Imaging of male urethra

Electrocoagulation Therapy for Urethral Condyloma Acuminata in a Male Patient: Case Report

Condyloma acuminata (CA) is a common manifestation of human papillomavirus (HPV) infection affecting the urogenital tract. While external genital lesions are frequently encountered, urethral involvement presents a therapeutic challenge due to the risk of recurrence and long-term complications such as urethral stricture. We present a case of urethral condyloma acuminata in a 43-year-old male patient who demonstrated favorable progression following electrocoagulation therapy. The patient presented with urethrorrhagia and lower urinary tract symptoms, with subsequent diagnosis confirmed via urological examination. Negative results from extensive microbiological testing supported the diagnosis. Treatment involved biopsy excision combined with electrocoagulation, resulting in complete resolution of symptoms without recurrence at 2-month follow-up. This case underscores the importance of individualized treatment strategies for intraurethral condyloma acuminata and highlights electrocoagulation therapy as a viable option with favorable outcomes.

Impact of Adding Urethral Sonography with Retrograde Urethrography in Preoperative Assessment of Anterior Urethral Stricture

Background

Even with underlying risk factors and limitations, retrograde urethrography (RGU) is the most popular imaging modality in the assessment of anterior urethral stricture. Urethral sonography (SUG) is an able imaging modality in use for the last few years which evaluates anterior urethral stricture without these risks, though it is still not much popular due to its complexity. This prospective study was designed to compare the assessment made on SUG with the results of RGU and to analyze its impact on surgical decision-making when the results of SUG were taken into consideration with RGU.

Methods

Thirty patients with anterior urethral stricture were assessed for stricture location, length, and associated urethral pathologies with RGU and surgery planned accordingly. Later, all were reevaluated with SUG, results compared with that of RGU and surgery replanned, considering both RGU and SUG findings. All results were compared with operative findings.

Results

The mean stricture lengths on SUG, RGU, and surgery were 20.45 mm, 17.15 mm, and 20.38 mm, respectively. Overall sensitivity and specificity of SUG in actual stricture length prediction were 92.3% and 96.1%, whereas these were 78.9% and 85.1%, respectively, on RGU. Spongiofibrosis was assessed only with SUG, that too, with 85%-90% accuracy. Surgical plan was changed in 31% of cases when SUG findings were taken into account along with RGU findings.

Conclusion

SUG was found more precise modality in the measurement of stricture length and more informative and elaborative in providing added knowledge of degree of spongiofibrosis and associated pathologies of diseased urethra and periurethral tissue. For better preoperative planning of anterior urethral strictures, SUG should be added to work-up along with RGU.

Ultrasound imaging of male urethral stricture disease: a narrative review of the available evidence, focusing on selected prospective studies

PURPOSE

To synthetize the current scientific knowledge on the use of ultrasound of the male urethra for evaluation of urethral stricture disease. This review aims to provide a detailed description of the technical aspects of ultrasonography, and provides some indications on clinical applications of it, based on the evidence available from the selected prospective studies. Advantages and limitations of the technique are also provided.

METHODS

A comprehensive literature search was performed using the Medline and Cochrane databases on October 2022. The articles were searched using the keywords "sonourethrography", "urethral ultrasound", "urethral stricture" and "SUG". Only human studies and articles in English were included. Articles were screened by two reviewers (M.F. and K.M.).

RESULTS

Our literature search reporting on the role of sonourethrography in evaluating urethral strictures resulted in selection of 17 studies, all prospective, even if of limited quality due to the small patients' number (varied from 28 to 113). Nine studies included patients with urethral stricture located in anterior urethra and eight studies included patients regardless of the stricture location. Final analysis was based on selected prospective studies, whose power was limited by the small patients' groups.

CONCLUSION

Sonourethrography is a cost-effective and safe technique allowing for a dynamic and three-dimensional urethra assessment. Yet, because of its limited value in detecting posterior urethral strictures, the standard urethrography should remain the basic 'road-map' prior to surgery. It is an operator-dependent technique, which can provide detailed information on the length, location, and extent of spongiofibrosis without risks of exposure to ionizing radiation.

Treatment of giant prostatic urethral stone with prostatolithotomy case report

INTRODUCTION

The patient with prostatic urethral stones of the size mentioned in the case report is very rare, and there is no standard surgical procedure for patients with giant stones in the prostatic urethra.

PRESENTATION OF CASE

A 62-year-old male patient presented to the emergency department with complaints of dysuria and hematuria. Computed tomography showed a prostatic urethral stone measuring 78x48x56 mm. Open prostatolithotomy was performed by extending the bladder incision towards the prostate capsule and the stone was removed.

