#M.W x Blade

[julday4]

Aight! Hey ya'll! Long time no see, whoowee-

Aight how do I start this-

So some of you might know goodnightverse by now! (If not, here) the post is a bit old so uh @awelldressedtornado fucking edit it.

And well, since I'm now co-owner of it (wowie) I DECIDED TO MAKE A GNV2 MUAAHAH-

Aka, Goodnightverse: Bed Bugs.

And yes, these are all of the refs I've been talking about. (Warning: some of the refs gotten lazier over time cause I got feddup with drawing the clothes and stuff.) and plus, most of the templates here are copied from discord ahaha aight let's go!

(Also i didn't do everyone refs yet but I did most of them! I'll do the others soon if ya'll are interested-)

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Name: Boots (Aka, Goodnightverse!Rust)

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Creators: Knife and Rose

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Age/Years lived: 13/16 y/o

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Rank: Gaurdian

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Gender: Male

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Weapon or Magic (Specify): A pirate sword that can easily cut through Shadow Demons and are really good for battle. (Especially sword fights). The pirate sword has an Iron blade thats bending a bit and golden plating on the handle.

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Human they protect: Jesse

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Allies: Shine, Flare, PI.FI, Floral and Bush

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Boots acts exactly like a pirate and loves anything pirate related. He says "YARR" unironically, when something intensive is happening or when something awesome (in his opinion) happens. He can get angry sometimes and is very attached to Jesse, Shine and his twin siblings Floral and Bush. He also LOVES fighting shadow demons with his pirate sword :).

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Name: Shine (Aka, Goodnightverse!Lukas)

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Creators: Heart and Lighter

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Age/Years lived: 13/16 y/o

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Rank: Gaurdain

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Gender: Male

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Weapon or Magic (Specify): A microphone that blasts out colorful musical notes, once you press the star button, which explode once they touch a surface. (He can also control how many musical notes that can come out, if he holds in the button, he can swing his microphone and a bunch of musical notes will come out. If he just touches the button once, only one musical note will come out. Its like those mechanics in games). The microphone is like those microphones you see on the news with a singular button. The microphone can also be used for singing and making special effects like: Gasping, laughing, screaming, oof, yay, ect.

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Human they protect: Emerald

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Allies: Boots, Flare, PI.FI, anyone

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Shine is a lil colorful boy who loves singing and making new friends. He loves learning new things and is very energetic! He talks alot like his dad, Lighter. Aka: Yo, bro, dude, BROSKI, broseph, pog, swag, ect. His aswell very attached to his bro, Boots. He loves going on pirate adventures with him, singing with him and everything else. Their the bestest of friends :). He aswell loves fighting Shadow Demons by his Bro's side. Thou sometimes his a bit soft with Shadow Demons and will comfort them if their hurt.

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Name: PI.FI/Pinkie Finger (Aka, Goodnightverse!Hypernova)

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Creators: M.W/Milky Way and Blade

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Age/Years lived: 13/16 y/o

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Rank: Gaurdian

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Gender: Female

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Weapon or Magic (Specify): A wand made out of magic that can be used to summon and levitate things and blast out sparkly magic. Thou she needs to train the wand so she can summon more and levitate heavier things over the years. (Once she becomes a guardian, her wand can levitate a closet or two and summon a brush, rope and shit. Thou she only uses it when necessary). The wand has a baby blue handle with a lil yellow glittery star on top that has a bunch of spikes around, looking like a pretty rock. (Hehhe Sprinkle).

Also uhh, her goop is made out of strawberry sauce. D. Does that count-

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Human they protect: Abigal

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Allies: Flare, Shine, Boots, anything.

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PI.FI is a sweet, lovely, calm but also bossy lil girl. (She's mainly bossy towards Boots and Shine due to their immaturity and stupidity). Shes loves EVERYTHING girly and especially loves sparkly things, like fairies. She's very protective over her friends and especially Flare because how how shy and easily frightened she is. She's very calm towards Flare aswell and tries to make her feel comfortable. She also loves singing with her wand with Shine, their a pretty good duo! (Not as good as Shine and Boots thou). And she loves trying out new things.

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Name: Gold (Aka, Goodnightverse!Drake)

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Creators: Indigo and Monarch

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Age/Years lived: 16/19 y/o

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Rank: Gaurdian......? (Yeah no his a fucking butler now)

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Gender: Male

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Weapon or Magic (Specify): Holographic purple or golden shields that are good for blocking off attacks or Shadow Demon essence. Gold has really good reflexes so his shields are pretty powerful at battles. He can also summon holograms that he uses to code so he can break through the barrier that's stopping him to travel through the multiverse.

He also has the ability to move his rat tail.

(also the reason he doesn't have any eyelights is well uh.. It happened when he started to slowly despise Jesse and despise gaurdians, like the eyelights started to slowly dissappear and they completely disappeared once he argued with Jesse and left her the next day.)

