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Urethral injury is one of the crucial intraoperative complications during transanal total mesorectal excision (taTME) for male patients with low rectal cancer. Urethral injury can occur during the anterior dissection around the inferior lobe of the prostate and the membranous urethra. A tool to visualize the urethra around this area would be useful to avoid urethral injury. We report a cadaveric demonstration of visualization of the urethra using a lighted stent during transanal intersphincteric resection. The lighted stent (InfraVision Ureteral Kit, Stryker) was placed through the irrigation channel of a clear three-way urinary catheter. After the anterior dissection, the visibility of the lighted stent was investigated under the three laparoscopic light conditions: (1) normal intensity; (2) low intensity; and (3) turned-off. In the proper dissection plane that led to preservation of the urethra, the lighted stent was hardly visible under the normal-intensity condition, but it was clearly visible under the turned-off condition. In the improper dissection plane that led to urethral injury, the lighted stent was clearly visible under both the normal-intensity and the turned-off conditions. Visualization of the urethra using the lighted stent under the turned-off condition of the laparoscopic light can be useful to avoid inadvertent urethral injury during the anterior dissection of male taTME. Clear visibility of the lighted stent under the normal-intensity condition can indicate that the dissection plane is too close to the urethra. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13691-018-0319-0) contains supplementary material, which is available to authorized users.

Virtually no information on the chronology of prenatal development of the human urinary tract and the sex-related differences in the emergence of urinary tract topography during embryonic development is presently available. The aim of our work was to study sex-related differences in urethra development in human embryos and early fetuses. Forty-nine preparations of human embryos and early fetuses without external signs of anatomical abnormalities were studied in order to achieve the aim and fulfill the objectives of the study. Embryos and early fetuses were divided into six groups according to gestational age and parietococcygeal length. The complex of adequate methods of morphological research used in the study included preparation and microscopy of serial histological and anatomical sections of human embryos, including female and male urinary tracts, preparation of 3D-reconstruction models, and morphometry. The formation of prostatic urethra, a derivative of the urogenital sinus, was shown to occur at the beginning of the ninth week of embryogenesis, and the primordium of the internal sphincter of the urinary tract was formed at the end of the tenth week. Formation of the terminal part of spongy urethra took place during weeks 10–11 and involved funnel-like protrusion of the ectoderm from the top of the balanus towards the urethra lumen. The secondary ventral displacement of the urethral opening does not occur in female fetuses, and, therefore, only the prostatic urethra is a homolog of the female urinary tract. The pelvic part of the urogenital sinus was transformed into the prostatic urethra and the membranous urethra of the male at the end of the first stage of fetal development. Elongation of the genital tubercle (a penis primordium) and formation of the urethral ridge walls that involved the urogenital folds occurred at the same time.

To identify a parameter predicting postoperative recovery of urinary continence after radical prostatectomy, associations between parameters on preoperative magnetic resonance imaging (MRI) and postoperative continence status were investigated.This prospective study enrolled 113 patients with localized prostate cancer who underwent MRI before radical prostatectomy. Continence was evaluated using the Expanded Prostate Index Composite instrument before surgery and at 1, 3, 6, 12, 18, 24, and 36 months postoperatively. We developed a novel parameter, minimal residual membranous urethral length (mRUL), defined as the distance between the lower margins of the puboperinealis and bulbospongiosus muscles in a direction parallel with the urethra on preoperative MRI, which is supposed to represent the minimal intact residual part of the membranous urethra during RP. Thicknesses of the levator ani and periurethral sphincter complex were also estimated on MRI.Continence recovery was significantly faster in patients with longer mRUL (≥6.4 mm) than in patients with shorter mRUL (6.4 mm; log-rank test, P = .003). Interestingly, incontinence rate before radical prostatectomy was significantly lower in patients with longer mRUL (2.0%) than in those with shorter mRUL (17.5%; P = .008). Multivariate analysis showed that longer mRUL was significantly related to superior continence recovery (hazard ratio, 0.78; P = .005). Thicknesses of the levator ani and periurethral sphincter complex were not associated with continence recovery.Preoperative mRUL offers an independent predictor of continence recovery after radical prostatectomy and is also associated with preoperative (baseline) continence status.

Objective: To measure changes in penile length (PL) over time before and after radical prostatectomy (RP), and to investigate the underlying mechanisms for these changes. Patients and Methods: The stretched PL (SPL) of 102 patients was measured before, 10 days after, and at 1, 3, 6, 9, 12, 18 and 24 months after RP. The perpendicular distance from the distal end of the membranous urethra to the midline of the pelvic outlet was measured on mid-sagittal magnetic resonance imaging (MRI) slice at three time points: preoperatively; 10 days after RP; and 12 months after RP. Pre- and postoperative SPLs were compared using paired Student's t-test. Predictors of PL shortening at 10 days and at 12 months after RP were evaluated on univariate and multivariate analyses. Results: The SPL was shortest 10 days after RP (mean PL shortening from preoperative level: 19.9 mm), and gradually recovered thereafter. SPL at 12 months after RP was not significantly different from preoperative SPL. On MRI examination, the distal end of membranous urethra was found to have moved proximally (mean proximal displacement: 3.9 mm) at 10 days after RP, and to have returned to the preoperative position at 12 months after RP. On univariate analysis, only the volume of the removed prostate was a predictor of SPL change at 10 days after surgery; on multivariate analysis, the association was not statistically significant. No predictor of SPL change was found at 12 months after RP. Conclusion: The SPL was shortest at 10 days after RP and gradually recovered thereafter in the present study. Anatomically, the glans and corpus spongiosum surrounding the urethra are an integral structure, and the proximal urethra is drawn into the pelvis during urethrovesical anastomosis. This is the first report showing that slight vertical repositioning of the membranous urethra after RP causes changes in SPL over time. These results can help inform patients about changes in penile appearance after RP. © 2017 BJU International., Embargo Period 12 months

ContextMembranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery.ObjectiveTo undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP.Evidence acquisitionA comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion.Evidence synthesisFour studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02–1.08, p

WOS: 000414976900032, PubMed ID: 29151330, Background/aim: We aimed to analyze the effects of stricture location, etiology, age, and catheterization time on recurrence rate and recurrence time in patients who underwent direct vision internal urethrotomy (DVIU) for urethral strictures. Materials and methods: Patients were divided into three groups according to the location of the stricture: penile urethra, membranous urethra, and prostatic urethra strictures. Patients were also divided into three groups according to etiologic factors: strictures secondary to endoscopic procedures, urethral catheterization, and open or radical prostatectomy (anastomotic strictures were included in this group). Patients were also divided into three groups according to catheterization time: < 2, 2-5, and > 5-7 days. Recurrence rate and time data were analyzed according to stricture location, etiology, age, and catheterization time. Results: The recurrence rate was significantly higher in endoscopic procedures. Recurrence rate was significantly lower and recurrence time was significantly earlier in penile urethral strictures. Recurrence rate was significantly lower and recurrence time was significantly longer in short catheterized group than in the other two groups. However, first recurrence time was not different between the groups, while second and multiple recurrence times were significantly earlier in patients < 60 years old. Conclusion: Patients are exposed to multiple operations as a result of frequently recurring urethral strictures. Although DVIU is an important first-line treatment method for strictures, alternative methods should be considered for frequently recurring cases.

Background: Pelvic multiparametric magnetic resonance imaging (mpMRI)–determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP). Objective: The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL. Design, setting and participants: Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed. Surgical procedure: Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL. Measurements: Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively. Results: Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p 1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118). Conclusions: Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery. Patient summary: Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients’ mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach. We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video. Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation. The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.

To evaluate histological changes in stenotic urethral tissue post-radiation therapy. Treatment of prostate cancer by radiation therapy carries a risk of off-target injury to the membranous urethra causing urethral stenosis. Limited characterization of post-radiation urethral stenosis exists in the literature. We hypothesize that specific histopathologic parameters distinguish this stricture etiology. Eighty-two consecutive patients with membranous urethral stenosis underwent urethroplasty between 2013 and 2018. Seventy specimens (86.4%) were available for evaluation: 51 from patients without radiation exposure and 19 from patients with history of radiation therapy for prostate cancer. All specimens were reviewed by a pathologist blinded to patient/stricture information. Histological scoring system was used for the quantification of collagen density, collagen organization, hyalinized fibrosis, vascular density, spindle-cell change, necrosis, hemorrhage, fat entrapment, vacuolation, acute and chronic inflammation, and foreign-body giant cells. Differences in histologic outcomes between groups were statistically analyzed. Post-radiation specimens had a higher collagen density (p = 0.01), higher collagen organization (p = 0.001), increased hyalinized fibrosis (p = 0.03), fat entrapment (p = 0.005) and spindle cell change (p = 0.005) when compared to membranous specimens without prior exposure to radiation. Post-radiation specimens also had a significantly decreased vascularity compared to specimens of non-radiated etiology (p = 0.0005). Fibrous connective tissue degenerative change with vacuolation was pronounced in post-radiation specimens and seldom seen in those without radiation (p = 0.0001). Membranous urethral stenosis following radiation demonstrates specific histologic characteristics including vascular loss and increased scarring (collagen density, organization). This histologic grading system may be used in grading severity of radiation damage, and conceivably adopted for correlation with clinical outcomes.

Lower urinary tract symptoms in men have previously been attributed to obstruction from an enlarged prostate. However, several factors in addition to prostate volume have been identified as impacting urine flow. Prostatic apex shape is one factor that has not been evaluated. This study evaluates the relationship between prostatic apex shape and voiding symptoms and urine flow. A retrospective, exploratory data review was conducted for 806 healthy men who underwent routine transrectal ultrasonography at our hospital, and data for 329 patients with uroflowmetric measurements were reviewed for the confirmatory study. Patients were categorized into four groups according to the prostatic apex shape on midsagittal ultrasonography. The association between prostatic apex shape and voiding symptoms was investigated. International Prostate Symptom Score (IPSS) and uroflowmetry were measured, and the associations between IPSS, uroflowmetry, and prostatic apex shape were analyzed. Patients in group 4 (356/806, 44.2%), whose prostatic apex did not overlap the membranous urethra anteriorly or posteriorly, had a significantly lower incidence of moderate and severe lower urinary tract symptoms compared to other groups. There was a significant relationship between prostatic apex shape and total International Prostate Symptom Score. Patients in group 3, whose prostatic apex overlapped posteriorly with the membranous urethra, had lower maximum flow rates on uroflowmetry. There were significant correlations between the maximum flow rate and independent factors including age, intravesicle prostatic protrusion, and prostatic apex shape. Prostatic apex shape is an independent risk factor for voiding symptom severity and low maximum flow rate.