DISCUSSION

Prostate stones can be classified into two types: true prostate stones, which form within the prostate's tissues, and urethral stones, which develop in the prostatic urethra. Urethral stones can be primary (forming in the urethra) or secondary (migrating from the upper urinary tract).

CONCLUSION

Treatment options vary based on stone size and patient history, with endoscopy recommended as the primary approach. However, in cases with large stone burdens, open surgical methods may be preferred.

An innovative method for occluding the urethral meatus and accessing urethra strictures in retrograde urethrography in males

OBJECTIVES

To observe and evaluate the effectiveness and safety of using a sponge plug method to occlude the urethral meatus during retrograde urethrography (RUG) for accessing male urethral strictures.

METHODS

40 male patients with a mean age of 51.4 years and a history of urethral injury were primarily diagnosed with urethral stricture using a urethrocystoscope. RUG was performed using a ureteral catheter with a sponge plug inserted into the external meatus. Iodixanol, a contrast medium, was injected into the urethra or bladder for performing RUG and voiding cystourethrography (VCUG). The patients were positioned obliquely to obtain urethrograms.

RESULTS

All X-ray radiologic procedures for performing urethrography were successful without any overflow of contrast liquid observed. In all cases, the sponge plugs became visible in the resulting images. The external meatuses were directly visualized in all cases on the obtained images, allowing identification of the number, location, and length of strictures as well as coexistent pathologies such as fistulas. In one case, the plug slipped off the meatus immediately after completing the procedure. The pain Visual Analogue Scale (VAS) was 0 to 2, mean 0.35. No instances of complication or adverse reactions was observed.

CONCLUSIONS

The sponge plug effectively occludes the external urethral meatus for retrograde urethrography, enabling visualization of the actual caliber of the entire urethra, including the strictures and external meatus, by filling it with contrast liquid. This technique is safe and well-tolerated by patients.

A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment

Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.

MRI and MR voiding cystourethrography in the evaluation of male primary bladder neck obstruction: preliminary experience

PURPOSE

Evaluation of male with primary bladder neck obstruction (PBNO) using MRI and MR voiding cystourethrography (MR-VCU) to study both anatomical aspects of bladder neck and urethral lumen.

METHODS

In this retrospective study 21 male patients (mean age 33 ± 14) with urodynamic diagnosis of PBNO and 5 healthy volunteers ((mean age 28 ± 2) as control group were enrolled. Both patients and control group underwent 1.5 T MRI. Sagittal and oblique coronal Turbo-Spin-Echo T2-weighted scans were performed. Only patients underwent MR voiding cystourethrography (MR-VCU) performed with T1-weighted spoiled 3D gradient-echo sagittal acquisitions. Bladder lumen was filled with contrast-material-enhanced urine. Blinded test by two radiologists was performed to evaluate causes of bladder outlet obstruction evaluating MR-VCU. Anatomical MRI features of both control group and patients were compared in consensus by senior radiologist and urologist using the analysis of variance (ANOVA) test.

RESULTS

MRI allowed evaluation of the bladder neck muscular structures. We found 4 groups of PBNO patients: 52% hypertrophy of posterior lip of bladder sphincter; 20% asymmetry of lateral portion of bladder sphincter; 14% bladder neck cyst; 14% showed normal aspect of bladder neck. Comparison between the control group and first and second PBNO groups was considered statistically significant (p < 0.05) with diagnostic accuracy of 87%. Only 13 patients (61%) were able to perform MR-VCU and radiologists always made the diagnosis of PBNO.

CONCLUSION

MRI together with MR-VCU provides useful anatomical and functional information in the study of bladder neck and urethral lumen. These preliminary results suggest that MRI could substitute for standard cystourethrogram in patients with PBNO.

Contrast-enhanced voiding urosonography part 2: urethral imaging

Ultrasound (US) has been increasingly used as an important imaging tool to assess the urethra in children. The earliest reports of pediatric urethral sonography involved imaging the urethra in a non-voiding state, during physiological voiding of urine, and after instillation of saline. The introduction of US contrast agents has continued to improve visualization of urethral anatomy. Contrast-enhanced US of the urethra can be performed during the voiding phase of a standard contrast-enhanced voiding urosonography (ceVUS) exam or with retrograde instillation of a contrast agent, depending on the exam indication. Both techniques are well tolerated by children and provide accurate information about urethral pathology and periurethral soft tissues. This article reviews the technical aspects and imaging findings of urethral pathologies in children using contrast-enhanced US, both by the voiding and retrograde instillation techniques.

