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The coexistence of empyema, nephropleural fistula and perinephric abscess is rare and presents diagnostic challenges, especially when patients exhibit atypical or mild symptoms. This case report details a female in her early 90s who presented with 3 weeks of chest pain and was found to have a left-sided pleural effusion. Further imaging revealed additional findings of a left-sided nephropleural fistula and left perinephric collection. The patient underwent thoracentesis and video-assisted thoracoscopic surgery, with cultures growing Streptococcus Anginosus Subsequently, she underwent a left nephrectomy, with pathology findings consistent with chronic pyelonephritis and a fistulous tract. The patient was discharged on intravenous antibiotics. Follow-up imaging showed improvement. The patient completed the antibiotic course and reported symptom resolution 2 weeks after discharge., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair., Methods: We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively)., Results: RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation., Conclusion: Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect., Competing Interests: Declaration of Competing Interest Kenneth Angermeier: Boston Scientific - consultant. The other authors declare no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Entero-urinary fistulas (EUF) are a rare complication of Crohn's disease (CD), observed in 1.6 to 7.7%. The management of EUF complicating CD is challenging. We aimed to report the outcome and surgical management of EUF in CD., Methods: A retrospective chart review was performed in all CD patients with EUF who underwent surgery in our center between January 2012 and December 2021. Patient demographics, preoperative optimization, surgical management, postoperative complications, and follow-up information were collected from a prospectively maintained database., Results: A total of 74 eligible patients were identified. The median interval between CD diagnosis and EUF diagnosis was 2 (0.08-6.29) years. Patients with EUF presented with pneumaturia (75.68%), urinary tract infections (72.97%), fecaluria (66.22%), and hematuria (6.76%). Fistulae originated most commonly from the ileum (63.51%), followed by the colon (14.86%), the rectum (9.46%), the cecum (2.70%), and multiple sites (9.46%). The EUF symptoms, weight, nutritional status, laboratory results were significantly improved after preoperative optimization. The absence of EUF symptoms was observed in 42 patients after the optimization and only 9 of which required bladder repair. However, 19 of 32 patients whose symptoms did not resolve required bladder repair (P = 0.001). Only 1 patient developed a bladder leakage in the early postoperative period and 3 patients experienced recurrent bladder fistula., Conclusions: Surgical management of EUF complicating CD is effective and safe, with a low rate of postoperative complication and EUF recurrence. Preoperative optimization, which is associated with the resolution of urinary symptoms and improved surgical outcomes, should be recommended., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Introduction: A rectourethral fistula (RUF) is an infrequent complication that can be iatrogenic in most cases. Multiple surgical interventions were described for RUF repair including transsphincteric, transanal, transperineal, and transabdominal approaches. To this day, there is no consensus on a standardized surgery of choice for acquired RUF., Materials and Surgical Technique: Our patient was diagnosed with RUF 4 weeks after undergoing laparoscopic low anterior resection for midrectum adenocarcinoma, with failure of conservative treatment. A three-port transabdominal approach was used to dissect the rectoprostatic space and close the fistula orifice on the anterior rectal wall. With the technical impossibility to develop an omental flap, the peritoneum on the posterior vesical wall was carefully dissected to form a rectangular flap pedicled by its inferior aspect. The harvested peritoneal flap was then anchored between the prostate and the rectum. Follow-up imaging showed the absence of RUF, concurrently with total remission of RUF symptomatology., Discussion: Management of acquired RUF can be challenging, especially after failure of conservative treatment. Laparoscopic repair of acquired RUF by vesical peritoneal flap is a valid option for a minimally invasive approach for the treatment of RUF., (© 2023 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

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.)

