Urethra stricture etiopathogenesis & evaluation

ETIOPATHOGENESIS AND
EVALUATION
OF STRICTURE URETHRA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical
College
Chennai
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai
2

DEFINITION
“urethral stricture is a ﬁbrotic process with varying degrees of
spongioﬁbrosis that results in poorly compliant tissue and decreased urethral
lumen caliber”
• The term urethral stricture refers to anterior urethral disease and is a
scarring process that involves the epithelium and the spongy erectile tissue
of the corpus spongiosum.
• Contraction of the scar reduces the urethral lumen.
• Posterior urethral strictures are more correctly referred to as PFUIs;
strictures of the prostatic urethra or bladder neck are properly referred to as
contractures or stenoses.
• “ no matter how uniform the urethra may look, if it does not expand to ≥ 8 mm in
diameter on imaging, then it is probably stenosed” – Brandes
• “ stricture measuring less than 11Fr will cause interference with the flow “ –Smith
1968
Chennai
3

EPIDEMIOLOGY
• prevalence of urethral stricture is estimated to range from 1 to 9 strictures
per 1,000 people.
• The rate then steadily increases throughout each subsequent decade
peaking with men over the age of 85 who have a 12-fold risk of urethral
stricture.
• in non-industrialized nations with up to 66 % of diagnosed urethral
strictures related to sexually transmitted illness
• $200 million in direct medical costs per year.
Chennai
4

ETIOLOGY
• It was originally thought that urethral strictures were the result of ulcers or
carnosities. Ambrosie Pare, also believed this to be the cause. By the 18th
century, such notions were discredited by the likes of John Hunter.
• Several theories for the etiology of urethral strictures included a “plastic
exudate” that reacted with urine resulting in a “collar of swelling” by
Tanchou and Lallemand, a false membrane by Ducamp and Laennec, or
granular urethritis .
• In the 18th century, most articles with urethral stricture were only
concerned with urinary retention and complete obstruction. Lesser degrees
of stricture were not emphasized.
Chennai
5

• The first classification system of urethral strictures was described by
Charles Bell in 1810 into: “simple, bridle, dilatable, spasmodic, callous,
and ulcerated” strictures.
• Bell felt that the etiology of urethral strictures was inflammation and
disagreed with John Hunter who believed the urethral strictures were
contractures of the “muscles” of the urethra.
• In 1827, Ducamp logically deduced that as “gonorrhea is the most frequent
as well as the most intense kind of inflammation to which the urethra is
subject, so it is the principal cause of stricture in this canal.” Furthermore,
• Amussat, the great French physician of the early 1800s, classified strictures
as organic, spasmodic, or inflammatory.
• Other common classifications used in the 1800s were by Syme,
“imaginary, slight, confirmed, irritable, and contractile,” and Thompson
(1854), “organic, inflammatory, and spasmodic.”
Chennai
6

Etiology
• Congenital
• Inflammatory- Gonococcal
Non-Gonococcal
Lichen Sclerosis
• Traumatic - PFUDD
Post Operative
Post Instrumentation
Radiation induced
Chennai
7

Chennai
8

Chennai
9

Chennai
10

Chennai
11

Cobb’s Collar
• In 1960 Cobb described number of cases of short narrowing in bulbar
urethra in young men that appear to be congenital
• Seen on VCUG as indentation distal to muscularis incisura and
verumontanum
• Exist as a normal common variant , rarely producing obstruction.
• Embryological development- inconclusive-but mostly due to persistent of
the urogenital diaphragm or cloacal membrane
Chennai
12

Cobb’s Collar
• Other synonymous term like
Moorman’s ring
COPUM
Type III PUV-inframontane membrane with central
rather than posterior hole
Chennai
13

VCUG
A)Cobb’s collar
B)Prostatic
urethra
C)Anterior
urethra
D)Muscularis
incisura
Chennai
14

Endoscopic view
Muscular Cobb’s
collar
Membranous Cobb’s
collar
Chennai
15

Gonococcal and NGU
• Sexually transmitted disease
• Still quite prevalent; detected incidentally
• Patients seek treatment earlier
• Sequelae avoided
• Urethral stricture results from untreated infections
• Organisms- Nisseriae gonorrhoea, C. trachomatis,
Mycoplasma, Ureaplasma, tuberculosis
Chennai
16