Outcome of Delayed Perineal Anastomotic Urethroplasty in Children with Post-Traumatic Urethral Stricture in a Tertiary Center, Addis Ababa, Ethiopia

Background

Urethral stricture is a challenging urologic problem resulting from congenital, idiopathic, traumatic, iatrogenic,and inflammatory causes. Road traffic accidents and falling-down accidents are the most common traumatic causes. Although most management principles are extrapolated from adults, stricture in children has a unique anatomic challenge. The outcome of urethroplasty is reported to be good in nearly all patients according to different studies. Since there is no study from Ethiopia on this subject, our work will show our experience with the problem.

Patients and Methods

We conducted a retrospective study of children who underwent delayed urethroplasty for post-traumatic urethral stricture from November 2011 to November 2019. A retrospective study was conducted on boys for whom delayed perineal anastomotic urethroplasty was performed after they sustained trauma. Sociodemographic data, pre-operative presentation of patients, and intraoperative conditions were assessed. The need of any further procedure to micturate, stream of urine and urethral caliber on post-operative cystourethrography were parameters used to measure the outcome. Data were entered into SPSS version 24 and analyzed, taking a p-value of 0.05 as statistically significant.

Results

Nineteen boys had delayed perineal anastomotic urethroplasty in the study period, with a mean age at the time of surgery being 9.8 years. Out of these 19 patients, nine had been involved in road traffic accidents, eight had fallen from a height, and two had bullet injuries. The membranous urethra was the most commonly affected part and, in seven of them, associated pelvic bone fracture was documented. The affected urethral segment length ranged from 1–3 cm, with a mean of 1.77 cm. For all of them delayed perineal urethroplasty was performed after a minimum of 3 months. Successful outcome after primary surgery and re-do surgery was 58% and 82%, respectively.

Conclusion

Urethral stricture is an uncommon condition in children but is one of the challenging conditions a pediatric urologist faces. Our study showed that perineal urethroplasty can be done safely in most children with urethral stricture, but unless adequate pre-operative evaluation and strict surgical principles are followed the outcome will be poor.

Pulsed fluoroscopy in retrograde urethrograms

OBJECTIVES

Retrograde urethrogram (RUG) is one of the corner stones for the reconstructive urologist. With hundreds of RUGs being performed yearly in busy reconstructive center, the concern for radiation exposure to the patient and the medical personnel becomes important. We propose the use of pulsed fluoroscopy to decrease the radiation exposure for patient and medical personnel.

METHODS

Patients presenting to our center with urethral strictures between March 2016 and March 2019 were included in our study. The fluoroscopy machine was set for pulsed fluoroscopy at a setting of 4 pulses per second. Patient information including demographics, pre-operative diagnosis, Intra-op findings, and fluoroscopy time were recorded. RUG was performed to localize the stricture pre-operatively and post-operatively.

RESULTS

A total of 185 RUG were performed between March 2016 and March 2019. The median age was 63 (14-81). The remaining 154 RUG had 77 performed pre-operatively and 77 performed post-operatively. Pathology was identified in 77 patients. Intra-operative confirmation of pre-operative finding was found in 76 patients (98.7%). Median fluoroscopy time was found to be 2.43 seconds (0.5 sec- 6.5 sec).

CONCLUSIONS

Pulsed fluoroscopy reduces the radiation exposure in RUG without a reduction in the diagnostic capacity of the test. Reduction of fluoroscopy can have beneficial cumulative effect as per the ALARA principle for patients and medical personnel. Further studies with randomized control trials could be of great benefit.

Contrast-enhanced voiding urosonography (CEVUS) as a novel technique for evaluation in a case of male urethral diverticulum

Male urethral diverticulum is an uncommon entity, the abnormality being more frequently encountered in females. The pathology may be congenital or acquired and the more frequent acquired type usually occurs following trauma. Afflicted patients usually lack specific symptoms, although in a few instances, symptoms of lower urinary tract obstruction, calculi, or infection may prevail. Imaging investigations utilizing a composite Retrograde urethrography (RGU)– Voiding cystourethrography (VCUG) protocol are accepted as standard approach and ultrasound is considered a secondary supplementary investigation. However, recent literature reports the utility of contrast-enhanced ultrasound (CEUS) as a novel technique in the evaluation of urinary bladder and urethra, for vesico-ureteric reflux (VUR) in children and for urethral diverticula in women. We report a case of acquired post-traumatic urethral diverticulum in an adult male patient and document a relatively unexplored novel application of contrast enhanced voiding uro-sonography (CEVUS) for the evaluation of this malady.