To evaluate standardized measurements of the membranous urethra length (MUL), the membranous urethra angle (MUA) and the prostate's apex type (AT) among further clinical parameters as potential preoperative risk factors of urinary incontinence (UI) after radical prostatectomy (RP).Our institutional review board approved this retrospective single center study. 316 patients (mean age 65 years) underwent MRI at 3 T prior to prostatectomy. MUL, MUA and AT were measured according to a standardized approach on T2w- sagittal sequences. In a second reading the inter-rater agreement for the MUL was determined. Image findings and clinical data were correlated by logistic regression to UI as evaluated by a standardized questionnaire determining the number of necessary hygiene pads (HP) at three different time points with corresponding patient subsets (one week, six months and 12 months after RP).There was a significant impact of the MUL on postoperative UI with odds ratios (OR) of 0.8 [p 0.001; confidence interval (CI) 0.73-0.91], 0.8 (p = 0.01; CI 0.68-0.94) and 0.7 (p 0.01; CI 0.56-0.89) at the respective time points. No significant impact was demonstrated regarding the MUA and AT. Of all clinical parameters there was significant impact of the patients' age and the degree of nerve-sparing surgery. Inter-rater agreement with respect to the MUL was good with an intraclass correlation coefficient of 0.82. The mean deviation of raters measuring the MUL was 1.2 mm.A shorter MUL in mpMRI should be considered as a risk factor of UI after RP. Standardized measurements enabling good inter-rater agreement should be considered for routine assessments to facilitate prospective classifications.

We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra.We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves.A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen.The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.

Introduction: Broadly defined, urethral strictures are narrowing of the urethral lumen that is surrounded by corpus spongiosum, i.e., urethral meatus through the bulbar urethra. Urethral stenosis is narrowing of the posterior urethra, i.e., membranous urethra through bladder neck/prostate junction, which is not enveloped by corpus spongiosum. The disease has significant quality of life ramifications because many times younger patients are affected by this compared to many other urological diseases. Methods: A review of the scientific literature concerning urethral stricture, stenosis, treatment, and outcomes was performed using Medline and PubMed (U.S. National Library of Medicine and the National Institutes of Health). Abstracts from scientific meetings were included in this review. Results: There is level 3 evidence regarding the etiology and epidemiology of urethral strictures, stenoses, and pelvic fracture urethral injuries. Outcomes data from literature regarding intervention for urethral stricture are largely limited to level 3 evidence and expert opinion. There is a single level 1 study comparing urethral dilation and direct vision internal urethrotomy. Urethroplasty outcomes data are limited to level 3 case series. Conclusions: Progress is being made toward consistent terminology, and nomenclature which will, in turn, help to standardize treatment within the field of urology. Treatment for urethral stricture and stenosis remains inconsistent between reconstructive and nonreconstructive urologists due to varying treatment algorithms and approaches to disease management. Tissue engineering appears to be future for reconstructive urethral surgery with reports demonstrating feasibility in the use of different tissue substitutes and grafts.

Rationale: Periurethral abscess is a life-threatening disease, and the occurrence of a urethral defect with periurethral abscess is a rare finding. In this case, the patient had a lengthy urethral defect from the bulbous urethra to the membranous urethra accompanied by periurethral abscess that developed within a short time. Herein, we report a case of a pedicle-sparing tunica vaginalis flap utilized in urethral reconstruction which degenerated due to fibrotic changes and soft tissue defects in the urethral bed. Patient concerns: The patient was a 36-year-old man with fever and lower urinary tract symptoms who had been treated with antibiotics and anti-inflammatory drugs for urinary tract infections 3 days before admission. Purulent necrosis was formed by the urethral abscess, and a long-length urethral defect was formed in the bulbous urethra. Diagnosis: Based on the initial computed tomography and laboratory findings, empirical antibiotics were administered to treat a lower urinary tract infection. On the 7th day of hospitalization, ultrasonography was performed due to the sudden swelling of the scrotum, and the patient was diagnosed with a periurethral abscess that was 10 × 3 cm in size. Intervention: Initial urinary diversion, wide debridement, and a large amount of abscess drainage were performed. Necrosis of the urethral ventral part caused a urethral defect that was 5 cm in size. After treatment with antibiotics, long-term disinfection and intermittent debridement were conducted and urethral reconstruction was performed using a tunica vaginalis flap with preserved vascular structure. Outcomes: No complications occurred until 6 months after urethral reconstruction. Lessons: Urethral reconstruction using a tunica vaginalis flap is a good method for selected patients. Pedicle-sparing tunica vaginalis is an advantageous material for resolving urethral defects, especially when the surrounding circulation conditions are poor.

The goal of radical prostatectomy is to eradicate oncological disease while achieving the best possible functional outcomes. In this regard, nerve sparing offers a greater chance of recovering potency after surgery. Accurately locating prostate cancer foci is instrumental for identifying good candidates for this approach whilst maintaining safe oncological margins. In addition to this, the length of membranous urethra is an independent predictor of time to, and extent of, continence recovery. The introduction of Mp-MRI allows visualising malignant tissue within the prostate gland, which could lead to image-directed surgery planning as with other solid-organ cancers such as kidney, pancreas, breast or testes. A narrative review of the available literature was performed. Mp-MRI demonstrated moderate sensitivity and high specificity to detect extra-capsular extension, seminal vesicle involvement or T3 stage. Measurements of membranous urethral length have shown to be useful in predicting probability of achieving continence after surgery. Furthermore, image-guided surgery has shown to be accurate to determine surgical planes to safely preserve neurovascular bundles. The use of Mp-MRI for pre-surgical planning introduces a new scenario where the previously homogeneous radical prostatectomy can be tailored to suit patient and tumour features. This has the potential to improve functional outcomes whilst not compromising on surgical margins. Moreover, the introduction of Mp-MRI increases the ability to predict functional outcomes after surgery and allows for a more accurate local staging. This in turn provides more information to both patients and clinicians in the decision-making process regarding treatment.

