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Pelvic fracture is a serious injury, which has a profound impact on sexual function due to concurrent nervous and urethral injuries. In this case report, we describe a 29-year-old single man who had retrograde ejaculation as a result of a pelvic fracture-related posterior urethral stricture. The patient wanted to improve his ejaculatory ability after experiencing urethral stricture for 8 years and retrograde ejaculation for 3 years following the pelvic fracture. We precisely located and measured the patient's urethral stricture using a retrograde urethrogram, and we used transrectal color Doppler ultrasound to track the patient's ejaculation process in real time. Next, we used urethral balloon dilatation to relieve the urethral stricture. Urinary obstruction symptoms have completely resolved, and the patient was able to urinate without any obstructions. Meanwhile, the real-time transrectal color Doppler ultrasound result showed that some semen might ejaculate externally by passing through the initial stricture area, while some semen continued to flow retrogradely into the bladder.

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Purpose: The primary objective of the conducted research was to develop an urological stent design for the treatment of male ure-thral stenosis. Given the variable loading conditions inside the urethra, the proposed stent should maintain normal tissue kinetics and obstruct the narrowed lumen. The suitable selection for the stent material significantly influences the regeneration and proper remodeling of the urethral tissues. Methods: In this work, the mechanical characteristics of some polymer materials were studied, including: polydi-oxanone (PDO) and poly(L-lactide) (PLLA)/polycaprolactone (PCL) composite. The obtained mechanical properties for static tensile testing of the materials, allowed the determination of such parameters as Young's modulus (E), tensile strength (R m) and yield strength (R e). Subsequently, the design of a urological stent was developed, for which a numerical analysis was carried out to check the behaviour of the stent during varying loads prevailing in the urethra. Result: The research indicated that PDO has better mechanical properties than the proposed PLLA/PCL composite. The numerical analysis results suggested that the developed stent design can be successfully used in the treatment of male urethral stenosis. The obtained stress and strain distributions in the numerical analysis confirm that the PDO material can be used as a material for an urological stent. Conclusions: The biodegradable polymers can be successfully used in urology. Their advantages over solid materials are their physicochemical properties, the ability to manipulate the rate and time of degradation and the easy availability of materials and manufacturing technology.

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The application of Botulinum toxin (Masport) in urology has a long history. We aimed to assess the effect of local Masport on improvement in patients with urethral stricture by reducing the recurrence of urethral stricture. This pilot study conducted was a double-blind randomized clinical trial with code IRCT20191222045852N1 on patients suffering from urethral stricture. Finally, 28 patients were allocated to intervention and control groups. Twelve patients received intralesional injection with Masport in addition to internal urethrotomy, while 16 patients underwent internal urethrotomy with normal saline. The Cox regression hazard model was used to evaluate the effect of treatment status on recurrence time adjusted for the age, length, and location of the stenosis, cause of the stenosis, and history of previous operations. The effect of treatment type was significant at the .05 level. The past medical history and cause of urethral stricture had a significant impact on relapse-free survival. Also, the improvement in the mean score of the EuroQol Visual Analogue Scale (EQ-VAS), International Prostate Symptom Score (IPSS), and Q-max in the group with Masport was significantly different from the group with normal saline. The internal urethrotomy with intralesional injection of Masport has a better survival prognosis than internal urethrotomy with normal saline group. Therefore, the authors suggest that, given this successful initial clinical trial, consideration be given to future studies involving the use of botox in the management of urethral strictures in conjunction with internal urethrotomy.