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Human they protect: Used to protect Jesse.

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Allies: Chloe, Floral.

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Gold is a very formal but ALSO EVIL ASS boy. He used to protect Jesse when they were 8-12 y/o until he started to get tired of them. He started to get tired of their same everyday problems, angryness, annoyance, everything. He was tired of humans. One day, he met Chloe and she started telling him her plans and thoughts about gaurdians and humans and about destroying and taking over the gaurdians, Gold, agreed. Gold started to despise gaurdians, despise humans, despise protection. He believe Shadow demons were victorious and were a better future for this world then gaurdians and humans. So one day, after an argument with Jesse, he abandoned them and left them for Chloe and started being Chloe's minion/butler.

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Name: Chloe

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Creators: Neptune and a bunch of glitches

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Age/Years lived: Forever 13 y/o

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Rank: Fucking Shadow Demon Outcode thing

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Gender: None but she calls herself female.

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Weapon or Magic (Specify): Dark pink Gasterblasters and Bones. The same dark pink as her eyelights. That glitch out depending on how long their used. For example: One hour, they'll be glitched out af, and if she hits the victim with them it'll be a PAINFUL CRITICAL DAMAGE SINCE THE VICTIMS BODY WILL START GLITCHING A BIT. Thou she uses Gold, aka her butler/minion, to attack for her since she's also a bit lazy lmao.

She has the ability to enter humans' dreams like everyone else but SHE'S VERY DANGEROUS CAUSE SHE CAN MAKE THE DREAM BECOME MELTY AND GLITCHY, DAMAGING THE HUMAN BRAIN A BIT WHICH ISN'T GOOD.

She has the ability to travel through multiverses and enter shadow pipes like other shadow demons.

Her voice and body will glitch out sometimes and when she teleports inside a dream, she might glitch out a bit aswell like if a gaurdian is failing to enter a human dream.

And her Shadow Demon form is behind her, which she rarely forms into, but it's always behind her, mimicking every action she does. Thou, only Shadow Demons can see her form.

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Human they protect: None. Fuck protection.

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Allies: Gold, Flare, Grain, Alexa, Charlotte(?).

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Chloe is an outcode who's quite lazy and doesn't really care about anyone. She plans on destroying this world and let Shadow Demons rise. But for now she's starting small. She has Gold by her side to help her in battles and give her souls to eat. Other then that, she's just a glitch, a very dangerous glitch. Her main enemy is Boots. (She's also the main villian, lmao)

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(Female)

(Male)

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Name & Last Name: Jesse Cherry Smith

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Parents: Chara Cherry Smith and Alec Margo

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Age: 15 y/o

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Sexuality: Transgender

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Gender: Male (But currently female)

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Hobby: being dead Drawing sometimes and playing the guitar a bit. They mainly just like laying on their bed and doing nothing.

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Personality: Anger issued closeted teen who dislikes being social and will beat up someone if necessary.

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Allies: Emerald, Kyle, Boots, her cat plushie Bow

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(Yes this is a Alec x Chara shipkid stfu it's apparently canon now -)

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Name & Last Name: Kyle Cherry Smith

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Parents: Chara Cherry Smith and Alec Margo

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Age: 8 y/o

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Sexuality: Straight

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Gender: Male

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Hobby: Writing and GOING ON IMAGINARY ADVENTURES ANYWHERE and playing outside.

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Personality: A sweet energetic adventurous imaginative boy who will always find a way to annoy someone and somehow sees good in anything people say. Like seriously how the fuck do I bully you you piece of-

Also he can't read.

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Allies: Abigal, Jesse/Jess/Best sissy in the entire world-, Flare/Flarey/Best partner in the entire world-

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(woah another alec x chara shipkid woa-)

ANNND THAT WAS EVERYONE!! WOOOWIEEEEEEEEEE THAT TOOK FORVER.

Anywho, I hope you guys like them and if you have any questions just ask away! (So sorry that it's so long like jesus-)

Anywho, Alec signing off 😎

(also goodnightverse belongs to @awelldressedtornado)

[damn-stark]

Dark hope ch.10

A/N- .... okay I hope you guys liked it :)

A/N- a lot of Kylo ren lately but then again this is a Kylo ren series so... I seriously don’t know the timeline in this movie so sorry i just know it takes place in like 2 days.

Warning- nothing

Pairing- Kylo ren x reader

Tagged- @angelmarie823

(Let me know if you want to be tagged)

—

“Y/N.” It was like a whisper. Barely audible but you heard it. You looked over your shoulder and noticed that no one was there. It couldn’t be Kylo ren because you would’ve felt his presence. “Y/N.” You heard it again. You halted where you walked and turned and again and no one was talking to you. It was weird but you also weren’t trying to look to into it at the moment. Poe needed you and you couldn’t leave him waiting at a crucial time.

