MR urethrogram versus combined retrograde urethrogram and sonourethrography in diagnosis of urethral stricture

Objectives: To compare the accuracy of magnetic resonance (MR) urethrogram versus combined RUG and sonourethrography (SUG) in diagnosis urethral stricture with evaluation of their impact in management choice.Material and methods: From March 2006 through February 2007; 30 male patients (mean age, 45 ± 18 years, range 15-75) with clinically suspected urethral stricture. All patients underwent RUG, SUG and MR urethrogram.Results: The final diagnosis of the 30 cases included in our study, after endoscopy and surgical management, was classified into two main groups either isolated stricture (20 cases) or associated with other pathologies (9 cases). There was one case with normal urethral caliber at endoscopy. For the anterior stricture the sensitivity, specificity and overall accuracy of RUG was 91%, 90% and 90%, respectively and for the posterior stricture it was 89%, 91.7% and 90%, respectively. At SUG, all cases of anterior were detected with 100% accuracy while for cases of posterior stricture, the overall accuracy was 60%. MR urethrogram diagnosed all the cases of anterior and posterior stricture with exact delineation of its length except one case of normal caliber was diagnosed falsely at MR as anterior short segment urethral with 100% sensitivity, 91.7% specificity and 95% overall accuracy.Conclusion: MR urethrogram has comparable results with the combined RUG and SUG in diagnosing the anterior and posterior urethral strictures as regard the site and extension and degree of spongiofibrosis but MR is superior in diagnosis of associated pathologies with stricture.     

A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures

AIM: This prospective study was undertaken to evaluate the abnormalities of the male anterior urethra using high-resolution ultrasound (sonourethrography) and to compare the efficacy with that of retrograde urethrography (RGU) using operative findings as the gold standard. MATERIALS AND METHODS: Seventy patients with symptoms of lower urinary tract obstruction underwent RGU followed by sonourethrography. The sonologist was blinded to the findings of RGU. The parameters studied were compared with the intra-operative findings as gold standard, and the sensitivity, specificity and overall accuracy for the procedures were calculated. Chi-square test and kappa statistics were used where appropriate. RESULTS: All patients found to have urethral stricture disease by RGU were also detected by sonourethrography and confirmed intra-operatively. In the estimation of stricture length, RGU showed a lower sensitivity (60-80%) for lengths 1-4 cm, compared with sonourethrography (73.3-100%). Spongiofibrosis was detected by sonourethrography with a sensitivity of 77.3-83.3%. All the false tracts and calculi detected at sonourethrography were confirmed at surgery, whereas RGU showed a low sensitivity in their detection. The complications encountered during the procedures were pain, urethral bleeding and contrast intravasation. The frequency of pain during RGU was greater (p < 0.001); however, the difference in frequency of bleeding after the two procedures was not significant (p < 0.5). CONCLUSION: RGU and sonourethrography are equally efficacious in detection of anterior urethral strictures. Further characterization of strictures in terms of length, diameter and periurethral pathologies, like spongiofibrosis and false tracts, is done with greater sensitivity using sonourethrography as compared with RGU, with the added benefit of lower incidence of complications.     

Anterior urethral strictures and retrograde urethrography: An update for radiologists

Urethral strictures are a relatively common affliction of men with the anterior urethra being most frequently affected. Anterior urethral strictures (AUS) typically present with obstructive voiding symptoms and appropriate management is often based on findings at cystourethroscopy and retrograde urethrography (RUG). In particular, determining the number, length, severity and location of urethral strictures is of pivotal importance. The accurate reporting of findings at RUG is dependent on a thorough knowledge of the urethral anatomy as well as recognizing periurethral structures that may opacify during the procedure. Obtaining a diagnostic, high-quality RUG study requires adherence to proper fluoroscopic technique as well as recognizing when to adjust or modify the technique to address pitfalls that may be encountered during the procedure. AUS may be treated by a variety of procedures including urinary diversion, transurethral procedures such as urethral dilation and internal urethrotomy and open surgical repair techniques termed urethroplasty. Some authors have recommended urethroplasty as first-line treatment given the high rate of stricture recurrence with other treatment options. Buccal mucosal grafts are a mainstay of modern urethroplasty. Familiarity with the commonly performed urethroplasty procedures allows radiologists to accurately assess the post-operative urethra thus guiding the management of these patients.     