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OBJECTIVE: To investigate the clinical effect of pulsed thulium laser (PTL) combined with triamcinolone acetonide injection in the treatment of failed posterior urethral anastomosis (FPUA). METHODS: This retrospective study included 35 male patients treated in Gongli Hospital for failed posterior urethral anastomosis from January 2018 to December 2023. All the patients underwent direct-vision internal urethrotomy (DVIU) with transurethral PTL (the PTL group, n = 15) or transurethral plasma (the TUP group, n = 20), and all received intralesional injection of triamcinolone acetonide. We followed up the patients for a median of 21 months, recorded the age, length of urethral stricture, operation time, pre- and post-operative maximum urinary flow rate (Qmax), postoperative complications and recurrence of urethral stricture, and compared the data obtained between the two groups. RESULTS: All the patients smoothly completed the treatment procedures. No statistically significant differences were observed in the age, length of urethral stricture, operation time and postoperative complications between the two groups (P > 0.05). The median follow-up time for the thulium laser group and plasma group was 21.0 months (IQR 16.0－24.0) and 21.0 months (IQR 17.0－25.0), respectively, with a statistically significant difference observed in the maximum urine flow rate before and after surgery at the 12-month mark (P < 0.01). No significant disparity was found in terms of relapse-free survival between the two groups (P = 0.398) Conclusion: Pulsed thulium laser combined with triamcinolone acetonide injection can effectively maintain a short-term cicatricial stability of the urethral stricture and satisfactory urethral patency, obviously superior to plasmotomy as a remedial treatment of urethral stricture after failed posterior urethral anastomosis.

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Cold knife urethrotome was introduced in 1971 and it had an 80% success rate. New advancements in this field have shed light on the use of various lasers such as carbon dioxide, Nd: YAG, KTP, Argon, Ho: YAG, and excimer lasers. It has been observed that cold knife urethrotomy has a higher recurrence rate than laser urethrotomy, but the superiority of either treatment modality has not been established yet. Data were thoroughly searched through PubMed, Scopus, and clinicaltrials.gov. We also used clinicaltrials.gov for ongoing and published research. The data was analyzed via R studio version 2023.12.1 (oceanstorm). For dichotomous variables, Odds Ratio (OR) were used to pool data and standardized mean difference was used for continuous variables with 95% confidence intervals (CIs). A total of 14 studies including 1114 participants were included in this meta-analysis. The results of the combined analysis revealed significant relation with a mean difference of 0.99 (95% CI: 0.37; 1.62), and favored laser group. The overall results have shown the laser to have a significant favorable profile demonstrating a recurrence, Odds Ratio of 0.42 (95% CI:0.27;0.65). Patients with laser therapy had a lower risk of complication rate (OR 0.49, 95% Cl: 0.35; 0.67). All the findings obtained by the analysis in this study favour lasers significantly over the cold knife technique especially when mean Qmax, with recurrence and complications taken into account.

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PURPOSE: To assess self-reported urethroplasty success rates and outcomes of recent GURS fellowship graduates and compare these data to the large body of published urethroplasty outcomes literature. METHODS: A voluntary survey was distributed from June 1 to June 30, 2023 to GURS fellowship graduates of the last 5 years. Participants were surveyed on time since graduation, operative volume, outcomes, and quoted success rates for urethroplasty. Data were then analyzed using descriptive statistics, binary logistic regression, and correlative analyses. RESULTS: We received responses from 49/101 (48.5%) GURS graduates. Five-year post-graduates were most represented (44.7%). The majority (52.2%) consider 81-90% of urethroplasty successful, without significant change with years in practice. Approximately 65% quoted excision and primary anastomosis (EPA) as > 90% successful. Over half of the respondents had performed > 60 urethroplasties since graduation. Only 31.3% of respondents reported re-intervening in > 10% of their postop patients, with a weak positive correlation between years in practice and need for re-intervention (p 0.01). Nearly 20% of respondents referred patients to an external reconstructionist. CONCLUSION: Increased length of time in practice does not result in higher reported urethroplasty success rates, counseling on successful outcomes, or rates of re-intervention and complications. Our survey highlights that the traditionally used success rates for urethroplasty may not be reflective of new graduates and lower volume reconstructive surgeons in their early career.

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OBJECTIVE: To evaluate the relationship between heart failure (HF), chronic obstructive pulmonary disease (COPD), and smoking with the development of urethral stricture (US) by examining the patients who underwent transurethral prostate resection procedure, with and without the development of US in their follow-ups. METHODS: Among the patients who underwent transurethral resection of the prostate, 50 patients who developed US during their follow-ups formed group 1, while a total of 50 patients who did not develop US and were selected by lot formed group 2. The relationship between the patients' data on HF, COPD and smoking status and the development of US was investigated. RESULTS: The mean number of cigarettes smoked was statistically significantly high in the group with stricture (p = 0.007). Furthermore, pulmonary function test parameters of patients such as forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC were found to be statistically significantly higher in Group 2 (p < 0.001, p < 0.001, and p = 0.008, respectively). In the logistic regression analysis, being a smoker was found to be the strongest predictor (p = 0.032). CONCLUSION: Our study concluded that smoking, HF, and COPD significantly increase the risk of developing stricture after transurethral resection of the prostate.

