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Objective: Female urethral diverticulum (UD), an evagination of the urethral mucosa into the surrounding connective tissue, is extremely rare in pregnancy. No clear guidelines on the optimal management of UD have been established, except for a common conservative approach. Here, we discuss how to manage UD with pregnancy., Case Report: A 39-year-old gravida 4, para 0, abortion 3 (G4P0A3) woman at 34 +0 gestational weeks (GW) visited our outpatient department with a 6-cm septate vaginal mass. Transvaginal ultrasound sonography (TVUS) revealed a 5.5 x 4.9-cm multicystic mass, which was confirmed as UD with pelvic MRI. She was admitted because of preterm labor. A cesarean section was performed at 36 +5  GW due to a previous myomectomy, and a healthy male baby was born. UD was still observed in the patient two months after delivery. Periurethral diverticulectomy was performed, and pathological analysis revealed UD with chronic inflammation and edema., Conclusion: Previous reports and our case report show that UD can develop during pregnancy and that pelvic MRI is suitable for its accurate diagnosis. Vaginal delivery is possible in pregnant women with the small size of the UD. UD aspiration can permit vaginal delivery in a few cases; however, pus can occur at the aspirated site after the operation. If UD is still observed after delivery, urethral diverticulectomy is recommended., Competing Interests: Conflict of interest statement The authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier B.V.)

This article delves into the diagnostic implications of the female prostate sign, a distinctive radiological sign observed in magnetic resonance imaging of female patients with substantial urethral diverticula. We discuss the association of this sign with urethral diverticula, emphasizing its mimetic resemblance to prostatic hypertrophy observed in older males. Through a comprehensive review of clinical presentations, diagnostic imaging advancements, and treatment modalities, our article underscores the significance of magnetic resonance imaging as a superior diagnostic tool. Our findings support the enhanced recognition and understanding of the female prostate sign among healthcare professionals, facilitating accurate diagnoses and informed management of urethral diverticula., Competing Interests: Declaration of competing interest The authors declare that they have no potential conflicts of interest related to the subject matter of this article and did not receive any financial support for the research, authorship, or publication of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Female urethral caruncle is the most common urethral mass in postmenopausal women, yet there is a lack of studies on its imaging. The aim of this study was to provide a summary of the clinical and ultrasound features as well as the precise location of female urethral caruncle. This study reviewed the clinical and ultrasonographic records of 20 consecutive women with pathologically confirmed urethral caruncle. Data on patient demographics, symptoms, and transperineal and transrectal ultrasound imaging features, including location, shape, margin, size, blood flow, and inner echo of the caruncle, were extracted. Each patient presented with only one mass at the urethral meatus. Most caruncles were located on the posterior lip (75%) of the urethra, presenting as oval (80%), mixed-echoic (50%), or hypo-echoic (40%) nodules with abundant linear (40%) or dendritic (60%) blood flow. The average distance between the bladder neck and the cranial end of the masses was 28 mm. Hyper-echogenic spots, cystic echo areas, and macrocalcifications were detected in thirteen caruncles (70%). This study shows that transperineal combined with transrectal ultrasound can be used to assess female urethral caruncle, and its relative location to the urethra can be accurately described, which is helpful for surgeons making preoperative localization and conversations., (© 2024. The Author(s).)

Purpose: Various complications following hypospadias surgery present distinct manifestations when examined with ultrasound. Utilizing high-frequency ultrasound, clinicians can promptly identify these complications and initiate appropriate treatment. The aim of this study is to catalogue the ultrasonographic presentations of various postoperative complications following hypospadias surgery, thereby providing a reference for ultrasonographic diagnosis., Methods: Ultrasonic images of post-hypospadias surgery from October 1, 2015, to June 30, 2023, recorded at the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences, serve as the basis for this investigation. Drawing on patient clinical diagnoses, this study compiles and selects representative ultrasound images of diverse complications., Results: The study encompassed a total of 121 subjects; 26 demonstrated urethral stricture on ultrasonic images, two presented local urethral dilation, six showed intraurethral hair-like structures, 17 revealed intraurethral septum, two exhibited intraurethral fold, one had urethral calculus, one displayed urethral calcification, 12 indicated intraurethral urine accumulation, and two showed urethral diverticulum., Conclusion: Ultrasound examination is helpful for postoperative diagnosis following hypospadias, detecting complications such as urethral stricture, urethral hair growth, and urethral diverticulum, which can help doctors choose appropriate clinical treatment strategies., (© 2024. The Author(s).)