Imaging of the adult male urethra, penile prostheses and artificial urinary sphincters

To discuss the imaging appearances of various pathologies affecting adult male urethra and to review the role of imaging in the assessment of artificial urinary sphincters and penile prostheses. Diagnosis of common male urethral diseases heavily depends on two conventional fluoroscopic techniques namely retrograde urethrography and voiding cystourethrography. These are useful in evaluating common urethral diseases like traumatic injury, infections, and strictures. Cross-sectional imaging can be useful in evaluating periurethral pathologies. Artificial urinary sphincters, slings, and periurethral bulking agents are used in the management of urinary incontinence and imaging can be utilized to detect complications in these devices. Cross-sectional imaging especially MRI plays a significant role in evaluating the different types of penile prostheses and their malfunctioning.

Biomechanical analysis of the interaction phenomena between artificial urinary sphincter and urethral duct

Male urinary incontinence is a widespread healthcare problem, leading to a miserable quality of life. Artificial urinary sphincter (AUS) is a device inserted mostly around the urethra in adult males, which mimics the urinary sphincter by providing a closure during urinary storage and a subsequent open to permit voiding. The interaction phenomena occurring between AUS cuff and urethral duct represent a fundamental problem in the investigation of AUS reliability and durability. In this work, computational methods are exploited to deeply investigate the mechanics of interaction phenomena occurring between urethral duct and AUS device. Experimental studies are performed on urethral tissues, and structural tests are carried out on the overall urethral duct to obtain a large set of information required for mechanical properties definition. The mechanical behavior of AUS cuff is investigated using mechanical and physicochemical procedures. The cuff conformation is acquired by computed tomography techniques for the definition of the numerical model. Numerical analyses are developed to evaluate the mechanical response of urethral duct in interaction with AUS cuff, considering the lumen occlusion process for maintaining urinary continence. Finally, the investigation of the compressive stress and strain fields within urethral tissues allows the identification of device performance and reliability in correlation with surgical practice.

Acute penile trauma: imaging features in the emergency setting

In an emergency department, penile traumas are uncommon and a prompt diagnosis is necessary. Penile injury may result from penetrating and non-penetrating trauma. Non-penetrating injuries can produce cavernosal hematomas or fractures: if not treated promptly, these lesions can result in fibrosis or erectile dysfunction. Penile traumatic lesions need a clinical approach first, but a radiological study is often required: ultrasonography with color and spectral Doppler study is usually the first approach. In some cases, magnetic resonance imaging may be performed to better recognize even small discontinuity of the tunica albuginea. Radiologists have to be aware of the various radiological patterns of penile traumatic lesions, in order to establish a prompt and correct diagnosis.

Morphological and clinical evaluation of prostatic urethra using modified sonourethrography with retrograde jelly injection

OBJECTIVE

Using modified sonourethrography (mSUG) with retrograde jelly injection to precisely measure the morphological characteristics of the prostatic urethra, we assessed prostatic urethral morphology associated with clinical parameters of benign prostatic hyperplasia (BPH).

METHODS

BPH patients (n = 43) and control patients with localized prostate cancer (PC; n = 57) were imaged by mSUG before surgery. Using the seminal colliculus as a landmark, prostatic urethral angulation (PUA), sagittal urethral diameter, and anterior or posterior prostatic urethral length were measured. The International Prostatic Symptoms Score (IPSS) was also evaluated in all patients. The Bladder Outlet Obstruction Index (BOOI) was measured in BPH patients that could void in a pressure-flow study. Parameters were compared between BPH and PC patients, and correlations among morphological and clinical parameters were evaluated.

RESULTS

Prostatic urethras were clearly observed in all patients by mSUG. PUA, sagittal urethral diameter, and posterior urethral length were all greater in BPH than PC patients (P < .05). Among all parameters examined, PUA had the strongest correlation with IPSS (r = 0.56). Longitudinal urethral diameter showed the strongest correlation with BOOI, whereas PUA was not correlated with BOOI.

CONCLUSIONS

Prostatic urethral morphology can be imaged precisely by mSUG. Morphometric measurements showed that increased PUA was strongly correlated with problematic urinary symptoms, and a flattened shape of the posterior urethra, such as extension of the sagittal urethral diameter, was correlated with urinary tract obstruction by BPH.