OBJETIVO: Evaluar la relación de la insuficiencia cardiaca, la enfermedad pulmonar obstructiva crónica y el tabaquismo con el desarrollo de estenosis de uretra en pacientes sometidos a resección transuretral de próstata con y sin desarrollo de estenosis de uretra en su seguimiento. MÉTODO: Cincuenta pacientes que desarrollaron estenosis de uretra durante su seguimiento formaron el grupo 1, y 50 pacientes que no desarrollaron estenosis de uretra y fueron seleccionados por lote formaron el grupo 2. Se investigó la relación de los datos de los pacientes sobre insuficiencia cardiaca, enfermedad pulmonar obstructiva crónica y tabaquismo con el desarrollo de estenosis uretral. RESULTADOS: La media de cigarrillos fumados fue significativamente más alta en el grupo con estenosis (p = 0.007). Además, se encontró que los parámetros de las pruebas de función pulmonar de los pacientes, como FEV1, FVC y FEV1/FVC, eran significativamente más altos en el grupo 2 (p < 0.001, p < 0.001 y p = 0.008, respectivamente). CONCLUSIONES: El tabaquismo, la insuficiencia cardiaca y la enfermedad pulmonar obstructiva crónica aumentan significativamente el riesgo de desarrollar estenosis después de una resección transuretral de próstata.

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OBJECTIVE: To analyze current standards in urethroplasty by urologists employing buccal mucosal grafts (BMG) for treating urethral stricture disease (USD). METHODS: An IRB-approved online survey was distributed to members of the Society of Genitourinary Reconstructive Surgeons (GURS) between July and October 2022 to assess BMG utilization in urethroplasty. Questions covered surgeon experience, graft harvest site, graft length, surgical technique, and perceived success rates. RESULTS: Of 350 invited GURS members, 134 responded (38%). Sixty-nine percentage were GURS fellowship-trained, performing 10-30 urethroplasties annually. Ninety-five percentage harvested their own grafts, with 99% preferring buccal mucosa as the primary site. Buccal mucosa was favored over fasciocutaneous flap for penile urethroplasty, regardless of circumcision status (95% with, 84% without). For bulbar urethroplasty with BMG, dorsal graft placement was favored (66%) over ventral (34%). Most surgeons (90%) preferred multiple BMGs over combined graft/flap for panurethral strictures. When harvesting long grafts, 56% preferred using both cheeks. Anastomotic urethroplasty was preferred over buccal graft urethroplasty for short bulbomembranous stenosis post-radiotherapy (63% vs 37%). Surgeons reported a success rate of 80%-90% (53%). CONCLUSION: The expanded scope of reconstructive urology has led to increased use of BMG in diverse urethral reconstructions. Buccal grafts are now preferred for penile, bulbar, and panurethral strictures, demonstrating high perceived success rates in the reconstructive community.

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INTRODUCTION: Internal urethrotomy (IU) has been the most commonly used procedure for the treatment of urethral strictures (US) since it was described by Scahse in 1974. Although simple to perform and associated with a short recovery time, the main disadvantage is the high recurrence rate of stenosis. At present, there are no markers available for the prediction of recurrence after IU. The aim of this study was to evaluate the correlation between MHR and recurrence rates. METHODS: The data of a total of 250 male patients who underwent IU for the first time for bulbar urethral stricture less than 2cm in our hospital between January 2011 and January 2019 were retrospectively analysed. The MHR was calculated as the ratio of monocytes to HDL-C. RESULTS: In all, 78 patients experienced a recurrence while the remaining 177 did not. The stricture recurrence rate was recorded as 31.2% at the 3-year follow-up. There was a statistically significant difference in stricture length and MHR (P=0.015 and 0.001 respectively). MHR was high in the recurrent group. As a result of the Chi-square test, the positive predictive values (PPV) and negative predictive values (NPV) were 65.3% and 89.7%, respectively. ROC analysis was used to determine the optimal cut-off value. The cut-off value was found to be 1.72. CONCLUSION: In our opinion, a high MHR may indicate the presence of immune inflammation and it can be used as a prognostic factor for stricture recurrence after IU.