Urethral lesions in pediatric patients can be visualized using ultrasonography. Therefore, sonographers and physicians should be familiar with the technique., (© 2024 Wiley Periodicals LLC.)

Background: Rectourethral fistulae (RUF) are the most prevalent type of anorectal malformations in boys, with various surgical treatment methods investigated in recent years. Currently, research is focused on preventing urethral damage or urethral diverticulum formation caused by imprecise dissection during the laparoscopically assisted anorectal pull-through (LAARP) technique. This study aimed to determine the efficacy of indocyanine green (ICG) fluorescence imaging to improve the localization and separation of the RUF during laparoscopic surgery., Methods: ICG was intrarectally injected through a pre-inserted gastric tube at the distal enterostomy port to locate the fistula. This retrospective analysis included children with RUF who were treated surgically with ICG fluorescence imaging localization-assisted LAARP between January and June 2022. We investigated the patient demographics, perioperative conditions, and subsequent follow-up results., Results: Four patients underwent ICG-assisted LAARP. Their median age was 80 days (range, 63-120) and the median duration of each procedure was 145 min (range, 120-165). Postoperatively, the duration of catheter retention and hospital stay was eight days. The children's prognosis was based on the follow-up outcomes of gastrointestinal, urinary tract function, and imaging examination. None of the included patients was diagnosed with urinary diverticulum, urinary tract injury, anal stricture, or rectal prolapse., Conclusions: Injection of ICG at the end of the rectum during LAARP surgery is a feasible adjunct for locating the RUF, providing a greater degree of accuracy for laparoscopic separation and resection of fistulae, thereby decreasing the risk of urological complications., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

An 85 year-old man was referred to our hospital because of a relapse of abscess after open surgical drainage of the right scrotum. Computed tomography (CT) showed fluid accumulation in the right scrotum and around the membranous urethra. The abscess was controlled by an open surgical drainage of the right scrotum, CT guided percutaneous drainage of the periurethral abscess and administration of antibiotics. However, the scrotal abscess recurred after 4 weeks. CT showed an enlarged abscess, and retrograde urethrography showed an urethral diverticulum extending into the scrotum associated with a scrotal abscess. Endoscopic urethral diverticulum unroofing and cautery were performed. The urinary catheter was removed 2 days after the operation. The abscess has been resolved without recurrence.

Background: The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula., Methods: A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample., Results: All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005)., Conclusions: A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula., (© 2022 Wiley Periodicals LLC.)

Introduction: Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma., Methods and Materials: Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required., Results: We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material)., Conclusion: A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention., (© 2022 Wiley Periodicals LLC.)

The management of male pelvic fracture urethral injury remains a urological challenge. Pelvic fracture urethral injury can be associated with sequelae, such as urethral gap, erectile dysfunction and urinary incontinence. Delayed anastomotic urethroplasty, the gold standard treatment for urethral gaps caused by pelvic fracture urethral injuries, is technically demanding, and reconstructive urologists should preoperatively obtain as much detailed anatomical information as possible. A combination of antegrade and retrograde urethrography is the fundamental preoperative evaluation, but it cannot accurately assess the urethral gap length, the degree of lateral prostatic displacement, the anatomical relationship of the urethra with its surrounding structures (such as the rectum and dorsal venous complex) or periurethral problems (such as minor fistulae or cavitation). To make up for these limitations of urethrography, magnetic resonance imaging has emerged as a non-invasive, multiplanar and high-resolution modality for the evaluation of pelvic fracture urethral injury. Magnetic resonance imaging has excellent soft-tissue contrast, and can clearly show the urethra and periurethral tissues without the effects of radiation, thus enabling clinicians to anticipate the required ancillary techniques for delayed anastomotic urethroplasty and to predict functional outcomes, such as erectile function and urinary continence, after delayed anastomotic urethroplasty. This review discusses the role of magnetic resonance imaging in the evaluation of pelvic fracture urethral injury and its impact on patient management., (© 2022 The Japanese Urological Association.)

