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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.

Bladder pain syndrome is a clinical condition with many aspects to its presentation and numerous suggested treatments, many of which remain controversial. Reconstructive surgery should only be considered when all the conservative options have been exhausted and only after careful counselling. The purpose of this review is to demonstrate the current evidence in the surgical management of this disease, preparatory to which we have reviewed the surgical aspects. For medical treatment, the evidence base is of poor quality and based on case series. Nevertheless, in carefully selected patients after appropriate counselling, excellent results can be achieved both with total cystectomy and augmentation cystoplasty or a continent or incontinent diversion. We reviewed the various success rates of the treatments which are described. A multidisciplinary approach is essential to a successful outcome, and it is essential to consider not only the urological, but also broader medical and psychological consequences seen with bladder pain syndrome. Further research should focus on clearly categorizing the patients with well-defined clinical criteria to provide high-quality evidence to support the selection of the most effective treatment.

Subfertility is a risk factor for testicular cancers (TT), and conversely, TT may induce subfertility due to local and regional toxic effects. We aimed to identify the association between TT characteristics and pre-orchidectomy azoospermia. A systematic review of the literature was performed according to the PRISMA checklist. Overall, eight non-randomised studies involving 469 men with TT (azoospermia, n = 57; no azoospermia n = 412) were included in the qualitative analysis. Bilateral TT (12.3% vs 2.9% in non-azoospermia), non-seminoma germ cell tumours (6.4% vs 1.9%), germ cell neoplasia in-situ (GCNIS) (11.1% vs 1.2%), stage 2-3 disease (22.2% vs 0%), Sertoli Cell only (SCO) on biopsy (60% vs 37.5%) and a history of undescended testis (UDT) (66.7% vs 50%) were more common in azoospermic men. FSH levels are higher (18.7-23.2 mIU/L vs

Background Urinary fistula (UF) is a global health problem but less common in well-resourced countries. Over the past decade there has been a trend toward managing UF in dedicated centres. Most of the evidence for surgical treatment is from individual case series, with few publications that involve high numbers. We describe the repair of recurrent and complex UF cases and outcomes in a tertiary referral setting. Objective To describe UF aetiology, repair techniques, and outcomes. Design, setting, and participants This is a retrospective study of a series of patients undergoing UF repair at a specialist unit. Outcome measurements and statistical analysis We describe the aetiology, cure rate, complications, and postoperative urinary incontinence rates for the series of UF cases. Results and limitations A consecutive series of 98 patients was identified, all of whom were tertiary referrals. Of these, 31 (31.6%) had at least one prior attempt at repair at another centre. The median age was 48 yr (interquartile range [IQR] 40–60.25). The median time from occurrence to repair was 12 mo (IQR 6–12). UF occurred most commonly following hysterectomy (48.0%), Caesarean section (9.2%), other gynaecological surgery (7.1%), and anti-incontinence surgery (7.1%). Complex fistulae (eg, repeat cases, radiation, ureteric involvement) comprised 41 of the cases (41.8%). Most patients with vesicovaginal fistula underwent repair via a transabdominal approach (70.4%). Tissue interposition was used in 96 cases (98%). There were no Clavien-Dindo grade >3 complications. Two patients (2%) had a persistent UF postoperatively. Two patients (2%) developed recurrence more than 2 yr after their initial repair, and both were successfully repaired at our centre. Twelve patients (12.3%) developed de novo overactive bladder, 22 (22.5%) developed stress urinary incontinence (13 had subsequent incontinence surgery), and two (2%) developed bladder pain (both had a subsequent cystectomy). Conclusions Despite a high rate of recurrent and complex UF, successful lasting closure was achieved in 96% of our cases. A minority of patients developed other problems such as de novo overactive bladder and stress urinary incontinence that may require further treatment. Patient summary Urinary fistula is an abnormal opening or connection in the urinary tract and is less common in well-resourced countries. As a consequence, management of this condition is more frequently undertaken at specialist units. Even patients with a complex fistula and those who have had multiple attempts at repair can experience a cure. Urinary leakage is a common complication after the operation but can be successfully managed with surgery., Take Home Message Despite a high number of complex and recurrent cases, we achieved a success rate in excess of 95% in the surgical management of genitourinary fistula. It is important that such cases are managed by teams of surgeons who are comfortable in undertaking both vaginal and abdominal approaches to repair.

