Sonourethrography in the evaluation of urethral strictures: a preliminary report

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.

Advancing Intraoperative Assessment of Urethral Stricture Anatomic Variation: A Prospective Proof-of-Concept Study

INTRODUCTION

Urethral strictures, particularly those refractory to endoscopic interventions, are commonly treated through open urethroplasty. However, predicting recurrence in homogeneous patient populations remains challenging.

METHODS

To address this, we developed an intraoperative urethral stricture assessment tool aiming to identify comprehensive risk predictors. The assessment includes detailed parameters on stricture location, length, urethral bed width, spongiosum thickness, obliteration grade, and spongiofibrosis extension. The tool was prospectively implemented in 106 men with anterior one-stage augmentation urethroplasty from April 2020 to October 2021.

RESULTS

An intraoperative granular assessment of intricate stricture characteristics is feasible. Comparative analyses revealed significant differences between bulbar and penile strictures. Bulbar strictures exhibited wider urethral beds and thicker spongiosum compared to penile strictures (all p < 0.001). The assessment showed marked variations in the degree of obliteration and spongiofibrosis extension.

CONCLUSION

Our tool aligns with efforts to standardize urethral surgery, providing insights into subtle disease intricacies and enabling comparisons between institutions. Notably, intraoperative assessment may surpass the limitations of preoperative imaging, emphasizing the necessity of intraoperative evaluation. While limitations include a single-institution study and limited sample size, future research aims to refine this tool and determine its impact on treatment strategies, potentially improving long-term outcomes for urethral strictures.

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.

Ultrasonographic Evaluation of the Hypospadiac Penis in Children

INTRODUCTION

Identifying key anatomical features of the hypospadiac penis is crucial to better understanding this pathology and guiding surgical reconstruction plans, thereby achieving superior functional and cosmetic outcomes.

OBJECTIVE

To Assess the feasibility and precision of penile ultrasonography (PUG) in determining key structural features for hypospadias cases (including distal extent of the spongiosal component of the urethral plate, to elucidate the healing process following tubularised incised-plate urethroplasty).

PATIENTS AND METHODS

Twenty-five children with hypospadias were assessed using PUG prior to surgical repair and then again under general anesthesia. Preoperative images were acquired using ultrasonography in sagittal and transverse planes, then later compared with anatomical findings obtained during surgical repair of urethral hypoplasia.

RESULTS

Median patient age was 1.2 years (range 0.5-12) and hypospadias types included coronal 17/25 (68%), mid-penile 5/25 (20%), and proximal penile 3/25 (12%). Distinct layers of the corpus spongiosa and mucosal layer, Buck fascia, tunica albuginea, glans, corpora cavernosa, and penile skin were delineated so that their spatial inter-relationship could be assessed. Distal extent of the spongiosal component of the urethral plate was determined by the mid-glans B-B line. The extent of urethral hypoplasia identified by PUG was relatively similar to measurements obtained intraoperatively.

CONCLUSION

PUG is a feasible and accurate approach to evaluating penile configuration in children with hypospadias. Distal extent of the spongiosal component of the urethral plate was accurately determined, hence PUG could potentially be used to improve surgical planning and appraisal of current repair procedures.

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.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

Retrograde urethrography, sonouretrography and magnetic resonance urethrography in evaluation of male urethral strictures. Should the novel methods become the new standard in radiological diagnosis of urethral stricture disease?

PURPOSE

To verify which of the diagnostic modalities: Voiding cystouretrography (VCUG), Sonouretrography (SUG) or Magnetic resonance uretrography (MRU) is the most accurate in the assessment of urethral strictures in males and in what cases the application of novel imaging techniques benefits most.