Purpose: To evaluate the use of magnetic resonance imaging (MRI) in preoperative delineation and surgical planning for the management of female urethral and periurethral cystic vaginal swellings, with emphasis on postoperative surgical outcomes., Materials and Methods: This is a retrospective analysis of females complaining of periurethral and urethral cystic swellings referred to our tertiary center, who underwent MRI for preoperative planning in the period from January 2014 till January 2021, with a total number of 57 patients. Data retrieved from the medical records included: patients' demographics, presenting symptoms and signs, preoperative radiological investigations, duration of symptoms, previous surgical intervention, detailed intraoperative data, postoperative complications, and postoperative follow-up., Results: Urethral diverticulum was the commonest cystic lesion representing (64.9%) followed by Skene gland cysts in 14%, Mullerian cysts in 7%, Gartner cysts in 3.5%, and dermoid inclusion cysts in 10.5%. MRI precisely diagnosed the various pathological entities and anatomical complex lesions prior to surgery. This was confirmed after surgery and pathology analysis. All patients were followed up with a mean duration of 35 months, without any evidence of recurrence., Conclusion: MRI as a standalone imaging technique is mandatory for diagnosis of all urethral and periurethral cystic lesions, as it offers the most accurate diagnostic modality for delineation of these lesions and hence aids in the preoperative surgical planning, aiming to avoid recurrence and improving surgical outcomes., (© 2022. The Author(s).)

The fibroepithelial polyp of the urethra is rare in adults. Hematuria and obstructive urinary symptoms are the most common findings. The investigation of these polyps usually includes imaging exams (voiding cystourethrography and ultrasonography) and urinary endoscopy. However, the diagnosis is primarily established by pathology. Ultrasonography can aid in diagnosis, as it can identify a polypoid lesion that can extend to the bladder neck, and cystourethroscopy allows the direct visualization of the lesion. We report this case of a polyp of the prostatic urethra in an adult male using prospective real-time sonographic diagnosis., (© 2021 S. Karger AG, Basel.)

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients. 1 Commonly associated with other fatal malformations, the condition is often incompatible with life. 2 Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule. 3 , 4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: This report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair., Case Presentation: A 44-year-old Latino male with history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum., Conclusions: Although rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus., (© 2021. The Author(s).)

An 8-month-old male child presented with the complaint of two separate urinary streams from the penis. The child had no complaints of incontinence or recurrent UTI (urinary tract infection). Initial diagnosis of urethrocutaneous fistula was made and proceeded to micturating cystourethrography (MCU) and found to be having a urethral duplication. The duplicated urethra was excised and accessory urethra closed. Postoperatively, the child was followed up for 1 year and had no complaints of recurrence or incontinence. Through this case report, we learn about different classification systems and types of urethral duplication and their associated anomalies, and mode of management, which is mainly surgical. Further, management should be individualised to each patient based on their complaints and intraoperative findings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized., Objective: This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD., Study Design: A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management., Results: A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy., Discussion: AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management., Conclusion: Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities., Competing Interests: Conflict of interest statement There are no personal, professional, or financial conflicts of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Urinary bladder and urethral injuries usually occur as part of multiple injuries in polytrauma patients. These injuries are easily overlooked because the initial evaluation is focused on other life-threatening injuries such as traumatic brain injury, hemopneumothorax or hemoperitoneum. Although the urinary bladder and urethral injuries are not life-threatening, they pose the risk of long-term morbidity which can be burdensome. These complications include urinary incontinence, voiding dysfunction, urethrocutaneous fistula, urethral stricture and erectile dysfunction. Computed tomography (CT) findings of urinary bladder and urethral injuries are usually subtle. Retrograde fluoroscopic/CT cystography and urethrography remain the mainstay imaging techniques for complete evaluation, diagnosis, staging, and follow-up of these traumatic injuries. In this review, we discuss the pathophysiology and imaging spectrum of urinary bladder and urethral injuries with an emphasis on the classification schemes. Familiarity with the pelvic anatomy and the injury pattern leads to the prompt diagnosis, accurate classification and appropriate management, which have been associated with better prognosis.