The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65–100% (mean/median follow-up, 12–59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit–harm balance and surgeon’s skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

Objective To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease. 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 the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion. Evidence synthesis Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. 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 male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations. Patient summary Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.To present a summary of the 2021 European Association of Urology (EAU) guidelines on diagnosis, classification, perioperative management, and follow-up of male urethral stricture disease.The panel performed a literature review on the topics covering a time frame between 2008 and 2018, and using predefined inclusion and exclusion criteria for the literature. Key papers beyond this time period could be included if panel consensus was reached. A strength rating for each recommendation was added based on a review of the available literature after panel discussion.Routine diagnostic evaluation encompasses history, patient-reported outcome measures, examination, uroflowmetry, postvoid residual measurement, endoscopy, and urethrography. Ancillary techniques that provide a three-dimensional assessment and may demonstrate associated abnormalities include sonourethrography and magnetic resonance urethrogram, although these are not utilised routinely. The classification of strictures should include stricture location and calibre. Urethral rest after urethral manipulations is advised prior to offering urethroplasty. An assessment for urinary extravasation after urethroplasty is beneficial before catheter removal. The optimal time of catheterisation after urethrotomy is72 h, but is unclear following urethroplasty and depends on various factors. Patients undergoing urethroplasty should be followed up for at least 1 yr. Objective and subjective outcomes should be assessed after urethral surgeries, including patient satisfaction and sexual function.Accurate diagnosis and categorisation is important in determining management. Adequate perioperative care and follow-up is essential for achieving successful outcomes. The EAU guidelines provide relevant evidence-based recommendations to optimise patient work-up and follow-up.Urethral strictures have to be assessed adequately before planning treatment. Before surgery, urethral rest and infection prevention are advised. After urethral surgery, x-ray dye tests are advised before removing catheters to ensure that healing has occurred. Routine follow-up is required, including patient-reported outcomes. These guidelines aim to guide doctors in the diagnosis, care, and follow-up of patients with urethral stricture.

Context Four techniques for graft placement in one-stage bulbar urethroplasty have been reported: dorsal onlay (DO), ventral onlay (VO), dorsolateral onlay (DLO), and dorsal inlay (DI). There is currently no systematic review in the literature comparing these techniques. Objective To assess if stricture recurrence and secondary outcomes vary between the four techniques and to assess if one technique is superior to any other. Evidence acquisition The EMBASE, MEDLINE, and Cochrane Systematic Reviews—Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED) databases and ClinicalTrials.gov were searched for publications in English from 1996 onwards. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), observational studies (cohort, case-control/comparative, single-arm), and case series with ≥20 adult male participants were included. Evidence synthesis A total of 41 studies were included involving 3683 patients from one RCT, four NRCSs, and 36 case series. Owing to the overall low quality of the evidence, a narrative synthesis was performed. Conclusions No single technique appears to be superior to another for bulbar free graft urethroplasty. Both DO and VO are suitable for bulbar augmentation urethroplasty, with a ≤20% recurrence rate over medium-term follow-up. No recommendations can be made regarding DI or DLO techniques owing to the paucity of evidence. Secondary outcomes including sexual function, and complications are infrequently reported. Recurrence rates deteriorate in the long term for both DO and VO procedures. Patient summary We reviewed the evidence for four different skin-graft techniques used to repair narrowing of a section of the urethra (bulbar urethra, under the scrotum and perineum) in men. Two of the techniques seem to give consistent results, with recurrence rates lower than 20%. Recurrence rates increase over time, so patients should continue to monitor their symptoms. There is poorer reporting of other outcomes such as sexual function, urinary symptoms, and complications, and it is possible that these occur more frequently than the current data suggest.