Role of MDCT in evaluation of urethral lesions

Objectives

To evaluate the role of multidetector computed tomography (MDCT) in the diagnosis of urethral lesions.

Methods

Thirteen CT urethrography examinations on 13 male patients were performed with 4-MDCT, over a 15 month duration. These patients were clinically examined and a urethral lesion was suspected. The study included recently traumatized patients and patients with suspected urethral lesions. The study was performed by retrograde urethral injection or during micturition after IV contrast injection. 3D-volume rendering (VR) images and VR-multiplanar reconstruction (MPR) sagittal images and virtual images were done.

Results

Out of the 13 patients, two patients were diagnosed having avulsed prostatic urethra.Nine patients were diagnosed having urethral strictures: two at the bulbous urethra (one of them associated with fistulous stricture), five at the membranous urethra (one of them having associated hypospadias) and two at the prostatic urethra. Two postoperative patients with hypospadias were evaluated, one with glans collection and the other with urethral stricture. One patient was diagnosed having urethral neoplasm.

Conclusion

MDCT urethrography is an accurate method in delineating small lesions, site, length, degree of strictures and extraluminal structures.     

Anterior urethral trauma: role of sonourethrography

We present a case of blunt anterior urethral trauma during sexual activity in a 20-year-old man. The patient had abundant urethrorrhagia, but there were no obvious clinical data to help locate the urethral lesion. Diagnosis was established by sonourethrography (SUG), which showed a coagulum in the urethral lumen from a small haematoma in the corpus spongiosum of the proximal pendulous urethra. No lesion was observed in the sonography performed previously without urethral distension or in the retrograde urethrography performed afterwards. The utility of SUG for early diagnosis of urethral contusion is analysed, and a novel technique for performing SUG is described. We believe that this procedure should be used routinely in the initial management of patients suspected with lesions of the anterior urethra.     

超声检查在男性创伤性尿道狭窄诊断中的价值

目的探讨超声检查对男性创伤性尿道狭窄的诊断价值。方法对21例男性创伤性尿道狭窄患者进行超声检查,14例同时联合尿道造影检查,结果与术中所见进行对比分析。结果21例超声结果与术中所见一致。14例联合检查中,造影检查有2例前尿道狭窄漏诊,2例狭窄近侧结石未发现,2例正常后尿道误诊为狭窄,2例后尿道狭窄长度不能估计;2例会阴部瘘管造影清晰显示而超声显示不佳。结论超声在狭窄定位、长度测量、瘢痕范围估测及显示继发结石等方面优于造影,造影显示瘘管清晰,必要时两者应联合应用。     

Optimisation of sonourethrography: the clamp method

Purpose

To describe the clamp method for performing retrograde sonourethrography (RSUG) and contrast-enhanced voiding sonourethrography (CE-VSUG) via the transperineal approach in male adults.

Materials and methods

Prospective study of 113 males (14-86 years) with urethral strictures confirmed by urethrography who received sonourethrography via the clamp method between 2011 and 2015. The characteristic parameters of the quantitative variables were calculated and a comparative analysis of the qualitative variables was conducted using the McNemar test.

Results

RSUG was performed successfully in all the cases (n = 113) and detected 49 cases with anterior urethral strictures; the strictures in the proximal bulbar cone in five of them (10.2%) were not visualised on retrograde urethrography (RUG) (p < 0.05). CE-VSUG was performed successfully in 97 cases and observed posterior urethral strictures in 82; the bladder neck strictures in 6 of them (7.3%) were not observed on voiding cystourethrography (VCUG) (p < 0.05). Retrograde bladder filling was achieved in approximately 6 min.

Conclusion

The clamp method enables RSUG and CE-VSUG to be performed simply, effectively and painlessly by a single operator. It also allows the evaluation of cases with urethromeatal alterations (stricture, hypospadias and meatotomy).

Key Points

? The clamp method enables RSUG to be performed simply and painlessly. ? The clamp method requires only one operator and allows assessing urethromeatal alterations. ? RSUG shows greater capacity for detecting anterior urethral strictures than RUG. ? The clamp method achieves retrograde bladder filling in approximately 6 min. ? CE-VSUG shows greater capacity for detecting strictures than VCUG.

     

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.

