Urethroplasty, what to expect after urethral stricture surgery. A pictorial review.

Transcription

1 Urethroplasty, what to expect after urethral stricture surgery. A pictorial review. Poster No.: C-1750 Congress: ECR 2016 Type: Educational Exhibit Authors: D. Butrón Hernández, M. M. Ruiz Ballesteros, L. Avila, J Vazquez Lamadrid ; Mexico, Distrito 3 4 Federal/MX, Mexico city/mx, México D.F./MX Keywords: Obstruction / Occlusion, Cystography / Uretrography, Conventional radiography, Urinary Tract / Bladder, Trauma DOI: /ecr2016/C-1750 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 38

2 Learning objectives Review "How to" realize cystourethrogram technique and its importance as a essential workup in urethral stricture diagnosis. Understand urethral strictures and their common and not so common radiological findings. Show radiologic changes in urethral anatomy after urethroplasty and its possible complications. Page 2 of 38

3 Background Introduction. Urethral stricture is the most common cause of obstructed micturition in young adults and its a complex pathology from the point of therapeutic approach. Retrograde urethrography and voiding (anterograde) cystourethrography evaluate the urethra in its different portions and provide detailed information to the urologist for treatment planning. Urethroplasty is the most common procedure to treat urethral strictures; however, surgical planning and familiarity of the surgeon with the many different types of techniques play an important role to obtain a satisfactory prognosis. Unfortunately, complications such as stricture recurrence, pseudo-diverticulum, false passage and fistulae may appear in a not so uncommon percentage, becoming more frequent after subsequent interventions; therefore radiologists must need to known the common and uncommon changes of urethral anatomy after urethroplasty procedure. Page 3 of 38

4 Findings and procedure details Urethral anatomy Male urethra is divided into 2 portions and 4 subdivisions: Anterior (fig. 1): Penile urethra: extends from the suspensory ligament to the external urethral meatus. Bulbar urethra: arises from the external sphincter to the penoscrotal junction; measures 4-6 cm. Posterior (fig. 2): Membranous urethra: located distal to the veromontanum and passes through the urogenital diaphragm; it measures 1 cm. Prostatic urethra: Begins at bladder neck up to the prostatic apex; it measures usually 3 cm Common urethral pitfalls Ejaculatory ducts. Placed in the prostatic urethra at the apex of the veromontanum, they drain the seminal vesicles (fig. 3). Cowper s ducts and glands. Two of each one located on either side of bulbous urethra (fig. 4). Littré glands. Situated along the anterior urethra, more commonly seen at the dorsal aspect of the penile urethra (fig. 5). Although this findings are more commonly seen on a pathologic urethra, sometimes these structures may be opacified during a normal urethrography and should not be confused with any type of urethral complication. Cystourethrogram technique Page 4 of 38

5 The adequate evaluation of the anterior and posterior urethra is achieved by two complementary techniques; retrograde urethrography and voiding (anterograde) cystourethrography, being the gold standard for accurate assessment of urethral strictures. Technique. Bladder must be empty. Preeliminary film is obtained prior to the start of the study Sterile technique. Patient is placed obliquely at 45 degrees; with the bottom leg flexed at the knee and the top leg straight. A Foley catheter is advanced into the urethra until the ballon is in the fossa navicularis, and then it is inflated with 2 ml of saline. Contrast is injected under fluoroscopic guidance, until the anterior urethra is well distended and images are obtained (fig. 6). Bladder should be filled with contrast until a detrusor contraction occurs, and images are obtained in different projections (fig. 7). Note: If the patient has a suprapubic catheter, bladder can be filled through it. In an oblique position, voiding is started under fluoroscopy and images are adquired (fig. 8). Post-void radiograph is obtained to document the degree of bladder emptying. Urethral stricture Nomenclature After the International Consultation on Urethral Strictures, taken place by the Société Internationale d'urologie on 2010, definitions are described as follows: Urethral stricture - abnormal narrowing of any segment of the urethra surrounded by corpus spongiosum, and that implies varying degrees of spongiofibrosis (fig 9, 10, 11,). Urethral stenosis - narrowing of the membranous urethra not secondary to pelvic fracture urethral injury, also the prostatic urethra, and the bladder neck, as they are not covered by corpus spongiosum (fig. 12, 13,). Pelvic fracture urethral injury - previously known as "pelvic fracture urethral distraction defects". Injuries of posterior urethra associated with a pelvic fracture, a large percentage Page 5 of 38

