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The degree of change in erectile (EF) and ejaculatory function (EjF) according to validated questionnaires following anterior urethroplasty and different techniques is unclear.To investigate the evidence on EF and EjF evaluated via validated questionnaires following anterior urethroplasty.A systematic review (PROSPERO ID: CRD42021229797) of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The PubMed and CENTRAL databases were searched on February 1, 2021, with an updated search performed on December 1, 2021. Studies evaluating EF and/or EjF using validated questionnaires in men aged ≥18 yr following anterior urethroplasty were included.Overall, 29 studies (two randomised and 27 nonrandomised) were included. The questionnaire most commonly used to evaluate EF and EjF was the International Index of Erectile Function (IIEF) and Male Sexual Health Questionnaire (MSHQ), respectively. The incidence of postoperative erectile dysfunction (ED) was 0-38% and the mean change in EF score according to the IIEF ranged from -4.0 to 2.5. The incidence of postoperative ejaculatory dysfunction (EjD) was 7.7-67% and the mean change in EjF score according to the MSHQ-EjD was 0.7-7.0. Meta-analyses revealed a mean difference of -0.87 (95% confidence interval [CI] -1.50 to -0.23; p = 0.008) in IIEF-EF score and 1.77 (95% CI 0.61-2.93; p = 0.003) in MSHQ-EjF score following anterior urethroplasty.EF and EjF may be affected following anterior urethroplasty and men should be counselled appropriately. Owing to the variation in questionnaires and cutoff scores used, EF and EjF outcomes following different urethroplasty techniques are heterogeneous, with limited data from randomised controlled trials. An agreement on questionnaires and cutoff scores should be established to allow consistent reporting. Future research should aim to investigate best approaches for minimising sexual dysfunction.Surgical repair of the urethra (urethroplasty) used to treat narrowing of the urethra (urethral stricture) may affect erectile and ejaculatory function. Different questionnaires and definitions are used to evaluate sexual function, so it is hard to compare data. The degree of disruption can be affected by different techniques and the severity of disease.

Context Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice. Objective To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients. Evidence acquisition The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion. Evidence synthesis Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates. Conclusions Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations. Patient summary Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. Take Home Message Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

Context Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain. Objective To identify and compare different tests to diagnose fBOO through a systematic review process. Evidence acquisition A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Evidence synthesis Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Qmax) and voiding detrusor pressure at Qmax. The sensitivity, specificity, and overall accuracy ranges were 54.6–92.5%, 64.6–93.9%, and 64.1–92.2%, respectively. Conclusions The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO. Patient summary Evidence on tests used to diagnose female bladder outlet obstruction was reviewed. The most common test used was pressure-flow studies ± fluoroscopy, which remains the current standard for diagnosing bladder outlet obstruction in women. Take Home Message The available evidence on diagnostic tests for female bladder outlet obstruction is limited and heterogeneous. The most common test used was video-urodynamics, which remains the current standard for diagnosing bladder outlet obstruction in women.

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. PATIENT SUMMARY: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

Context In recent years, there has been a rapid uptake in the use of laparoscopic and robotic surgery within urological oncological surgery. There is now growing interest in applying these surgical techniques to functional and reconstructive urology (FRU). Objective To provide an overview of the use of robotic surgery within the sphere of functional and reconstructive urology and discuss the research needs and the likely role of robotic technology in future. Evidence acquisition A PubMed-based literature review performed in March 2019 identified all articles published regarding the use of robotic surgery within FRU for the reconstruction of the upper tracts, bladder, bladder neck, pelvic floor, and urinary sphincter; creation of urinary diversion; and repair of genitourinary fistulae. Evidence synthesis There is a need to study the robotic approach in carefully designed prospective studies to better establish safety and clinical efficacy as well as the economic viability as compared with laparoscopic and open approaches. Conclusions The use of the robotic minimally invasive approach has many potential advantages; however, there is a need for a high level of technical expertise and experience, especially in some of the complex and technically challenging scenarios often seen within FRU. Surgeons should ensure that they have received sufficient training in not only the surgical principles of FRU, but also the assessment, management, and follow-up of patients. Moreover, it is imperative not to compromise important surgical steps. Patient summary In this report, we looked into the use of robotic technologies in the treatment of functional and reconstructive problems of the urinary tract. We found that the robotic approach has not yet been evaluated in prospective clinical studies in this field. There is a need for carefully designed prospective studies to establish the safety and efficacy of robotic surgeries.