METHODS

55 male patients with a diagnosis of urethral stricture, were enrolled in this prospective study. Initial diagnosis of urethral stricture was based on anamnesis, uroflowmetry and VCUG. Additional imaging procedures-SUG and MRU were performed before the surgery. Virtual models and 3D printed models of the urethra with the stricture were created based on the MRU data. Exact stricture length and location were evaluated by each radiological method and accuracy was verified intraoperatively. Agreement between SUG and MRU assessments of spongiofibrosis was evaluated. MRU images were independently interpreted by two radiologists (MRU 1, MRU 2) and rater reliability was calculated.

RESULTS

MRU was the most accurate [(95% CI 0.786-0.882), p < 0.0005] with an average overestimation of 1.145 mm (MRU 1) and 0.727 mm (MRU 2) as compared with the operative measure. VCUG was less accurate [(95% CI 0.536-0.769), p < 0.0005] with an average underestimation of 1.509 mm as compared with operative measure. SUG was the least accurate method [(95% CI 0.510-0.776), p < 0.0005] with an average overestimation of 2.127 mm as compared with the operative measure. There was almost perfect agreement of MRU interpretations between the radiologists.

CONCLUSIONS

VCUG is still considered as a 'gold standard' in diagnosing urethral stricture disease despite its limitations. SUG and MRU provide extra guidance in preoperative planning and should be considered as supplemental for diagnosing urethral stricture. Combination of VCUG and SUG may be an optimal set of radiological tools for diagnosing patients with urethral strictures located in the penile urethra. MRU is the most accurate method and should particularly be considered in cases of post-traumatic or multiple strictures and strictures located in the posterior urethra.

Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture

OBJECTIVES

The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques.

METHODS

Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison.

RESULTS

Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis.

CONCLUSIONS

Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

MRI in patients with urethral stricture: a systematic review

Magnetic resonance imaging (MRI) is gaining acceptance as a diagnostic tool in urethral stricture disease. Numerous publications emphasize on the advantages of MRI including its ability to determine periurethral spongiofibrosis, thus overcoming the main limitation of retrograde urethrography (RUG). It is also becoming an alternative for sonourethrography (SUG), which is a highly subjective examination. Magnetic resonance urethrography (MRU) has become an increasingly appreciated tool for diagnosing patients with urethral stricture disease. Obtained data provides radiologists and urethral reconstructive surgeons with additional information regarding anatomical relationships and periurethral tissue details, facilitating further treatment planning. Considering the great prevalence of urethral stricture disease and necessity of using accurate, and acceptable diagnostic method, this review was designed to provide radiologists and clinicians with a systematic review of the literature on the use of MRI in the urethral stricture disease.

Acquired Renal Cystic Disease and Its Complications in Continuous Ambulatory Peritoneal Dialysis Patients

Purpose

To determine whether there is any difference in the prevalence of acquired cystic disease and malignancy of the kidney in patients on continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis.

Data Identification

Relevant studies published from January 1983 to June 1991 were identified by manual search and MEDLINE search.

Study Selection

We reviewed the studies in which acquired renal cystic disease and/or renal cell carcinoma developed in patients on CAPD.

Data Extraction

Details of the prevalence of acquired cystic disease and renal malignancy as a complication of acquired cysts in CAPD patients were tabulated with the duration of treatment.

Results

Acquired cystic disease was observed in 195 of 425CAPD patients(41.1%), which is comparable to the prevalence of 47.1% (520/1103) seen in hemodialysis patients. The overall prevalence of renal cell carcinoma accompanying acquired cystic disease in this series of CAPD patients was 2 of 375 (0.4%), which is comparable to the prevalence of 1.5% (17/1103) in hemodialysis patients. So far, eight other instances of renal cell carcinoma complicating acquired cystic disease in CAPD patients were described as case reports. Retroperitoneal bleeding due to the rupture of acquired cysts has been reported on a few occasions.

Conclusion

In this review no differences were detected in the prevalence or severity of acquired renal cystic disease in patients treated with CAPD as compared with those on hemodialysis. Therefore, the incidence of complications associated with acquired cysts may also be the same for the two treatment modalities, although reports on such complications are rare.