The rate of burnout among physicians appears to be on the rise and urologist are no exception. In fact, urology appears to be one of the specialties most affected, with European urologists reporting burnout rates of up to 54% and those working in the United States up to 68%. Herein, we review the relatively few studies looking at burnout in European urologists to estimate its prevalence and discuss what could be done to reverse the trend. A total of seven studies were identified assessing burnout in urologists in Europe and Turkey. While the rates vary (9.3–68%), they indicate that burnout is prevalent within urology, with data from other studies suggesting there is a rising trend. Although the topic has been studied for many years, with an increased focus in the last decade, little seems to have been done to improve the situation.

Background Female urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management. Objective The video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position—a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position. Design, setting, and participants A retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed. Surgical procedure Urethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap). Measurements Subjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured. Results and limitations A total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3–40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0–40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I–II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo. Conclusions The modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established. Patient summary Surgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Current bladder dysfunction reports (2019). doi:10.1007/s11884-019-00531-w, Published by Current Medicine Group, Philadelphia, Pa.

Purpose of review Urethrotomy remains the first-line therapy in the treatment of a urethral stricture despite data showing no real chance of a cure after repeated urethrotomies. An anastomotic or an augmentation urethroplasty using oral mucosa can be offered to patients following failed urethrotomy. The potential for a tissue engineered solution as an alternative to native tissue has been explored in recent years and is reviewed in this article. Recent findings More than 80 preclinical studies have investigated a tissue-engineered approach for urethral reconstruction mostly using decellularized natural scaffolds derived from natural extracellular matrix with or without cell seeding. The animal models used in preclinical testing are not representative of disease processes seen with strictures in man. The available clinical studies are based on small noncontrolled series. Summary There is a potential role for tissue engineering to provide a material for substitution urethroplasty and work has demonstrated this. Further work will require a rigorous basic science programme and adequate evaluation of the material prior to its introduction into clinical practice. The research with tissue engineering applied to the urethra has not yet been resulted in a widely available material for clinical use that approaches the efficacy seen with the use of autologous grafts.

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.

Urethrotomy remains the first-line therapy in the treatment of a urethral stricture despite data showing no real chance of a cure after repeated urethroplasties. An anastomotic or an augmentation urethroplasty with oral mucosa should be offered to patients with a failed urethrotomy. The availability of grafts can be a concern for both patients and surgeons. The potential for a tissue-engineered solution has been explored in recent years and is explored in this article.More than 80 preclinical studies have investigated a tissue-engineered approach for urethral reconstruction mostly using decellularized natural scaffolds with or without cell seeding. The animal models used in preclinical testing are not representative of disease processes seen with strictures in man. The available clinical studies were of small sample size and lacked control groups. The choice of biomaterial were mostly acellular matrices derived from natural extracellular matrix. The reported success rates in the pilot clinical studies were highly variable.The research with tissue engineering of the urethra has not yet been translated into a clinically available material. This is an area where much more research is needed and we would conclude that it is an area of unmet clinical need where users of tissue-engineered urethra in the future need to carry out a rigorous basic science programme and need to be cautious in drawing conclusions based on initial experience and report on long-term clinical results.

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 disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates.To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD.A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist.A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.50; p 0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11-0.48; p 0.001; intraluminal injection: OR 0.11, 95% CI 0.02-0.61; p = 0.01). Urinary tract infection (2.9-14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen.Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence.We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.

Urinary incontinence (UI) in men is far less common than it is in women. There is a direct reverse in the frequency of type of UI in men as compared with women, with urgency UI being most common, followed by mixed UI and then stress UI being least frequent. Urgency UI in men is largely managed in similar fashion as it is in women, with conservative measures, behavioural modification, oral pharmacotherapy, intravesical therapies and electrical stimulation techniques. SUI in men is mainly related to iatrogenic injury particularly following radical prostatectomy. With the increasing trend in the early diagnosis of prostate cancer and its surgical management, stress UI is being encountered with increasing frequency despite refinements in surgical techniques associated with newer technology. In this chapter, we discuss how UI is assessed and managed in men with a particular focus on Stress UI after prostatectomy.

The overactive bladder, underactive bladder and bladder pain syndrome commonly present with characteristic groups of symptoms, and are recognized as the common symptom complexes in urology. Each is highly bothersome to the patient whilst little is understood about their aetiopathogeneses and each lacks a simple and effective cure. This chapter outlines the principles which underpin our current understanding of these symptom complexes.