Background: Anterior urethral valves (AUV) and associated anterior urethral diverticula (AUD) are a rare cause of congenital lower urinary tract obstruction. They occur 25-30 times less frequently than posterior urethral valves (PUV) and historically tend to have a less aggressive presentation and outcome. However, due to the low incidence, little is known about management and long-term prognosis., Objective: We aim to evaluate the outcomes after AUV valve ablation and compare this group to a previously studied PUV cohort., Study Design: In this IRB-approved study, we retrospectively identified all patients from 2002 to 2017 undergoing valve ablation using CPT code 52400. Charts were manually reviewed to identify AUV patients, their presenting symptoms, timing of diagnosis, pre and postnatal imaging findings, age at presentation and valve ablation, creatinine, recurrences, additional surgeries and follow-up. The AUV group was then compared to a previously studied PUV cohort of 104 patients from our institution., Results: Nine AUV patients were identified. Only four (44%) patients were diagnosed prenatally. Three (33%) patients were diagnosed neonatally, one for weak stream/dribbling and two for febrile UTIs. The remaining two patients were diagnosed at ages 3 and 4 due to dysuria and penile swelling with micturition. Patients presenting later in life had no evidence of renal dysfunction or VUR. All patients underwent primary TUR-AUV (1 laser, 4 cold knife, 4 cautery), but 55% had residual valves and/or diverticula identified on routine postoperative imaging in two patients and due to development of clinic symptoms in three patients. All five patients with recurrences underwent repeat endoscopic evaluation, and thereafter two patients required urethral reconstruction. In contrast, only 15% (16/104) of PUV patients required re-TUR (p = 0.01). At an average follow-up time of 4.24 years (range 0.6-11.4 years), 44% of patients had no evidence of CKD, and two patients (22%) had progressed to CKD of at least stage IIIA, compared to 21.4% in the PUV cohort at a mean follow-up of 2.3 years., Discussion: The overall incidence of AUV is low, making it difficult to characterize these patients definitively. However, despite a milder phenotype and later presentation in most AUV patients, they do require more aggressive surgical treatment for complete resolution of the AUV. Furthermore, the long-term renal outcomes appear more severe than previously reported., Conclusions: The poorer outcomes of AUV patients both with respect to recurrence and long-term CKD indicate that close urologic follow-up is essential in this group., (Copyright © 2020. Published by Elsevier Ltd.)

The aim of this study was to assess the imaging features of urethral and peri-urethral masses on transvaginal or transperineal ultrasound (US) in a cohort of 95 women. In this retrospective study, medical records of 95 female patients with 98 asymptomatic or symptomatic urethral and peri-urethral masses were retrospectively reviewed. Data regarding patient demographic characteristics, symptoms, signs, imaging features on 2-D and 3-D transvaginal or transperineal US, diagnostic tests and physical and intra-operative findings were extracted. The US imaging features and clinicopathologic characteristics of each urethral or peri-urethral mass were compared. On ultrasound, 39 masses (in 39 patients) were diagnosed as urethral diverticula, which manifested mostly as complex cystic masses (24/39, 61.5%); 35 masses (in 33 patients) were diagnosed as para-urethral cysts, which manifested mostly as simple cystic masses (19/35, 54.3%); 13 hypo-echoic solid masses (in 12 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral leiomyomas; hypo-echoic or heterogeneous solid masses (in 8 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral caruncles, including one complicated by malignant transformation; solid masses with mixed echogenicity (in 2 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral squamous cell carcinoma or adenocarcinoma, and a hypoechoic solid mass (in one patient) with blood-flow signals on color Doppler imaging was diagnosed as urethral condyloma associated with human papillomavirus infection. This study confirmed transvaginal or transperineal 2-D and 3-D ultrasonography to be a valid, non-invasive, cost-effective diagnostic modality for the differential diagnosis of urethral and periurethral masses., (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: The objective was to apply tomographic ultrasound imaging (TUI) to diagnose urethral diverticulum (UD) and summarize the specific imaging findings., Methods: This was a retrospective analysis of 42 women with a paraurethral cyst. All women underwent a clinical interview, three-dimensional pelvic floor ultrasound and a transvaginal cystectomy between May 2016 and March 2019. UD was defined on TUI if a tract connecting the paraurethral cyst to the urethral lumen was shown in the urethral rhabdosphincter circular muscle in the pelvic floor axial plane. All patients' demographics, history, clinical evaluation and surgical outcomes were reviewed., Results: On surgical findings, 33 women had a UD and 9 had a Gartner duct cyst. Characteristics of paraurethral cysts described by TUI were consistent with surgical findings in 40 patients (95%). Good agreement was shown by κ test (κ = 0.88, p < 0.001). Of 33 UD patients, the mean age was 45 years and the mean duration of symptoms was 6.5 months. The most common presenting symptom was recurrent urinary tract infection (17, 52%), followed by stress urinary incontinence and a vaginal lump (15, 46%). The mean maximum diameter of 33 UDs was 26 mm (range 8-45 mm). On TUI, one tract, connecting the paraurethral cyst to the urethral lumen, was identified as a gap in the hyperechoic rhabdosphincter muscle circle in the pelvic floor axial plane in 23 UDs (70%); there were two or more tracts in 8 (24%)., Conclusions: The diagnostic sign to identify urethral diverticulum is a gap in the hyperechoic urethral rhabdosphincter circle formed between the cyst and urethral lumen in the axial plane.