Vorticity in lower urinary tract can be assessed and associates with urinary tract morphology in men

OBJECTIVES

The aim of this study is to develop a method to evaluate the fluid dynamics of urine flow in the lower urinary tract (LUT), especially that of vorticity.

MATERIALS AND METHODS

This investigation included three sub-studies to demonstrate urine flow in the entire LUT. First, we attempted to observe vorticity generation in the urinary bladder during spontaneous voiding using transabdominal color Doppler ultrasonography (CDUS). Second, we performed transrectal CDUS to evaluate the vorticity of urine flow in the prostatic urethra. Patients with prostate cancer were enrolled before robotic surgery and divided into the vorticity and non-vorticity groups based on CDUS findings for comparisons of longitudinal urethral diameter and prostatic urethral angle. Third, the vorticity of the voided urine stream was observed using a high-speed video-camera. Micturition was done in a standing position while synchronously monitored for urine flow using uroflowmetry.

RESULTS

Vorticity formation could be dynamically demonstrated in the urinary bladder and prostatic urethra using CDUS. The prostatic urethral angle of the vorticity group was more than that of the non-vorticity group. High-speed video recording could clearly capture vorticity and spiral shape generation in voided urine. The distance from the external urethral orifice to the first twist changed in accordance with urine flow rate.

CONCLUSIONS

In a series of sub-studies, this investigation proved vorticity generation in the LUT and voided urine. Vorticity was detectable in the LUT and in voided urine using CDUS and a high-speed video-camera. Vorticity generation might be associated with urethral morphology.

The Benefits of Using a Small Caliber Ureteroscope in Evaluation and Management of Urethral Stricture

Introduction and Objective

The proper evaluation of urethral strictures is an essential part of the surgical planning in urethral reconstruction. The proper evaluation of the stricture can be challenging in certain situations, especially when the meatus is involved. We propose that the use of a small caliber ureteroscope (4.5 Fr and 6.5 Fr) can offer additional help and use for the surgical planning in urethroplasty.

Methods

We prospectively collected data on 76 patients who underwent urethroplasties in Kulkarni Reconstructive Urology Center, Pune, India and Thunder Bay Regional Health Sciences Center, Thunder Bay, Canada. Patients had retrograde and micturition urethrograms performed preoperatively. The stricture was assessed visually using a 6.5 Fr ureteroscope. If the stricture was smaller than 6.5 Fr, we attempted using the 4.5 Fr ureteroscope. In nonobliterated strictures, we attempted bypassing the stricture making sure not to dilate the stricture. A glide wire would be passed to the bladder under vision. Stricture length, tissue quality, presence of other proximal strictures, false passages, and bladder tumors or stones would be assessed visually. If the penile stricture was near obliterative (smaller than 4.5 Fr caliber), a two-staged procedure is elected to be performed. For proximal bulbar strictures, if the urethral caliber is less than 4.5 Fr and the stricture length is less than 1 cm, we perform a nontransecting anastomotic urethroplasty (NTAU). If the stricture length is >1 cm, we perform a double-face augmented urethroplasty (DFAU). If the urethral caliber is >4.5 Fr and particularly those who are sexually active, ventral inlay with buccal mucosal grafts (BMGs) is performed. In mid to distal bulbar strictures, if the urethral caliber is >4.5 Fr, our procedure of choice is dorsal onlay with BMG. For those with urethral caliber <4.5 Fr and a stricture less than 1 cm, we perform a NTAU. For strictures longer than 1 cm, we perform a DFAU. With the exception of trauma, we very rarely transect the urethra. For panurethral strictures, we almost exclusively perform Kulkarni one-sided dissection.