Pathogenesis
• Infection , ‘Littritis”, abscess formation
• Bursts into corpus spongiosum
• Heals by scarring; urine forced into spongy tissue and scarring
spreads
• Maximum density of glands in the bulb small percentage in
distal pendulous urethra
• These sites are most prone to stricture formation
Chennai
17

Chennai
18

Lichen sclerosis
Chennai
19

Definition
Definition
• It’s a chronic lymphocyte mediated skin disease affecting any part but has a
predilection for anogenital skin
• up to 47 % of patients with lichen sclerosus develop urethral stricture and
lower urinary tract obstruction
Chennai
20

Clinical features
In females
• Insidious or aggressive
• Anogenital area-85-90%
• Extragenital -10-15%
• Intractable pruritus, soreness of vulva , dysuria ,
dyspareunia , pain on defecation
• O/E-figure “8’ pattern skin change , fissure and cracks
,thinning of skin , narrow introitus ,buried clitoris
Chennai
21

In Males
• Genital involvement 5 times more common then extra
genital
• Involves mainly glans and foreskin and not the perineum
• 57%glans and fore skin
• 4%meatus
• 20% urethral involvement
Chennai
22

Urethral lichen sclerosus
• Common in male , rare in female
• 47% of urethral LS – obstructive
• Usually doesn’t involve posterior urethra or bladder mucosa
• Usually sharp demarcation, Rarely patchy skip lesions
• Panurethral strictures typically start as meatal stenosis and meatitis.
• high pressure voiding and infected urine, lead to secondary Littritis >
corresponding annular (band-like) strictures at the level of each of the
glands.
• The stenotic bands that develop are typically multiple and throughout the
bulb and pendulous urethra.
(LSA is a good example of how untreated and ignored meatal stenosis can
progress to the complex and difficult to repair paraurethral stricture)
Chennai
23

Etiology
• Koebner phenomenon
• Genetic susceptibility
• Autoimmunity
• Oxidative stress
• Infection
Chennai
24

Chennai
25

IATROGENIC STRICTURE IS TYPICALLY CAUSED BY
INSTRUMENTATION
• transurethral resection (41 %)
• prolonged catheterization (36.5%)
• cystoscopy (12.7 %)
• prior hypospadias repair (6.3 %)
• radical prostatectomy surgery (3.2 %).
Chennai
26

Stricture following TURP
• Incidence-
anterior urethra 1.5-3.8 %
bladder neck contracture 2-2.4%
Risk factors-
extensive resection, undermining or fulguration of the bladder neck,
and over-resection of a small prostate, weight of the prostate chips
(as a surrogate marker of initial gland size and suggest that for anticipated resections
<10 g, transurethral incision of the prostate may yield fewer bladder neck
contractures).
large resection loops may generate excessive heat producing a
hypertrophic scar in a small intraurethral adenoma.
Urethra-resectoscope disproportion and stray current caused by the
use of faulty loops, faulty insulation, or nonconductive lubricating
gels with non-insulating lubricant.
Duration of catheterization and extravasation of urine
colonization or infection of urine.
Chennai
27

Posterior urethral stricture
(post operative)
Chennai
28

Post RP stricture
• Usually occurs within 6 months
• Incidence usually 1.3-27%
• Early “immature” strictures- days to weeks after catheter removal
• “Mature” stricture occurs late
• vesicourethral anastomotic strictures are usually the result of scar
tissue encircling and narrowing the reconfigured bladder neck.
• Risk factors:
anastomotic tension, inflammation from urinary extravasation, poor
tissue handling, and ischemia.
excessive blood loss, type of bladder neck dissection, postoperative
urinary leakage, adjuvant radiotherapy, and prior TURP
Chennai
29

Post instrumentation stricture
• Occurs due to
Faulty catheter - local tissue reactions and destruction
(from best to worst: silicone, plastic, latex, and rubber).
Failure to dilate a narrow meatus
Narrow urethra
Larger calibre resectoscope
Faulty introduction of resectoscope
Chennai
30

