female anterior urethroplasty techniques

female anterior urethroplasty techniques

1. Female urethroplasty Ahmed M Eliwa M.D. Zagazig University Secretary pf reconstructive urologic surgery at EUA member of UMERG ISURU

2. Scenario 54 y female patient Persistent …..last 4 years Frequency Urgency Dysuria US and UA ----- NAD

3. What next?

4. Female urethroplasty Ahmed M Eliwa M.D. Zagazig University Secretary pf reconstructive urologic surgery at EUA member of UMERG ISURU

5. Female Urethral stricture likely underdiagnosed 4% to 18 % of women with BOO 8%-22.4 % in women with obstructive symptoms. urethral lumen too narrow to admit a 17 Fr flexible cystoscope feel of scar tissue by cystoscopic haptic feedback is diagnostic for stricture. Blaivas JG, Santos JA, Tsui JF, et al. Management of urethral stricture in women. J Urol 2012;188:1778-82. DOI PubMed Mukhtar BMB, Spilotros M, Malde S, Greenwell TJ. Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women. BJU Int 2017;120:710-6.

6. Santucci and the Urologic Diseases in America Project reported in 2008 They note that while there were less than 40 reports of true female urethral strictures in the literature at that time, more than 1.2 million office visits for female urethral stricture occurred in the United States between 1992 and 2000 at a cost of $61 million per year

7. urethral stricture is unknown in females, it may complicate traditional female genital mutilation (circumcision ) which is a common practice in Sub‑Saharan Africa

8. . According to Mugalo , urethral stricture may complicate vesicovaginal fistula [ obstetric origin] Only a few authors have reported on female urethral stricture in Sub‑Saharan Africa , and it appears to be 3% or less of all urethral strictures in the region .

9. Etiology Idiopathic Iatrogenic: prior urethral dilations , prior urethral diverticulectomy , sling insertion or excision, transvaginal fistula repair and/or transurethral bladder surgery. Inflammatory traumatic . urethral tuberculosis fibroepithelial polyps Sarin I, Narain TA, Panwar VK, Bhadoria AS, Goldman HB, Mittal A. Deciphering the enigma of female urethral strictures: a systematic review and meta-analysis of management modalities. Neurourol Urodyn 2021;40:65-79. DOI PubMed 5. Keegan KA, Nanigian DK, Stone AR. Female urethral stricture disease. Curr Urol Rep 2008;9:419-23. DOI PubMed 6. Desai S, Libertino JA, Zinman L. Primary carcinoma of the female urethra. J Urol 1973;110:693-5. DOI PubMed 7. Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int 1992;48:436-8.

10. CP asymptomatic ranging from minor discomfort to a wide spectrum of voiding and storage symptoms Faiena et al. state that physical examination bimanual pelvic, vaginal and speculum high index of clinical suspicion . tissue quality , meatal stenosis , pelvic organ prolapse and/or concomitant lichen sclerosus Faiena I, Koprowski C, Tunuguntla H. Female urethral reconstruction. J Urol. 2016;195(3):557–567. doi:10.1016/j.juro.2015.07.1243. Sarin I, Narain TA, Panwar VK, Bhadoria AS, Goldman HB, Mittal A. Deciphering the enigma of female urethral strictures: a systematic review and meta-analysis of management modalities. Neurourol Urodyn . 2021;40(1):65–79. doi:10.1002/nau.245844

11. VCUG (VCUG) do not play a central role in the diagnosis DDx : primary bladder neck obstruction, a urethral sphincter obstruction, a pelvic floor obstruction, or a urethral stricture itself patient in an A-P fashion voiding film. help determine the position of the stricture (proximal, mid, distal, or panurethral ). “wine glass image”

12. pelvic MRI pelvic organ prolapse or additional pathology such as malignancy.

13. uroflowmetry or PVR volumes Plateau flow less than 12 to 15 mL/s PVRs > 100, may suggest obstruction Agochukwu-Mmonu N, Srirangapatanam S, Cohen A, Breyer B. Female Urethral Strictures: Review of Diagnosis, Etiology, and Management. Curr Urol Rep. 2019 Nov 8;20(11):74. doi : 10.1007/s11934-019-0933-1. PMID: 31705324.

