How I Do It - Evaluation of the Urethra

Transcription

1 How I Do It - Evaluation of the Urethra Parvati Ramchandani, MD Professor, Radiology and Surgery University of Pennsylvania Medical Center Philadelphia, PA, USA

2 Disclosure of Commercial Interest Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content

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4 Posterior Urethra P M Penile B

5 Males Indications Urethral Stricture Disease Urethral Trauma Urethral malignancy

6 Males- Most useful Procedures Urethral Stricture Disease Retrograde urethrogram +/- voiding cystourethrogram for diagnostic and post op evaluation Urethral Trauma Posterior urethral injury often first diagnosed on a trauma CT RUG+/-VCUG to confirm and follow Anterior Urethral injury- RUG Urethral malignancy- Cross sectional Imaging

7 Retrograde Urethrogram (RUG) I will start with a RUG in a patient with a prior history of urethral trauma, stricture or surgery 35 yo, previous stricture treatment at another hospital, no old records available

8 Retrograde Urethrogram (RUG) Key Points in Technique Use fluid to inflate balloon of Foley catheter for stability of catheter position -2-4 ml Do not lubricate catheter Patient should be placed in oblique position to visualize urethra without overlap Extend penis to remove curve at penoscrotal junction

9 Retrograde Urethrogram (RUG) Key Points in Technique Use fluid to inflate balloon of Foley catheter for stability of catheter position Do not lubricate catheter Patient should be placed in oblique position to visualize urethra without overlap Extend penis to remove curve at penoscrotal junction

10 Retrograde Urethrogram (RUG) Key Points in Technique

11 Retrograde Urethrogram (RUG) Key Points in Technique Cowpers Duct Glands of Littre

12 Retrograde Urethrogram (RUG) Key Points in Technique Patient in oblique position to visualize urethra without overlap Extend penis to remove curve at penoscrotal junction

13 Glands of Littre Small mucous secreting submucosal glands, more numberous in bulbar sump and the dorsal urethra Secrete mucous during sexual stimulation Become infected during gonococcal/other STD infections

14 Another chronic urethral stricture

15 Pre-Op Post- Urethroplasty Examination Peri-catheter study Pediatric Feeding Tube No Extravasation

16 Post- Urethroplasty Examination Peri-catheter study Pre-Op

17 Complication of RUG Intravasation of Contrast

18 Straddle injury Trauma- Anterior urethra Bulbar urethra compressed against pubis by hard object Partial disruption > complete Usually no associated bony injury Complications: stricture, impotence Other causes: iatrogenic e.g catheterization kick to the perineum Penetrating trauma Penile fracture

19 Trauma- Penile fracture Eggplant penis

20 Posterior urethral Injury

21 Sequelae of Posterior urethral Injury- Urethral Occlusion

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23 Iatrogenic Posterior urethral Injury Requires a voiding Cystourethrogram

24 Urethral Tumors MRI is modality of choice

25 Urethral Tumors MRI is modality of choice Enlarged Nodes

26 Diagnosis Please

27 Female Urethra Indications for Evaluation: Recurrent UTI- look for diverticula Dribbling/leakage from vaginalook for fistula VCUG is the usual procedure

28 45 yo lady with perineal discomfort

29 45 yo lady with perineal discomfort

30 45 yo lady with perineal discomfort

31 What imaging information is crucial to the surgical planning? The relationship between the superior part of the diverticulum to the bladder neck is important for surgical planning to avoid injury to the sphincter mechanism at the bladder neck Important to know where the communicating neck or necks between the diverticulum and the urethra are located, so that these can be resected, to prevent post surgical recurrence.

32 MRI on same patient

33 Evaluation for fistula Retrograde opacification of vagina from urethral meatus should not be mistaken for fistula on VCUG

34 Vesicovaginal fistula

35 Primary urethral neoplasm More common in females than males Rare - accounts for % of all female malignancies Usually white postmenopausal females, age > 50 Associated causes: chronic irritation (UTI, HPV 16,18, proliferative lesions e.g. urethral caruncle 2.5%) Present with mass, obstructive symptoms, urethral bleeding

36 Axial T2 Cor fat sat T2 Axial T1 Sag T2

37 Axial T2 Cor fat sat T2 Axial T1 Sag T2 Normal Normal

38 Experience is that marvelous thing that enables you to recognize a mistake when you make it again

39 THANK YOU