Complete penoscrotal transposition is an extremely rare congenital anomaly and is usually associated with other urinary system abnormalities. Prenatal diagnosis is feasible by demonstrating perineal anatomy and its relation with scrotum and phallus. We describe two prenatal cases presenting with oligohydramniosis and megacystis due to lower urinary tract obstruction. Postnatal diagnosis was confirmed in both cases. Considering the dismal perinatal outcome, an accurate prenatal diagnosis is required for counseling the parents and preparing for postnatal care., (© 2020 Wiley Periodicals, Inc.)

During the last years the role of sonourethrography (SUG) in the assessment of anterior male urethra pathologies, has significantly increased. The investigation is easily performed, not time consuming and should be considered the imaging technique of choice for preliminary diagnosis, without exposing the patient to X-rays. In this paper we present the technique of examination and the most common pathologies in which SUG is indicated.

Background: Urethral duplication associated with epispadias is a rare malformation. Few cases are described in Literature. We report the experience of two centers to add to the literature., Methods: A retrospective study was conducted in two Italian Centers. All patients with urethral duplication associated with epispadias, treated from 1997 to 2017 were included. The preoperative work-up included renal-urinary ultrasonography and voiding cystourethrogram. All patients underwent surgery according to the Mitchell-Caione technique. Cosmetic result, urinary continence and satisfaction degree of patients at the last follow-up were evaluated as outcomes. Six male patients with urethral duplication in epispadias were included. Two patients presented penile epispadias and four penopubic epispadias. Only one patient had urinary incontinence as presenting symptomatology. The diagnosis of urethral duplication was accidental during preoperative evaluation in the remaining five patients., Results: At last follow-up (mean 8.3 years) all patients but one presented good cosmetic result, one patient presented mild stress urinary incontinence, one presented nocturnal enuresis. The physical genital appearance was improved in all patients. Urethral duplication in association with epispadias is a rare urogenital abnormality. No classification is universally accepted., Conclusions: Based on our experience, we believe that the presence of any duplication should be carefully searched during surgery for male epispadias.

As gender-affirming genital surgery for transgender men becomes more common, general urologists may be confronted with unfamiliar anatomy and complications. We describe the use of voiding cystourethrogram and retrograde urethrogram in a transgender man in demonstrating the anatomy of the urethra, urethrocutaneous fistula, and a vaginal remnant after phalloplasty., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: Report our experience with the use of contrast-enhanced serial voiding urosonography (SVU) for posterior urethral valve (PUV) patient diagnosis and management., Material and Methods: Descriptive retrospective study in 0- to 14-year-old patients with suspected PUV at SVU performed as a first contrast-enhanced urinary tract test with subsequent cystoscopic study. Variables were analyzed using SPSSv22., Results: 18 patients were studied (median age: 6 months). Most patients (15) presented posterior urethral dilatation (mean diameter: 9.56 mm) and a >2 mm gap between proximal and distal urethra. 13 cases had bladder thickening and 9 had VUR. 15 PUV cases, 1 case of distal urethral mucocele, and 1 case of bladder diverticulum obstructing the urethra were diagnosed. Complete PUV resection was performed in 10 patients (66.6%) at the first cystoscopy. The control SVU detected one case of recurrence due to persistence of posterior urethral dilatation. The recurrence case and the 5 incomplete resection cases were treated with a second cystoscopy and resection. The youngest patients required a third resection and cutting balloon dilatation due to residual stenosis. Mean creatinine levels at diagnosis were 0.28 mg/dl., Conclusions: Serial voiding urosonography (SVU) is a useful complementary test in pediatric patients with posterior urethral valve. Its dynamic nature and its advantages - absence of irradiation, safety, and high sensitivity - make it an ideal imaging test for PUV diagnosis and follow-up.

Female urethral pathology can be challenging to diagnose clinically due to non-specific symptoms. High-resolution MRI has become a powerful tool in the diagnosis of urethral lesions and staging of malignancy. Additionally, dynamic MRI, fluoroscopy or ultrasound can evaluate for pelvic floor prolapse and the effectiveness of surgical interventions. This article will review the imaging features of common benign and malignant conditions of the female urethra including diverticula, benign cystic and solid lesions, malignancy, surgical slings, and injection of bulking agents.