We describe the case of a 76-year-old woman with a spontaneous nephroduodenal fistula. The patient was initially evaluated for gastrointestinal and urinary symptoms associated with fever and anemia, after which she was admitted with the diagnosis of right chronic pyelonephritis, hydronephrosis, and renal lithiasis. The fistula was diagnosed incidentally by percutaneous pyelography during a right nephrostomy and was later confirmed with an abdominal CT scan. A multidisciplinary decision was made to surgically treat the fistula (right nephrectomy plus duodenal repair); the surgery had a short-term positive outcome. We report a systematic review of the literature related to spontaneous pyeloduodenal fistulæ and their treatments., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)., Methods: We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases., Results: Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences., Conclusion: IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Studies on non-obstetric urogenital fistulas (NOUGFs) provide limited information on predictive outcome factors. This study was aimed at specifying and analyzing the risk factors for long-term anatomical and functional results., Methods: A cross-sectional study of surgical repair for non-obstetric urogenital fistula was performed. From 2012 to 2020, a total of 479 patients with urogenital fistulas were treated in two tertiary centers. Patients with isolated ureteral fistulas and rectal injuries were excluded. For evaluation of the long-term results, patients with vesicovaginal and urethrovaginal fistulas with at least 12 months of follow-up were identified and contacted by phone and/or examined in the clinic. The anatomical outcome was assessed by resolution of symptoms and/or clinical examination. The Urinary Distress Inventory (UDI-6) was used for the functional outcomes., Results: Overall, 425 patients were studied (mean age was 49.8; BMI 27.5; mean fistula size 1.4 cm, mean follow-up was 12 months). Vesicovaginal fistula affected 73% of patients. Hysterectomy without radiation was the most common etiology (66.3%), followed by hysterectomy with subsequent radiation (16%) and pelvic radiotherapy (12.2%). The transvaginal approach was used in 54.4%, abdominal in 12.4%, transvesical in 22.4%, and a combined approach in 10.8%. The successful closure rate was 92.9% for primary cases, 71.6% for secondary cases, and 66.7% for radiation fistulas. A high risk for relapse was found for NOUGFs with ureteral involvement (RR 2.5; 95% CI 1.3-4.5; p = 0.003), radiation fistulas (RR 2.1; 95% CI 1.3-3.5, p = 0.003); and combined radiation and hysterectomy cases (RR 2.9; 95% CI 1.8-4.6; p = 0.0001). In multifactorial analysis, fistula size >3.0 cm, pelvic radiation, and previous vaginal surgeries were associated with a higher risk for failure or lower urinary symptoms., Conclusions: Factors for successful NOUGF closure are fistula size less than 3.0 cm, absence of pelvic radiation, and previous vaginal surgeries., (© 2022. The International Urogynecological Association.)

Background: To evaluate the efficacy of double percutaneous nephrostomy (PCN) combined with ureter occlusion stent for treating cervical cancer complicated with vesicovaginal fistula (VVF). Materials and Methods: A retrospective analysis was performed for 12 patients with cervical cancer complicated with VVF. Regardless of surgical resection, radiotherapy alone or combined chemoradiotherapy were carried out in all patients. After VVF was diagnosed by gynecological examination, imaging, and cystoscopy, concurrent double PCN and ureter occlusion stent implantation were performed for all patients. Results: All patients successfully received ureter occlusion stent implantation after nephrostomy. The success rate of nephrostomy and stent placement was 100% (12/12). After intervention, urinary fistula immediately disappeared in all patients. One week post-surgery, bilateral hydronephrosis disappeared in 4 patients, and their renal insufficiency and renal function returned to normal. One month after operation, 6 patients with genital eczema or ulcer and 5 patients with urinary tract infection were cured. During follow-up, there were no recurrence in urinary fistula, renal dysfunction, and other complications. Conclusion: Double PCN combined with ureter occlusion stent could effectively treat cervical cancer complicated with VVF hydronephrosis, urinary tract infection, and renal insufficiency and contribute to alleviate all kinds of clinical discomfort.