Chlamydiosis is the most documented and serious disease of koalas, characterized by ocular, urinary, and reproductive lesions. Since little attention has been paid to the pathological effects of this infection in the male reproductive system, we aimed to determine the incidence and severity of reproductive pathology associated with chlamydial infection in male koalas submitted to koala hospitals in southeast Queensland. The entire reproductive tract from 62 sexually mature male koalas not suitable for rehabilitation was evaluated and 677 tissue samples were collected for histology, immunohistochemistry (IHC), and real-time polymerase chain reaction (qPCR). Lymphoplasmacytic inflammation was observed in 178 of 677 (26.3%) tissue samples from the upper and lower reproductive tract, mainly in the prostatic, penile, and membranous urethra. IHC was positive for the chlamydial antigen in 19 of 451 normal samples (4.2%) and 46 of 178 samples with inflammation (25.8%), located within the cytoplasm of epithelial cells of the epididymis, vas deferens, prostate, bulbourethral glands, and the prostatic membranous and penile urethra. Chlamydia pecorum was detected via qPCR in 319 of 451 normal samples (70.7%) and 159 of 178 samples with inflammation (89.3%), with the highest incidence in the penile urethra, prostate, membranous urethra, and bulbourethral glands. This study suggests that Chlamydia infection in the male reproductive tract is more widespread than originally thought. Furthermore, the male reproductive tract might be a reservoir for persistent chlamydial infections in koalas, with important implications for prophylactic strategies and epidemiology.

Introduction Preserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered. Material and methods A PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management. Results Modifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery. Conclusions There is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

The anatomy of the rectourethralis muscle is essential for performing radical prostatectomy and proctectomy. The rectourethralis muscle is known to continue to the rectal wall posteriorly and to the membranous urethra anteriorly. However, the lateral extent of the rectourethralis muscle remains unclear. This study aimed to verify the hypothesis that the rectourethralis muscle laterally extends and directly adheres to the levator ani. Eight male cadavers were used for macroscopic dissection, and three male cadavers were used for immunohistological analysis using anti-smooth muscle and anti-skeletal muscle antibodies. The rectourethralis muscle laterally extended smooth muscle fibers both superoposteriorly and inferoanteriorly toward the levator ani. The smooth muscle fibers sandwiched the levator ani superoanteriorly and inferoanteriorly. A few smooth muscle fibers of the rectourethralis muscle inserted into the levator ani. This study clarified the spatial distribution of the rectourethralis muscle and its detailed positional relationship with the levator ani. The findings are valuable especially to urologists and anorectal surgeons for dissecting an optimal layer around the urethra and the rectum, and for avoiding rectal or urethral injuries during surgery. Clin. Anat. 31:1167-1176, 2018. © 2018 Wiley Periodicals, Inc.

Purpose of Review: Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures. Recent Findings: Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated. Sin financiación 2.079 JCR (2018) Q3, 43/80 Urology & Nephrology 0.712 SJR (2018) Q2, 34/107 Urology, 918/2844 Medicine (miscellaneous) No data IDR 2018 UEM

Objective To assess the chronological changes in urinary incontinence and urethral function before and after radical prostatectomy (RP), and to compare the findings of pelvic magnetic resonance imaging (MRI) before and after RP to evaluate the anatomical changes. Patients and methods In total, 185 patients were evaluated with regard to the position of the distal end of the membranous urethra (DMU) on a mid-sagittal MRI slice and urethral sphincter function using the urethral pressure profilometry. The patients also underwent an abdominal leak point pressure test before RP and at 10 days and 12 months after RP. The results were then compared with the chronological changes in urinary incontinence. Results The MRI results showed that the DMU shifted proximally to an average distance of 4 mm at 10 days after RP and returned to the preoperative position at 12 months after RP. Urethral sphincter function also worsened 10 days after RP, with recovery after 12 months. The residual length of the urethral stump and urinary incontinence were significantly associated with the migration length of the DMU at 10 days after RP. The residual length of the urethral stump was a significant predictor of urinary incontinence after RP. Conclusion This is the first study to elucidate that the slight vertical repositioning of the membranous urethra after RP causes chronological changes in urinary incontinence. A long urethral residual stump reduces urinary incontinence after RP.

