Usefulness of retrograde urethrography in diagnosing strictures of the anterior urethra

Imaging of the male urethra for stricture disease

Imaging of the urethra for suspected stricture disease should initially consist of conventional imaging with a dynamic RUG. It is easy to perform and detects clinically relevant strictures involving the anterior urethra and those with extension into the membranous urethra. Additional studies, including antegrade imaging, sonographic urethrography, and MRI are best used in conjunction with RUG as clinically indicated to better define the extent of disease and assist in guiding reconstruction. Post-operatively, VCUG is appropriate to evaluate complete healing and adequacy of repair. Sonourethrography is a simple technique that provides a dynamic, precise assessment of anterior urethral strictures. It is best employed as a staging study in men with known symptomatic strictures in whom the need for operative therapy is clear. For short bulbar strictures ultrasound is more accurate in measuring stricture length than conventional radiographic RUG and is therefore helpful in determining whether to excise or graft. For long or complex strictures assessment of the stricture's diameter may be helpful in determining flap width or in identifying the focal urethral segments to be excised. The simplicity, precision, and availability of sonography along with the absence of radiation exposure make sonourethrography a valuable staging tool for the reconstructive urologist. MRI is valuable for defining the distorted pelvic anatomy that is frequently associated with posterior urethral strictures resulting from trauma. By determining the location of the prostate and the length of the prostatomembranous defect, MRI may help determine whether a transperineal or transpubic approach for reconstruction is necessary.

Urethral stricture following transurethral prostatectomy

Urethral stricture is the most common late complication of transurethral prostatectomy. Uroflowmetry is recommended as the routine screening procedure for strictures postoperatively. If maximal urinary flow rate (Qmax) is below 10 mL/second the patients should be investigated further. The etiology of urethral stricture is still unclear. Further studies are necessary to evaluate the possible etiologic role of infected urine pre- and/or postoperatively, urethral catheterization pre- and postoperatively, catheter material, and the type and size of the resectoscope. A narrow urethra is probably a predisposing factor for stricture formation, but this is not definitively clarified. Only few randomized studies have been performed to evaluate the different prophylactic methods against development of strictures postresection. Resection via perineal urethrotomy, perhaps preceded by urethral calibration, seems to be a way to avoid anterior urethral strictures. The effects of internal urethrotomy preoperatively on stricture formation are conflicting. Further randomized studies are necessary.

Functional evaluation of anterior urethral strictures with combined antegrade and retrograde urethrography

The merits of radiological examination for functional evaluation of urethral strictures of the anterior male urethra were studied by comparing the results of combined retro- and antegrade urethrography with the patient's maximum urinary flow-rate. A correlation was found between stricture diameter and maximum flow-rate (r=0.67) and a still higher correlation between the ratio stricture diameter-prestenotic urethral diameter and the flow-rate (r=0.73). A low but significant (p less than 0.05) negative correlation was obtained between the prestenotic urethral diameter and the flow-rate (r=0.25).

Visual internal urethrotomy with postoperative cystostomy or urethral catheter

Visual internal urethrotomy is nowadays considered by many to be a very useful method of treating urethral strictures. There is still controversy, however, about how long the postoperative urethral catheter should be left in situ. A prospective randomised study was therefore performed to evaluate the influence on the results of urethral catheterisation versus a suprapubic cystostomy for 5 weeks. After 12-36 months of follow-up (mean 25 months) there was a significant difference in result in favour of the urethral catheter. In the catheterised group, 13 out of 20 patients were without recurrence, compared to 4 out of 17 patients in the cystostomy group. Of the total number of 76 patients treated by postoperative urethral catheterisation, 37 (48%) had a normal or slightly subnormal flow-rate 12-60 months after the urethrotomy. Young patients and patients with stricture treated for the first time showed significantly better results than older patients or patients who had previously been treated twice or more. The stricture diameter-prestenotic urethral diameter ratio, obtained by combined retrograde and antegrade urethrography, provided a fairly accurate measure of the functional significance of a stricture.

Direct vision cold knife urethrotomy

During a 3-year period urethral strictures in 75 patients were treated by cold knife urethrotomy. Analysis of the etiology, diagnosis, surgical technique, complications and postoperative management is described. Satisfactory results were achieved in 71 per cent of the cases. The over-all morbidity rate was 9 per cent. Patients with strictures more than 2 cm. long had unsatisfactory results, while those managed with a silicone catheter postoperative for less than 7 days had better results. Direct vision cold knife urethrotomy is a safe technique that should be exercised as a therapeutic trial before a final decision is made to perform definitive urethroplasty.

The role of selective internal urethrotomy in the management of urethral stricture: a multi-centre evaluation

The advent of selective internal urethrotomy under direct vision has enabled precision endoscopic surgery to be undertaken on a wide range of urethral strictures. A multi-centre survey of 197 cases involving 322 urethrotomy procedures from 5 urological departments in England is reported. The overall results after a follow-up of up to 4 years suggest that there is no indication for further procedures currently existing in 160 (81%) of those cases subjected to selective internal urethrotomy. The additional injection of triamcinalone acetate into the strictured area prior to urethrotomy is recommended in resistant cases. The procedure of selective internal urethrotomy is, in our opinion; the best primary method for the treatment of urethral stricture, and it is hoped this will reduce the indications for anastomotic or substitution urethroplasty.

Transurethral urethrotomy under vision

Transurethral urethrotomy under vision with the Sachse urethrotome is a new surgical procedure for the treatment of urethral strictures. The chief advantage of the urethrotome is the fact that the surgeon can cut strictures selectively and accurately under clear vision. The procedure is less painful than blind internal urethrotomy and less extensive cases can be done in the office with the patient under local anesthesia. We report on 36 cases with at least 6 months of followup. In 20 cases the strictures were distal to the prostate and the results were considered good in 16, improved in 3 and a failure in 1. The other 16 cases involved vesical neck contractures and all patients had good results. The technique for urethral strictures distal to the prostate and for vesical neck contractures is described and postoperative treatment is emphasized and discussed.