Introduction: Thromboangiitis obliterans (TAO) is a rare disease of unknown cause that causes segmental vasculitis in peripheral blood vessels. It is uncertain whether its presence causes serious adverse events in patients receiving external beam radiotherapy., Patient Concerns: A 73-year-old Japanese man with prostate cancer underwent external beam radiotherapy., Diagnosis: After completion of radiotherapy, fingertip pain occurred, leading to the diagnosis of TAO., Interventions: The patient was instructed to stop smoking, but was unable to do so., Outcomes: Nine months after the completion of radiotherapy, fecaluria appeared, and a rectourethral fistula was diagnosed by contrast enema. The patient's TAO was poorly controlled, and the patient died from aspiration pneumonia 33 months after completion of the radiotherapy regimen. No tumor recurrence was observed during this process, and there were no risk factors other than TAO that may have formed a rectourethral fistula., Lessons: This is the first report of rectourethral fistula caused by external beam radiotherapy for prostate cancer in which TAO was suspected to be involved. Although little is known about the relationship between TAO and radiotherapy, it should be noted that radiotherapy itself may increase the risk of normal tissue toxicity in patients with TAO., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Aphallia is an extremely rare congenital malformation of unknown cause, with few reports in the literature. It is usually associated with other urogenital and gastrointestinal anomalies and is believed to be a result of either the absence of a genital tubercle or chromosome polymorphism. Herein, we describe an extremely rare case of congenital aphallia with congenital urethrorectal fistula and describe our treatment for this patient., Patient Concerns: An 8-year-old boy was brought to our hospital by his parents because of congenital absence of the penis. The child was male per karyotype and had excess heterochromatin on chromosome 9 (46 XY with 9 qh+). No urethral orifice was identified, and urine passed rectally since birth; thus, urinary tract outlet obstruction led to urine reflux from the anus to the epididymis for a long time. The boy had to be placed on prophylactic antibiotics because he developed urinary tract infection and epididymitis almost every day., Diagnosis: Congenital aphallia (46 XY normal male karyotype) associated with congenital urethroretal fistula., Interventions: We performed urethral exteriorization via perineal urethroplasty and urethrorectal fistula repair. The parents approved for phallic reconstruction when the boy reached puberty., Outcome: A new external urethral orifice was created on the lower scrotum. The urinary reflux was corrected, and the epididymitis symptoms disappeared. The urethral fistula was then closed. At 8 months follow up, the patient was no longer on antibiotics and had no symptoms of urinary tract infection or epididymitis., Conclusions: Compatible treatment should be adopted to address urinary tract drainage and infection. Management requires a stepwise approach to address needs as they arise. Neophalloplasty should be performed by an experienced team in early adolescence., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Fistula formation between the kidney and the colon is a rare occurrence. Colorenal fistulas have been reported after renal cryoablation, calculous pyonephrosis, and renal cell carcinoma. Fistula formation is reported in as many as 35% of patients with Crohn's disease. Crohn's-related urinary fistulas may include enterovesical, enteroureteral, rectourethral, urethrocutaneous, and entero-urachal fistulas. Here, we report a rare case of a patient who was found to have a left colorenal fistula in the setting of a left staghorn calculus and recurrent urinary tract infections with a question about the eventual definitive management of the patient., (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).)

Objective: To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery., Methods: An IRB-approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors., Results: We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n = 32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic, and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures., Conclusion: Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone., (Copyright © 2020. Published by Elsevier Inc.)

There are few reports of radiation associated colorectal-genitourinary tract (CRGU) fistulae causing Fournier's gangrene (FG). We describe a case of FG in a patient with possibly two CRGU fistulae in the context of previous high-dose brachytherapy and external beam radiation therapy for prostate cancer. Unfortunately, CRGU fistulae are not well classified as significant risk factors for the development of FG. Our case demonstrates the rationale for maintaining a broad differential in patients presenting with recurrent urinary tract symptoms or necrotising soft tissue infections to include undiagnosed fistulae., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 3-year-old boy presented to our pediatric urology with a history of urine flow under the scrotum when voiding in a squatting position but not when standing. And the ventral side of the front penis became enlarged during urination and dribbled afterward. Physical examination revealed the boy had 2 urethras opening at the tip of glans, and another accessory urethra opening at perineum. Rigid cystoscopy and voiding cystourethrography confirmed it to be a urethral triplication malformation. This condition, the combination of urethral diverticulum and urethral triplication, consisting of urethro-perineum fistula, has not been previously reported., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty., (Copyright © 2020. Published by Elsevier Inc.)