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A urethral stricture is an abnormal narrowing of the urethra due to spongiofibrosis of the urethral mucosa and the underlying corpus spongiosum. The diagnostics include uroflowmetry, sonography and radiology. For penile strictures the success rate of endoscopic treatment is low. Therefore, urethroplasty should always be performed, preferably using oral mucosa. Depending on the complexity, reconstruction must be carried out in one or multiple stages. For short bulbous strictures endoscopic treatment can primarily be carried out. In the case of recurrence urethroplasty should be carried out. The indications for urethral reconstruction are primarily given for long bulbous strictures. Depending on the length and extent of the stricture, a scar resection and end-to-end anastomosis, non-transsecting end-to-end anastomosis or augmentation urethroplasty can be performed. Perineal urethrostomy (the so-called boutonnière procedure) is a treatment option for patients with complex strictures or for patients who want a straightforward solution.

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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.

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OBJECTIVE: To investigate the potential clinical benefits of mid-urethral sling (MUS) and urethral dilatation (UD) operations for the treatment of stress urinary incontinence (SUI) combined with urethral stricture. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China, from January 2017 to 2022. METHODOLOGY: Patients with Qmax <15ml/s or PVR >50ml, and video urodynamic study (VUDS) capable of confirming the presence and position of urethral stricture were included. The clinical efficacy was evaluated by International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, maximum flow rate (Qmax), and postvoid residual (PVR) urine. ICIQ-SF, Qmax, and PVR were measured presurgery, on postoperative 2-week, and 1-month postsurgery. RESULTS: There were total 19 patients with an average age of 61.37 ± 11.28 years (range 39-84) with SUI and urethral stricture. ICIQ-SF scores were decreased significantly at one month postoperatively compared with the preoperative [5.0 (0.0, 7.0) vs. 14.0 (13.0, 15.0), p <0.001]. Qmax was increased dramatically compared with the preoperative [21.3 (14.0, 28.4) vs. 13.0 (8.7,18.0), p <0.001], and PVR was decreased remarkably than the preoperative [0.0 (0.0,0.0) vs. 0.0 (0.0,60.0), p = 0.018]. Of 19 patients primarily managed with MUS and UD, two patients experienced recurrence requiring repetitive dilation till sling excision surgery was conducted, and improvement was evident in one patient after repeating UD. CONCLUSION: The overall incidence of SUI combined with urethral stricture in women is low. With a success rate of 89.5%, MUS and UD were effective therapies for the co-existence of SUI with urethral stricture, and repeated UD can be performed safely if necessary in long-term follow-up. KEY WORDS: Stress urinary incontinence, Urethral stricture, Mid-urethral sling, Urethral dilatation.

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Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.

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OBJECTIVE: To assess changes in the urinary microbiota after buccal urethroplasty. METHODS: At the University of California San Francisco, we enrolled 9 adult males with urethral strictures undergoing buccal urethroplasty where we collected urine and oral swabs intraoperatively and 3 months postoperatively. 16S rRNA sequencing was used to profile the microbiota. RESULTS: At baseline, the mouth contains twice the number of unique bacteria (alpha diversity) and the microbial community is significantly distinct compared to the urinary tract. Despite having a buccal mucosa in the urinary tract after urethroplasty, the number of unique bacteria in the urine remained stable. However, the bacterial community composition and structure significantly changed in the urinary tract with the enrichment of Corynebacterium genus at 3 months post-urethroplasty procedure. CONCLUSION: In this pilot study, we showed that the alpha diversity in the urinary microbiota did not significantly change despite having a buccal tissue with the capacity to support high bacterial diversity in the urinary tract. To our surprise, the post-urethroplasty urinary microbiota was not a hybrid of baseline oral and urine microbiotas; the changes detected, such as an enrichment of the Corynebacterium genus, were more nuanced yet could profoundly impact surgical outcomes like graft changes and stricture recurrence. Our study not only established the feasibility but also outlined a blueprint for conducting a large-scale study to assess alterations in the urinary microbiome in relation to surgical outcomes.