Urethral lumen occlusion by artificial sphincteric devices: a computational biomechanics approach

The action induced by artificial sphincteric devices to provide urinary continence is related to the problem of evaluating the interaction between the occlusive cuff and the urethral duct. The intensity and distribution of the force induced within the region of application determine a different occlusion process and potential degradation of the urethral tissue, mostly at the borders of the cuff. This problem is generally considered in the light of clinical and surgical operational experience, while a valid cooperation is established with biomechanical competences by means of experimental and numerical investigation. A three-dimensional model of the urethra is proposed aiming at a representation of the phases of the urethral occlusion through artificial sphincters. Different conformations of the cuff are considered, mimicking different loading conditions in terms of force intensity and distribution and consequent deformation caused in soft tissues. The action induced in the healthy urethra is investigated, as basis for an evaluation of the efficacy and reliability of the sphincteric devices. The problem is characterized by coupled nonlinear geometric and material problem and entails a complex constitutive formulation. A heavy computational procedure is developed by means of analyses that operate within an explicit finite element formulation. Results reported outline the overall response of the urethral duct during lumen occlusion, leading to an accurate description of the phenomenon in the different phases.

Urethroscrotal Fistula: A Rare Cause of Scrotal Swelling

Background

Urethroscrotal fistula (USF) is an abnormal communication between the urethra and the scrotum. This rare abnormality may be iatrogenic or secondary to perforation of the urethra by a stone. After the passage of urine to the scrotum through the fistula, painless scrotal swelling develops, which disappears completely with manual compression, and voiding can be maintained in this way. Retrograde urethrography (RU) and voiding cystourethrography (VCU) are traditional diagnostic methods, but they have limitations, such as technical difficulties and inability to evaluate the surrounding tissues. Multidetector CT (MDCT), together with reformatted images, can provide valuable information about the surrounding tissues and associated pathologies.

Case Report

We present a case of a 36-year-old male patient who had painless scrotal swelling after cystolithotomy and urethral stone surgery. The patient indicated that the swelling disappeared after manual compression. A fistula between the bulbous urethra and the scrotum was discovered by MDCT. In our case, we believe that the fistula developed iatrogenically during stone excision or secondary to perforation of the urethra by a stone.

Conclusions

As a rare pathology, urethroscrotal fistula should be considered in men with a history of urethral stone surgery and symptoms, including painless scrotal swelling, which can be manually compressed after voiding.

Cross-sectional imaging of complicated urinary infections affecting the lower tract and male genital organs

Complicated urinary tract infections (C-UTIs) are those associated with structural or functional genitourinary abnormalities or with conditions that impair the host defence mechanisms, leading to an increased risk of acquiring infection or failing therapy. C-UTIs occur in patients with risk factors such as neurogenic dysfunction, bladder outlet obstruction, obstructive uropathy, bladder catheterisation, urologic instrumentation or indwelling stent, urinary tract post-surgical modifications, chemotherapy- or radiation-induced damage, renal impairment, diabetes and immunodeficiency.

Multidetector CT and MRI allow comprehensive investigation of C-UTIs and systemic infection from an unknown source. Based upon personal experience at a tertiary care hospital focused on the treatment of infectious illnesses, this pictorial essay reviews with examples the clinical features and cross-sectional imaging findings of C-UTIs affecting the lower urinary tract and male genital organs. The disorders presented include acute infectious cystitis, bladder mural abscesses, infections of the prostate and seminal vesicles, acute urethritis and related perineal abscesses, funiculitis, epididymo-orchitis and scrotal abscesses. Emphasis is placed on the possible differential diagnoses of lower C-UTIs.

The aim is to provide radiologists greater familiarity with these potentially severe disorders which frequently require intensive in-hospital antibiotic therapy, percutaneous drainage or surgery.

Teaching Points

• Complicated urinary tract infections occur in patients with structural or functional risk factors.

• CT and MRI comprehensively investigate complicated urinary infections and sepsis from unknown sources.

• Infections of the urinary bladder, prostate, seminal vesicles, urethra and scrotum are presented.

• Emphasis is placed on differential diagnoses of complicated lower urogenital infections.

• Unsuspected urinary infections may be detected on CT performed for other clinical reasons.

[Urethral condylomata acuminata]

Condyloma acuminata are the most frequent cause of infections in the anal genital area. They are caused by the human papilloma virus (HPV). Risk factors are early onset of sexual activity, multiple sexual partners, a history of sexually transmitted disease, and immunosuppression. The urethra is afflicted in only 20% of cases; of these, 80% of the warts are at the meatus and 20% in the proximal urethra. This article reports on two cases with condyloma acuminata affection of the total urethra. The current diagnostic, different treatment modalities, and prophylaxis are reviewed.

Ureteroscopy and cystoscopy training: comparison between transparent and non-transparent simulators

BACKGROUND

Simulators have been widely used to train operational skills in urology, how to improve its effectiveness deserves further investigation. In this paper, we evaluated training using a novel transparent anatomic simulator, an opaque model or no simulator training, with regard to post-training ureteroscopy and cystoscopy proficiency.