You turn to your left and go into where Poe was waiting for Finn. As you enter you see still an unconscious General organa. You can’t help but feel guilt as you pass by her bed.

“Still nothing?” You asked as you stood across from Poe. He shook his head and you could tell he was worried. And who wouldn’t be. The life of the resistance rested on Finn and Rose to do what they needed to do. And with the first order hitting the crusisers the worry arose in everyone even you. And there’s nothing you could do right now but wait for Finn and Rose.

Poe was more anxious then you were, you could feel it and see it. He’s an impatient man and that’s not good when it came to stuff like this. Yet again you felt the same. Your kept shaking your leg and tapping your fingers on your lightsaber. The room was quiet making it easier to get lost in your own mind. You were not used to this. Being still in one place before when you were with Han and Chewie you were always on the move, never to long in one place or the other until now. And it just seemed weird. You didn’t like it. Because now you thought of memories you’d rather push back but they came up. The memories took over like the darkness and the light that invaded you, fighting for one to take over.

-

Waiting was something you did a lot. You waited for your father to return home. You would sometimes look out the window of the little hut you lived in, you would look outside just in case if your father would show up. Other times you played with the two toys he managed to get for you to play with. But today it seemed that you were restless. Nothing entertained you. You lay on the floor and saw the sky through the window on the ceiling. The sky was clear and blue with no clouds to find a certain form like you did many times when their was clouds. You groaned as you threw your toy across the room. The sound the toy made when it hit the wall was hollow. You quickly sat up and walked towards it.

Your young self to curious not check it out. You let your fingers graze the wall to try and figure out if there was some secret door in the wall. You squinted your eyes and took a step back. A wide smile spread on your lips as you saw the unplaced lining along that spot. Your fingers began to hurt as you tried to pull it out. And when you did you smiled to yourself. That’s when you heard something. A voice. Calling out to you.

“Y/N.” It couldn’t be. There was no one here beside you. You looked around frieghtned but you were also curious and tempted. “Y/N.” You heard the voice say again. You stretched your hand into the opening and then found a box. You felt a strong force in the box. Your fingers trailed along the Initials the box had, M.W. “Y/N” the voice sounded louder and you felt more tempted to open it. As you opened the mysterious box you found something metal. It was not long but also not short and it had a button on it. You touched it to take it out and as soon as you did you got flashes. You quickly let go and dropped the box. Your eyes were wide and you were breathing heavily.

You heard footsteps approaching which caused you to quickly react and put the box away. You closed the little door and made it seem like it was before. You grabbed your toy and rushed to the floor and lay there. The door opened and your father came in. Even if half of his face was covered with a mask you could still his eyes and they seemed to gleam at the sight of you. You jumped up and wrapped your little arms around his neck.

“Hey daddy.” You greeted him with so much joy. Your eyes gazed over to the hidden door on the wall.

“Hey little star.” He responded.

-

“Y/N? Hey. You there?” Your eyes snapped to Poe who was in front of you waving his hand in front of your face.

“Sorry I was just uhmm..thinking of something.” You said with a fake smile. He nodded but you knew he barely believed it himself. “Uhmm I think all this waiting is just making me very nervous.” You say to him as you got up and went to the table.

“Yeah me too why don’t you go rest I know that things haven’t been easy for you.. you know with everything that went on recently.” He said to you. You know what he was referring to and you sighed.

“I’m fine I want to wait here and hear what Finn has to say.” You said to him with a half smile to try and convince him but he didnt look it.

“Go really Y/N I’ve got it handled I’ll get you if I hear anything okay?” You were hesitant but you listened to him.

When you made it to your room you stood in the center. You remembered the memory you had while you were waiting with Poe. Your hand reached for your lightsaber without much thought. You take it out and now that you see your lightsaber you know that before when you had opened that box it was a lightsaber. But who’s? Who was M.W.? As far as you remember you never saw your father use it then again you were young. But the voice you heard was the same voice you heard in the hall before.

You closed your eyes and rubbed them. Their was to much on your mind. When you opened your eyes you saw your lightsaber and ignited it. Revealing the purple double blades. You closed your eyes again for a brief moment and tried to forget your surroundings and focus on your lightsaber. You twirled it in your hand and then swung before throwing it to your other hand. You fought better with your left hand but you also didn’t have problem fighting with your right. Everything around you seemed to disappear as you lost yourself to the movements you were doing with your lightsaber. You felt every thought that worried you disappear. All your problems vanished for that moment.

The moment though was then broken and you felt your lightsaber clash onto someone else’s. You saw the red blade and knew who it belonged to. You looked up and saw Kylo. Your chest was going up and down rapidly due to your training with your lightsaber. It seemed that you were really focused on your training because this time you didn’t feel his presence.

“Ben.” The name escaped your lips without thought as if almost natural. You both didn’t move from your position. Both lightsabers against one another. But it wasn’t in a threatening way. You both just got lost in the moment and saw nothing else but eachother. At that moment you saw it again, you saw it in eyes the soft look. You saw Ben solo. You didn’t see Kylo ren. Just him, Ben. You both at the moment didn’t question the fact that your lightsabers were physically touching.