To evaluate the outcome of the retrourethral transobturator sling (RTS) by functional magnetic resonance imaging (MRI) and to identify parameters associated with sling failure. Of thirty recruited men with postprostatectomy stress urinary incontinence (SUI), 26 consecutively underwent functional MRI before sling procedure and 12 months thereafter in a prospective clinical cohort observational study. Periurethral/urethral fibrosis and sling visualization were evaluated on static sequences. The angle of the membranous urethra, position of the bladder neck and external urethral sphincter were assessed during Valsalva’s maneuver and voiding. Sling success was defined as no or one dry “security” pad. The success and failure rates were 58 % (15/26 patients) and 42 % (11/26 patients), respectively. The sling leads to reduction in the membranous urethra angle during Valsalva’s maneuver (39.55° vs. 36.82°, p = 0.025) and voiding (38.25° vs. 34.83°, p = 0.001) and elevation of the external urethral sphincter (2.9 vs. 4.8 mm, p = 0.017). Preoperative wider angle of the membranous urethra was significantly correlated with severe preoperative incontinence. Sling failure (p = 0.001) and severe preoperative incontinence (p = 0.001) were significantly related to only small changes of the membranous urethra angle. The interrater and intrarater reliability for membranous urethra angle was excellent (intraclass correlation coefficient ≥0.75). The RTS leads to reduction in the membranous urethra angle. The extent of the changes in the membranous urethra angle is associated with RTS outcome. Functional MRI is a reliable noninvasive visualization tool of interactions between the sling and pelvic floor for further research on the complex nature of postprostatectomy SUI.

The male sling is the preferred surgical treatment for mild to moderate post-prostatectomy stress urinary incontinence. The Virtue male sling is a hybrid device, combining proximal relocation of the membranous urethra and compression of the bulbous urethra, relying on quadratic fixation of both a trans-obturator and a pre-pubic component. By incorporating a novel method of sling fixation, with appropriate sling tensioning to a retrograde leak point pressure of 60–70 cm water, subjective and objective success rates are 71% and 79% respectively, with a median pad weight reduction of 88% at 12 months. Baseline degree of incontinence and adjuvant radiation do not appear to adversely affect sling success, and there have no reports of prolonged urinary retention or sling erosion. The quadratic male sling adds to the surgical armamentarium for the treatment of intrinsic sphincter deficiency.

Introduction Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique. Materials and methods This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation. Results A total of 14 patients (median age, 64 ± 13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45 ± 26.5 mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were 177 ± 76 min and 1.5 ± 1 day, respectively. The preoperative Qmax and PVRV values were 4.5 ± 4.45 ml/s and 212.5 ± 130 cc, respectively. The postoperative values were 15.15 ± 7.2 ml/s and 6 ± 21.5 cc, respectively (p Conclusion The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

To investigate whether differences in the anatomy and dynamics of the pelvic floor (PF) in patients after radical prostatectomy (RP) depicted on magnetic resonance imaging (MRI) are associated with continence status. In the prospective designed study, 24 patients with post-prostatectomy stress urinary incontinence were enrolled. Additionally, 10 continent patients after RP were matched for age, body mass index and perioperative parameters. All patients underwent continence assessment and MRI (TrueFISP sequence; TR 4.57 ms; TE 2.29 ms; slice thickness 7 mm; FOV 270 mm) 12 months after RP. Images were analyzed for membranous urethra length (MUL), angle of the membranous urethra (AMU), severity of periurethral/urethral fibrosis, lifting of the levator ani muscle, lowering of the posterior bladder wall (BPW), bladder neck (BN) and external urinary sphincter (EUS), and symphyseal rotation of these structures during the Valsalva maneuver and voiding. Compared to continent controls, incontinent patients showed a significant wider AMU during voiding (p = 0.002) and more pronounced lowering of the BN and EUS (p

Pelvic injuries occur in major crash accidents. Injury to the bladder and membranous urethra are the commonest associated urogenital injuries. More and more urethral injuries are being managed conservatively in the acute phase for fear of hemorrhage and infection, which may result in late sequel of urethral injuries. The definitive surgery can be delayed in favor of simple.

Pelvic fracture urethral injuries commonly result from motor vehicle collisions, and the mechanism of injury conventionally thought was a shearing injury at the membranous urethra, which would destroy the striated sphincter. Continence would therefore depend on the bladder neck. Striated sphincter and the site of injury have not been shown clearly on preoperative imaging. We demonstrate our protocol of performing magnetic resonance imaging whereby the membranous sphincter is seen intact and the injury is shown to be at the membranobulbar junction contrary to conventional belief. This suggests that surgical reconstruction can be undertaken, preserving both sphincter mechanisms and improving postoperative continence.

Objective To report our experience and the feasibility of end-to-end anastomotic urethroplasty, as this is an excellent technique for the management of post-traumatic urethral stricture. Methods We present an end-to-end anastomotic urethroplasty in a 17-year-old patient who had abdominopelvic polytrauma at the point of impact. Upon review, the lesional balance revealed a splenic rupture with haemoperitoneum and complete rupture of the membranous urethra, clearly visible on anterograde and retrograde opacification, and fractures of the pubis and the orthopedically treated ischium. The patient underwent an urgent splenectomy for haemostasis with suturing of a grievous wound. After a period of 3 months urethroplasty was performed. Results Two tips to gain sufficient length of the urethra: the mobilisation of the anterior urethra and the separation of corpora cavernosa in the median line. Two solutions are possible to better individualise the upstream end: the use of a soft fibroscope light or the Beniquet, as in our patient. The urethral anastomosis was performed mucosa against mucosa, the bladder catheter was removed 1-month postoperatively, with a follow-up of 5 years without recurrence. Conclusion End-to-end anastomotic urethroplasty is a reliable technique for the treatment of post-traumatic urethral stricture.