METHODS

Anatomically correct transparent and non-transparent endourological simulators were fabricated. Ten experienced urologists provided a preliminary evaluation of the models as teaching tools. 36 first-year medical students underwent identical theoretical training and a 50-point examination of theoretical knowledge. The students were randomly assigned to receive training with the transparent simulator (Group 1), the non-transparent simulator (Group 2) or detailed verbal instruction only (Group 3). 12 days after the training session, the trainees' skills at ureteral stent insertion and removal were evaluated using the Uro-Scopic Trainer and rated on an Objective Structured Assessment of Technical Skills (OSATS) scale.

RESULTS

The new simulators were successfully fabricated in accordance with the design parameters. Of the ten urologists invited to evaluate the devices, 100% rated the devices as anatomically accurate, 90% thought both models were easy to use and 80% thought they were good ureteroscopy and cystoscopy training tools. The scores on the theoretical knowledge test were comparable among the training groups, and all students were able to perform ureteral stent insertion and removal. The mean OSATS scores of groups 1, 2 and 3 were 21.83 ± 3.64, 18.50 ± 4.03 and 15.58 ± 2.23 points, respectively, (p = 0.001).

CONCLUSIONS

Simulator training allowed students to achieve higher ureteroscopic and cystoscopic proficiency, and transparent simulators were more effective than non-transparent simulators.

Surgical tips and tricks during urethroplasty for bulbar urethral strictures focusing on accurate localisation of the stricture: results from a tertiary centre

BACKGROUND

There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken.

OBJECTIVE

We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons.

SURGICAL PROCEDURE

Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy.

OUTCOME MEASURES AND STATISTICAL ANALYSIS

Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed.

RESULTS AND LIMITATIONS

A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence.

CONCLUSIONS

Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex.

PATIENT SUMMARY

We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture.

Rapid evaluation of urinary retention and penile pain using point-of-care ultrasound

We describe the case of an 18-year-old male with a history of nephrolithiasis presenting with acute urinary retention and penile pain. Point-of-care ultrasound was used to rapidly identify a urethral calculus causing obstruction of urinary outflow and allowed for expedited care. Further visualization of the kidneys gave reassurance that the presentation was not complicated by the presence of hydronephrosis.

Transabdominal ultrasound-guided urethral catheterization with transrectal pressure

BACKGROUND

Occasionally, difficulty with standard urethral catheterization is encountered.

OBJECTIVE

We conducted a pilot study to evaluate whether transabdominal ultrasound (TAUS) showed the tip of a urethral catheter and whether TAUS-guided catheterization with transrectal pressure is successful in male patients in whom performing standard catheterization is difficult.

METHODS

The eligible study participants included adult male patients in whom standard catheterization failed in our emergency department or who were transferred from other facilities after failure of catheterization and subsequent urethral bleeding. The enrolled patients included those in whom the tip of a catheter could not be advanced through the posterior and bulbar urethra judging from the inserted length. First, an emergency nurse advanced a catheter until the progress was obstructed. Next, an emergency physician performed TAUS to detect the tip of the catheter. If the tip was detected, the physician inserted the index finger into the rectum and kept pushing the site of the obstruction. After following these procedures, the nurse again advanced the catheter.

RESULTS

Six patients were enrolled. The tip of a catheter was detected in the urethra or the false passage using TAUS in 4 of the 6 patients. In these 4 patients, the curve of the urethra became gentle or the false passage was compressed by transrectal pressure and the tip was advanced smoothly to the bladder.

CONCLUSIONS

In some male patients in whom performing standard urethral catheterization is difficult, TAUS reveals the tip of the catheter and TAUS-guided catheterization with transrectal pressure can be safe and useful.

MRI of the penis

MRI of the penis is an expensive test that is not always superior to clinical examination or ultrasound. However, it shows many of the important structures, and in particular the combination of tumescence from intracavernosal alprostadil, and high-resolution T(2) sequences show the glans, corpora and the tunica albuginea well. In this paper we summarise the radiological anatomy and discuss the indications for MRI. For penile cancer, it may be useful in cases where the local stage is not apparent clinically. In priapism, it is an emerging technique for assessing corporal viability, and in fracture it can in most cases make the diagnosis and locate the injury. In some cases of penile fibrosis and Peyronie's disease, it may aid surgical planning, and in complex pelvic fracture may replace or augment conventional urethrography. It is an excellent investigation for the malfunctioning penile prosthesis.

Urethral ultrasound as a screening tool for stricture recurrence after oral mucosa graft urethroplasty

OBJECTIVE

To evaluate the efficacy of sonourethrography (SUG) in combination with voiding pattern analysis to determine success after oral mucosa graft (OMG) urethroplasty. OMG urethroplasty is a standard treatment for men with recurrent urethral stricture. Because of its performance, the optimum follow-up algorithm remains controversial.