Urethral stricture is one of the common male urological disorders with an increasing incidence. Patients may be asymptomatic or present with decreased urine flow, increased pressure required for urinating, a feeling of incomplete urination, urinating in a drop by drop manner and urinary retention. Moreover, ejaculation disorders, often underestimated by physicians, may be encountered, significantly influencing patients’ quality of life (1).Stricture might be caused by inflammatory, traumatic, ischemic, congenital or iatrogenic factors resulting in formation of scar tissue along the tract and reducing the caliber of the urethra (2). Disease is associated with high recurrence rate. Mechanisms underlying traumatic strictures include straddle injury, pelvic fracture-related urethral injury and iatrogenic injury secondary to instrumentation also in reference to worldwide increase in endoscopical transurethral treatment methods in the last decades (3).Given that the number of patients suffering from urethral stricture disease is increasing, there is a need for improvement of diagnostic methods determining the choice of the optimal treatment method. Despite numerous surgical methods for treatment of this disease, it is still associated with high recurrence rates.Process of stricture formation is usually associated with scarring within corpus spongiosum and is known as spongiofibrosis. Histological and immunohistochemical studies showed significant changes within the structure of the strictured part of urethral wall in the microscopic images. In contrast to normal urethra wall, the epithelial layer at the site of a stricture is much thicker. Collagen and bundles of elastin are densely packed around the strictured urethra (4). Thus, the most effective method of treatment for patients with urethral stricture with extensive spongiofibrosis is excision of the whole stricture followed by an end-to-end anastomosis of the two healthy ends (5). Therefore, more and more radiologists and urologists require information on the presence of spongiofibrosis and periurethral pathologies for the correct choice of treatment method.     

尿道带管造影的临床应用价值

目的 探讨尿道带管造影在尿道狭窄(闭锁)手术后的应用价值.方法 男性尿道狭窄(闭锁)患者62例,年龄18～49岁,平均32岁.其中,44例行尿道端端吻合术,18例行黏膜替代尿道成形术.所有患者术后行尿道带管造影.如造影片提示尿道吻合口愈合良好.则拔除导尿管;如造影片提示尿道吻合口愈合不良,则继续留置导尿管,直到尿道带管造影片提示尿道吻合口愈合良好.结果 93.2%的尿道端端吻合术患者术后2～3周拔除导尿管.88.9%的黏膜替代尿道成形术患者术后2～3周拔除导尿管.尿道端端吻合术的手术成功率为88.6%,黏膜替代尿道成形术的手术成功率为83.3%.结论 尿道带管造影可以准确检测尿道狭窄(闭锁)患者手术后尿道吻合口愈合情况,在术后拔除导尿管时间的选择上有重要的指导意义.     

Traumatic strictures of the prostatomembranous urethra in children: radiologic evaluation before and after urethral reconstruction

Impassible strictures of the posterior urethra are frequent sequelae of injuries of the prostatomembranous urethra. To select the appropriate type of urethral reconstructive procedure, the surgeon must know the length of the stricture, whether local complications are present, and whether the anterior urethra is strictured or bound down by fibrosis. The authors describe the radiographic techniques they use to plan urethral reconstruction and evaluate the operative result. The principles of the one-stage transperineal and combined transpubic-transperineal repairs and the two-stage Turner-Warwick scrotal skin inlay urethroplasty are presented to enable radiologists and urologists to interpret contrast studies of the lower urinary tract in patients who have undergone these operation.     

Traumatic strictures of the prostatomembranous urethra in children: Radiologic evaluation before and after urethral reconstruction

Impassible strictures of the posterior urethra are frequent sequelae of injuries of the prostatomembranous urethra. To select the appropriate type of urethral reconstructive procedure, the surgeon must know the length of the stricture, whether local complications are present, and whether the anterior urethra is strictured or bound down by fibrosis. The authors describe the radiographic techniques they use to plan urethral reconstruction and evaluate the operative result. The principles of the one-stage transperineal and combined transpubic-transperineal repairs and the two-stage Turner-Warwick scrotal skin inlay urethroplasty are presented to enable radiologists and urologists to interpret contrast studies of the lower urinary tract in patients who have undergone these operation.     