Context Detrusor underactivity (DUA) is a common but relatively under-researched bladder dysfunction. Underactive bladder (UAB) is the symptom-based correlate of DUA. Recently, there has been renewed interest in this topic. Objective To systematically review and summarise the most recent literature and discuss this in the context of what is already known. Evidence acquisition A systematic review of the literature was performed in December 2017 using Medline and Scopus databases. Separate searches of each database used a complex search strategy including “free text” protocols. Search terms included “underactive bladder”, “detrusor underactivity”, “acontractile bladder”, “detrusor failure”, “detrusor areflexia”, “atonic bladder”, “chronic retention”, and “impaired bladder contractility”. Evidence synthesis The initial search retrieved a total of 1690 studies; of these 44 were included in the final analyses. Conclusions Although there has been an expansion in the literature concerning all aspects of DUA and UAB, knowledge on its epidemiology and aetiopathogenesis is still lacking; there remains a need to develop accurate reproducible diagnostic criteria and effective treatments, in particular drug therapies. Patient summary Recently, there has been renewed interest in underactive bladder with expanding research in this area. The lack of simple, reproducible, noninvasive diagnostic criteria has precluded an accurate estimation of the magnitude of the problem. Recent studies have highlighted the potential role of impaired bladder blood supply in causing bladder underactivity.

Objectives: To look at the changing role of cystoplasty in the neuropathic population. Design: Retrospective case series. Setting: Single center over a 10-year period from 2004 to 2014. Participants and intervention: In 1995, the Princess Royal spinal injuries unit published the outcomes of 78 neuropathic patients who had undergone cystoplasty in the 10-year period from 1982 to 1992. [Singh G, Thomas DG. Enterocystoplasty in the neuropathic bladder. Neurourol Urodyn 1995; 14(1): 5–10.]. In this series, we review 51 consecutive patients undergoing the same operation over a 10-year period from 2004 to 2014 in the same single unit. Outcome measures: Demographic data were collected to include patient age, condition, and previous treatments. Pre- and post-operative details included sphincter insertions, renal function, continence rates, and complications. Results: Despite an increase in the number of patients seen at the unit, there were considerably fewer cystoplasty procedures performed in the current series (51 vs. 78 in the 1982–1992 series). There were also significantly fewer patients with spina bifida and fewer concomitant sphincter insertions in the latter series (eight patients vs. 52 in the 82/92 series). Nevertheless, similar outcomes are observed between the current and 1982–1992 series, with continence rates of 93.7 and 93.6%, respectively and low numbers of reported adverse events for both retrospective cohorts. Conclusions: Cystoplasty remains a safe and effective option for the management of neuropathic bladder in a carefully selected group of patients.

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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.

Objective To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae. Patients and methods We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty. Results Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up. Conclusions Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

The acontractile bladder (AcB) is a urodynamic-based diagnosis wherein the bladder is unable to demonstrate any contraction during a pressure flow study. Although it is often grouped with underactive bladder, it is a unique phenomenon and should be investigated independently. The purpose of the present review was to examine the current literature on AcB regarding its pathology, diagnosis, current management guidelines, and future developments. We performed a review of the PubMed database, classifying the evidence for AcB pathology, diagnosis, treatment, and potential future treatments. Over the 67 years covered in our review period, 42 studies were identified that met our criteria. Studies were largely poor quality and mainly consisted of retrospective review or animal models. The underlying pathology of AcB is variable with both neurological and myogenic aetiologies. Treatment is largely tailored for renal preservation and reduction of infection. Although future developments may allow more functional restorative treatments, current treatments mainly focus on bladder drainage. AcB is a unique and understudied bladder phenomenon. Treatment is largely based on symptoms and presentation. While cellular therapy and neuromodulation may hold promise, further research is needed into the underlying neuro-urological pathophysiology of this disease so that we may better develop future treatments.

