure is curative, whilst more extensive, persistent or SUI-associated diverticula require Martius fat interposition. Sling procedures can be deferred until the results of primary excision are assessed.

Objective To review pelvic fracture urethral injuries in women, generally regarded as rare and thus discussed infrequently. Patients and methods Twelve patients (age range 7–51 years) with such injuries were reviewed; most had associated injuries, generally more severe than seen in males with urethral injuries. Results Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence. Conclusions Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males.

Objective To assess the use of unenhanced spiral computed tomography (CT) as the primary investigation of choice for suspected acute renal colic in clinical urological practice. Patients and Methods Between 1 August 1997 and 31 July 1998, all patients attending a hospital accident and emergency department with acute loin pain suggestive of renal colic underwent a physical examination, urine analysis, plain abdominal radiography (if clinically indicated) and unenhanced spiral CT. The effective radiation dose and financial cost of unenhanced spiral CT and standard three-film emergency intravenous urography (IVU) were calculated. Results In all, 116 patients were assessed, 63 of whom had calculi and related secondary phenomena of obstruction identified on unenhanced spiral CT. There were two false-positive and one false-negative result. An alternative urinary tract diagnosis was made in four patients, including two with renal cell carcinoma and one ureteric transitional cell carcinoma. Causes other than in the urinary tract were diagnosed in three patients, i.e. two with ovarian cyst and one with sigmoid diverticulitis. The effective radiation dose of unenhanced spiral CT was 4.7 mSv and that for three-film IVU was 1.5 mSv. The costs of both IVU and unenhanced spiral CT were identical. Conclusions Unenhanced spiral CT allows a rapid, contrast-medium-free, anatomically accurate diagnosis of urinary tract calculi and in the present series had a sensitivity of 98% and a specificity of 97%. CT provided an alternative diagnosis in 6% of patients. These advantages must be weighed against the threefold greater radiation dose of unenhanced spiral CT than with three-film IVU, and in practice the requirement for a radiologist to interpret routine axial scans.

Objective To establish the presence or absence of any diurnal or long-term variation in N-nitrosamine levels (which might be important in the development of cancer in enterocystoplasties) in enterocystoplasty urine, and to assess other factors that might alter enterocystoplasty N-nitrosamine levels. Patients, subjects and methods Thirty-six patients with enterocystoplasties and six normal controls were assessed. Urine samples were collected every 4 h over a 24-h period and N-nitrosamine levels determined using a modification of the Pignatelli method. An additional urine sample was assessed by microscopy, culture and sensitivity. In a subgroup of 16 patients with an enterocystoplasty, the urinary N-nitrosamine levels were re-measured at 3-monthly intervals. Results No diurnal or long-term variation in urinary N-nitrosamine levels was identified. The mean N-nitrosamine levels were significantly higher in the cystoplasty group than in the controls (1.7 vs 1.0 µmol/L; P = 0.008). Mean N-nitrosamine levels were also significantly higher in enterocystoplasty patients with sterile pyuria than in those with no pyuria (P = 0.01). Those taking prophylactic antibiotics had significantly lower mean N-nitrosamine levels than those not doing so (P = 0.05). Individuals with infected urine and those needing to intermittently catheterize had higher N-nitrosamine levels than their counterparts, but this difference was not significant. Conclusion There were no diurnal or long-term variations in urinary N-nitrosamine levels. Levels were consistently higher in patients with inflamed or infected cystoplasties, those using intermittent self-catheterization and those not taking antibiotic prophylaxis.