Results

Urethroscopy was performed in 76 patients who presented for urethroplasty from July 2014 to September 2014 (in Pune) and between April 2016 and September 2017 (in Thunder Bay). Bypassing the stricture was achieved in 68 patients (89%) while it was unsuccessful in 8 patients (11%). In all unsuccessful urethroscopies, the stricture was near obliterative <4.5 Fr. Our surgical planning changed in (13) 17% of the cases. Out of 43 bulbar strictures, the decision was changed in (9) 21% where we performed 4 DFAU, 3 AAU (augmented anastomotic urethroplasty), and 2 EAU (end anastomotic urethroplasty). In 13 penile strictures, we opted for staged urethroplasty including 3 Johansons and 1 first-stage Asopa in 30.7%. In 20 panurethral urethroplasties, 1 patient (5%) had a urethral stone found in a proximal portion of the bulbar urethra distal to a stricture ring that was removed using an endoscopic grasper.

Conclusion

The use of the small caliber ureteroscope can help in evaluation of the stricture caliber, length, and tissue quality. The scope can also aid in placing a guide wire, evaluating the posterior urethra, and screening for urethral or bladder stones. It can also improve the preoperative patient counselling and avoid unwanted surprises.

A Novel Endoluminal Ultrasound Imaging Technique to Determine Urethral Luminal Cross-Sectional Area

INTRODUCTION AND OBJECTIVES

Retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) are currently the gold standard imaging technique for diagnosis of urethral stricture and determination of stricture location. However, RUG and VCUG have multiple limitations. These techniques require exposure to ionizing radiation, the quality is operator and patient dependent, there is a moderate degree of invasiveness with urethral catheterization, can have artifacts because of patient positioning that underestimates stricture length. The development of novel imaging modalities without ionizing radiation to accurately evaluate the presence, location, length, and lumen cross-sectional area (CSA) of the urethral stricture would be of great value. The objective of this study was to develop a novel endoluminal ultrasound (ELUS) imaging technique that permits the accurate quantitation of urethral stricture.

METHODS

Urethral strictures were created in rabbits (n = 5) by electrocautery and an ELUS technique was developed for subsequent luminal imaging. A 3.2F 40 MHz ultrasound (US) probe was introduced transurethrally and infused with US contrast agent. Images were recorded as the catheter was pulled back at a constant speed to acquire tomographic images. Lumen CSA over the entire urethral length was calculated using a custom methodology and validated in our laboratory.

RESULTS

Urethral luminal CSA over the entire length of urethra before and after experimental stricture development was quantified including the length of stenosis. Intra- and interobserver variability (r = 0.99 for both) was excellent.

CONCLUSIONS

Feasibility of ELUS as a quantitative technique to determine healthy urethral lumen and stricture CSA was demonstrated. The translational potential for a nonionizing imaging modality to better describe CSA, length, location, and uninvolved urethral CSA of the stricture is a significant improvement over current methodology.

Overcoming scarring in the urethra: Challenges for tissue engineering

Urethral stricture disease is increasingly common occurring in about 1% of males over the age of 55. The stricture tissue is rich in myofibroblasts and multi-nucleated giant cells which are thought to be related to stricture formation and collagen synthesis. An increase in collagen is associated with the loss of the normal vasculature of the normal urethra. The actual incidence differs based on worldwide populations, geography, and income. The stricture aetiology, location, length and patient's age and comorbidity are important in deciding the course of treatment. In this review we aim to summarise the existing knowledge of the aetiology of urethral strictures, review current treatment regimens, and present the challenges of using tissue-engineered buccal mucosa (TEBM) to repair scarring of the urethra. In asking this question we are also mindful that recurrent fibrosis occurs in other tissues-how can we learn from these other pathologies?

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.

Three-Dimensional Computerized Model Based on the Sonourethrogram: A Novel Technique to Evaluate Anterior Urethral Stricture

PURPOSE

The sonourethrogram is a useful alternative to the traditional retrograde urethrogram to evaluate anterior urethral strictures. With the development of 3-dimensional reconstructive techniques 3-dimensional urethral imaging can provide more accurate and useful information to enable the surgeon to make the best surgical decisions. We evaluated the accuracy and efficacy of a 3-dimensional reconstructed digital model of the urethra based on the sonourethrogram to assess anterior urethral disease.