14. urodynamic study classic high pressure low flow pattern. West et al. suggest that detrusor contraction at a maximum of > 25 cm H2O, with a flow < 12 cc/s , could be diagnostic of BOO, video-UDS to maximize the data a UDS offers. functional and anatomic Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn . 2000;19(5):553-64. doi : 10.1002/1520-6777(2000)19:5<553::aid-nau2>3.0.co;2-b. PMID: 11002298.

15. calibration of < 14 F (most commonly used cut-off value by authors) evidence of BOO on urodynamics and visualization of narrowing on urethroscopy or VCUG

16. How to treat ?

17. Conservative management urethral dilation direct vision internal 69% of urologists were still regularly practicing UDchanged over the past 15 years favoring surgical intervention. poor outcomes of repeated dilations

18. Goals of surgical repair restore function urinate without obstruction Maintain continence prevent vaginal voiding maintain sexual function.

19. Green = ventral urethra…….. vagina red = dorsal urethra

20. Dorsal onlay Dorsal inlay

21. Surgical Techniques

22. EPA Meatoplasty with or without Distal Urethrectomy Ventral Incision and Anastomosis Flaps Grafts

23. Excision with primary anastomosis pelvic fracture and under a sine qua non condition that stricture is short and in the proximal or mid urethra.

24. meatoplasty isolated distal urethral stricture after traumatic instrumentation, radiation therapy to the pelvis, in postmenopausal patients with vulvar and vaginal atrophy. Avoid too ventral meatotomy to prevent vaginal voiding. circumferential, distal urethrectomy and advancement meatoplasty work best for treating these distal strictures Rosenblum N, Nitti VW. Female urethral reconstruction. Urol Clin North Am. 2011 Feb;38(1):55-64, vi. doi : 10.1016/j.ucl.2010.12.008. PMID: 21353080.

25. Ventral Incision and Anastomosis Short strictures located primarily on the ventral Heineke –Mikulicz principle. Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. J Urol. 2003;170:82–6.

26. Substitution and tissue transfer Approach Dorsal Inlay or onlay Ventral Inlay or onlay Tissue transfer Flaps Grafts Interposing layer Martius flap Gracillis Omentum

27. Flap Urethroplasty Techniques

28. U-Shaped Ventral Vaginal Flap Urethroplasty (Blandy) first described by Blandy, but first reported by Schwender et al in 2006 hypospadic urethra leading to an inward, splaying urinary stream

29. Gormley EA. Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn . 2010;29 Suppl 1:S42-5. doi : 10.1002/nau.20814. PMID: 20419801.

30. U-Shaped Ventral Vaginal Flap Urethroplasty (Palou)

31. C-Shaped Ventral Vaginal Flap Urethroplasty Simonato A, Varca V, Esposito M, Carmignani G. Vaginal flap urethroplasty for wide female stricture disease. J Urol. 2010;184 (4):1381–1385. doi:10.1016/j.juro.2010.06.04227

32. Ventral Lateral Based Anterior Vaginal Wall Flap Urethroplasty Romero- Maroto et al described a ventral lateral-based anterior vaginal wall flap urethroplasty inspired by the Orandi technique

33. Vaginal Wall Urethroplasty/Tubularized Vaginal Flap Urethroplasty FLISSER AJ, BLAIVAS JG. Outcome of Urethral Reconstructive Surgery in a Series of 74 Women. Journal of Urology [Internet]. 2003 Jun 1 [cited 2024 Jun 4];169(6):2246–9.

34. Lateral Vestibular Flap Urethroplasty Romman et al described a lateral vestibular flap.44

35. Dorsal Vestibular Flap Urethroplasty Montorsi et al described a dorsal vestibular flap.45 In this approach, a suprameatal inverted Y-shaped incision is performed

36. Pedicle Flap from the Labia Minora Tanello M, Frego E, Simeone C, Cosciani CS. Use of pedicle flap from the labia minora for the repair of female urethral strictures. Urol Int. 2002;69:95–8.