Rationale: Vaginal stone is a rare condition that is often misdiagnosed due to its low incidence. It can be divided into 2 types, primary vaginal and secondary vaginal, based on the etiology of the disease. Vaginal stones involve pathologic calcification. The formation of vaginal stones is mainly due to stasis and urine infection. We describe a procedure for the safe extraction of vaginal stones., Patient Concerns: We report a case of a 25-year-old female patient with congenital genitourinary malformation and urethrovaginal fistula. A urogenital tract malformation repair operation was performed before she was 21 years old. Frequency of urination occurred before and after menstruation for 9 years, and dyspareunia occurred for 1 year., Diagnoses: B ultrasound examination showed a 59 × 55 × 23 mm fusiform region of increased signal intensity in the vagina followed by a sound shadow. We performed a gynecologic examination and found that the long diameter of the vaginal opening was 20 mm. A brown substance observed in her vagina had a hard texture and felt like a stone, and a palpation hand test revealed the size was approximately 60 × 50 mm. A cystoscope was inserted into the urethra and revealed that the broken end of the urethra was connected to the vagina. The proximal broken end of the urethra was 20 mm from the distal end., Interventions: The purpose of this operation was to make a definite diagnosis and remove the stones. We performed vaginal stone removal surgery and cystoscopy under anesthesia., Outcomes: We removed the stone successfully. The patient was discharged from the hospital after a smooth recovery without any complications. Follow-up was conducted 1 month after the operation and then every 3 months., Lessons: Although vaginal stones are rare, we must pay attention to this disease, especially in patients with congenital genitourinary malformations and urethrovaginal or vesicovaginal fistulas. Obstruction of urine discharge combined with repeated urinary tract infection is the main cause of vaginal stone formation. For these patients, follow-up every 3 months, including a physical examination, B-mode ultrasonography of the urinary system and cystoscopy if necessary, can avoid the occurrence of the disease.

Renocolic fistulas are abnormal connections between the upper urinary tract and the colon. Chronic renal obstruction and delayed treatment of obstructive renal stones can lead to loss of renal function, inflammation of the kidney and surrounding structures, and the development of fistulas. However, due to the increased availability of CT scans and cystoscopy for diagnosis and treatment, renocolic fistulas resulting from obstructing renal stones have become rare. This article describes a patient who was found to have a renocolic fistula on antegrade percutaneous nephrostogram. The patient was treated with a laparoscopic nephrectomy and minimally invasive colon repair and recovered.

Bladder outlet obstruction is a common aetiology of lower urinary tract symptoms in adult men and several treatment options are available. We report on a case of a 73-year-old man with a complicated soft tissue infection due to an urinoma after laser prostatectomy. He was treated by several surgical interventions and long-term antibiotic therapy.

Introduction: Arterioureteral fistulas are rare, life-threatening, and difficult to diagnose. Risk factors are medical interventions in the lesser pelvis (general, urological, gynecological, and vascular surgery), radiation therapy of the lesser pelvis, permanent double J catheters, and previous vessel malformations., Materials and Methods: We retrospectively evaluated all cases of arterioureteral fistulas registered over the last 10 years in the clinic's documentation system. For all cases, clinical symptoms, diagnostics, therapies as well as clinical outcome were evaluated., Results: Four of the 5 patients were women. The most common initial symptom was a gross hematuria (4/5). All patients had a permanent double J catheter after extensive surgery of the lesser pelvis. In one case the initial diagnosis was done by retrograde ureterography, in 2 patients by provocative angiography and in the other 2 cases with a laparotomy due to cardiovascular problems. Three patients were treated by open surgery and 2 patients were treated by stenting of the iliac artery. One patient died, 2 patients had a permanent kidney fistula, and 2 patients continued treatment with a permanent double J catheter., Conclusion: Based on the more aggressive therapy regimens, we expect that the number of patients presenting with arterioureteral fistulas will continue to rise. The identification of these patients based on their risk profile is essential.