Chennai
31

TRAUMATIC ORIGIN
• PFUDD injury leads to a shearing force that plucks the prostatic
urethra from the membranous urethra or, more probably, the
membranous urethra from the bulbar urethra, and that this is more
commonly a complete injury rather than a partial injury, leading to
distraction of the two ends.
• Recent evidence suggests that most pelvic fracture-related injuries
are partial injuries rather than complete injuries.
• It also suggests that although “switchblade” transection of the
urethra, partial or complete, by a bone fragment can occur, most
commonly urethral injury depends on what happens to the soft
tissues of the pelvis rather than the bones, and particularly on what
happens to the perineal membrane and puboprostatic ligaments
(MID SUBSTANCE)
Chennai
32

• incidence of pelvic fracture has been estimated at 20 per 100,000
population. The male to female incidence ratio is about 1.8 to 1
• mortality of such trauma is about 10%
• incidence of urethral injury is variably reported at about 5–10%
• bulbomembranous junction that is the most common site of urethral
injury.
Chennai
33

Radiation induced strictures
• incidence of bulbomembranous urethral stricture or BNC is 3–16%.
• presentation is delayed (24 months) and insidious.
• unhealthy or pale appearance on cystoscopy, with varying degrees
of local tissue induration or dense fibrotic scarring
• Tissues with a rapid cell turnover such as skin and mucous
membranes are most susceptible to the acute effects of radiation.
Chronic tissue damage is characterized by cell ischemia and
fibrosis. (microvascular endarteritis)
• initial ulceration with subsequent proliferation of a stratified
squamous epithelium with infiltration of elongated myofibroblasts
and clumps of multinucleated giant cells. The proliferation of
myofibroblasts have been proposed as causative factors for stricture
formation and giant cells are thought to promote collagen synthesis
in the strictured area.
Chennai
34

PATHOLOGY
• normal urethra is lined mostly by pseudostratified columnar epithelium.
Beneath the BM there is a connective tissue layer of the spongiosum rich in
vascular sinusoids and smooth muscle.
• The connective tissue is composed of mainly fibroblasts and and ECM that
contains collagen, proteoglycans, elastic fi bers, and glycoproteins.
• most dramatic histologic changes of urethral strictures occur in the
connective tissue.
• Strictures are the consequence of epithelial damage and spongiofibrosis.
• rich in myofibroblasts and giant multinucleated giant cells, both are related
to stricture formation and collagen production.
• The change in the ratio of type I to III collagen was associated with a
decrease in urethral elasticity and compliance
Chennai
35

EVALUATION
Chennai
36

Chennai
37

DIAGNOSIS
History:
Trauma
External trauma: Pelvic fracture, straddle injury.
Internal trauma: Large catheters and instruments.
Infection
Gonococcus
Sexual contact history
TB
Chennai
38

SYMPTOMS AND SIGNS:
Predominantly Obstructive voiding symptoms
Thin urinary stream
Splaying/double stream
Post void dribbling
Intermittency
Frequency
Dysuria
Chronic urethral discharge
Symptoms of acute cystitis /UTI /prostatitis/epididymitis
Urinary retention
Chennai
39

Chennai
40

The overlap with
radiation cystitis
symptoms can lead to
misdiagnosis or delayed
diagnosis of the stricture.
Chennai
41

PHYSICAL EXAMINATION
• chronic urinary retention and a palpably distended bladder.
• Examination of the penile skin may reveal the presence of lichen sclerosus.
• Examination of the urethral meatus stenosis or sequelae of hypospadias.
Hypospadias pt with or without previous surgery are at risk for urethral
stricture.
• urethrocutaneous ﬁstula in cases of previous urethral surgery or have long-
standing lower urinary tract obstruction.
• Tender enlarged masses along the urethra : periurethral abscess.
Chennai
42

• Palpation of the urethra often reveals thickening and/or induration which
correlates well to the severity of periurethral fibrosis identified
intraoperatively.
• Diffuse urethral induration often indicates severe spongiofibrosis, as in
cases of lichen sclerosus, but if extensive should suggest the diagnosis of
urethral carcinoma.
• Digital rectal examination (DRE) is performed to rule out other possible
prostate pathology
• Clinically, it is important to document clearly, objectively, and
subjectively whether the patient has normal erections or erectile
dysfunction, for obvious medicolegal reasons
• patients with complete erectile dysfunction, particularly if associated with
a cold numb penis, are likely to have a more profound disruption of the
local blood supply and may therefore be more prone to recurrent stricturing
after urethroplasty.
Chennai
43