OBJECTIVE To review the outcomes of all patients referred with vesico-vaginal (V VF) and urethro-vaginal (UVF) fistulae to a tertiary centre, and to investigate the patient, fistula and surgical factors relevant to success. PATIENTS AND METHODS We reviewed retrospectively the case-notes of 41 consecutive patients (32 with V VF; nine with UVF) treated between January 2000 and January 2006. RESULTS All patients were tertiary referrals, eight after failed local repairs. Four patients were unsalvageable and had a supravesical diversion. In all there were 47 repairs (23 transvaginal; 24 transabdominal) on 37 patients by two specialist surgeons. The fistula was closed in 92%; five V VF and one UVF required a second procedure, and one V VF a third procedure. One patient with a V VF awaits a second attempt at repair. In one V VF (one attempt) and one UVF (three attempts) the procedure failed and the patient had a diversion. A transvaginal approach cured all 11 patients with a V VF and eight of nine with a UVF, whilst an abdominal approach used for larger/complex fistulae was successful in 18 of 24 (75%) attempts (P = 0.13). The major determinants of success were fistula size (>3 cm; P = 0.02) and the availability of tissue for interposition. V VF repairs using Martius/omental interposition were mostly successful, whilst abdominal repairs in which omentum was unavailable tended to fail (37.5% cure; P = 0.002). CONCLUSIONS Despite varied aetiology, V VF/UVF were repaired successfully in 92% of patients. Complex (V VF) fistulae were challenging and a quarter of these required more than one attempt. Failure of repair was more likely in larger fistulae (>3 cm) requiring an abdominal approach, if omental interposition was not possible. Good-quality tissue interposition for complex fistula is essential for a successful outcome.

OBJECTIVE To quantify experience of pelvic fracture-related urethral trauma (PFUT), a condition not often encountered and managed by urologists. METHODS The consultant urologists of the UK and Ireland were contacted informally to establish their experience with PFUT and its management, both immediate and delayed. In addition, particular individuals thought to have a specific interest in PFUT were targeted for more data. RESULTS The overall response rate was 49% (235 responders), representing 78% of urological departments, including all the targeted individuals. Of the responders, 129 (55%) had never seen PFUT in 1-25 years of consultant practice. Only four urologists (2% of responders) saw three or more cases a year. Another four (2%) saw one or two cases per year and the remaining 98 (41%) saw PFUT less frequently. Acutely, 69% of urologists who treated PFUT did so by placing a urethral catheter. Subsequent strictures were treated endoscopically for as long as this was possible. The other 31% inserted a suprapubic catheter and referred the patient for reconstructive surgery if needed. Those who used urethroplasty for strictures after PFUT were identified and targeted; half used urethral mobilization and spatulated anastomosis alone. Only three surgeons performed more than five procedures a year. CONCLUSION Whatever a specialist reconstructive unit might do, practice in the wider urological community is different. Even within specialized units, PFUT is rare and the surgical management is often significantly different from published 'expert' opinion.

OBJECTIVE To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.

OBJECTIVE To evaluate the outcome of renal denervation for the treatment of loin pain-haematuria syndrome (LPHS), a rare syndrome of unknown cause associated with debilitating and intractable loin pain. PATIENTS AND METHODS The case notes of 32 patients having 41 renal denervations were reviewed. Data collected included patient demographics, possible causes, cure or not after renal denervation, time to recurrence of pain after denervation and further operative intervention for managing LPHS. RESULTS Full data were available for 24 patients (13 women; median age 43 years, range 28-74) having 33 denervations (eight bilateral and one repeat) with a median follow-up of 39.5 months. Most patients had no identifiable underlying cause although many had initially been diagnosed as having stone disease (42%) or pyelonephritis (25%), but with no corroborative evidence. All patients had been extensively investigated and had normal urine samples and cytology, and no abnormality on intravenous urography, renal tract ultrasonography and isotopic renography. Twenty-four renal denervations (73%) were followed by recurrent ipsilateral pain at a median (range) of 11 (0-120) months after surgery. Nine denervations (25%) in six men and two women were curative (median follow-up 16.5 months). Of those with recurrent pain, nine (38%) proceeded to nephrectomy, of whom three then developed loin pain on the contralateral side and two developed disabling wound pain. The analgesic requirement was less after eight non-curative denervations. There were no significant postoperative complications. CONCLUSIONS Renal denervation has only a 25% success rate for managing pain associated with LPHS and should be used cautiously for this indication. Men had more benefit from the treatment; a third of patients had less requirement for analgesic after non-curative denervation.