MATERIAL AND METHODS

Forty-nine patients (mean age 51 years) who underwent OMG urethroplasty were retrospectively identified. All men were subjected to a validated voiding questionnaire (International Prostate Symptom Score [IPSS]), SUG, uroflowmetry, and residual urine measurement. The predictive value was analyzed with regard to stricture recurrence or patency as well as to urethral diameter. Retrograde urethrography was done to confirm the diagnosis.

RESULTS

Strictures were bulbar in 39, penile in 4, and combined in 6 patients. Mean stricture length was 3.8 cm (range 1-10). Mean follow-up after surgery was 35 (range 15-70) months. SUG showed a mean diameter of 7.6 mm for bulbar grafts and 4.6 mm for penile grafts. Stricture recurrence was seen in 4 (8%) patients, yielding a significantly lower urethral width of 2.3 mm (P<.005). Retrograde urethrography confirmed the patency status in all. The average maximum flow rate after successful repair was 36.6 mL/s, whereas those with recurrent strictures showed rates of 11.2 (P<.03). Similar results were achieved for residual urine (P<.05). IPSS values increased from 5.1 to 12.5 in patients with recurrence (P<.01).

CONCLUSION

An algorithm consisting of SUG, uroflowmetry, residual urine and IPSS assessment reliably identifies stricture recurrence. Routine retrograde urethrography may therefore be unnecessary in the follow-up of OMG urethroplasty.

Congenital anterior urethral diverticulum in a male teenager: a case report and review of the literature

We present the case of a 13-year-old boy with a congenital anterior urethral diverticulum. This is a rare condition in males which can lead to obstructive lower urinary tract symptoms and urosepsis. Diagnosis is by urethroscopy and radiological imaging. Surgical treatment can be open or endoscopic. Long-term followup is required to check for reoccurrence of the obstruction.

Microrobots for minimally invasive medicine

Microrobots have the potential to revolutionize many aspects of medicine. These untethered, wirelessly controlled and powered devices will make existing therapeutic and diagnostic procedures less invasive and will enable new procedures never before possible. The aim of this review is threefold: first, to provide a comprehensive survey of the technological state of the art in medical microrobots; second, to explore the potential impact of medical microrobots and inspire future research in this field; and third, to provide a collection of valuable information and engineering tools for the design of medical microrobots.

The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery

PURPOSE

The ability of uroflowmetry to diagnose recurrent stricture disease after urethroplasty has not been fully investigated.

MATERIALS AND METHODS

Our routine post-urethroplasty monitoring includes retrograde urethrogram and voiding cystourethrogram at 3 and 12 months, in addition to uroflowmetry at 3-month intervals for a year. All uroflowmetry data, including maximum flow rate, voided volume and voiding curve shape, as well as retrograde urethrogram/voiding cystourethrogram and voiding symptom data are stored in a prospectively maintained urethroplasty database that was analyzed for patients with postoperative retrograde urethrogram/voiding cystourethrogram and satisfactory uroflowmetry in the same period. Uroflowmetry data points and urinary symptoms were compared with corresponding findings on retrograde urethrogram/voiding cystourethrogram to determine the ability of uroflowmetry to predict recurrence.

RESULTS

A total of 278 men (68%) met study inclusion criteria, of whom 63 (23%) had recurrent stricture. Using a maximum flow rate of less than 10 ml per second resulted in only 54% test sensitivity to predict recurrence. The highest sensitivity and negative predictive value (each 99%) were achieved when all men with symptoms and/or obstructed flow curves were evaluated. Symptoms alone had a high specificity (87%), sensitivity (88%) and negative predictive value (95%).

CONCLUSIONS

Uroflowmetry is an adequate test to screen for postoperative stricture recurrence but only when the voiding curve and urinary symptoms are also evaluated. The flow rate alone does not appear to be a reliable tool to evaluate stricture recurrence.

Giant urethral stone presenting as a scrotal mass: Case report

Primary urethral stones are a rare form of urolithiasis accounting for less than 0.3% of urinary stones. We are reporting a case of a giant primary urethral stone that developed in the penile urethra resulting from a post-surgical complication of urethral stricture. The patient presented with difficulty urinating, ejaculatory dysfunction, and a hard palpable scrotal mass.

A perfected device for performing retrograde urethrography

The present study describes a perfected device for retrograde urethrography (RUG). The device allows RUG to be performed using a balloonless catheter and with assessment of the various problems of the urethra. The procedure is simple and well tolerated by patients and represents an interesting alternative to the conventional RUG technique.