Purpose To evaluate the changes in pelvic floor anatomy using MRI before and after continence recovery after radical prostatectomy (RP). Materials and Methods Thirteen men with prostate cancer who underwent RP (mean age, 67.4 ± 8.8 years) volunteered for this study. Prostate MRIs were performed during the preoperative (i), incontinent (ii), and continent (iii) periods. The membranous urethra length (MUL), puborectalis muscle (PRM) thickness, and the position of the bladder neck in relation to the pubic bone (Dx) and the pubococcygeous line (Dy) were measured. We compared all parameters in the preoperative, incontinent, and continent periods. Results MUL2 and MUL3 was significantly longer compared with MUL1, although no difference was found between MUL2 and MUL3. PRM3 thickness was significantly increased compared with PRM2 thickness. The Dx of the continence period was shorter than that of the incontinence period. The Dy of the continence period was longer than that of the incontinence period. Conclusion The PRM thickened and the bladder neck moved upward and forward during the continence period. The changes in PRM thickness and the position of bladder neck may play an important role in the recovery of continence after RP. J. Magn. Reson. Imaging 2014;39:1431–1435. © 2013 Wiley Periodicals, Inc.

A 70-year-old man presented for evaluation of recurrent urinary tract infection. He had history of hypertension and had undergone suprapubic prostatectomy 8 years ago for enlarged obstructive prostate. Digital rectal examination found a stony irregular prostate and urine culture grew Escherichia Coli that was susceptible to Cephalosporines. As part of the evaluation, a plain radiograph was performed and incidentally showed a radiopaque prostatic calculus (Red arrows). A retrograde urethrocystography, performed after a 10-days course of antibiotics, confirmed the presence of an approximately 35 mm non-obstructive calculus occupying almost the whole prostatic bed (Red arrows) with a stricture of the membranous urethra (Yellow arrow), the bladder however showed no abnormalities (Orange arrows). Stones that form in the prostatic fossa are uncommon but can occur after all forms of prostatectomy. They are caused by a ligature, infection, a chip of prostate left behind in the prostatic bed or as a result of an iatrogenic urethral stricture. A meticulous operative and postoperative care is the best prevention of such a complication. Our patient was treated endoscopically by the combination of urethrotomy and transurethral ultrasonic lithotripsy. At 6 months follow-up, he voided properly and had a sterile urine culture. Pan African Medical Journal 2015; 21

Primary urethral carcinoma (PUC) is a rare and aggressive cancer, often underdetected and consequently unsatisfactorily treated. We report a case of advanced PUC, surgically treated with combined approaches. A 47-year-old man underwent transurethral resection of a urethral lesion with histological evidence of a poorly differentiated squamous cancer of the bulbomembranous urethra. Computed tomography (CT) and bone scans excluded metastatic spread of the disease but showed involvement of both corpora cavernosa (cT3N0M0). A radical surgical approach was advised, but the patient refused this and opted for chemotherapy. After 17 months the patient was referred to our department due to the evidence of a fistula in the scrotal area. CT scan showed bilateral metastatic disease in the inguinal, external iliac, and obturator lymph nodes as well as the involvement of both corpora cavernosa. Additionally, a fistula originating from the right corpus cavernosum extended to the scrotal skin. At this stage, the patient accepted the surgical treatment, consisting of different phases. Phase I: Radical extraperitoneal cystoprostatectomy with iliac-obturator lymph nodes dissection. Phase II: Creation of a urinary diversion through a Bricker ileal conduit. Phase III: Repositioning of the patient in lithotomic position for an overturned Y skin incision, total penectomy, fistula excision, and “en bloc” removal of surgical specimens including the bladder, through the perineal breach. Phase IV: Right inguinal lymphadenectomy. The procedure lasted 9-and-a-half hours, was complication-free, and intraoperative blood loss was 600 mL. The patient was discharged 8 days after surgery. Pathological examination documented a T4N2M0 tumor. The clinical situation was stable during the first 3 months postoperatively but then metastatic spread occurred, not responsive to adjuvant chemotherapy, which led to the patient's death 6 months after surgery. Patients with advanced stage tumors of the bulbomembranous urethra should be managed with radical surgery including the corporas up to the ischiatic tuberosity attachment, and membranous urethra in continuity with the prostate and bladder. Neo-adjuvant treatment may be advisable with the aim of improving the poor prognosis, even if the efficacy is not certain while it can delay the radical treatment of the disease.

INTRODUCTION AND OBJECTIVES: Length of membranous urethra (MU) and the amount of striated muscle (SM) removed with the apical aspect of the prostate can be predictive of urinary incontinence after radial prostatectomy. The aim of the present study was to assess whether these histological measurements correlate with urinary incontinence after laparoscopic radical prostatectomy (LRP) and robotassisted radical prostatectomy (RARP). METHODS: We retrospectively reviewed the charts of 179 patients who underwent LRP (n1⁄498) and RARP (n1⁄481) from July 2010 to May 2014. Two uropathologists reviewed the hematoxylin and eosin sections of the apical margin to measure the length of MU (distance from the resection margin of the urethra to the prostate apex) and semiquantitatively assess the amount of SM, which was expressed as the percentage of total apical margin surface area occupied by SM. Patient-reported continence status was determined at 3, 6 and 24 months postoperatively, with urinary continence considered as 0 1 pads. The histological measurements were compared between continent and incontinent patients using Student’s t test. Multivariable logistic regression analyses were also performed to determine adjusted odds ratios (OR). RESULTS: Patients had a median age of 67 years at surgery. Urinary incontinence was observed in 55% of the patients after 3 months, 22% after 6 months and 10% after 24 months. The length of MU was significantly longer in patients with incontinence compared to those with continence at 3, 6 and 24 months, Fig. 1). While, no significant differences were observed in the amount of SM between the groups at any time point. Multivariable analyses revealed that the length of MU was associated with significantly increased odds of incontinence at 3 months (OR, 1.46; 95% CI, 1.09-2.00), 6 months (OR, 1.58; 95% CI, 1.14-2.23) and 24 months (OR, 2.43, 95%CI 1.44-4.49) after adjustment for age, length of membranous urethra measured on preoperative MRI, preservation of the neurovascular bundle and type of surgery. CONCLUSIONS: These results demonstrated that the length of MU in the pathology specimen was an independent predictor of urinary incontinence after radical prostatectomy. Care should be taken to preserve maximal length of MU for optimal continence outcomes.

