Case 267: Cecureterocoele Manifesting in a Man with Infertility.

History A 28-year-old man presented with lifelong anejaculation, which had become an issue because of family planning. The patient had a history of normal erections and experienced the sensation of orgasm without ever ejaculating. On physical examination, both testes were present in the scrotum, with normal dimensions and a normal epididymis bilaterally. The patient had a slightly tender left testicle, and digital rectal examination findings were normal. The patient underwent further investigation for the possibility of retrograde ejaculation with urine cytology, the results of which were negative. Genetic testing was performed to exclude Y chromosome microdeletions. Serum-luteinizing and follicle-stimulating hormone levels were normal, with a borderline low level of testosterone (7.6 nmol/L; normal range, 8.0-29.0 nmol/L). All other pertinent laboratory results were noncontributory. Pelvic MRI was requested to exclude an anatomic cause of anejaculation. MRI was performed in accordance with the standard clinical prostate protocol, with a dynamic contrast material-enhanced study. CT of the upper abdomen was also performed. The patient subsequently underwent cystoscopy, which revealed an intravesicular fluid-filled mass near the left ureteric orifice

Evaluation of image‐based prognostic parameters of post‐prostatectomy urinary incontinence: A literature review

Abstract: Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high‐risk disease. However, post‐prostatectomy urinary incontinence remains a major functional side‐effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre‐ and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post‐prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging‐based articles evaluating the pelvic floor and surrounding structures pre‐ and/or postradical prostatectomy to predict post‐prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post‐prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single‐center nature of studies, and the heterogeneity in patient populations and methodologies used

Case 267.

History A 28-year-old man presented with lifelong anejaculation, which had become an issue because of family planning. The patient had a history of normal erections and experienced the sensation of orgasm without ever ejaculating. On physical examination, both testes were present in the scrotum, with normal dimensions and a normal epididymis bilaterally. The patient had a slightly tender left testicle, and digital rectal examination findings were normal. The patient underwent further investigation for the possibility of retrograde ejaculation with urine cytology, the results of which were negative. Genetic testing was performed to exclude Y chromosome microdeletions. Serum-luteinizing and follicle-stimulating hormone levels were normal, with a borderline low level of testosterone (7.6 nmol/L; normal range, 8.0-29.0 nmol/L). All other pertinent laboratory results were noncontributory. Pelvic MRI was requested to exclude an anatomic cause of anejaculation. MRI was performed in accordance with the standard clinical prostate protocol, with a dynamic contrast material-enhanced study ( Figs 1 - 3 ). CT of the upper abdomen was also performed ( Fig 4 ). The patient subsequently underwent cystoscopy, which revealed an intravesicular fluid-filled mass near the left ureteric orifice ( Fig 5 ). Figure 1a: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 1b: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 1c: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 2a: (a) Coronal T2-weighted (repetition time msec/echo time msec, 4574/86.5) MR image of the pelvis. (b) Axial T2-weighted (3000/85.4) MR image of the pelvis. Figure 2b: (a) Coronal T2-weighted (repetition time msec/echo time msec, 4574/86.5) MR image of the pelvis. (b) Axial T2-weighted (3000/85.4) MR image of the pelvis. Figure 3: Unenhanced axial fat-saturated T1-weighted (6.2/3.1) MR images. Figure 4: Coronal CT urogram. Figure 5: Image obtained at cystoscopy

What is the most effective treatment for nocturia or nocturnal incontinence in adult women?

Acknowledgments The authors express their thanks to F.C. Burkhard for invaluable logistic support during the conception of the manuscript.Peer reviewedPostprin

Continuous low-dose antibiotic prophylaxis for adults with repeated urinary tract infections (AnTIC): a randomised, open-label trial

Funder: UK National Institute for Health Research. Open Access funded by Department of Health UK Acknowledgments We thank all the participants for their commitment to the study, Sheila Wallace for updating the systematic review, members of the Trial Steering Committee and members of the Data Monitoring Committee for their valuable guidance. We thank the National Health Service organisations, principal investigators and local research staff who hosted and ran the study at site. We thank the Health Technology Assessment Programme of the UK NIHR for funding the study (no. 11/72/01). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Government Department of Health. A full report of the study30 has been published by the NIHR Library.Peer reviewedPublisher PD

Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT

Peer reviewedPublisher PD

Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non-inferiority trial.