37. Dorsal Labial Flap Urethroplasty

38. Dorsal Vestibular Flap Urethroplasty Montorsi F, Salonia A, Centemero A, et al. Vestibular fl ap urethroplasty for strictures of the female urethra: impact on symptoms and fl ow patterns. Urol Int. 2002;69:12–6.

39. Tubularized Labial Flap Urethroplasty Xu et al describes their technique of using transpubic access for a pedicled tubularized labial flap urethroplasty in the treatment of 8 patients with urethral obliterative strictures associated with urethrovaginal fistulas secondary to a pelvic fracture Xu Y-M, Sa Y-L, Fu Q, Zhang J, Xie H, Jin S-B. Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas sec ondary to pelvic fracture. Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046

40. Tubularized Labial Flap Urethroplasty the labia minora flap is too small, a double face technique can be used where two flaps are approximated, sutured together, and then tubularized

41. Tubularized Labial Flap Urethroplasty Radwan et al also described a tubularized labial flap urethroplasty for patients with posttraumatic urethral loss rather than FUS. transvaginal Radwan MH, Abou Farha MO, Soliman MG, et al. Outcome of female urethral reconstruction: a 12-year experience. World J Urol. 2013;31(4):991–995. doi:10.1007/s00345-013-1087-247

42. Bladder Flap Urethroplasty Tanagho first described the use of a bladder flap urethroplasty. It has also been reported in studies by Hemal et al and Radwan et al.20,46 While these studies did not necessarily use this technique for FUS alone, they are effective techniques for urethral reconstruction. Tanagho EA. Urethrosphincteric reconstruction for congenitally absent urethra. J Urol. 1976;116(2):237–242. doi:10.1016/S0022- 5347(17)58762-5 HEMAL AK, DORAIRAJAN LN, GUPTA NP. POSTTRAUMATIC COMPLETE AND PARTIAL LOSS OF URETHRA WITH PELVIC FRACTURE IN GIRLS: AN APPRAISAL OF MANAGEMENT. Journal of Urology [Internet]. 2000 Jan 1 [cited 2024 Jun 4];163(1):282–7. Available from: https://doi.org/10.1016/S0022-5347(05)68037-8

43. Flaps success rate that ranges between 60%-100% The anterior vaginal wall flap and lateral vaginal wall flap techniques have proven safety and efficacy some Lateral flap is superior since it does not result in a retrusive meatus robust vascularity and adequate mobility relatively low morbidity. 3.7 % de novo stress urinary incontinence (SUI ) Simonato A, Varca V, Esposito M, Carmignani G. Vaginal flap urethroplasty for wide female stricture disease. J Urol. 2010 Oct;184(4):1381-5. doi : 10.1016/j.juro.2010.06.042. Epub 2010 Aug 19. PMID: 20727538. Romero- Maroto J, Verdú-Verdú L, Gómez-Pérez L, Pérez-Tomás C, Pacheco-Bru JJ, López-López A. Lateral-based Anterior Vaginal Wall Flap in the Treatment of Female Urethral Stricture: Efficacy and Safety. Eur Urol. 2018 Jan;73(1):123-128. doi : 10.1016/j.eururo.2016.09.029. Epub 2016 Sep 28. PMID: 27692474. Sarin I, Narain TA, Panwar VK, Bhadoria AS, Goldman HB, Mittal A. Deciphering the enigma of female urethral strictures: a systematic review and meta-analysis of management modalities. Neurourol Urodyn 2021;40:65-79. DOI PubMed Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. Intermediate outcomes after female urethral reconstruction: graft vs flap. Urology 2014;83:1181-5.