Descending urethral ultrasound of the native and reconstructed urethra in patients with hypospadias

A retrospective study, over a 7 year period, examining the use of descending urethral ultrasound in corrected and uncorrected hypospadias was performed. 15 examinations were performed on 14 patients; 12 patients had undergone previous surgery for hypospadias, ranging from urethral reconstruction to stricture dilatation. Eight strictures, four irregular urethras, two normal post-operative urethras and one urethral valve were demonstrated. All the clinically significant abnormalities (those which impaired the flow of urine) demonstrated by ultrasound were confirmed with subsequent urethroscopy or contrast urethrography. This small series illustrates the application of descending urethral ultrasound in patients with hypospadias who are difficult to examine with more conventional radiographic techniques.     

Changes in the male urethra produced by instrumentation for transurethral resection of the prostate.

Radiographic changes produced in the male urethra by instrumentation were studied by pre- and postoperative urethrograms in 50 consecutive men as well as in several hundred selected patients. All 50 patients showed postoperative changes in the urethra. Obvious findings developed in 30% without symptoms while 14% of the men suffered severe symptomatic strictures. In our total operated cases, patients who were entered through the urethral meatus showed a 17.2% rate of stricture formation, while those entered transperineally showed only an 8.5% stricture rate. We conclude that all transurethral instrumentation produces trauma as evidenced by varying degrees of radiographic change.     

Segmental and total oesophageal transit time in patients with corrosive-induced oesophageal stricture

INTRODUCTION: The mainstay of treatment of corrosive oesophageal strictures is endoscopic dilatation. However, even after adequate dilatation, some patients may continue to have dysphagia. An associated oesophageal motor dysfunction in such patients may contribute to the persistence of dysphagia. AIM: To assess oesophageal motor dysfunction in patients with corrosive strictures using segmental and total oesophageal transit time by radionuclide scintigraphy. METHODS: Thirty-five patients with corrosive-induced oesophageal strictures were evaluated after having achieved a dilatation of 15 mm. All patients underwent barium swallow and upper endoscopy for assessment of stricture(s). Oesophageal motility was assessed by radionuclide scintigraphy using Tc sulfur colloid. Total oesophageal transit time (ETT) and segmental (upper, middle and lower third of oesophagus) ETT were determined. RESULTS: Thirty-five patients (age 18-53 years) were evaluated. Twenty-eight (80%) patients had a single stricture while seven (20%) had either two or three strictures. Eighteen patients had no dysphagia, 13 patients had grade 1 dysphagia and four patients grade 2 dysphagia. Total ETT was prolonged in 12 patients. Upper, middle and lower third ETT was prolonged in four, seven and six patients, respectively. Length of the stricture correlated with prolongation of ETT as 6.66% patients with length < or = 5 cm, and 53.84% of patients with length >5 cm had prolonged total ETT (P=0.019). Patients with tortuous stricture had more prolongation of ETT as compared to those with straight strictures though it did not reach statistical significance. No significant correlation was observed between number of strictures and prolongation of total ETT. The severity of dysphagia correlated with prolongation of total ETT (P=0.011). CONCLUSION: Oesophageal transit time as assessed by scintigraphy is prolonged in one-third of patients with corrosive-induced oesophageal strictures despite having achieved adequate dilatation. Prolongation of ETT correlates with length of the stricture and severity of dysphagia correlates with prolongation of total ETT. These observations suggest impairment of oesophageal motility in these patients.     

MR imaging of the male and female urethra.

Conventional radiographic contrast material-enhanced studies (eg, retrograde urethrography [RUG], voiding cystourethrography [VCUG], double-balloon catheter urethrography) and ultrasonography are useful in evaluating the anatomy of the urethra but are limited in demonstrating anatomic derangement of adjacent structures. Since the anatomic details of both the urethra and periurethral tissues can be evaluated noninvasively with magnetic resonance (MR) imaging, this modality can be used as an adjunctive tool for evaluation of urethral abnormalities. In patients with congenital anomalies, MR imaging is reserved for cases of intersex anomalies or complex genitourinary anomalies, in which evaluation of internal organs is essential. MR imaging may demonstrate diverticula that are not seen on radiographic contrast-enhanced studies, including VCUG, RUG, or double-balloon catheter study. In cases of inflammation, MR imaging can demonstrate not only inflammatory infiltration around the urethra but also the presence of a periurethral abscess or sinus tract. In cases of trauma, MR imaging is helpful in assessing the presence and extent of anterior or posterior urethral injury and predicting the occurrence of complications. At MR imaging, a fistula can be seen as a direct communicating channel with an adjacent organ. In patients with urethral tumors, the major role of MR imaging is in local staging.     