You saw the way his eyes wondered down below to your lips yours doing the same to his. When you both looked at one another again this time he seemed to wake from the stupor he was in and cleared his throat. You both turned off your lightsaber. You blinked rapidly and then you let your eyes wonder until they landed on him once again. You swallowed thickly as you saw that his exposed chest. You quickly tried to look else where beside him.

“Hold your arm more up.” He said and you looked at him again but avoided looking further then his face. You felt your face get warm and you felt flustered.

“What?” You questioned and not focused on what he was meaning. You saw that he stepped forward and pushed your arm in a higher position. “Oh yeah okay....wait how are you doing this?” You questioned as you furrowed your eyebrows.

“For some reason the force is connecting us and the connection it’s stronger then I thought.” He said. You hummed in agreement and again avoided looking at him. It had seemed that he noticed what was going on with you because he got closer. He moved your arm again into a better figting position. “Now you’ll get a better hit on your opponent.” He told you.

“Should I try it on you?” You questioned with a smirk playing at your lips. He didn’t say anything but you only smiled. “It’s a joke.”

“This is why you need someone to teach you .... I can teach you.” He said with a certain softness to his tone. You sighed and looked away, once again he was trying to convince you. But this time it was different, You saw that his fingers ghosted over your tattoo and scars on your arm. “They won’t hurt you again.” He said quietly. You then felt his hand on yours, you didn’t move your hand away instead you let it happen.

“Ben..” You whispered. When you looked into his eyes you saw this certain look that you couldn’t quite define. Not now anyway. But it felt like he needed you to be with. But what you didn’t see was that when he looked at you he saw everything he’s always wanted, but when he sees himself he sees nothing you deserve. He felt it again, he felt it everytime he was around you,the light. He tried to deny and hide that feeling but he couldn’t. That’s why he always asked to you join him so could deny what he felt. And because when he went to his grandfathers mask it told me do so. To make you join him.

You noticed that his face was just inches from yours, you could feel his breath on you. You both didn’t say anything. You moved your hand slowly to touch his cheek but as you did you heard someone out your door. Poe.

You looked at your door and heard Poe call to you. And in that instant Ben was gone again.

.

.

.

.

.

[juniperpublisherscasestudies]

Juniper Publishers- Open Access Journal of Case Studies

Female Urethroplasty for a Childbirth Related Stricture: A Case Report

Authored by Nicolaas Lumen

Abstract

This article describes a case report of a female who suffered a 23-year long history of urethral stricture disease after a childbirth injury to the urethral meatus and anterior vaginal wall. Despite different attempts of urethral dilations and urethrotomies, the stricture and the obstructive complaints persisted affecting the patient’s quality of life. The patients were finally treated with a dorsal only urethroplasty using a buccal mucosa graft. This was combined with local resection of abundant inflammatory scar tissue at the ventral vaginal wall and urethral meatus. This case report will emphasize on the clinical decision making and the tools used for this as well as on the surgical technique and postoperative care.

Keywords: Urethral stricture; Inflammatory; Postoperative care; Urologic; Diagnosis; Infections; Urethrotomies; Cysto-urethroscopy; Proximal urethra; Dorsal onlay; Vestibulum

Introduction

Reports on diagnosis and treatment of female urethral strictures are rare in urologic literature, as opposed to male urethral stricture disease. Nevertheless, female urethral stricture disease might cause severe obstructive and irritative voiding symptoms as well with a substantial impact on the patient’s quality of life. There are no exact data on the incidence of female urethral stricture disease [1-3]. There is no international consensus nor any guideline on how to diagnose or treat female urethral strictures. Herein, we describe the case of a female suffering a long-standing history of urethral stricture disease finally treated with dorsal onlay buccal mucosa graft urethroplasty with emphasis on the diagnostic work-out, surgical technique and postoperative care.

Clinical Case Description

Previous urological history

A 51-year old female consulted a reconstructive urologist (M.W.) with complaints of painful micturition, incomplete emptying of the bladder, recurrent urinary tract infections, a weak urinary stream and urgency but without any incontinence. She suffered an anterior vaginal laceration extending into the urethral meatus during childbirth 23 years ago. This injury was primarily sutured but no further details on the technique could be obtained from her medical file. Shortly thereafter, she developed the above-mentioned complaints. Numerous (>10) dilations and internal urethrotomies have been performed with only a short temporarily relief of the symptoms.

Diagnostic workout

Clinical gynecological examination revealed abundant inflammatory and indurated tissue just below the urethral meatus (Figure 1). This scar tissue was painful during digital palpation.