MATERIALS AND METHODS

A total of 50 patients with an anterior urethral stricture and 10 healthy volunteers were enrolled in this study from April 2014 to January 2017. All patients and volunteers underwent sonourethrogram and retrograde urethrogram. Three-dimensional urethral models were reconstructed based on the sonourethrogram. Stricture length and location on retrograde urethrogram or sonourethrogram based images were compared with those found at operation.

RESULTS

The 3-dimensional digital model revealed the entire anterior urethra, including the navicular fossa, and the penile and bulbar parts. The semitransparent model clearly demonstrated the structure of the corpus spongiosum and inside the urethral lumen. Further information on spongiofibrosis could also be seen in the 3-dimensional digital model. There was no significant difference in stricture length or location in the 3-dimensional model compared with retrograde urethrogram imaging and actual surgical findings. However, the latest technique could only reconstruct the short segment of the anterior urethra due to the probe width limitation.

CONCLUSIONS

The 3-dimensional computerized model based on the sonourethrogram is a novel and effective technique of evaluating anterior urethral strictures.

Comparison of Diagnostic Value of Sonourethrography with Retrograde Urethrography in Diagnosis of Anterior Urethral Stricture

BACKGROUND

In spite of the advanced imaging methods, MRI and CT-Scan, the role of ultrasonography is still unique in some fields of genitourinary tract diseases.

AIM

This study was aimed at assessing this role in the evaluation of male urinary stricture, and comparison with standard retrograde urethrography (SUG).

METHODS

This was a cross-sectional study. The patients include those who were suspected of anterior urethral stricture and were introduced assessed with imaging techniques (RUG). The patient underwent ultrasonography too. The results of both methods were compared. RUG was considered as the gold standard for this comparison.

RESULT

Ninety-seven patients were studied. The mean age was 46.9 ± 11.7 years (range 21-88 years), in RUG, 22 patients (22.8%) and SUG 23 patients (23.7%) had a stricture, 3 cases with a stricture in RUG had not evidenced of stenosis in SUG. The mean length of urethral stricture in RUG was 12.9 ± 8.1 mm and in SUG was 8.1 ± 7.3 mm. The estimated length in RUG way was significantly higher than SUG way (P=0.025). The sensitivity and specificity in using of SUG were 86.6% and 94.6%, respectively.

CONCLUSION

The result of this study showed stricture length measured by ultrasound is shorter than the length measured by RUG and the sensitivity and specificity in using of SUG was 86.6% and 94.6% respectively that due to the advantages it is an acceptable way.

Three-Dimensional Imaging of Urethral Stricture Disease and Urethral Pathology for Operative Planning

Diagnosing urethral pathology can prove difficult, as clinically, the presentation is often nonspecific and may be suggestive of multiple etiologies. Therefore, detailed and accurate urethral imaging in both males and females is critical. Since the early 1900s, conventional imaging studies including RUG and VCUG, with adjunct cystourethroscopy, have remained the gold standard diagnostic techniques to evaluate urethral pathology. However, limitations of conventional imaging have generated interest in finding alternative imaging modalities with comparable, if not superior, diagnostic accuracy, the goal being a more complete assessment of urethral pathology and anatomy that would allow for appropriate surgical planning. Imaging modalities with three-dimensional (3D) capabilities may provide more comprehensive information regarding urethral diseases through a more detailed illustration of periurethral soft tissue structures. Whether or not these imaging modalities will replace conventional studies is unclear, though there is an increasing body of literature that support their use.

Male Urethral Stricture: American Urological Association Guideline

PURPOSE

The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture.

MATERIALS AND METHODS

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed.

RESULTS

The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures.