OBJECTIVE: To test and compare the efficacy of methenamine hippurate for prevention of recurrent urinary tract infections with the current standard prophylaxis of daily low dose antibiotics. DESIGN: Multicentre, open label, randomised, non-inferiority trial. SETTING: Eight centres in the UK, recruiting from June 2016 to June 2018. PARTICIPANTS: Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment. INTERVENTIONS: Random assignment (1:1, using permuted blocks of variable length via a web based system) to receive antibiotic prophylaxis or methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed. MAIN OUTCOME MEASURE: Absolute difference in incidence of symptomatic, antibiotic treated, urinary tract infections during treatment. A patient and public involvement group predefined the non-inferiority margin as one episode of urinary tract infection per person year. Analyses performed in a modified intention-to-treat population comprised all participants observed for at least six months. RESULTS: Participants were randomly assigned to antibiotic prophylaxis (n=120) or methenamine hippurate (n=120). The modified intention-to-treat analysis comprised 205 (85%) participants (antibiotics, n=102 (85%); methenamine hippurate, n=103 (86%)). Incidence of antibiotic treated urinary tract infections during the 12 month treatment period was 0.89 episodes per person year (95% confidence interval 0.65 to 1.12) in the antibiotics group and 1.38 (1.05 to 1.72) in the methenamine hippurate group, with an absolute difference of 0.49 (90% confidence interval 0.15 to 0.84) confirming non-inferiority. Adverse reactions were reported by 34/142 (24%) in the antibiotic group and 35/127 (28%) in the methenamine group and most reactions were mild. CONCLUSION: Non-antibiotic prophylactic treatment with methenamine hippurate might be appropriate for women with a history of recurrent episodes of urinary tract infections, informed by patient preferences and antibiotic stewardship initiatives, given the demonstration of non-inferiority to daily antibiotic prophylaxis seen in this trial. TRIAL REGISTRATION: ISRCTN70219762

Surgical therapy for benign prostatic hypertrophy/bladder outflow obstruction

Monopolar transurethral resection of the prostate (TURP) with endoscopic electrocautery remains the gold standard surgical technique for benign prostatic hypertrophy (BPH) by which all new procedures are compared. We reviewed the current literature, and international urological guidelines and consensus opinion on various surgical options for BPH and present a brief overview of alternative techniques including bipolar TURP, transurethral incision of the prostate, transurethral vaporization of the prostate, laser prostatectomy (with holmium, thulium and potassium titanyl phosphate greenlight lasers) and open prostatectomy (with mention of new techniques including laparoscopic and robotic prostatectomy). Emerging, experimental and less established techniques are also described including endoscopic heat generation (transurethral microwave thermotherapy, radiofrequency transurethral needle ablation of the prostate, high intensity focused ultrasound, hot water induced thermotherapy, pulsed electromagnetic radiofrequency), injection therapy (transurethral ethanol ablation and botulinum toxin) and mechanical devices (intraprostatic stents and urethral lift devices). Despite a plethora of surgical options, none have realistically improved outcomes in the long-term compared with TURP. Improvements have been made on improving surgical morbidity and time in hospital. Questions remain in this area, including what specific elements of bladder outflow obstruction (BOO) result in damage to the urinary tract, how does BPH contribute to BOO and how much prostate volume reduction is necessary to relieve BOO or lower urinary tract symptoms. Given these unanswered questions and the multitude of procedures available, it is clear that appropriate counselling is necessary in all men who undergo BPH surgery