Uroflowmetry showed a plateau-shaped obstructive voiding curve with a maximum urinary flow of 11ml/s. Cystourethroscopy was poorly supported because of local pain and not possible because the stricture started directly at the meatus. A 10Fr urethral catheter could not be passed into the bladder. Voiding cysto-urethrography (VCUG) was performed after a 5Fr feeding tube was introduced into the bladder. VCUG showed a distal urethral and meatal stricture with a remarkable dilation of the proximal urethra (Figure 2). Pelvic MRI was performed to exclude any peri-urethral abnormalities. Especially, we wanted to exclude an infected urethral diverticulum or a peri-urethral abscess because of the observed local inflammation. However, MRI was negative for this (Figure 3).

After counseling the patient, it was decided to perform a dorsal onlay urethroplasty with a buccal mucosa graft and excision of the inflammatory scar tissue surrounding the ventral circumference of the urethral meatus. A preoperative urine culture was sterile.

Antifungal resistance

The operation was performed by 2 urethral surgeons (M.W. and N.L.). Prophylactic antibiotics were administrated (1g cefazoline) at induction of general anesthesia. The patient was placed in the lithotomy position with the hips and knees 90° flexion and the legs 45° abduction. The buttock was slightly over the end of the operation table. The feet and lower legs were placed in supportive boots (Figure 4). The surgical field was disinfected using a povidone-iodine solution. Nasal intubation was performed, and the oral cavity was disinfected with chloramine solution in aqua. The labia minora were retracted by a self-retaining hook retractor in order to have a good exposure of the vestibulum, the urethral meatus and the vaginal introitus. A guidewire (5Fr feeding tube) was placed through the urethra inside the bladder in order to avoid creation of false passage during opening of the stricture (Figure 5).

A semi-lunar suprameatal incision was made (Figure 5). The plane between the clitoris bodies and the dorsal urethra was carefully dissected. The pubic bone was digitally palpated and marked the point of proximal dissection. The urethra was progressively opened at the dorsal side and stay sutures were immediately placed at the urethral edges (every centimeter) to facilitate further identification of the urethral mucosa. The stricture was further opened until healthy proximal urethra was encountered which allowed passage of a 25Fr metal sound (Figure 6).

The ventral scar tissue was locally excised until healthy urethral and vaginal mucosa were left over at the ventral aspect of the meatus. The edges were approximated to each other using monocryl™ 4.0 separate sutures. At that stage, a Doyen’s blade was placed at the posterior vaginal wall to further expose the anterior vaginal wall (Figure 7).

A graft was harvested according to the dimensions of the stricture. In this case, a slightly triangular graft was harvested of 3cm long and 2.5cm width. A mouth retractor was used, and the dimensions of the graft were projected at the inner surface of the left cheek with respect for the orifice of Stenon’s duct. The buccal mucosa was infiltrated with a diluted solution of xylocain with adrenalin as a measure of hydrodissection. Dissection was performed using Jones scissors in a submucosal plane above the buccinator muscle. Hemostasis was achieved using bipolar coagulation and the donor area was further left open. The graft was carefully defatted on a silicone plate and meshed. During preparation of the graft, the graft was held wet constantly. A stay suture was placed at the distal end of the graft (Figure 7b).

The graft was transferred to the acceptor area, presented on the silicone plate. The proximal end of the graft (the tip) was sutured to the proximal end of the opened urethra with 2 sutures monocryl™ 4.0. The mucosal surface of the graft was turned towards the urethral lumen and the knots of the suture were outside the lumen. These monocryl™ sutures were further used to approximate the edges of the graft to the edges of the opened urethra on both sides in a running suture fashion from proximal to distal. This suturing also included the peri-urethral tissues in order to have a good fixation of the graft to the surrounding tissues. In addition to this, the graft was centrally quilted to the clitoral bodies with separate monocryl™ 4.0 sutures. At the meatus, the distal end of the graft was sutured to suprameatal incision using separate stitches monocryl™ 4.0 (Figure 8).

At the end of the operation, a 20Fr catheter was inserted, and a fatty gauze was wrapped around this catheter and pushed against the grafted meatus. A vaginal packing was inserted as well for hemostatic reasons (Figure 9). The oral cavity was checked for bleeding before extubation. Operation time (skin-toskin) was 125 minutes.

Postoperative care and follow-up

At the recovery, amoxicillin + clavulanic acid 3 x 500mg and oxybutynin 3 x 5mg daily were initiated until catheter removal. After 3h, patient went back to the standard hospital room. The oral cavity was washed morning and evening, and after every meal with corsodyl™ during 2 weeks. The vaginal packing was removed after one day. The patient was discharged at the 2nd postoperative day without any problems. The catheter was removed after 2 weeks with VCUG showing a patent urethra and no signs of extravasation (Figure 10). Upon clinical examination, there were no wound healing problems. The resected tissue was inflammatory but not malignant upon pathological examination.