Objective: The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction., Results: Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG., Conclusions: Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

This study describes the clinical presentation of superficial swellings and evaluates the utility of ultrasonography in the diagnosis of such swellings in sheep and goats. Ninety-three sheep and 73 goats were included in this study on the basis of presence of superficial swellings on the head (n=56), neck (n=16), chest wall (n=3), abdominal wall (n=40), umbilicus (n=14), scrotum (n=16), testes (n=1), udder (n=7), limbs (n=2), gluteal region (n=5), tail (n=1), and penile urethra (n=5). Ultrasonographic evaluation of these superficial swellings allowed the diagnosis of abscesses (n=54; 32.52%), cysts (n=12; 7.23%), hernias (n=57; 34.33%), hematomas (n=14; 8.44%), tumors (n=24; 14.45%), and urethral diverticula (n=5; 3.03%). Each lesion type could be precisely discriminated (sensitivity, 88-100%; specificity, 80-100%; and P=0.001). Ultrasonography was found to have a specificity of 100% for the diagnosis of hernias, urethral diverticula, and tumors, and a lower specificity of 80% for hematomas and 93% for abscesses when used for evaluation of superficial swellings in sheep and goats. In conclusion, ultrasonography is a unique, non-invasive diagnostic imaging tool that allows the diagnosis, differential diagnosis, and subsequent surgical treatment of different types of superficial swellings in sheep and goats.

Aims: Functional obstruction secondary to a high-tone nonrelaxing sphincter (HTNRS) may lead to the formation of a proximal-to-mid-urethral diverticulum (pmUD) in patients without a history of anatomical obstruction, vaginal delivery, vaginal and/or urethral surgery, or periurethral gland infection, that is, a functional pmUD (fpmUD). We used measurements of the urethra-sphincter complex volume (USCv) as a proxy for the maximal urethral closure pressure to evaluate this potential etiological factor., Methods: We compared 17 consecutive women with fpmUD (mean age ± SD of 49.4 ± 13.2 years) with a control group consisting of 24 age-matched women (mean age: 50.8 ± 11.2 years) with no previous urological symptoms having MRI for posthysterectomy vesicovaginal fistula, and in all 71 women (mean age: 48.1 ± 11.6 years) with classical urethral diverticulum (cpmUD) referred in the same time period. The urethra-sphincter complex was measured using T2-weighted MRI and OsiriX © was then used to determine the USCv., Results: The mean USCv of the fpmUD group was 10.01 ± 6.97 cm 3 . The mean USCv of the cpmUD was 5.19 ± 1.19 cm 3 and for the control group was 3.92 ± 1.60 cm 3 . There was a high statistically significant (P = .01) difference between the USCv in the fpmUD group and the USCv of both the cpmUD and the control groups., Conclusions: Women with fpmUD demonstrated USCv that were significantly higher than those in women with cpmUD and the control group. These findings suggest that high pressure in the proximal urethra during voiding secondary to a HTNRS may contribute to the formation of urethral diverticula., (© 2019 Wiley Periodicals, Inc.)

Aims: To assess the incidence and management of urodynamic stress urinary incontinence (USUI) in women undergoing transvaginal excision of a urethral diverticulum (UD) at our institution., Methods: A prospective database, capturing patients undergoing urethral diverticulectomy over a 9-year period (May 2007 to August 2016), was reviewed focusing on USUI and subsequent management., Results: One hundred patients underwent UD excision (with modified Martius labial fat-pad flap interposition). Preoperative magnetic resonance imaging data, available in 90 patients, demonstrated that 80% had complex diverticula. Complete urodynamic data were available for 93 patients. Preoperatively, 27 patients (29%) had USUI of which 16 patients resolved with either UD excision alone (n = 8) or 3 months of pelvic floor muscle therapy (PFMT) (n = 8). All 11 with persistent postoperative USUI had video urodynamics (VUDs) confirming Blaivas type 3 USUI. Six patients had a rectus fascial pubovaginal sling (RFPVS) with success in five (83.3%) while five had a mid-urethral obturator tape (MUT-O) with 100% success. Sixteen patients developed de novo stress urinary incontinence (SUI) postoperatively, with resolution after PFMT in 12 (75%). VUDS identified USUI (Blaivas type 3) in two (of the remaining four) patients, managed successfully with MUT-O (n = 1) and RFPVS (n = 1)., Conclusion: Preoperative USUI is present in 29% with UD. Postoperatively, 35.5% (n = 33) have pre-existing (19) or de novo (14) SUI, of which 60.6% (n = 20) resolves after 12 months of conservative management. Surgery for USUI is required in 13 (13.9%), with cure in 92.3%. This supports our practice to excise UD primarily and delay USUI surgery, therefore, avoiding overtreatment for the majority., (© 2019 Wiley Periodicals, Inc.)