INTRODUCTION AND OBJECTIVES: The predictive value of membranous urethral length (MUL) and shape of the prostatic apex (PA) for early recovery of urinary continence after radical prostatectomy (RP) were evaluated by preoperative magnetic resonance imaging (MRI). METHODS: Three-hundred three patients who underwent RP at our institute were prospectively analyzed. The MUL and shape of PA were measured by preoperative MRI. The urethral pressure profiles (UPP) were assessed preoperatively in all patients. The preand postoperative UPP were measured in a subgroup of 100 patients to assess the effect of change in UPP on early recovery of continence. Continence, defined pad-free state with no leakage of urine, was assessed at 3 months and 1 year after surgery. RESULTS: Of 303 patients, 213 patients (70.3%) initially achieved urinary continence 3moths after surgery, and a total of 251 (82.8%) patients achieved urinary continence 1 year after surgery. The MUL was longer in the continent group than in the incontinent group (11.2 mm vs. 12.4 mm, p1⁄40.001). Patients with the PA covering the membranous urethra on the anterior side (type 1 PA) showed worse urinary continence rates than those without (type 2 PA) (57.9% vs. 89.2%, p 12 mm and type 2 PA, showed a markedly increased probability of continence recovery compared to patients with a MUL 1⁄412 mm and type 1 PA (odds ratio 27.430, p

Objectives: To evaluate the clinical prognosis of incontinence and to determine the predictors for further recovery of urinary continence in patients not achieving urinary continence within 1 year after radical prostatectomy. Methods: A total of 708 patients were evaluated regarding urinary continence status at 1 year after surgery from a prospectively maintained radical prostatectomy database. Of these, 73 (10.3%) did not recover urinary continence within 1 year after surgery. For these patients, incontinence status and the number of pads for urinary control were assessed serially. Results: In 708 patients, factors associated with the recovery of urinary continence within 1 year after radical prostatectomy were membranous urethral length, prostatic apex shape and patient age. Among 73 patients with urinary incontinence, 41 (56.2%) achieved urinary continence with a mean time of 15.4 months subsequent to the first year after radical prostatectomy (baseline). A younger age at surgery (P = 0.027) and one pad being required (vs≥2 pads) at baseline (P = 0.046) were identified as independent factors for achievement of urinary continence within a further 2 years. Only the number of pads was a significant factor for further recovery of urinary continence in the longer follow up (hazard ratio 0.36, P = 0.029). Conclusion: Compared with factors related to the prostate or membranous urethra, patient age and severity of incontinence at 1 year after radical prostatectomy are more strongly related to the recovery of urinary continence later than 1 year after surgery. These findings might help to decide whether a definite treatment is required for persistent incontinence beyond 1 year after radical prostatectomy.

The aim of the present study was to assess the impact of a novel posterior reconstruction technique during robot-assisted laparoscopic prostatectomy on continence recovery. A total of 116 consecutive patients who received the novel posterior reconstruction (case group) were retrospectively compared with a cohort of 126 patients who did not receive posterior reconstruction (control group). The primary end-point was the duration of continence recovery (no pad use) after robot-assisted laparoscopic prostatectomy. The posterior reconstruction was obtained by opposing the median dorsal fibrous raphe to the posterior counterpart of the detrusor apron, rather than the Denonvilliers' fascia. The case group showed higher continence rates at all points of evaluation, which were 2 weeks (30.1% vs 19.8%), 1 month (58.4% vs 45.7%), 3 months (82.7% vs 70.5%) and 6 months postoperatively (95.3% vs 86.4%) (P = 0.007). Application of the novel posterior reconstruction technique, age and length of membranous urethra were significant variables for the complete recovery of continence on multivariable analysis. This study shows that the application of this novel PR technique significantly improves the recovery of continence in patients undergoing robot-assisted laparoscopic prostatectomy.

A number of anatomic components work in concert to produce precise control of micturition in the healthy male, including the sphincter with its striated and smooth muscle components, the surrounding muscular and ligamentous support structures, neural components, and the urothelium. Radical prostatectomy is often associated with injury to one or more of these tissues, culminating in stress urinary incontinence (SUI). Although the causes of urinary incontinence can vary, among patients with residual urethral sphincter function, the increased laxity and reduced functional length of the membranous urethra are thought to play key roles in incontinence. Most surgical treatments for urinary incontinence, such as the artificial urinary sphincter and various slings, achieve continence via compression of the urethra, but the AdVance ® transobturator retrourethral sling (American Medical Systems, Minnetonka, MN, USA) repositions the urethral sphincter complex back into the pelvis and increases the functional membranous urethral length. Emerging reports on the AdVance ® sling suggest favourable cure rates and few complications. Thus, the AdVance ® sling provides an alternative approach to treating postprostatectomy SUI that is both less obstructive and more dynamic.