At the next postoperative visit (after 3 months), patient reported no voiding difficulties and absence of pain. There was no incontinence. She was very satisfied with the result. Clinical examination showed no abnormalities and a well healed graft in the urethral meatus (Figure 11). The urethra allowed passage of a 14Fr cystoscope without signs of narrowing. The patient provided written informed consent for anonymous publication of this case report.

Comment

Only 10% of women who consult a urologist with obstructive voiding will have a true (“anatomical”) urethral stricture [1- 3]. In this case, stricture etiology was the consequence of childbirth injury. Obsteteric urethral injuries are an import etiology of female stricture formation [2,4]. Frequently reported complaints are a weak urinary stream, sensation of incomplete voiding, straining, frequency and nocturia [5,6]. As in this case, many women also experience pain during micturition, urgency [1,3,6,7] and suffer recurrent urinary tract infections [3,5,6,8]. In women with lower urinary tract symptoms, uroflowmetry must be part of the diagnostic work-out and a plateau-shaped curve is suggestive for a stricture [9]. A gynecological examination is indispensable as it might directly reveal a meatal stenosis and the presence of lichen sclerosus, pelvic organ prolapses or periurethral abnormalities. This examination must also emphasize on the quality of local tissues which might be used for urethral reconstruction [1,2]. In this case, the presence of inflammatory scar tissue at the ventral aspect of the meatus revealed during gynecologic examination was important for the choice of technique. In the present case, a 10Fr catheter could not be passed through the stricture. Although there is no strict definition about the caliber of the urethral diameter, the inability to pass a 14Fr catheter is generally considered pathognomonic for the presence of a urethral stricture [3,10,11]. Cysto-urethroscopy is not possible in case of meatal or very distal urethral strictures [11], but it might directly visualize a more proximal stricture without providing information about the stricture length. Voiding cysto-urethrography (VCUG) is more informative about the stricture location and stricture length. Filling of the bladder is accomplished by either suprapubic access, if a suprapubic catheter has been placed, or by passing a small-caliber (e.g. 5Fr feeding tube) catheter through the stricture inside the bladder. During voiding, the urethra proximal to the stricture will show dilation with abrupt narrowing at the stricture site [5,12]. This so called “wine glass image” was clearly visible upon VCUG (Figure 2) and directly disappeared postoperatively (Figure 10). In case of any doubt of concomitant abnormalities (urethral diverticula, abscess formation, etc.), pelvic MRI is advised to diagnose or rule this out [2,9,11].

No guidelines exist on which diagnostic modalities must be used during the work-out [3], but before start of urethroplasty, the surgeon should have sufficient information on the presence, extent and location of the stricture as well as on the quality of surrounding structures in order to be prepared for the urethroplasty.

The patient in the present case underwent numerous dilations and internal urethrotomies. This initial trial with endoluminal treatments is common practice in female urethral stricture disease despite disappointing long-term results. Based on a systematic review of Osman et al., the composite success rate was only 47% but should be considered even too optimistic as most of these women underwent intermittent catheterization which is a surrogate form of dilations [11]. All types of urethroplasty are associated with a higher success rate. Vaginal flap urethroplasty, vaginal/labial graft urethroplasty and oral mucosa graft urethroplasty have a composite success rate of respectively 91%, 80% and 94% [11]. No large and well-conducted comparative trials have been performed to evaluate whether one technique is superior to another, whether the dorsal location is better than the ventral one or whether a specific type of graft performs better than the others. As a consequence no, general recommendations exist on which technique to choose [13]. In this case, we opted for buccal mucosa. This was in part the preference of the surgeon who is familiar with harvesting buccal mucosa for male urethral stricture disease. Vaginal mucosa seemed not suitable as the local vaginal tissues were inflammatory. The dorsal approach was opted here above the ventral approach. Again, because of the inflammatory vaginal tissue at the ventral aspect of the urethra, we estimated that the dorsal side of the urethra would be a more secure graft bed. Furthermore, because of pain, we opted to resect this abnormal tissue and we feared for paucity of local tissue to cover an eventually placed ventral graft. In this case, a Martius fat flap would be an option but this add to the morbidity of the operation (labial hematoma, cosmetic labial problems, decreased sensitivity, local pain) and was not preferred by the patient after discussing the options [14,15]. On the other hand, ventral procedures are reported technically easier to perform [11]. Nevertheless, we experienced no specific technical challenges during the dorsal approach performed herein. Another theoretic advantage of the ventral approach is the reduced risk of stress urinary continence because of the omega-shape of the female urethral sphincter with its ventral midline deficiency [3,9]. However, this hypothesis seems to be solely theoretical as no excess in stress urinary incontinence has been reported with dorsal procedures so far [11]. Our patient also reported no incontinence, despite this dorsal approach. Another concern with the dorsal approach is the risk of bleeding and damage to the clitoral bodies [3]. The fear of injury to the clitoral neurovascular bundle seems not to be justified [11]. We experienced no problems with this during the operation herein reported. In this case, the graft was meshed to allow fluid evacuation and quilted against the graft bed to ensure a close contact between the graft and the graft bed. A close contact between the graft and a well-vascularized graft bed is an important prerequisite in graft urethroplasty [16]..