Pubic bone osteomyelitis is a rare infectious condition which is characterized by a complex diagnostic and therapeutic workup, due to its various clinical manifestations. Among the many causes of this condition, urinary fistula is the most common in case of previous urological procedures. In order to solve this complication, it is crucial to treat both the fistula and (moreover) the infectious locus arising from it, because treating the fistula alone does not provide any control on the infectious noxa. We present the first case of pubic bone osteomyelitis arising from a urinary fistula after a robotic radical cystectomy with intra corporeal continent neobladder, which has been successfully treated through a multidisciplinary approach.

Purpose: To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome., Patients and Methods: Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification)., Results: The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B., Conclusion: Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients., Level of Evidence: This is a case control study (level III evidence)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Acquired urethrovaginal fistulae and urethral atresia are rare findings in pediatric patients, but have been described in adult patients related to trauma or iatrogenic injury. Little exists in the published literature to guide management of such conditions in children, but lessons learned from congenital causes can help. Herein we discuss the preoperative evaluation and management of a child with an acquired urethrovaginal fistula and urethral atresia likely related to in utero compression from an intrapelvic sacrococcygeal teratoma and provide several images detailing the complex anatomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Iliac-urinary fistula is a rare cause of severe hematuria after urinary diversion. Indwelling stents and advanced atherosclerosis may be risk factors. Angiography with embolization is usually resolutive., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

The emphysematous pyelonephritis is a uncommon and potentially fatal entity. The recognition of this condition enables the early correct management of patients. Diabetes and ureteral obstruction are the main risk factors identified. We present the case of a patient with no relevant risk factors or prior medical history, in which the reason of admission to the emergency department was back pain, eventually evolving into septic shock in the early hours. The imaging tests identified the presence of peri-renal and subcutaneous gas which guided the medical team to the right diagnosis (emphysematous pyelonephritis secondary to fistulized urothelial neoplasia) and the optimal surgical treatment. However, in the post-operative period the patient died, as the clinical condition and laboratory test results performed during the admission were predicting. It should also be mentioned that this same case illustrated a bacteraemia by Sphingomonas Paucimobilis (acquired in the community) with cavitated damage to lungs (probable septic embolism).

Objective: To know the diagnostic tools and proper management of ureterovaginal fistula following neglected vaginal foreign body in order to achieve optimal outcome., Case Report: A case of ureterovaginal fistula associated with a neglected vaginal foreign body. The patient was complaining of a foul-smelling vaginal discharge and lower abdominal pain. On vaginal examination, a hard and large foreign body was found. Examination under anesthesia was performed, and an aerosol cap was removed from her vagina. The patient developed urinary incontinence after removal of the foreign body. Subsequent work-up demonstrated the presence of a right ureterovaginal fistula. The patient underwent an abdominal ureteroneocystostomy. At one year follow up, the patient had fully recovered., Conclusion: Ureterovaginal fistula following neglected vaginal foreign body is a serious condition. Early diagnosis, treatment of infection and proper surgical management can improve the outcome and decrease complications., (Copyright © 2018. Published by Elsevier B.V.)

Recto-perineal-urethral fistula caused by Crohn's disease is a rare, for which fundamental treatment has not been established yet. We analyzed the clinical characteristics, diagnosis, treatment, and prognosis of six male patients with anorectal lesions caused by Crohn's disease. Three patients were treated with abdominoperineal resection and the other three with rectal excision without anastomosis. Excluding one case, which presented worsening immediately after surgery, symptoms of urethral fistula improved without urethral stenosis, dysuria, or sexual dysfunction. Recto-perineal-urethral fistula is currently treated with various treatment modalities, including colostomy and drug therapy. Although the evaluation of these modalities is required, abdominoperineal resection or rectal excision without anastomosis may be a valuable treatment option because these approaches improve the urethral fistula while sparing the urethra without any significant complications.