44. Flaps Not with lichen sclerosus or radiation

45. Free Graft Urethroplasty

46. Graft vaginal buccal Lingual Labia Minora Skin

47. Dorsal Onlay Agochukwu-Mmonu N, Srirangapatanam S, Cohen A, Breyer B. Female urethral strictures: review of diagnosis, etiology, and management. Curr Urol Rep. 2019;20(11):74. doi:10.1007/s11934- 019-0933-1 https://www.youtube.com/watch?v=YVtVuP57GIE&t=41s

48. Dorsal inlay https://link.springer.com/article/10.1007/s00192-022-05262-x#citeas Linder, B.J., Balzano , F.L. & Warner, J.N. Transurethral dorsal buccal graft urethroplasty for proximal female urethral strictures. Int Urogynecol J 33, 2317–2319 (2022). https://doi.org/10.1007/s00192-022-05262-x

49. Ventral Onlay Ozlulerden Y, Celen S, Zumrutbas AE, Aybek Z. Female buccal mucosa graft urethroplasty: a new modified ventral onlay "AZ" technique. Int Urogynecol J. 2020 Dec;31(12):2543-2550. doi : 10.1007/s00192-020-04354-w. Epub 2020 Jun 4. PMID: 32500163. Berglund RK, Vasavada S, Angermeier K, Rackley R. Buccal mucosa graft urethroplasty for recurrent stricture of female urethra. Urology. 2006;67:1069–71.

50. Ventral Inlay Hoag et al first described a vaginal sparing urethroplasty using a ventral inlay with BMG Hoag N, Gani J, Chee J. Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: a novel modification of surgical technique. Investig Clin Urol. 2016;57(4):298–302. doi:10.4111/icu.2016.57.4.298

51. Double Faced Inlay Joshi PM, Kulkarni SB. A new technique of double-face buccal graft urethroplasty for female urethral strictures. Turk J Urol. 2019;46 (2):165–168. doi:10.5152/tud.2019.19228

52. Tubularized Graft Urethroplasty described once. In the study by Onol et al Önol FF, Antar B, Köse O, Erdem MR, Önol ŞY. Techniques and results of urethroplasty for female urethral strictures: our experience with 17 patients. Urology. 2011;77(6):1318–1324. doi:10.1016/j. urology.2011.01.017

53. Labia Minora Skin graft The Labia minora graft is an alternative to the vaginal inlay flap and is well described by Rehder et al

54. Vaginal wall inlay graft 1. A transverse segment of anterior vaginal wall measuring as large as 6 cm × 2.5 cm is harvested

55. urethral meatal preservation ventral urethroplasty

56. Grafts augmentation had an 80%-87% mean success rate oral mucosa grafts’ mean success rate ranged between 89%-94% With an average follow-up of over 18 months closely matches that of patients who underwent flap urethroplasty. Sarin I, Narain TA, Panwar VK, Bhadoria AS, Goldman HB, Mittal A. Deciphering the enigma of female urethral strictures: a systematic review and meta-analysis of management modalities. Neurourol Urodyn 2021;40:65-79. DOI PubMed Osman NI, Mangera A, Chapple CR. A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol. 2013 Dec;64(6):965-73. doi : 10.1016/j.eururo.2013.07.038. Epub 2013 Aug 3. PMID: 23937829.

57. oral mucosa (buccal, lingual) graft Gained popularity Versatility. Easy to harvest, with low donor site morbidity. Easy to handle, have good graft take Minimal contracture Sharma et al lingual mucosa grafts with acceptable results

58. urethral stricture and concomitant stress urinary incontinence de novo SUI is rare as only 6% of at the same time at interval dorsal buccal mucosa graft urethroplasty, and the stress urinary incontinence with a pubovaginal sling. Martius flap may be utilized if needed. Lane GI, Smith AL, Stambakio H, et al. Treatment of urethral stricture disease in women: a multi-institutional collaborative project from the SUFU research network. Neurourol Urodyn . 2020;39 (8):2433–2441. doi:10.1002/nau.24507

59. Martius flap Some authors in all cases when performing a ventral onlay buccal mucosa graft urethroplasty healthy vascular base for the graft, prevents urethrovaginal fistula provides healthy tissue between the reconstructed urethra and the overlying vagina to facilitate any future surgery for subsequent SUI . Mukhtar BMB, Spilotros M, Malde S, Greenwell TJ. Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women. BJU Int 2017;120:710-6.