This case shows that a surgeon performing female urethroplasty should master different techniques in order to be able to adapt his technique to the local circumstances. In this case we opted for a dorsal approach because of poor quality of the ventral tissues. However, in case of the opposite situation, a ventral approach might be more suitable. Therefore, these techniques should not be regarded as competitive to each other but more complementary in the armamentarium of the reconstructive surgeon. The duration of urethral catheterization varies among series but is usually 2-3 weeks [7,9,13]. In this case, we maintained the catheter for 2 weeks and used VCUG upon catheter removal to exclude extravasation. This is inspired from our experience in males [17]. Vaginal packing during 24h is also advised by others for hemostatic reasons [10]. Longer follow-up of this case is needed because grafts might have the tendency to retract with time and long-term results in male have showed a steady deterioration [18].

Conclusions

This case showed the initial success of dorsal onlay urethroplasty with a buccal mucosa graft in a female with a urethral stricture refractory to endoluminal treatments. Longer follow-up and larger, preferable comparative series are needed to define the exact place of this technique in female urethroplasty.

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[damn-stark]

Dark hope ch.3

A/N- I know this was not the best chapter but the next one is going to be great!! Because we’re finally going to have Kylo in it!! Hope you still enjoy it tho :)

I know this isn’t a long chapter like the previous chapters but I want to include the battle and just focus on that in the next chapter all together.

Warning- nothing much.

Pairing- Kylo Ren x Reader

Tagged- @angelmarie823

(Let me know if you want to be tagged)

—

As you land on takodana Rey gets off first with much exciment. As she sees the green earth her face looks like that of a little kids when they see a sweet. You look like the way she reacted and looked at the planet with much and new found love. Han and chewie left the cockpit leaving just Finn and you alone. You turn to look at him and you swear you see almost see the expression Rey had on his face.

“So you’re a big part of the resistance?” You ask him causing him to turn to face you. He swallowed thickly and eyes seemed to look all over the place beside you.

“Uh yeah yeah I am, big deal.” He said fumbling with his words. You raised an eyebrow and narrowed your look at him as if you were reading his thoughts. I mean you probably could using the force but you didn’t know how and you didn’t want to.

“I know someone from the resistance. He’s a great pilot and he’s one of my best friends beside Chewie. You might know him.” You say and he swallowed thickly again and rubs the back of his neck.

“Uh maybe what’s his name?” He asks still only making minimal eye contact with you. You knew something was up. He seemed very nervous everytime he talked about the resistance.

“His name is—-”

“Big deal come here I have something to give you.” You hear Han shout to Finn. Finn clears his throat and quickly gets up from where he was sitting. He turns to look at you one last before he left to go find Han. He was probably being very secretive or something else was up. You were going to find out one way or another.

-

As you enter Mazs castle you hear the music being played. You see a lot people inside. Some people you notice from running into them from jobs you’ve had. After joining Hans crew you became a pretty well known smuggler especially after almost all the team got taken out only leaving you three. A couple of them wave your way and you do the same in return.

“HAN SOLO!” You hear someone say. All of sudden all music stops and everyone stops talking. You along with them turn to look at the voice who had called out to him and it was none other than Maz Kanata.

“oh boy. Hi Maz.” Han responds as he waves her way. The music and the people start back up again and maz walks your way. A smile grows on your features as she goes to where you all are standing.

“Y/N my favorite human!” She says to you with a smile of her own.

“Hey maz!” You tell her in return. She looks over to Han and then you and then looks over at Rey and Finn.

“Where’s my boyfriend?” She asks and you knew immediatly who she was talking about. You now have a smirk on your face in amusmant as she said that.

“Chewies working on the falcon.” Han responded to her question.

“I like that Wookiee. I assume you need something desperately, let’s get to it.” She says as she begins to walk you all to go sit down and talk with her.

Han is the one that does the explaining on how BB8 has a map to Luke skywalker and we need her help to get him back to the resistance base. And her answer was kind of surprising to you, you expected her to say that she would help but she said no. And when she did you could tell Han had the same suprised look. But when she explained why you actually agreed somewhat agreed with her but you didn’t admit that out loud to Han.

“The only fight against the dark side, through the ages Ive seen evil take many forms the empire today it is the first order their shadow spreading across the galaxy we must face them. Fight them. All of us.” Maz explained. You sat your food down and as you were about to agree with her and her statement Finn talked first. You looked at him and he seemed almost afraid.

“Their is no fight against the first order not one we can win. Look around theirs no chance we haven’t been recognized already I bet you the first order is on their way right—-” he suddenly stopped and looked at maz who was doing something with her glasses. Finn looked over at you confused on her actions. He looked at you to see if you had an answer and you just shrugged your shoulders as you continued eating your snack.