Use of Cutting Balloon in the Treatment of Urethral Stricture: A Novel Technique

The peripheral cutting balloon has been used to treat various nonvascular strictures as well as vascular stenosis. In this article, we describe for the first time the use of the cutting balloon in the treatment of patients with urethral stricture. Four patients with bulbar urethral stricture were included in the study. All strictures were successfully dilated with the cutting balloon, and patients were free of symptoms at 6-month follow-up. Cutting-balloon dilatation is a safe, easy-to-perform, and effective treatment for patients with tight urethral strictures.     

Measurements of tooth length in panoramic radiographs. 1. The use of indicators.

The aim of this study was to investigate both the actual and the radiographic tooth lengths of the maxillary first molar and second premolar and the mandibular premolars in panoramic radiographs. The actual length of 64 extracted teeth was measured. Steel balls were then attached to the cusp and apex and the teeth embedded in plastic moulds. Each pair of plaster casts with their set of teeth was radiographed with an Orthopantomograph twice at an interval of 1 month. The actual and the radiographic tooth length was measured twice by one observer. The mean tooth length of the molar was shorter than that of the premolars. The mean difference between the repeated measurements of the actual tooth length was small and ranged between 0.47 and 1.16% of the tooth length. The mean difference between repeated measurements of the radiographic tooth length was also small, with a method error of 0.13-0.21 mm. The vertical magnification in panoramic radiography was lower for mandibular premolars (13-15%) than for the maxillary second premolar and first molar (17-28%). The palatal root of the maxillary first molar had the highest vertical magnification (28%). Following the second set of radiographs, the mean difference between the measurements was small, except for the palatal root of the maxillary first molar (P < 0.001). Radiographic measurements of this root should therefore be used with caution. The results for the other roots examined indicate that these could be measured with high reproducibility.     

经耻骨径路治疗骨盆骨折后复杂性后尿道狭窄

目的 探讨经耻骨径路治疗骨盆骨折后复杂性后尿道狭窄的手术安全性和长期疗效.方法采用经耻骨径路治疗复杂性后尿道狭窄26例,其中男21例,女5例;年龄16～65岁,平均26岁.后尿道狭窄长度2.5～4.0 cm 23例,>4.0 cm 3例,其中尿道闭锁5例.尿道断端彻底切除瘢痕后采用端端吻合术,观察手术效果及术中术后并发症.结果 随访1～7年,平均4年.22例(85%)手术成功,排尿通畅.无耻骨炎、骨盆分离、骨盆不稳定、尿失禁等并发症.1例(4%)排尿不畅,3例(11%)失败.结论经耻骨径路治疗骨盆骨折后复杂性后尿道狭窄安全可行,切除尿道瘢痕彻底,无严重并发症,长期疗效良好,值得临床选择性使用.     

Rhenium-188 mercaptoacetyltriglycine-filled balloon dilation in the treatment of recurrent urethral strictures: initial experience with five patients

PURPOSE: To evaluate the efficacy of beta-irradiation therapy with use of a rhenium-188 mercaptoacetyltriglycine ((188)Re-MAG(3))-filled balloon for the prevention of restenosis in urethral strictures refractory to repetitive surgical or interventional procedures. MATERIALS AND METHODS: Five male patients with traumatic (n = 4) or postoperative anastomotic (n = 1) recurrent urethral strictures were included. One to four sessions of 20-30 Gy beta-irradiation at a 1-mm tissue depth with (188)Re-MAG(3)-filled balloon dilation were undertaken in each patient. RESULTS: No procedural complications or toxicities were noted. During the mean follow-up period of 16.2 months, the stricture did not recur in two patients, whereas three patients required additional interventional procedures. In two of these patients, the treatment intervals between the required sessions were significantly prolonged. For the entire group, the mean treatment interval was prolonged from 2.2 months before (188)Re-MAG(3)-filled balloon dilation to 10.7 months after therapy. CONCLUSION: (188)Re-MAG(3)-filled balloon dilation shows promise in preventing or delaying stricture recurrence in patients with recurrent urethral strictures.