Chennai
44

Uroflowmetry
• Constrictive obstruction - “plateau”-shaped trace with little change in
flow rate and little difference between Qmax and Qave
• Qmax is below 10 ml/s then the chance of the patient having BOO is
90%
• If the Qmax is 10 ml/s to 15 ml/s then the incidence of BOO is 71%
or less
• Helpful in finding recurrence of the stricture disease.
• Despite limited use of urodynamic evaluation, the goal is to
document obstruction in the setting of a functioning bladder prior further
operative intervention.
• After RRP, urodynamics should be considered before proceeding to
aggressive electrosurgical incision of refractory strictures of the
vesicourethral anastomosis, as these patients will likely require
subsequent anti-incontinence surgery
Chennai
45

Chennai
46

Chennai
47

• For an appropriate treatment plan to be
devised, it is important to determine
the location, length, depth, and density
of the stricture (spongiofibrosis).
• The length and location of the stricture
can be determined with contrast
radiography,urethroscopy, and
ultrasonography.
Chennai
48

• The depth and density of the scar in the
spongy tissue can be deduced from the
physical examination, the appearance
of the urethra in contrast-enhanced
studies, and the amount of elasticity
noted on urethroscopy.
The depth and density of fibrosis are
difficult to determine objectively.
Chennai
49

IMAGING
AUG VCU
Chennai
50

URETHROGRAPHY
• oldest radiographic test for assessing urethral stricture disease, and
remains the gold standard for diagnosis and staging
• performed in a retrograde fashion
• contrast medium is injected to the urethra under direct fluoroscopic
or radiographic vision, and multiple images are obtained. This is
known as a dynamic retrograde urethrogram, which allows for live
assessment of the urethra as contrast is delivered
• patient should be in an oblique position(35-45 degrees) to maximize
visualization of the bulbar urethra.
• Proper positioning can be confirmed by a closed downward oriented
obturator foramen.It ensures that the majority of the urethra is
parallel to the radiographic film.
• Improper positioning will place the urethra at an angle relative to the
film, and result in underestimation of stricture length
Chennai
51

• The penis should be placed on stretch in order to maximize
complete assessment of the urethra.
• The use of anesthetic-impregnated lubrication can obscure the
image, induce edema, and provide questionable benefit to patient
comfort
• the key features of stricture that a RUG must identify- location,
length, number and coexistent urethral pathology.
• In some cases, compression of the anterior leaf of the
bulbospongiosus muscle (musculus compressor nuda) may be seen
in the very proximal bulbar urethra. This is a normal finding that
should not be mistaken for a proximal bulbar urethral stricture.
• Sensitivities between 75% and 100% have been observed, with
specificities of 72-97%. Positive predictive values have been
reported from 50-93%, with negative predictive values varying in the
76-100% range Dept Of Urology, KMC and GRH,
Chennai
52

complicating features such as fistula, false passage, and significant
ductal reflux can be readily identified.
Limitations include-
• variation in the appearance of the stricture with the position of the
patient and the degree of stretch of the penis.
• it simply delineates the primary stricture with no accurate
determination of site, length or diameter of the stricture
• radiation exposure to the testes.
• patient discomfort, urinary tract infection, and contrast agent
reaction
Chennai
53

Chennai
54

CYSROGRAPHY
• can stage urethral strictures both in a dynamic and static fashion.
• Voiding cystourethrogram (VCUG) can provide excellent
assessment of the posterior urethra.
• Contrary to RUG, the bladder neck and prostatic urethra are
distended during a VCUG assessment, therefore better proximal
assessment of an obliterated or near-obliterated stricture that fails to
be adequately staged with RUG alone.
• VCUG can give indication of the degree of functional impairment
that the stricture imparts, by examining the hydrodistension effect of
dilation of the urethra proximal to the stricture
• Modes: 1)immediately following contrast instillation at time of RUG
2) a small-bore ureteral access catheter can be passed through the stricture to instill contrast into the bladder
3) suprapubic catheter in-situ
4) following administration of intravenous contrast. Such a technique is uncommon.
Chennai
55

• In PFUDD, deformity in most instances is characteristic: the
posterior urethra is displaced posteriorly, and there is a
characteristic S-bend deformity at the site of injury.
• It is common to see an apparently long gap between the distal limit
of a complete obliteration on ascending (retrograde) urethrogram
and the bladder neck on a cystogram (through a suprapubic
catheter). This doesn’t mean that the stricture extends all the way up
to the bladder neck, only that the detrusor is unable to contract and
open the bladder neck and so allow contrast down to the upper end
of the obliteration.
Chennai
56