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients.The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion.Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. TAKE HOME MESSAGE: Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

Context Bladder pain syndrome/interstitial cystitis (BPS/IC) is a poorly understood chronic debilitating condition. Surgery is reserved for severe refractory cases; however, there is no consensus on patient selection or optimal approach. Objective To evaluate the evidence relating to the safety and efficacy of surgical interventions for treating BPS/IC. Evidence acquisition PubMed and Scopus databases were searched for original studies, using keywords “cystectomy”, “interstitial cystitis”, and “bladder pain syndrome”. Articles were reviewed and screened by three independent reviewers. Evidence synthesis A total of 450 patients were identified from 20 eligible studies: mean age was 54.5 yr and 90.2% were female. The median duration of symptoms preoperatively was 60 mo (range 9–84), with a mean follow-up of 45.5 mo. A total of 448 patients underwent surgery: subtotal cystectomy with cystoplasty (48.6%), cystectomy and orthotopic neobladder (21.9%), cystectomy and ileal conduit (11.2%), and urinary diversion only (18.3%). Symptomatic improvement occurred in 77.2%, with higher rates in the total cystectomy and orthotopic neobladder group. Thirty-one patients (6.9%) required secondary total cystectomy and/or ileal conduit diversion; 48.4% subsequently improved. Seventeen studies reported 102 complications overall (26.5%). Overall mortality was 1.3%. Conclusions Overall surgical intervention is associated with a 23% risk of failure to improve symptoms. Higher rates of improvement were reported in patients with total cystectomy. Interpretation should be guarded given the small patient number, multiple centres, and variable outcome measurements. There is a need for prospective randomised studies to answer questions regarding patient selection and optimal surgical approach. Patient summary In this review, we looked at the outcomes of surgery for treatment-refractory bladder pain syndrome/interstitial cystitis. We found overall symptom improvement in 77.2% of patients with a complication rate of 26.5%. However, there remains a need for further studies of higher quality to identify patients who will have symptom improvement and the best surgical option.

Botulinum toxin and nerve stimulation are viable options for overactive bladder refractory to pharmacotherapy. Treatment choice depends on multiple factors including associated symptoms, bladder function, and health economics. Decision-making should be individualised to the particular situation taking into account patient preference.

Background Botulinum neurotoxin (BotN) is used to treat detrusor overactivity (DO) refractory to medical treatment. Catheterised patients with symptoms of bladder spasm and catheter bypass leakage are challenging to manage and the efficacy of BotN is not established. Objective To review our experience using intravesical BotN to treat refractory bladder pain and catheter bypass leakage in patients with long-term indwelling catheters. Design, setting, and participants We carried out a review of data prospectively collected for patients with indwelling urethral or suprapubic catheters receiving BotN for the treatment of bladder spasms and catheter bypass leakage in a UK tertiary centre. An unvalidated structured questionnaire was used to ascertain quality of life (QoL) outcomes. Outcome measurements and statistical analysis Qualitative data were collected for patient-reported symptoms and QoL. Paired Student t tests were applied for statistical analysis. Results and limitations Of the 54 catheterised patients who received BotN, 14 (26%) were male and 40 (74%) were female. The mean follow-up was 38 mo. Of the patients, 34 (63%) had a neurological aetiology and 94% had experienced failure of medical therapy before BotN administration. The BotN starting dose was 100 or 200 U and 17 patients (31%) required dose escalation. All 34 neurogenic and six non-neurogenic patients started on 200 U. After treatment, 63% of patients managed their catheter with intermittent drainage and 37% managed on free drainage; 51 patients (94%) reported that their symptoms were controlled and 38% reported being treated for a urinary tract infection following BotN. Patients reported a mean improvement in QoL of 7.7/10 following BotN, while 83% reported a significant reduction in urine leakage (p = 0.0001). Conclusions Outpatient intravesical BotN is safe and efficacious for patients with long-term catheters suffering from bladder pain and catheter bypass leakage. Patient summary Outpatient administration of intravesical botulinum toxin is a safe and effective treatment for patients with a long-term indwelling catheter with bothersome urine storage symptoms. Attention should be paid to urine microbiology results before treatment to ensure appropriate prophylactic antibiotic treatment to reduce the incidence of urinary tract infections.