Background/purpose: We evaluated routine intraoperative residual rectourethral fistula measurement (IRRFM) in 20 consecutive male imperforate anus with recto-bulbar (RB; n=12) or recto-prostatic (RP; n=8) fistula during laparoscopically assisted anorectal pull-through (LAARP) for preventing incomplete fistula excision (IFE) on mid-term follow-up., Methods: Twenty consecutive LAARP performed at a mean age of 10months (range: 3-30) followed-up for a mean of 4.8years (range: 1.5-9) were reviewed. IRRFM involves using a calibrated catheter and a cystoscope to measure the distance between where dissection was ceased at the rectal end and the urethral orifice (Figure). Dissection and IRRFM were repeated until the fistula was <5mm, then tied, and divided. Magnetic resonance imaging (MRI) and pelvic ultrasonography were used to exclude IFE and cyst formation., Results: Residual fistula was 4-18mm on initial IRRFM. Unless measured, dissection cannot proceed to <5mm safely with poentical for urethral injury or IFE. With experience, initial IRRFM were shorter, especially in RP (Table 1). Before the IRRFM era, our incidence of cysts was 2/11 (18%), but here we found no evidence of cyst formation on MRI, no dysuria, and no urinary tract infections., Conclusions: Mid-term review demonstrates that IFE can be prevented successfully by IRRFM during LAARP., Level of Evidence: Case Series with no Comparison Group, Level IV., (Copyright © 2017. Published by Elsevier Inc.)

Urinothorax, an unusual and rare cause of pleural effusion, is usually secondary to urinary obstruction and abdominal trauma. We describe an uncommon case of left-sided urinothorax in a 35-year-old man with diabetes and hypothyroidism associated with an autoimmune disorder without obvious obstructive uropathy. Workup revealed pancytopenia, mild proteinuria, positive anti-nuclear and anti-dsDNA antibodies suggestive of probable systemic lupus erythematosus. Contrast-enhanced CT-chest and abdomen showed hepatosplenomegaly with bilateral renal abscesses and a fistulous connection between left superior calyx and left the pleural cavity. Patient was initially managed by intravenous antibiotics, intercostal tube drainage and ipsilateral double-J stent placement. The definitive management in the form of closure of nephropleural fistula was achieved with sclerotherapy using 0.1% povidone-iodine instillation, while oral steroids were started for the probable autoimmune disorder. To the best of our knowledge, this is the first case of spontaneous non-obstructive nephropleural fistula associated with an autoimmune disorder, managed by minimally invasive methods., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: To explore and summarize the reasons why urethral calculi cause a urethral fistula., Case Presentation: We retrospectively studied 1 patient in Xiangya hospital and all relevant literature published in English between 1989 and 2015. The patients (including those reported in the literature) were characterized by age, origin, location of calculus, size of calculus, fistulous track, and etiological factors. Most of urethral calculi associated with a urethral fistula were native generated. Urethral calculi can be formed in various locations of the urethra, and the size of the calculus ranged from small (multiple) calculi to giant stones. The fistula external orifice located at the root of the penis was relatively common, and there were various etiological factors, such as urethral strictures, urethral trauma induced by long-term catheterization, lumbar fractures, and congenital anomaly factors. They were managed by the excision of the fistulous tract, retrieval of the urethral stones, and/or debridement and pus drainage operations., Conclusion: Some elements, such as trauma, recurrent urinary tract infections, abscess formation induced by long-term catheterization, and urethral calculus, may be the risk factors for a urethral fistula.