CONCLUSIONS

Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Comparison of sonoelastography with sonourethrography and retrograde urethrography in the evaluation of male anterior urethral strictures

OBJECTIVE

Retrograde urethrography (RUG) is the most common and preferred imaging modality for imaging of the anterior urethral strictures despite its well-known limitations and disadvantages. Sonourethrography (SUG) was introduced in 1988 to overcome the limitations of RUG and to provide more accurate results. As proper selection of imaging modality is very important for planning the treatment, various advances in this area are required. One of the major factors for recurrence of stricture disease is spongiofibrosis. Sonoelastography (SE) is a newer technique, tried in various other pathologies. In this study, we have used this technique for the first time to assess its efficacy in the evaluation of anterior urethral stricture disease by comparison with RUG and SUG.

MATERIAL AND METHODS

Between August 2014 and May 2015, 77 patients with clinical features of anterior urethral stricture disease were included in the study and evaluated by RUG followed by SUG and SE for stricture location, length, depth of spongiofibrosis and periurethral pathologies. The results were then correlated with operative and histopathological findings.

RESULTS

Overall diagnostic accuracy of SE, SUG, and RGU for the estimation of stricture location, and length were estimated 92.68% vs. 91.54%, 79% vs. 78.87% and 80.48% vs. 43.66%, respectively, while for depth of spongiofibrosis SE, and SUG had accuracy rates of 87.3%, 48%, respectively. The mean length measured on SE was nearest to the mean intra-operative stricture length (21.34+11.8 mm). SE findings significantly correlated with the colour of bladder mucosa on cystoscopic examination (p=0.003) whereas the association was non-significant (p=0.127) for difficulty in incision. While a nonsignificant correlation existed between SUG findings related both to the colour of the bladder mucosa and difficulty in incision on cystoscopy, SE findings had a significant association (p<0.001) with histopathology findings for severe degree of fibrosis.

CONCLUSION

Sonoelastography estimates stricture site and length better in comparison with RUG and SUG. It estimates degree of spongiofibrosis which serves as an important prognostic factor for stricture recurrence more accurately than SUG.

Management of radiation-induced urethral strictures

Radiation as a treatment option for prostate cancer has been chosen by many patients. One of the side effects encountered are radiation-induced urethral strictures which occur in up to 11% of patients. Radiation damage has often left the irradiated field fibrotic and with poor vascularization which make these strictures a challenging entity to treat. The mainstay of urologic management remains an urethroplasty procedure for which several approaches exist with variable optimal indication. Excision and primary anastomoses are ideal for shorter bulbar strictures that comprise the majority of radiation-induced urethral strictures. One advantage of this technique is that it does not require tissue transfers and success rates of 70-95% have consistently been reported. Substitution urethroplasty using remote graft tissue such as buccal mucosa are indicated if the length of the stricture precludes a tension-free primary anastomosis. Despite the challenge of graft survival in radiation-damaged and poorly vascularized recipient tissue, up to 83% of patients have been treated successfully although the numbers described in the literature are small. The most extensive repairs involve the use of tissue flaps, for example gracilis muscle, which may be required if the involved periurethral tissue is unable to provide sufficient vascular support for a post-operative urethral healing process. In summary, radiation-induced urethral strictures are a challenging entity. Most strictures are amenable to excision and primary anastomosis (EPA) with encouraging success rates but substitution urethroplasty may be indicated when extensive repair is needed.

Imaging of urethral stricture disease

Accurate imaging of urethral strictures is critical for preoperative staging and planning of reconstruction. The current gold standard, retrograde urethrography (RUG), allows for accurate diagnosis, staging, and delineation of urethral strictures, and remains a cornerstone in the management of urethral stricture disease. In complex situations, the RUG can be combined with voiding cystourethrogram (VCUG) in order to better visualize the posterior urethra or complex distraction defects. Direct visualization of the stricture by cystoscopy, either retrograde or antegrade, can provide additional information as to the location and appearance of stricture, as well as precise location on fluoroscopic imaging. Sonourethrography (SU) is a useful adjunct to allow for three-dimensional assessment of stricture length and location, and can be a useful intraoperative assessment tool, however, its use remains limited to a second-line setting. Cross-sectional imaging in the form of computed tomography (CT) or magnetic resonance urethrography can provide additional three-dimensional information of anatomic structures and their relations, and can serve as a useful adjunct in complex clinical scenarios.