Purpose: To evaluate magnetic resonance imaging findings that differentiate among periurethral bulking agents (primarily collagen), urethral diverticulum, and periurethral cyst., Methods: We searched our radiologic database retrospectively from 2001 to 2017 for periurethral cystic lesions, identifying a total of 50 patients with 68 lesions. Final diagnoses in 68 lesions were bulking agents (27), urethral diverticula (29), and periurethral cysts (12). Two abdominal radiologists, blinded to clinical history, independently evaluated T1, T2, and post-contrast images. The readers assessed number, morphological features, location, connection to urethra and mass effect, signal intensity, and enhancement for each lesion. Fisher exact test and logistic regression analysis were performed for each univariate significant feature. The operative and pathologic reports were the reference standard., Results: Magnetic resonance imaging features found more often in bulking agents versus urethral diverticulum were multiple lesions (P = 0.011), upper or upper-mid-urethral location (P ≤ 0.0001), lack of internal fluid/fluid level (P = 0.002), no urethral connection (P = 0.005), T1 isointensity, and T2 mild hyperintensity compared to muscles but lower T2 signal than urine (P < 0.0001). Most cases of urethral diverticula and periurethral cysts were detected at mid- and lower urethra. Urethral diverticula were larger than bulking agents and periurethral cysts (P = 0.005 and P = 0.023) (mean diameter = 24, 16, 15 mm, respectively). Most bulking agents (93%) and urethral diverticula (90%) showed mass effect on urethra, while periurethral cysts (75%) did not (P < 0.0001)., Conclusion: Signal intensity and lesion characterization on magnetic resonance imaging can significantly differentiate bulking agent from urethral diverticulum and periurethral cyst. Radiologists should consider differential diagnosis of a bulking agent, especially when distinguishing characteristics described here are present to prevent incorrect diagnosis and ultimately unnecessary surgical intervention.

Purpose: To compare utility of supine Magnetic Resonance Defecography (MRD) with upright Voiding Cystourethrogram (VCUG) for evaluation of cystocele and urethral hypermobility (UHM)., Methods: This was an IRB-approved, HIPAA-compliant, retrospective study of 51 consecutive patients with symptomatic pelvic organ prolapse (POP) and lower urinary tract symptoms who underwent both upright VCUG and supine MRD. Cystocele height was defined in centimeters with reference to the inferior edge of the pubic bone on VCUG and the pubococcygeal line on MRD. Urethral angle at rest (UAR) and during straining (UAS) was measured in degrees between the urethral axis and a vertical line at the external meatus. Pairedt-test and simple linear regression were applied to compare VCUG and MRD data sets. p <  0.05 was considered significant., Results: The mean cystocele extent was 1.58 cm lower (more inferior to the reference point) (95% CI for the mean difference: 1.21, 1.94;p < 0.0001) on MRD (-2.73 ± 1.99 cm) than on VCUG (-1.16 ± 1.75 cm). Mean UAS on MRD (72.29 ± 26.45) was 31.8 degrees higher compared to that on VCUG (40.45 ± 21.41), (95% CI for mean difference in UAS: 37.57, 26.11; p < 0.0001). Mean UAS-UAR on MRD (74.30 ± 28.50) was 58.6 degrees higher compared to that on VCUG (15.70 ± 11.27) (95% CI for mean difference in UAS-UAR 65.94, 51.26; p < 0.0001). Cystocele size was upgraded in 22 (43.3%) patients on MRD compared to VCUG. Five (9.8%) patients demonstrated UHM on VCUG; 48 (94.1%) patients demonstrated UHM on MRD. The differences between VCUG and MRD scores persisted across the range of VCUG measurements. Cystocele size was significantly larger in POP (+) patients than in POP (-) patients on MRD (p =  0.005) but not on VCUG (p =  0.06)., Conclusions: Supine MRD demonstrates significantly higher prevalence and degree of cystocele and UHM than upright VCUG, and alters the grade of bladder prolapse in a significant portion of the patient population. Cystocele size on MRD correlates with clinical presence of prolapse symptoms., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Recto-urethral fistulae are the most common finding in males born with an anorectal malformation (ARM). A high pressure distal colostogram is an important tool in visualizing the fistula, although the precise level at which the fistula communicates with the urethra may be difficult to interpret and is not reported in a uniform manner. This anatomy affects the surgical plan; determining the likelihood that the rectum is reachable via a posterior sagittal incision or better approached through the abdomen via laparoscopy or laparotomy helps counsel families and stratifies diagnoses for outcomes work. Herein we present a figure used at our Center to assist with correlating findings on the distal colostogram with the anatomic level of the recto-urethral fistula in males with anorectal malformations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In this case report, giant calculus in the urethral diverticulum was found through ureteroscopy investigation, the pneumatic lithotripsy combined with ultrasound lithotripsy (PLCUL) was successfully performed to break down this rare and giant urethral calculus in the diverticulum without open surgery., Case Presentation: A 82-year-old male presented to the urology department, complaining of frequent urination and dysuria. One giant, dark brown stone (6.5 × 6 × 5.5 cm) was revealed in the diverticulum of the anterior urethra using combination of local ultrasound, pelvic Computer Tomography (CT) and Magnetic Resonance Imaging (MRI). The stone was then successfully broken down via the PLCUL, and the emptied anterior urethral diverticulum was left untreated. In the 18 months' follow-up, no new calculus was found in urethral tract, anterior diverticula became gradually smaller, eventually disappeared., Conclusion: In the treatment of giant calculus in the urethral diverticulum, this case report provides an effective method of lithotripsy in the clinical trials.