Our patient suffered a perineal straddle injury, resulting in right cavernosal artery pseudoaneurysm in combination with a cavernosal-urethral fistula. The urethra failed to heal after several weeks, and the patient presented with severe intermittent urethral bleeding. The pseudoaneurysm was successfully treated by coil embolization, with resolution of the bleeding. The patient recovered completely, with normal erectile and voiding function. This type of injury is very rare in the literature: traumatic cavernosal arterial pseudoaneurysm is known to cause high flow priapism, but in this case additional cavernosal-urethral fistula resulted in a severe urethraggia. This is the only case, to our knowledge, of delayed urethral bleeding from cavernosal artery pseudoaneursym in combination with a cavernosal-urethral fistula., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Pelvic fracture urethral defects associated with urethrorectal fistulas are rare and difficult to repair. The aim of this study was to evaluate the efficacy of transperineal urethroplasty with gracilis muscle interposition for the repair of pelvic fracture urethral defects associated with urethrorectal fistulas., Materials and Methods: We identified 32 patients who underwent transperineal urethroplasty with gracilis muscle interposition to repair pelvic fracture urethral defects associated with urethrorectal fistulas. Patient demographics as well as preoperative, operative and postoperative data were obtained., Results: Mean followup was 33 months (range 6 to 64). The overall success rate was 91% (29 of 32 cases). One-stage repair was successful in 17 of 18 patients (94%) using perineal anastomosis with separation of the corporeal body and in 12 of 14 (86%) using perineal anastomosis with inferior pubectomy and separation of the corporeal body. All 22 patients (100%) without a previous history of repair were successfully treated. However, only 7 of 10 patients (70%) with a previous history of failed urethroplasty and urethrorectal fistula repair were cured. Recurrent urethral strictures developed in 2 cases. One patient was treated successfully with optical internal urethrotomy and the other was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent urethrorectal fistulas associated with urethral strictures developed in an additional patient., Conclusions: Transperineal urethroplasty with gracilis muscle interposition is a safe and effective surgical procedure for most pelvic fracture urethral defects associated with urethrorectal fistulas. Several other factors may affect its postoperative efficiency., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate pain intensity perception in prostate cancer survivors with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula before and after definitive surgical management., Materials and Methods: We performed a review of an institutional review board-approved database of prostate cancer survivors with pubic bone osteomyelitis from 2010 to 2015. Demographic and clinical data were extracted. Pain scores were assessed in patients at varying points before and after definitive treatment using an 11-point numeric rating scale. Statistical analysis was performed using a Wilcoxon signed-rank test and NcNemar's test., Results: We identified 16 patients with a median age of 72 who met inclusion criteria. Chronic narcotic use for pain management was noted in 6 of 16 (37.5%) patients preoperatively. No statistical difference was identified between the pain score at the time of diagnosis and after completion of conservative measures (5.5 vs 5.5, P = .76). A statistically significant decrease in median pain score at the first follow-up appointment was seen compared to the preoperative pain score (0 vs. 5.5, P = .0005). At a median follow-up of 9.4 months (interquartile range 3.7-16.5), a sustained decrease in the median pain intensity score was noted in our cohort compared to their preoperative baseline pain score (5.5 vs 0, P = .0005) and pain score at the time of diagnosis (5.5 vs 0, P = .004.) CONCLUSION: Pubic bone resection provides immediate and sustained improvement in pain intensity perception in the prostate cancer survivor with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The residual terminal bowel after pull-through surgery for anorectal malformation has been reported to cause urinary complications. We report two boys where residual bowel has fistulated postoperatively into the alimentary tract causing metabolic and septic complication in one and a large pelvic mass with urinary and rectal obstruction in the other., Competing Interests: Conflicts of Interest: None declared., (2017 BMJ Publishing Group Ltd.)