“What are you doing?” Finn asked as he continued looking at Maz confused. Maz then continued to get on the table and get closer to Finn.

“Solo what is she doing?” Finn asked.

“I don’t know but it ain’t good.” Han responded withlist remaining the same calm expression. You and Han shared a knowing look though as Maz stared at Finn.

“If you live long enough you see the same eyes in different people. I’m looking at the eyes of a man who wants to run.” Maz said to Finn. You sat in your seat and watched and heard the exchange carefully.

“You don’t know a thing about me, where I’m from, what I’ve seen you don’t know the first order like I do. They’ll slaughter us we all need to run.” Finn said to Maz as he leaned in on the table.

“This one is here has seen and has been through things you don’t see her running away.” Maz says talking about you. You avoid everyone’s glance your way as she does. “Hmm you see those two they’ll work for trasportion to the outer rim. There you can disappear.” Maz said to him. You were quite taken back that Finn wanted to run away. You felt hurt a little and it felt strange because you had just known the man. Rey started protesting to his decision. You didn’t want to watch their conversation or the way Rey sounded hurt when she talked to him. So instead you looked somewhere else. But when you felt and heard Finn stand up you couldn’t help but look his way and you two made eye contact. It looked like he wanted to tell you something but he just pressed his lips together and went to hand Han the weapon he had given him but Han told him to keep it.

Finn and you shared one last glance and before he turned to leave you smiled at him and he returned it. When he turned around Rey followed. You wanted to, you really did but stayed put. You wanted to tell him to stay you wanted to know what you were feeling for him. But you didn’t so instead kept sitting alongside Han and Maz.

“Ive got something for you.” Maz said to you with a smile. You knew what it was and it made you somewhat happy after what just had happened.

-

You follow Maz into one of her many rooms. As you enter she starts looking in a chest. It takes her while of searching until she lift her head back up turns to face you revealing a box in her hands. She hands it to you and you take it carefully. On the lid theirs two letters engraved on them M.W. Your fingers trace the letters wondering what they meant. You opened the box and you unfolded the fabric to only reveal a....lightsaber.

“A lightsaber?” You question her.

“Its belongs to you, You have to find Luke skywalker so he can help you so you can be that hope the galaxy needs.” Maz said and she grabbed onto your hands. You offered her a small smile.

“I will.” You say. She pats the back of your hand and begins to leave.

“One Last thing .” She says as she turns she grabs something and turns to hand it to you, it was your last remaining piece. You had so many questions but as you look up she’s gone.

You sit down and set each piece in the way it was going to form. The last piece you set on the floor is the crystal. As you set it in place, you take a deep breath and shut your eyes for a couple seconds. When you open them you feel ready.

You outstretch your hand and open your palm and point in at the unbuilt saber on the floor. You do as you did many times before when you were going to use the force. You feel it within you and aim it at the saber. The saber floats in the air and you close your hand gently and the saber begins to form. As you close your hand tighter the saber then shines and everything is in place. You then set the saber on your hand. You feel proud of yourself as you see that it’s complete at last. A wide smile grows on your face. You quickly stand up and then turn on your saber.

You now had two lightsabers now that could also turn into a double bladed saber. You grab the one that Maz had given you and in instant you’re somewhere else.

You’re back at your house. You see a shadow of man when you look up you see his face hidden under his hood. You stand to get a better look but the same purple blade ignites sending you back. The man says yours name but he disappears. You exit your home and see two people now leaving. He was your father and the mysterious man.

“Father!” He doesn’t turn just keeps walking away like that day years ago. You turn back to your house it’s all of sudden dark and same hooded man falls back breaking the glass and over the edge. You quickly run to reach for him but you’re now in a different place. You look around in a panic, fear is overcoming every emotion until you see someone hidden behind a mask. In that instant you feel different then you did a minute ago.

“Please.” He says as he has his hand out to you. You want to take it but it begins to rain and thunder and lightening follow, the man is gone and the fear returns. The lightening is the only thing that lights the darkness, in the flashes of light theirs a slioutte if someone to hard to distuguish. The thunder stops but you see a chair now, built like one for some king but consumed with evil. An evil laugh echoes through the room and then you’re back in Maz castle.

As you see your saber in your hand. The fear disappears and you feel happy as you see your completed saber. You wanted to show someone what you had just completed. You turn to the side as if expecting someone to be there to celebrate your small sucess but you remember that you’re here alone. The first person that came to mind though was the man hidden behind the dark helmet and you didn’t know why but he did. You shrugged him out of your thoughts and then made your way out to go look for Han or Rey.

As you go out you notice that everything began to shake. Rubble fell from the ceiling. You stood still in your tracks and tried to listen to what was happening. And that’s when you heard the passing of TIE fighters. You swallowed thickly at the the thought. You grip onto your newly built saber that you have in your hand. The first order is here.

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