Underactive bladder (UAB) is a voiding disorder which generates disabling lower urinary tract symptoms (LUTS) due to the inability to produce an effective voiding contraction sufficient to empty the bladder. The underlying abnormality, that is usually appreciated when performing urodynamic studies, has been defined by the International Continence Society (ICS) as detrusor underactivity (DUA). DUA is a common yet under-researched bladder dysfunction. The prevalence of DUA in different patient groups suggests that multiple aetiologies are implicated. Currently there is no effective therapeutic approach to treat this condition. An improved understanding of the underlying mechanisms is needed to facilitate the development of new advances in treatment. The purpose of this review is to discuss the epidemiology, pathophysiology, common causes and risk factors potentially leading to DUA; to aid in the appropriate diagnosis of DUA to potentially improve treatment outcomes.

The individual lower urinary tract symptoms (LUTS) commonly occur in conjunction. Particularly important combinations may reflect associations of symptoms (e.g. overactive bladder) or a shared underlying mechanism (e.g. bladder outlet obstruction, detrusor underactivity or nocturnal polyuria). Finally, urinary retention covers a range of potential presentations and mechanisms.

Introduction In the last decade therapeutic options for patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have constantly increased. Although transurethral resection of the prostate (TURP) is still considered the surgical gold standard, different lasers and advanced techniques have been introduced as alternatives to TURP. Evidence acquisition A non-systematic Medline/Pubmed literature search was performed with different combination of terms including: "BPH," "M-TURP," "B-TURP" "bladder outlet obstruction," "YAG laser," "Diode laser," "Potassium titanyl phosphate," "KTP," "bladder outlet obstruction" (BOO), "BOO in small prostate". Only studies reporting prostate volume ≤40 cc were considered for this review. Evidence syntesis Current evidence on the use of laser as a therapeutic modality as compared to TURP reported similar functional results of bipolar-TURP, Thulium laser and Greenlight. For prostate gland ≤40 cc, HoLEP can be technically more difficult while Holmium-TUIP seems to be a valid option but with a higher rate of retrograde ejaculation which is considerably higher than the rate in electrocautery series. The diode laser showed excellent intra-operatively haemostasis with clear endoscopic vision and durable improvements in functional results, but may produce greater passive thermal energy conduction that can cause scrotal edema and anal pain. However, conclusions need to be drawn after median to long term evaluation of patients and consideration of the economic implications, coupled with the potential for reducing morbidity. Conclusions Evidence acquisition from the literature showed that mini-invasive surgeries, including Greenlight laser and Holmium laser incision represent valid alternatives to TURP in prostate ≤40 g. We reported effective results of laser therapy as therapeutic modalities as compared to TURP for the small prostate ≤40 mL, both for enucleation and excision or cauterization, however cost effective of laser in the current literature are still scarce and it should be implemented.

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.

Context Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series. Objective We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide. Evidence acquisition We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries. Evidence synthesis Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p =0.0176). Conclusions It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful. Patient summary Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

It is increasingly recognized that the bladder is the originator of storage lower urinary tract symptoms, including overactive bladder in men. As these symptoms are most bothersome for patients, there has been an increasing interest in the evaluation of drug treatment to better target the bladder. Consequently, several new drug classes have been introduced to the therapeutic armamentarium. Antimuscarinics, which were previously avoided due to the concern regarding urinary retention, are now used in routine practice; however, their use is still hampered by discontinuation due to side effects.

Serious complications can develop with the mesh implants used for stress urinary incontinence and pelvic organ prolapse surgery. We evaluated 2 materials currently in clinical use and 2 alternative materials using a rabbit abdominal model to assess host response and biomechanical properties of the materials before and after implantation.Poly-L-lactic acid and polyurethane meshes were electrospun to be compared to commercially available polypropylene and polyvinylidene fluoride meshes. A total of 40 immunocompetent full-thickness abdominal wall defect rabbit models were used, including 8 in each of the poly-L-lactic acid, polyurethane, polyvinylidene fluoride and polypropylene experimental groups, and sham controls. Two 20 mm defects were created per animal and primarily repaired. The experimental groups then underwent onlay of each repair material while sham controls did not. Four rabbits per group were sacrificed at days 30 and 90. Abdominal wall specimens containing the defect with or without repair material were explanted to be assessed by histology (hematoxylin and eosin staining, and immunohistochemistry) and biomechanical testing at 30 and 90 days.At 90 days of implantation tissues repaired with all 4 materials showed biomechanical properties without significant differences. However, polypropylene and polyvinylidene fluoride meshes demonstrated a sustained chronic inflammatory response profile by 90 days. In contrast, poly-L-lactic acid and polyurethane meshes integrated well into host tissues with a decreased inflammatory response, indicative of constructive remodeling.Poly-L-lactic acid and polyurethane alternative materials achieved better host integration in rabbit models than current synthetic repair materials.