60. Dorsal vs ventral Dorsal adv Dorsal dis vasculature and support, blood loss urethral meatus directed upward to avoid stream facing the vagina, injury to the clitoris or neurovascular bundle 3) future anti-incontinence procedure increased risk of incontinence pubourethral ligaments and the dorsal muscular fibers of the external urethral sphincter. Ventra dis Adv ventral increased vasculature and support, blood loss urethral meatus hypospadiac facing the vagina, injury to the clitoris or neurovascular bundle 3) future anti-incontinence procedure increased risk of incontinence pubourethral ligaments and the dorsal muscular fibers of the external urethral sphincter.

61. Inlay vs Onlay Most urethroplasty techniques described in the literature were “ onlays ” Advantages of the inlay approach include 1) avoidance of dorsal urethral mobilization which can reduce postoperative pain 2) avoidance of dissection and possible disruption to the nerve and vascular supply of the clitoris which can decrease blood loss and postop sexual dysfunction 3) avoidance of a vaginal incision which can reduce both pain and risk of a urethrovaginal or vesicovaginal fistula 4) avoidance of dissection of anterior vaginal wall by protecting this tissue for future anti- incontinence procedures 5) avoidance of division of pubourethral ligaments . Hoag N, Gani J, Chee J. Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: a novel modification of surgical technique. Investig Clin Urol. 2016;57(4):298–302. doi:10.4111/icu.2016.57.4.298 Nayak P, Mandal S, Das M. Ventral-inlay buccal mucosal graft urethroplasty for female urethral stricture. Indian J Urol . 2019 ;35 (4):273–277. Joshi PM, Kulkarni SB. A new technique of double-face buccal graft urethroplasty for female urethral strictures. Turk J Urol . 2019 ;46 (2):165–168.

62. Future directions Both tissue engineering drug coated balloons may be options Versteegden LRM, de Jonge PKJD, IntHout J, van Kuppevelt TH, Oosterwijk E, Feitz WFJ, de Vries RBM, Daamen WF. Tissue Engineering of the Urethra: A Systematic Review and Meta-analysis of Preclinical and Clinical Studies. Eur Urol. 2017 Oct;72(4):594-606. doi : 10.1016/j.eururo.2017.03.026. Epub 2017 Apr 4. PMID: 28385451.

63. Postoperative Care leaving a catheter indwelling for 2–4 weeks, obtaining a voiding cystourethrogram at time of catheter removal, maintaining antibiotics, usually low dose Ciprofl oxacin or trimethoprim sulfamethoxazole, for the duration of catheterization

64. The harvest

65. no guidelines on how to treat FUS in regard to length and location despite the multitude of techniques Meatoplasties can be appropriate for strictures involving the distal few milli ventral vaginal flap urethroplasty is also appropriate for distal urethral strictures up to 2cm from the meatus. mid and proximal urethral strictures, options include the U-shaped ventral vaginal flap urethroplasty described by Palou, a tubularized vaginal flap urethroplasty and a graft urethroplasty.

66. Voiding cystourethrogram showing proximal urethral dilatation with distal urethra narrowing and distortion of bladder morphology from spherical to oblong (Both: Used with permission from Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: Defi nition and Characteristics. Neurourol Urodyn 2000, 19:213–220)

67. 86 to 93%

68. Where to place the graft remains a subject of controversy dorsal vs. a ventral approach. ventral graft relies on the presumption that it is an easier dissection and that it would preserve sexual function, although there is one study that showed that sexual function is not affected with dorsal approach and, even more, it documented an improvement in sexual function scores[38]. In their respective series, none of the authors performing a dorsal approach reported a decrease in sexual function[39-41]. A dorsal approach preserves ventral tissue planes in case there is a need for a future continence procedure. Additionally, Gomez and Pfeifer[45] proposed the idea that the dorsal approach may entail a lesser risk of incontinence by preserving ventro -lateral supporting structures. Similar de novo SUI rates were found in both approaches (3.6% with a dorsal approach vs. 5.8% with a ventral approach) in a review by Sarin et al.[4]. Although it has been suggested that the ventral approach might increase the risk of urethro-vaginal fistula, there is no data available regarding this complication. Coguplugil et al.[43] suggest that performing a full-thickness vaginal dissection might prevent fistula formation .