Objectives To evaluate the role of multidetector computed tomography (MDCT) in the diagnosis of urethral lesions. Methods Thirteen CT urethrography examinations on 13 male patients were performed with 4-MDCT, over a 15 month duration. These patients were clinically examined and a urethral lesion was suspected. The study included recently traumatized patients and patients with suspected urethral lesions. The study was performed by retrograde urethral injection or during micturition after IV contrast injection. 3D-volume rendering (VR) images and VR-multiplanar reconstruction (MPR) sagittal images and virtual images were done. Results Out of the 13 patients, two patients were diagnosed having avulsed prostatic urethra. Nine patients were diagnosed having urethral strictures: two at the bulbous urethra (one of them associated with fistulous stricture), five at the membranous urethra (one of them having associated hypospadias) and two at the prostatic urethra. Two postoperative patients with hypospadias were evaluated, one with glans collection and the other with urethral stricture. One patient was diagnosed having urethral neoplasm. Conclusion MDCT urethrography is an accurate method in delineating small lesions, site, length, degree of strictures and extraluminal structures.

Objectives: To determine the association of vesico-urethral anastomosis location (VUAL) with early recovery of urinary continence (UC) after radical prostatectomy (RP). Methods: A retrospective analysis of 678 patients who underwent RP was carried out. Patients were divided into three groups based on the VUAL as determined by postoperative cystography: group I – VUAL above the upper margin of the symphysis pubis (SP), group II – between the upper margin and the middle of the SP, and group III – below the middle of the SP. Early recovery of UC was defined as using no pads or an occasional security pad within 3 months. Recovery rates were compared between the groups and factors predicting an early recovery of UC were investigated. Results: Among all patients, 62.2% achieved an early recovery of UC. Patients in group I were younger, with a longer membranous urethra, greater percent of nerve sparing and shorter time to continence than those in groups II or III. Early recovery rates were 89.5%, 69.8% and 40.7% in group I, II and III, respectively (P < 0.001). VUAL remained an independent predictor of early recovery of UC (OR 3.2 for group I vs II and 10.8 for group I vs III [P < 0.001]) when adjusted for age, operative time, membranous urethral length and operation by surgeon with high surgical volume. Conclusion: VUAL represents an independent predictor of recovery of UC after RP. A higher VUAL is associated with a higher rate of early recovery of UC.

Objectives : Pelvic fracture urethral distraction defect (PFUDD) may be associated with disabling complications, such as recurrent stricture, urinary incontinence, and erectile dysfunction. In this article we review the current concepts in the evaluation and surgical management of PFUDD, including redo urethroplasty. Materials and Methods : A PubMedTM search was performed using the keywords "pelvic fracture urethral distraction defect, anastomotic urethroplasty, pelvic fracture urethral stricture, pelvic fracture urethral injuries, and redo-urethroplasty." The search was limited to papers published from 1980 to March 2010 with special focus on those published in the last 15 years. The relevant articles were reviewed with regard to etiology, role of imaging, and the techniques of urethroplasty. Results : Pelvic fracture due to accidents was the most common etiology of PFUDD that usually involved the membranous urethra. Modern cross-sectional imaging, such as sonourethrography and magnetic resonance imaging help assess stricture pathology better, but their precise role in PFUDD management remains undefined. Surgical treatment with perineal anastomotic urethroplasty yields a success rate of more than 90% in most studies. The most important complication of surgical reconstruction is restenosis, occurring in less than 10% cases, most of which can be corrected by a redo anastomotic urethroplasty. The most common complication associated with this condition is erectile dysfunction. Urinary incontinence is a much rarer complication of this surgery in the present day. Conclusions : Anastomotic urethroplasty remains the cornerstone in the management of PFUDD, even in previously failed repairs. Newer innovations are needed to address the problem of erectile dysfunction associated with this condition.

Despite its vulnerable conservation status there is scant information on male Greater Bilby Macrotis lagotis reproduction. Observations of gross anatomy revealed a testis to body weight ratio of 0.08 - 0.17% (n = 4), the presence of a carrot shaped prostate with an oblique coronal segmentation of ventral and dorsal orientated prostatic tissue, an elongated membranous urethra, two bulbourethral glands and a bifurcated urethra in the glans penis (n = I).The testis contained a high proportion of Leydig tissue (37.5 ± 2.7%) and a seminiferous epithelial cell cycle (8 stages identified) with a predominance of pre-meiotic stages (61.4%) and Sertoli cells with unusually large nuclei. A GnRH stimulation test conducted on four different intact sexually mature Bilbies using 2μg Buserelin resulted in maximal plasma androgen secretion 30 to 60 mins after injection. While steps of M. lagotis spermiogenesis were similar to those described in peramelid marsupials, the morphology of the Bilby spermatozoan at spermiation,was radically different to that of the bandicoot sperm cell. Similar to the bandicoot, M. lagotis spermatozoa in the corpus epididymidis dislocated their neck insertion from the primary implantation fossa, so that by the time the sperm cell had reached the cauda epididymidis, the acetabulum had migrated cranially Into a secondary implantation fossa and the nucleus had become streamlined with respect to the flagellum.This study reports the first description of large crystalloid inclusions in the principal cells of the caput epididymidal epithelium, the significance of which remains unknown. Male Bilby reproduction reported in this study supports the present taxonomic position of the Thylacomyidae.