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 Urethral strictures can be difficult to diagnose at an early stage because the urinary flow rate does not diminish until the urethral calibre is ≤3mm. In the past, posturethral surgery follow-up has relied upon flow rates and contrast imaging. Objective To evaluate the role of flexible urethroscopy in the follow-up of patients undergoing urethroplasty. Design, setting, and participants Prospective flexible urethroscopy follow-up of 144 male patients who underwent urethroplasty by a single surgeon over a 10-yr period at a tertiary referral centre. Intervention Flexible urethroscopy at 3, 6, and 12 mo postoperatively, and annually thereafter. Outcome measurements and statistical analysis Type of recurrence, based on urethroscopy findings, and further interventions were measured. Actuarial analysis was performed using Kaplan-Meier curves and a log-rank test. Results and limitations All 144 patients underwent flexible urethroscopy follow-up over a median postoperative follow-up of 22 mo (range: 1–96 mo). No further intervention was required for 117 patients (81.25%); 27 (18.75%) developed recurrences that required further treatment. Recurrences included diaphragms (13 patients) or significant restenosis (14 patients). Diaphragms were treated by urethrotomy, gentle dilatation, or a short course of intermittent self-dilatation. Restenosis required repeated simple procedures or surgical revision. Most recurrences (26 of 27, 96%) were detected within the first year. Urinary peak flow-rate data were available for 11 of 27 of these recurrences; 7 patients had flow rates >15ml/s. Anastomotic procedures had greater success than augmentation urethroplasty ( p =0.0136); there was no significant difference in outcomes between redo and non-redo surgery ( p =0.2093) Conclusions Endoscopic follow-up of patients after urethroplasty enables earlier identification and treatment of recurrences compared to the use of urinary flow rates alone. It also enables the identification of two different morphologic recurrence patterns that require different types of intervention. Patient summary Endoscopy detects most stricture recurrences within 1 yr after urethroplasty and is more sensitive than using urinary flow rates alone.

Pelvic fracture urethral injuries comprise one of the most challenging reconstructive procedures in urology. The obliterated or stenosed urethra can usually be effectively repaired by an end-to-end anastomosis (bulbomembranous anastomosis). To achieve this, a progression of surgical steps can be used to make a tension-free anastomosis. Before undertaking surgery it is important to comprehensively assess the patient to define their anatomical defects, in particular the site of the stenosis, the length of the distraction injury and the integrity of the bladder neck, and thus guide preoperative decision-making. Contemporary reports suggest that most pelvic fracture urethral distraction defects (PFUDD) can be adequately managed by a perineal approach. Nevertheless it is essential that all surgeons treating these injuries are familiar with the whole spectrum of operative steps that are necessary to repair PFUDD.

Detrusor underactivity (DU) is an important contributor to lower urinary tract symptoms (LUTS). While DU has been defined in the literature in urodynamic terms, current definitions lack specific parameters. In addition, the clinical syndrome associated with and manifesting itself as DU, underactive bladder (UAB), has not been well defined in the literature. In the absence of a precise definition of UAB, it is difficult to appreciate the true nature and burden of this condition. We review the evidence regarding the epidemiology, pathogenesis, diagnosis, and treatment of DU and UAB and discuss the challenges in gathering data in the absence of precise definitions. DU may be idiopathic or caused by ageing, medications, or a number of causes of neurogenic, myogenic, or iatrogenic origin. Treatments are largely palliative due to a lack of curative options, and include watchful waiting, catheterization, medications, and surgical interventions. In light of the evidence available in the literature, we propose that a new symptom-based definition of UAB syndrome should be developed as a first step in furthering more standardized research. Further discussion on this proposed definition to reach expert consensus will enable researchers to gather more robust data, allowing greater insights into DU and UAB diagnosis and treatment.