The role of surgery in the management of bladder pain syndrome is unclear; particularly the optimum surgical approach. Treatment refractory patients should be managed in a multi-disciplinary setting including psychological support. Further prospective studies using validated assessments and clear diagnostic criteria would be useful to guide patient selection.

Background The prayer ritual is an essential component of Islam that requires entry into a state of physical purity (wudhu) through ablution, which is invalidated by voiding. An important dilemma for patients and surgeons may arise when a Muslim patient is counselled on cystectomy because of the belief by some that an incontinent urinary diversion will automatically invalidate their wudhu. Objective To determine if there are any religious barriers and implications for Muslim patients undergoing an incontinent urinary diversion. Design, setting, and participants A questionnaire was distributed to all UK mosques, addressed to the imam (n = 804). Results and limitations A total of 134 imams (response rate 16.7%) responded. There was general agreement among imams, with >90% answering that it is possible for a Muslim to perform ablution, pray, and enter a mosque with a urinary stoma. The majority of imams (86.6%) also stated that refusal of a urinary stoma was not justified by religious teachings. When asked if patients should choose the option of a neobladder despite this surgery having greater risk, 57.5% of respondents stated that they were either unsure or agreed with this alternative. Conclusions The majority of imams agreed that Muslims with a urinary stoma are able to maintain their ablution, allowing them to conduct their daily prayers, and that this form of surgery should not be refused on religious grounds. Our study suggests that the consensus view is that a urinary stoma is not contraindicated with regard to the practice of Islamic prayer rituals. Patient summary In this study we investigated if having a urinary stoma would be a religious barrier for Muslim patients in performing their obligatory prayer rituals. The overwhelming majority of imams stated that having a urinary stoma should not stop Muslim patients practising important aspects of their faith.

Currently, underactive bladder, the symptom-based correlate of the urodynamic diagnosis of detrusor underactivity, has no effective drug treatments. Use of sympathomimetics, targeting cholinergic receptors, is not supported by current evidence. Several potential targets are the subject of ongoing investigation.

Context Stress urinary incontinence (SUI) is a common and bothersome problem that frequently requires operative management. Over the past two decades, novel techniques have been introduced into clinical practice. With the greater variety of surgical options now available, there is an increasing focus on selecting the appropriate procedure for the individual patient based on the likely underlying pathophysiologic mechanism. Objective To review the methods used in the evaluation of SUI and the proposed classification systems. Evidence acquisition A search of the PubMed database for the relevant search terms was conducted, and selected articles were retrieved and reviewed. Evidence synthesis Standardised terminology for the description of SUI has been produced by the International Continence Society describing the problem in terms of symptoms, clinical signs, and urodynamic observations. The two major pathophysiologic theories that have emerged over the past 50 yr, urethral hypermobility and intrinsic sphincteric deficiency, have influenced the development and adoption of surgical techniques. It is now recognised that these two entities are not dichotomous but often coexist. The primary aim of the evaluation of the patient presenting with SUI is to confirm the diagnosis and assess symptom severity before instituting conservative treatments. Secondary evaluation consists of more sophisticated techniques that assess anatomy of the bladder neck and urethra under rest and stress (eg, videourodynamics, ultrasound) or direct or indirect physiologic measures of the integrity of the sphincter mechanism. Conclusions Classification of patients with SUI into distinct groups based on probable pathophysiologic mechanism could help guide the choice of surgical procedure, but current systems are likely too simplistic, and methods of assessment lack standardisation in techniques and sensitivity. Patient summary Urinary leakage on exertion, termed stress incontinence , is a common problem that affects many women. There is a need to develop better ways of categorising the underlying causes of leakage to ensure that patients receive the optimal treatments.