6 are actually partial injuries, and even complete ruptures do not always present as a separation of the urethral ends. For this reason, acronym was replaced (fig 14, 15, 16). Pathophysiology. Any type of injury that results in disruption of the urethral epithelium with or without spongy tissue damage or spongiofibrosis, that determines a narrowing of the urethral caliber secondary to scarring due to tissue healing. Passage of urine through this defect during voiding results in further inflammation and subsequent damage. Etiology The etiology of urethral stricture disease may be categorized into: - Iatrogenic - Traumatic - Inflammatory/infectious - Idiopathic - Congenital Most common etiologies are idiopathic and iatrogenic subtypes. Urethroplasty Preoperative assessment of urethral stricture The anatomy of the urethral stricture is an essential part to decide the type of definitive treatment, and it is of great interest to the urologist. Factors to take into consideration: - Location and length of stricture (fig. 17). - Depth and density of the spongiofibrosis. - Associated urethral pathology. Page 6 of 38

7 Spongiofibrosis may not be assessed by retrograde urethrography, therefore, urethral ultrasonography should take place to evaluate it (fig. 18). The most common locations of urethral stricture disease are the bulbar and penile urethra. Urethroplasty techniques Over time, different treatment techniques, both surgical and non-surgical, have been developing for stenotic urethral disease. The type of treatment, as well as its prognosis will depend heavily on the stricture anatomy, as well as its familiarity and experience that the reconstructive urologists have with them. Currently the procedures can be grouped into two broad categories, those who are considered management and those who are curative. Management procedures: Urethral dilatation, direct vision internal urethrotomy, laser urethrotomy, urethral stenting. Curative procedures Primary anastomotic urethroplasty, substitution urethroplasty, ventral/dorsal onlay urethroplasty, augmented anastomoric urethroplasty, urethral plate lengthening. Urethroplasty remains the gold standard for the management of urethral stricture disease Follow-up after urethroplasty The first pericatheter urethrogram is done 3-4 weeks after surgery, it is made to confirm the patency of the reconstruction and to evaluate possible complications such as leakages, fistulae etc Further evaluation should be considered if persistence of outflow urinary symptoms or worsening in voiding patterns (uroflowmetry), when compared with previous. What to expect after urethroplasty. Page 7 of 38

8 Normal changes Expected changes observed during urethrography comprise an area with a minimal decrease in its caliber and which clinically does not compromise urine flow output (fig. 19, 20). Stricture recurrence Considered the most common mid and long-term complication. Risk factors included, smoking, strictures longer than 1 cm and prior urethral intervention. Findings on urethrogram include moderate to severe narrowing in urethral caliber at the same level of previous stricture or adjacent to it; low urine outflow may show as the main symptom. (fig. 21, 22) Fistula. Most common perioperative complication. Urethra anomalous communication with the rectum, perineum, bladder or genital structures. Urethrography and cystourethroscopy are the elective diagnosis methods to demonstrate fistulous tract. Depending on the type of fistula, patients may present with: fecaluria, recurrent urinary tract infections, urine per the rectum, urinary dribbling, urinary incontinence (fig 23, 24). Pseudo-diverticulum. It forms due to hydrostatic pressure or turbulence exerted during voiding causing a progressive dilatation and divirticulum formation, in a ventrally positioned unsupported graft or flap. Clinically patients will present with post-voiding dribbling, urinary infection and foul smell. (fig. 25, 26, 27) False passage. Rare complication after urethroplasty. It presents especially in internal urethrotomy, laser urethrotomy o repeated attempts to catheterize urethra, resulting in perforation of urethral wall, creating a false passage communication. (fig. 28) Page 8 of 38