A comparative study of ascending urethrogram and sono-urethrogram in the evaluation of stricture urethra

To compare the efficacy of sono-urethrogram and ascending urethrogram in the evaluation of stricture urethra.

Current trends in urethral stricture management

The recent International Consultation on Urological Disease (ICUD) panel 2010 confirmed that a urethral stricture is defined as a narrowing of the urethra consequent upon ischaemic spongiofibrosis, as distinct from sphincter stenoses and a urethral disruption injury. Whenever possible, an anastomotic urethroplasty should be performed because of the higher success rate as compared to augmentation urethroplasty. There is some debate currently regarding the critical stricture length at which an anastomotic procedure can be used, but clearly the extent of the spongiofibrosis and individual anatomical factors (the length of the penis and urethra) are important, the limitation for this being extension of dissection beyond the peno-scrotal junction and the subsequent production of chordee. More recently, there has been interest in whether to excise and anastomose or to carry out a stricturotomy and reanastomosis using a Heineke-Miculicz technique. Augmentation urethroplasty has evolved towards the more extensive use of oral mucosa grafts as compared to penile skin flaps, as both flaps and grafts have similar efficacy and certainly the use of either dorsal or ventral positioning seems to provide comparable results. It is important that the reconstructive surgeon is well versed in the full range of available repair techniques, as no single method is suitable for all cases and will enable the management of any unexpected anatomical findings discovered intra-operatively.

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.

Male urethral strictures and their management

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

Thermo-expandable metallic urethral stents for managing recurrent bulbar urethral strictures: To use or not?

Objectives

To assess the role of temporary thermally expandable urethral stents in maintaining urethral patency in patients with a recurrent bulbar urethral stricture.

Patients and methods

Twenty-three men with a recurrent bulbar urethral stricture after several attempts at direct visual internal urethrotomy (DVIU) and/or failed urethroplasty were managed with a thermally expandable, biocompatible nickel–titanium alloy urethral stent (Memokath® MK044, Pnn Medical, Kvistgaard, Denmark). The stents were applied by a special mounting device via a rigid urethroscope after DVIU. All patients were followed using plain radiography, uroflowmetry and urine analysis every 3 months for 1 year, and then every 6 months.

Results

The mean (SD) age of the patients was 55.4 (7.3) years and the mean (SD) stricture length was 3.6 (1.2) cm. All patients tolerated the stent, with minimal discomfort in some patients. Four patients (17%) had urinary tract infections, three (13%) had haematuria, three (13%) had obstructed stents due to encrustation, in five (22%) the stent migrated, and two patients had no delayed complications. The mean (SD) follow-up was 17.4 (6.1) months.

Conclusion

Urethral stenting with nickel–titanium alloy thermally expandable stents can be an acceptable temporary procedure for patients with recurrent bulbar urethral strictures who are unfit for or who refuse urethroplasty. However, they have limitations; the search for an ideal urethral stent continues.

[Establishment of a stable urethral stricture model in New Zealand rabbits]

OBJECTIVE

To explore the method of building a stable urethral stricture (US) model in New Zealand white rabbits.

METHODS

Through 10X magnification optical microscope, a resection of 1.0cm urethral mucosa was made in 6 male rabbits and other 6 male rabbits were controlled. After 60 days, the rabbits were evaluated with urethrography, urethral pressure profile (UPP) and histology.

RESULT

Urethrography demonstrated a stricture with narrow lumen and discontinuous mucosa in the resection group. The urethras of the control animals were all normal. UPP showed that the urethral pressure on operative site in the controlled group was 14.67±2.16cmHO, and 27.83±3.71 cmHO in the resection group. There was significant statistical difference between the two groups (P<.01). The urothelium was well-distributed, covered without any inflammatory cells in the controlled group, which had 3-4 layers of the epithelial cells. And the urothelium was unequally covered with neutrophils and lymphocytes in the resection group.