MR imaging of nonmalignant penile lesions

Magnetic resonance (MR) imaging is potentially useful in the assessment of many benign penile diseases. When T1- and T2-weighted sequences are used, MR imaging can clearly delineate the tunica albuginea and can be used to diagnose penile fracture and Peyronie disease; in both conditions, MR imaging may help refine the surgical approach. It is also useful in cases of priapism; in these cases, intravenously administered contrast material can help assess the viability of the corpora cavernosa and the presence of penile fibrosis. In the assessment of a penile prosthesis, MR imaging provides excellent anatomic information and is the investigation of choice. In the evaluation of erectile dysfunction, MR imaging has limited value, and for urethral stricture, it has not yet proved adequately superior to other modalities to justify its routine use.

Imaging of the Male Urethra

For imaging of the male urethra, conventional radiographic contrast studies including retrograde urethrography are most commonly utilized. They are best suited for delineating luminal abnormalities of the urethra and thus are commonly used as the primary imaging modality for patients with various urethral abnormalities such as trauma, inflammation, and stricture. More recently, the cross-sectional imaging techniques of ultrasound, computed tomography and magnetic resonance imaging have been utilized increasingly for urethral and periurethral abnormalities. These studies are most valuable as an adjunctive tool in patients with the complex anatomical derangements such as congenital anomalies, posterior (or bulbomembranous) urethral injuries, and with urethral or periurethral tumors. These cross-sectional techniques can be performed during micturition or with retrograde injection of saline or jelly through the urethral meatus to improve visualization of the urethral luminal abnormalities. This article describes imaging techniques, anatomy, and findings of various urethral and periurethral pathology in the male including congenital anomalies, infection/inflammation, stricture, traumatic injury, fistula, tumors, and calculi.

Gray Scale and Color Doppler Sonography With Extended Field of View Technique for the Diagnostic Evaluation of Anterior Urethral Strictures

PURPOSE

We compared the clinical relevance of radio urethrography with that of sonourethrography for evaluating male urethral strictures.

MATERIALS AND METHODS

From 2002 to 2004, 93 men were referred to our institution for urethral strictures. Patients were evaluated by conventional voiding cystourethrography, retrograde urethrography, and gray scale and color Doppler sonourethrography. For sonourethrography the extended field of view technique was used to obtain 1 image of the whole anterior urethra. In all cases the urethra was evaluated cystoscopically or at open surgery. Radio urethrography and sonourethrography findings were compared with cystoscopy or surgery findings.

RESULTS

All strictures were evaluated and treated cystoscopically with visual internal urethrotomy (34%) or at open operation (66%), which allowed comparison of the ability of each study to predict operative stricture length. Sonourethrography correctly identified the stricture and its site in all cases, whereas radio urethrography yielded 2 false-negative results. There was a significant difference between stricture length measured by radio urethrography compared to that measured by sonourethrography (correlation coefficient 0.72 vs 0.92, p<0.005). Mean+/-SD stricture length measured by radio urethrography was 1.5+/-1.3 cm and by sonourethrography it was 2.1+/-0.9 cm. Comparison of radio urethrography and sonourethrography stricture length with operative lengths demonstrated a good correlation in the penile urethra (correlation coefficient 0.91 vs 0.98), whereas a poor correlation was found in the bulbar urethra (correlation coefficient 0.65 vs 0.92).

CONCLUSIONS

Gray scale and color Doppler sonourethrography using the extended field of view technique with a Siemens Sonoline Elegra is a promising tool for defining male urethral strictures. It seems to be superior to radio urethrography for treatment planning.

Obliterative urethral stricture: MR urethrography versus conventional retrograde urethrography with voiding cystourethrography

Institutional review board approval and informed consent were obtained. The purpose of the study was to prospectively evaluate magnetic resonance (MR) urethrography for the depiction of obliterative urethral stricture. Twelve patients with obliterative urethral stricture were examined preoperatively with T2-weighted, T1-weighted, and contrast material-enhanced T1-weighted MR imaging of a urethra distended with sterile lubricating jelly. Ten of the 12 patients were examined with conventional retrograde urethrography (RGU) combined with voiding cystourethrography (VCUG) prior to MR imaging. Each imaging result was compared with either a surgical specimen or a description of the surgical findings to determine which method allowed accurate estimation of stricture length. MR measurements of stricture length demonstrated significantly lower errors (P < .05) and better linear fit to surgical measurement than did conventional RGU combined with VCUG measurements (r(2) = 0.85, P < .001 and r(2) = 0.03, P > .05, respectively). MR imaging of the urethra distended with sterile lubricating jelly is an effective tool for evaluating obliterative urethral strictures.