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The aim of the study was to compare the efficacy of Mathieu combined urethral plate incision (Mathieu-IP) versus onlay island flap urethroplasty in patients with distal hypospadias complicated by urethral stenosis. The clinical data of 70 patients with distal hypospadias complicated by urethral plate stenosis treated in the Department of Urology, Anhui Provincial Children's Hospital (Hefei, China), from May 2019 to May 2022, were retrospectively analyzed. Thirty-eight patients underwent Mathieu-IP (Mathieu-IP group) and 32 underwent onlay island flap urethroplasty (Onlay group). Follow-ups at 1 month, 6 months, and 12 months postoperatively assessed operative time, complications, urethral meatus morphology, and family satisfaction. The Mathieu-IP group had significantly shorter operative time (mean ± standard deviation [s.d.]: 81.58 ± 5.18 min) versus the Onlay group (mean ± s.d.: 110.75 ± 6.05 min; P < 0.05). Surgical success rates were 78.9% (Mathieu-IP group) and 75.0% (Onlay group), with no significant difference ( P > 0.05). Complications were comparable between the groups. The Mathieu-IP group resulted in a vertical slit-shaped urethral meatus in 89.5% versus 13.8% in the Onlay group ( P < 0.05). Family satisfaction with general penile appearance and skin shape showed no significant differences, but the Mathieu-IP group had higher satisfaction with meatal position ( P < 0.05). Mathieu-IP offers simplicity, safety, and shorter operative time compared to Onlay. Both the techniques effectively treat urethral plate stenosis in distal hypospadias, with reduced postoperative complications compared to tubularized incised plate urethroplasty. Mathieu-IP results in a vertical slit-shaped urethral meatus which enhances urinary stream, indicating its potential for broader adoption.

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INTRODUCTION AND OBJECTIVES: Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management. METHODS: A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US. RESULTS: Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%). CONCLUSIONS: The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

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INTRODUCTION: There are currently no clinical criteria for obstructed urinary flow after hypospadias repair surgery. Previous studies have utilized adult and pediatric nomograms and flow shapes to define obstruction, however these methods are limited by a lack of standardization and lack of interrater reliability when determining flow shapes, respectively. The idealized voider derived flow indexes offer a way to track uroflowmetry results in a volume and age agnostic manner. OBJECTIVE: We sought to evaluate all our hypospadias patients over a 10-year period and identify patients without complications and those with complications and determine their respective flow parameters. Our secondary objective is to identify which uroflowmetry parameters are the most significant predictors of urethral stricture and meatal stenosis at the time of the uroflowmetry study. STUDY DESIGN: Retrospective chart review was used to compile demographic information, details of hypospadias repair surgeries, and uroflowmetry results from pediatric hypospadias repair patients. Subjects were divided into distal, midshaft, and proximal groups based on the initial location of their urethral meatus. Flows from the hypospadias repair groups were compared to flows from normal age matched controls from a previous study. We compared flows from hypospadias repair patients with no complications present with those who had urethral stricture or meatal stenosis present at the time of uroflowmetry. Binary logistic regression and ROC analysis was used to assess different uroflowmetry parameters' ability to detect the presence of obstructed urine flow. RESULTS: 467 uroflowmetry studies from 200 hypospadias repair patients were included in the database. Compared to controls, the hypospadias repair groups tended to have significantly lower Qmax, Qavg, Qmax FI, Qavg FI, and longer ttQmax. Significant differences in flow parameters were observed when comparing hypospadias repair patients with and without flow obstructing complications at the time of uroflowmetry. Binary logistic regression including various uroflowmetry parameters showed Qmax FI had a significant effect on the odds of observing the absence of a stricture in proximal and distal hypospadias cases. DISCUSSION: Of the uroflowmetry parameters analyzed, binary logistic regression and the likelihood ratio of a positive result all point to Qmax FI as the better parameter to use to detect the presence of complications in patients who have undergone distal or proximal hypospadias repair surgery. CONCLUSION: We have established normal parameters for post-operative hypospadias repair patients which can be used to follow patients over time and allow for the identification of complications by keeping track of flow indexes which are volume and age agnostic.

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