Urethral diverticulum is a condition where the urethra or the periurethral glands push into the connective tissue layers that surround it. Patients of urethral diverticulum present with nonspecific symptoms such as incontinence, urinary frequency and urgency, and pain during sexual intercourse and urination. The incidence of this condition is low. We report a case of giant anterior urethra stones combined with a diverticulum with no lower urinary tract symptoms. We believe that this case is extremely rare, and the process of diagnosis and treatment is of great significance in clinical practice.

Background: Recently, it has been reported that anorectal malformation with rectourethral fistula in male neonates can be managed by primary neonatal reconstruction without colostomy. To prevent urethral injury during anorectoplasty, the fistula's location is important. To date, the use of voiding cystourethrograms to determine the presence and location of fistulas in neonates with anorectal malformations has not been studied., Objective: To compare the accuracy of ultrasound (US) and voiding cystourethrogram for determining the presence and location of fistulas in neonates with anorectal malformation., Materials and Methods: We included 21 male neonates with anorectal malformation with rectourethral fistula (n=16), rectovesical fistula (n=1) or no fistula (n=4) who underwent US and voiding cystourethrogram preoperatively on the day of surgery. Fistula imaging was classified into three grades (0-2), and grades 1-2 were considered fistula positive. We compared the imaging-based location of the fistula with surgical findings., Results: US performed significantly better than voiding cystourethrogram for determining the presence of fistulas (area under the receiver operating characteristic curve, 0.90 vs. 0.71, respectively; P=0.044) (diagnostic accuracy 85.7%, 95% confidence interval [95% CI] 63.7-97.0% and 52.4%, 95% CI 29.8-74.3%, respectively). In cases with fistulas detected by either modality, the accuracy of locating the fistula by US was 50.0% (95% CI 24.7-75.3%) and by voiding cystourethrogram was 100% (95% CI: 59.0-100%)., Conclusion: US accurately detected, but did not accurately locate, fistulas in neonates with anorectal malformation. When planning primary neonatal reconstruction of anorectal malformation without colostomy, voiding cystourethrogram could provide additional information about fistula location.

Prostatic-type polyps are uncommon lesions in the urinary tract. They are sometimes found in the lower urinary tract, particularly on the posterior urethra, but are rarely found in the bladder. We report a case of 15-year-old boy who presented with dysuria. Routine ultrasonography showed a mass in the bladder arising near the internal orifice of urethra. Further inspection with cystoscopy followed by transurethral resection and pathology confirmed the lesion to be a prostatic-type polyp. An overview of other similar case studies showed that the pathogenesis of this condition is controversial, haematuria and dysuria are common clinical symptoms and endoscopic transurethral resection is the best treatment option. Since the polyp is benign, recurrence and progression of this disorder is unlikely to occur.