Introduction and Hypothesis: In the developed world, urethrovaginal fistulas are most the likely the result of iatrogenic injury. These fistulas are quite rare. Proper surgical repair requires careful dissection and tension-free closure. The objective of this video is to demonstrate the identification and surgical correction of an urethrovaginal fistula., Methods: The case presented is of a 59-year-old woman with a history of pelvic organ prolapse and symptomatic stress urinary incontinence who underwent vaginal hysterectomy, anterior colporrhaphy, posterior colporrhaphy, and synthetic sling placement. Postoperatively, she developed a mesh extrusion and underwent sling excision. After removal of her synthetic sling, she began to experience continuous urinary incontinence. Physical examination and cystourethroscopy demonstrated an urethrovaginal fistula at the midurethra. Options were discussed and the patient wished to undergo transvaginal fistula repair., Results: The urethrovaginal fistula was intubated with a Foley catheter. The fistula tract was isolated and removed. The urethra was then closed with multiple tension-free layers. This video demonstrates several techniques for identifying and subsequently repairing an urethrovaginal fistula. Additionally, it demonstrates the importance of tension-free closure., Conclusions: Urethrovaginal fistulas are rare. They should be repaired with careful dissection and tension-free closure.

Purpose: To evaluate the long-term clinical efficacy and safety of double-layered polytetrafluoroethylene membrane-covered self-expandable segmental metallic stents (Uventa) in patients with chronic ureteral obstruction., Materials and Methods: In a retrospective study, a total of 50 ureter units (44 patients) with chronic obstructions were included from July 2010 to May 2015. Indications for Uventa placement were primary stenting for malignant ureteral obstruction, failed conventional polymeric Double-J stent (PS), or percutaneous nephrostomy (PCN) technique, with comorbidities or fears limiting PS/PCN changes, or with irritation or pain due to PS/PCN. Patients underwent Uventa stent placement using the antegrade or retrograde approach., Results: There were no immediate procedure-related complications, and all stents were placed in the proper sites. During the median follow-up of 30.9 (interquartile range [IQR], 8.1-49.0) months, the primary (no obstruction and no additional intervention) and overall success (no obstruction and no additional intervention except supplementary Uventa) was 30.0% and 34.0%, respectively. Moreover, 14 of 50 ureter units (28.0%) experienced major complications (≥Clavien-Dindo class IIIb), such as ureteroarterial fistula (three cases, 6.0%), ureteroenteric fistula (three, 6.0%), ureterovaginal fistula (one, 2.0%), ureter perforation (one, 2.0%), uncontrollable bleeding (one, 2.0%), and complete obstruction (five, 10.0%). On univariate analysis, major complications were associated with female (odds ratio [OR] = 6.000), cervical cancer (OR = 4.667), ureteral stricture length (≥6.0 cm, OR = 4.583), and placement duration (≥24.0 months, OR = 20.429; all p < 0.05)., Conclusions: In long-term follow-up, the Uventa stent demonstrated poor treatment outcomes with frequent major complications in patients with chronic ureteral obstructions.

Purpose: To compare the efficacy and safety of two approaches in retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD) for intractable chyluria: completely or partly mobilize the kidney., Materials and Methods: Retrospectively reviewed the clinical data of 77 patients, who underwent RRPLD because of intractable chyluria in our institution. We mobilized the whole affected kidney in 22 patients during the operation, but only dissected the lower part in other 55 patients. Operative time, blood loss, visual analog scale (VAS) score, postoperative bed rest, postoperative hospital stay, recurrence, intraoperative and postoperative complications were compared between the two groups., Results: All operation was successful, and none convert to open. The chyluria was resolved immediately after surgery. Compared with completely mobilized RRPLD (CMR), partly mobilized RRPLD (PMR) was superior in terms of operative time (132.91 ± 35.65 vs. 91.73 ± 24.14 min), blood loss (35.68 ± 8.21 vs. 25.09 ± 7.41 ml), VAS score (4.63 ± 0.44 vs. 2.34 ± 0.80), postoperative bed rest (3.36 ± 0.49 vs. 1.80 ± 0.85 days) and hospital stay (6.77 ± 1.57 vs. 4.98 ± 1.89 days). Compilations occurred in three patients in CMR group and two in PMR. Recurrence was confirmed by cystoscopy in three patients during 3-103-month follow-up, CMR group with 1 and PMR with 2., Conclusion: In our study, we found PMR was equally effective and safe as CMR. Moreover, it is more minimally invasive, painless and economical. Therefore, we believe it is unnecessary to completely mobilize the kidney in RRPLD for intractable chyluria.