69. Dorsal onlay buccal graft urethroplasty sexual dysfunction with this dissection is low, leaving the ventral plane untouched might be convenient for a possible continence procedure in the future if needed. In addition, it helps prevent sacculation of the graft. typically open the meatus; however, a meatus-sparing technique

70. Dorsal Buccal Graft Migliari R, Leone P, Berdondini E, et al. Dorsal buccal mucosa graft urethroplasty for female urethral strictures. J Urol. 2006;176:1473–6.

71. Suprapubic tube obliterative strictures, particularly in radiated patients, antegrade access is helpful. undergoing augment urethroplasty required a suprapubic tube placement preoperatively, and 14% of patients intraoperatively. In rare cases, a suprapubic tube placement or formal urinary diversion should be considered the definitive treatment if reconstructive alternatives fail Riechardt S, Waterloos M, Lumen N, et al. European Association of Urology Guidelines on urethral stricture disease part 3:management of strictures in females and transgender patients. Eur Urol Focus 2021.

72. This not only resulted in deterioration of patients’ health and quality of life but also resulted in increased health costs with $61 million/year spent on female urethral dilation. Data are limited to retrospective series, small patient populations without adequate long-term follow-up. UD overall success is noted to be between 47%-49%[4,20], with success defined as the lack of need for further intervention. These numbers parallel what is seen in male patients as well regarding endoscopic management of urethral strictures. Mean time to failure with UD was 12 months[21]. In our practice, we follow the same principle as in male patients with no more than one attempt of UD per patient given the ( 30%), unless the patient is not a surgical candidate[22]. Spilotros et al.[23]

73. reported a low success rate with one UD procedure, and half of those patients required an additional dilation. Some authors reported a 67%-68% success rate with UD, but this may be attributed to a shorter follow-up period[24,25]. With the increasing interest in this uncommon problem, there has begun a paradigm shift that reflects different training, and more surgeons are choosing to abandon the practice of serial dilations in favor of performing definitive reconstructive repairs. Table 1 summarizes available original articles with outcomes for women undergoing urethral dilation for urethral stricture over the last ten years. The mean success rate in these studies was 54.4% at a mean follow-up of 34.1 months[21-25].

74. Santos JV, Görgen AR, Bortolini T, Silva GV, Santos EB, Tavares PM, et al. Outcomes of urethral meatal preservation ventral urethroplasty for female urethral stricture: a series of cases. Rev Bras Ginecol Obstet. 2024;46:e-rbgo20.

75. Using local tissue to harvest graft is not advised in patients with LS. Also, care needs to be taken when considering estrogen-sensitive local grafts in post-menopausal patients. Hormone creams may be helpful when using local grafts in these women, as suggested by Romero- Maroto et al

76. Pelvic radiation Gomez et al.[ maximizing a conservative approach with these patients. If local tissue is of poor quality, a Martius flap may be utilized to provide a healthy graft bed Gomez RG, Segura FJ, Saavedra A, Campos RA. Female urethral reconstruction: dorsal buccal mucosa graft onlay. World J Urol. 2020 Dec;38(12):3047-3054. doi : 10.1007/s00345-019-02958-6. Epub 2019 Sep 21. PMID: 31542825.

77. Obliterative stricture kissing grafts (dorsal and ventral) may be utilized. Lane et al.[25] reported that 14% of patients Lane GI, Smith AL, Stambakio H, Lin G, Al Hussein Alawamlh O, Anger JT, Brandes ER, Carmel ME, Chung DE, Cox L, DeLong J, Elliott CS, Eltahawy E, Aparecido França W, Gousse A, Gupta P, Hagedorn JC, High RA, Khan A, Kowalik C, Lee RK, Lee UJ, Lucioni A, MacDonald S, Malaeb B, McKay S, Padmanabhan P, Powell CR, Sajadi KP, Sutherland SE, Theva D, Vollstedt A, Welk B, Zheng Y, Cameron AP; Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Research Network (SURN). Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network. Neurourol Urodyn . 2020 Nov;39(8):2433-2441. doi : 10.1002/nau.24507. Epub 2020 Sep 14. PMID: 32926460.