CONCLUSIONS

We establish the way to build a stable urethral stricture model of New Zealand rabbits by the microsurgical technique, which is a good laboratory model to research all kinds of urethral stricture. Urethrography and histology combined UPP are the reliable methods to identify the urethral stricture.

Ultrasound of the male anterior urethra

Imaging of the anterior male urethra has traditionally been performed by fluoroscopic contrast urethrography. While providing easily interpretable images, this technique has a number of disadvantages associated with it. An alternative approach is to use ultrasound to assess the lumen of the urethra and the periurethral tissues. Here we describe the development of urethral ultrasound and the ascending and descending urethral ultrasound techniques employed in our institution with reference to commonly and uncommonly encountered pathologies. We also identify common pitfalls and how to avoid them.

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.

Magnetic resonance urethrography to assess obliterative posterior urethral stricture: comparison to conventional retrograde urethrography with voiding cystourethrography

PURPOSE

We prospectively evaluated magnetic resonance urethrography for depicting obliterative posterior urethral stricture.

MATERIALS AND METHODS

A total of 25 men with a mean age of 48.7 years (range 21 to 72) with complete posterior urethral stricture were studied preoperatively with axial and sagittal turbo spin-echo T2, sagittal T1 and contrast enhanced sagittal T1-weighted images. Of the 25 patients 22 underwent conventional retrograde urethrography with voiding cystourethrography. For magnetic resonance urethrography aseptic lubricant was infused through the external urethral meatus to dilate the distal urethra up to the stricture. Each imaging result was compared with a surgical specimen or a description of the surgical findings. Measurement errors were analyzed using the Wilcoxon signed rank test. The relationship between true and measured stricture length was evaluated by linear regression analysis.

RESULTS

Based on magnetic resonance urethrography findings 2 patients with a less than 1 cm stricture were treated with internal urethrotomy, 21 with a more than 1 cm stricture underwent open urethroplasty and 2 with prostatic displacement and a 4 cm stricture needed the combined perineal and transpubic approach. The mean +/- SD measurement error on magnetic resonance urethrography imaging was significantly lower than that on conventional retrograde urethrography combined with voiding cystourethrography (0.4 +/- 0.4 vs 1.4 +/- 1.1 cm, p <0.001). Linear regression analysis showed a stronger linear relationship between magnetic resonance urethrography and surgical measurement (r(2) = 0.62, p <0.01).

CONCLUSIONS

Magnetic resonance urethrography is more effective for evaluating obliterative posterior urethral stricture than retrograde urethrography combined with voiding cystourethrography.

Stricture recurrence after urethroplasty: a systematic review

PURPOSE

Urethroplasty remains the gold standard for the management of urethral stricture disease with acceptable long-term success. However, the standard by which stricture recurrence is defined and evaluated after urethral reconstruction remains widely variable. We conducted a systematic review of the urological literature to determine how stricture recurrence is defined and evaluated.

MATERIALS AND METHODS

A systematic review was conducted on all contemporary urethroplasty articles published between 2000 and 2008. Using the term "urethroplasty" 302 articles were identified and evaluated. A total of 86 articles were included in the analysis.

RESULTS

The overall recurrence rate for all reconstructive procedures was 15.6%, which remained stable between 2000 and 2008. Stricture recurrence was determined by a mean of 3 (range 1 to 8) different diagnostic tests. The most common primary diagnostic tests for recurrence were uroflowmetry (56% of articles) and retrograde urethrography (51%). Cystourethroscopy was used as a primary screen to identify stricture recurrence in 25% of articles, and as a secondary procedure in another 21%. Recurrence was defined as the need for an additional surgical procedure or dilation in 75% and 52% of articles, respectively.

CONCLUSIONS

The methods used to determine stricture recurrence after urethroplasty remain widely variable. The use of a standardized surveillance protocol to define stricture recurrence after urethral reconstruction may allow more effective comparison of urethroplasty outcomes across institutions.

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.