9 Images for this section: Fig. 1 Page 9 of 38

10 Fig. 2 Page 10 of 38

11 Fig. 3 Page 11 of 38

12 Fig. 4 Page 12 of 38

13 Fig. 5 Page 13 of 38

14 Fig. 6 Page 14 of 38

15 Fig. 7 Page 15 of 38

16 Fig. 8 Page 16 of 38

17 Fig. 9: Penile urethral stricture. Page 17 of 38

18 Fig. 10: Penile urethral stricture with posterior and bulbar urethral dilatation. Page 18 of 38

19 Fig. 11: Bulbar urethral stricture Page 19 of 38

20 Fig. 12: Narrowing of the bladder neck. Page 20 of 38

21 Fig. 13: Arrows showing membranous urethral stenosis and penile stricture Page 21 of 38

22 Fig. 14: Pelvic fracture urethral injury with complete disruption Page 22 of 38

23 Fig. 15: Pelvic fracture urethral injury with partial disruption Page 23 of 38

24 Fig. 16: Pelvic fracture urethral injury with complete disruption Page 24 of 38

25 Fig. 17: Anatomy of the stricture. L1 - thight stricture lenght L2 - whole stricture lenght D1 - normal diameter D2 - reduced lumen Page 25 of 38

26 Fig. 18: Penile ultrasound showing multiple areas of stricture and spongiofibrosis wich appears hyperechoic and sometimes calcified. Page 26 of 38

27 Fig. 19 Page 27 of 38

28 Fig. 20 Page 28 of 38

29 Fig. 21 Page 29 of 38

30 Fig. 22 Page 30 of 38

31 Fig. 23: Urethroperineal fistula. A. Antero-posterior projection. B. Lateral projection. Page 31 of 38

32 Fig. 24: Urethrorectal fistula. A. Antero-posterior projection. B. Lateral projection. Page 32 of 38

33 Fig. 25 Page 33 of 38

34 Fig. 26 Page 34 of 38

35 Fig. 27 Page 35 of 38

36 Fig. 28 Page 36 of 38

37 Conclusion Early detection of urethroplasty complications allows the urologist to plan a new treatment intervention. Radiologists should be able to differentiate between expected normal radiological changes and possible complications after urethroplasty treatment, using urethrography as the gold standard to diagnose urethral stricture. Page 37 of 38

38 References Levine M, Ramchandi P, Rubesin S. Fluoroscopic evaluation of the bladder, urethra, and urinary diversions. Practical fluoroscopy of the GI and GU tracts. Cambridge University Press Wein A, Kavoussi L, Partin A, Peters C. Surgery of the penis and urethra. th Campbell-Walsh Urology. 11 ed. Elsevier Yachia D. Urethroplasty for penile urethral stricture. Text Atlas of Penile Surgery. Informa healthcare Andrich D, Mundy A. What is the best technique for urethroplasty?. European Urology (2008) Babnik-Peskar D, Visnar-Perovic A. Comparison of radiographic and sonographic urethrography for assessing urethral strictures. Eur Radiol (2004) 14: Jordan G, Chapple C, Heyns C. Urethral Strictures. An International Consultation on Urethral Strictures. Société Internationale d'urologie. Meeks J, Erickson B, Granieri M, Gonzalez C. Stricture Recurrence after Urethroplasty: A Systematic Review. The Journal of Urology, Vol 182, No 4. Bertolotto M, Sera#ni G, Savoca G, et al. Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications. RadioGraphics 2005; 25: Yu N, Raman S,Patel M, Barbaric Z. Fistulas of the Genitourinary Tract: A Radiologic Review. RadioGraphics 2004; 24: Kawashima A, Sandler C, Wasserman N, et al. Imaging of Urethral Disease: A Pictorial Review. RadioGraphics 2004; 24:S195-S216 Page 38 of 38