Static cystography-
• has a minor role in the evaluation of anterior urethral stricture
• In PFUI it can provide an estimate of the length of distraction defect.
• provides an assessment of the competency of the bladder neck.
Pelvic fracture patients carry a significant risk of neurologic injury, and subsequent
incontinence following attempts at reconstruction. A study by Iselin et al. have associated
the presence of an open bladder neck on static cystogram prior to reconstruction to carry
a 53% rate of incontinence.
Chennai
57

Chennai
58

Chennai
59

Chennai
60

Chennai
61

SONOURETHROGRAM
• the use of ultrasonography to evaluate anterior urethral strictures
was ﬁrst reported by McAninch in 1988
• is used primarily as an adjunctive technique
• It has got sensitivities and specificities of 66-100% and 97-98%,
with corresponding positive and negative predictive values of 50-
80% and 96-98%.
• it gives three-dimensional anatomic assessment of stricture length
and location.
• Ultrasound may be used to determine the extent of spongiofibrosis
and absolute stricture length (AUA; Grade C), but its use is
recommended in conjunction with RUG for preoperative staging and
length assessment of anterior urethral strictures (SIU; Grade C).
Chennai
62

• It is done using a standard ultrasound scanner using a 7.5 MHz
linear-array transducer;
• With the patient supine, the glans is disinfected and a truncated 8 F
infant feeding tube is introduced into the urethra.
• The penis is then cranially extended over the lower abdomen and
the ultrasonic transducer is placed on the ventral surface of the
penis.
• Sterile 0.9% normal saline is injected continuously (50–250 mL) via
the feeding tube, after taking care to exclude air bubbles, while the
penile urethra is visualized to the penoscrotal junction.
• Subsequently the transducer is repositioned to visualize the
proximal penile and bulbar urethra trans-scrotally and
transperineally.
Chennai
63

• During SUG, on saline injection, the urethra will be distended and
appears as a homogenous echo-free band of 8–10 mm in diameter.
• Below the urethra, there will be an echogenic band that is produced
by dorsal acoustic enhancement and reﬂection from the tunica
albuginea.
• Strictures will be located as segments of reduced distensibility on
injection with saline. In cases where the proximal extent of the
stricture is unclear, the patients will be asked to strain with a full
bladder, which helps to delineate the proximal limit of stricture.
Chennai
64

• SUG to have a greater sensitivity in estimating stricture length, with
a better correlation with operative ﬁndings. This was especially true
for the bulbar urethra.
• The reason is that in SUG, the hand-held transducer is positioned
directly perpendicular to the distal urethral segment. However, in
RUG, the pelvis is aligned obliquely to the anteroposterior X-ray
beam and the bulbar portion of the urethra is ﬁxed in the same axis
as the pelvis. Thus the radiographic image is an ‘end-on view’,
which reduces the apparent stricture length.
• SUG could also be used during surgery to monitor the site, extent
and depth of urethrotomy, which could lead to a more adequate
incision of scar tissue during visual internal urethrotomy (VIU), and
thus avoid recurrence. (In a retrospective review of 232 patients, Buckley et al. found that
intraoperative SU changed surgical approach in 19% of patients, and influenced decision-making in 26% of
patients.)
Chennai
65

• SUG is particularly useful for a high-grade stenosis when the entire
stricture segment cannot be filled adequately for standard
radiographic techniques. In such a case the patient can be advised
to strain with a full bladder at the time of SUG, which would also
distend the urethra proximal to the stricture and thus define the full
extent of the stricture.
• dynamic nature of SUG delineates the degree of spongiofibrosis by
forming an echogenic shadow along the urethra, resulting from the
high collagen content. SUG directly visualizes the fibrosis deep to
the area of stricture and its extent beyond it.
• It also delineates associated pathologies like false tract, stone,
diverticulum.
• Limitations of SUG - for imaging the posterior urethra, inherent
observer bias.
Chennai
66

Chennai
67

Chennai
68

Chennai
69

Chennai
70

Chennai
71

CROSS SECTIONAL IMAGING
• potentially useful adjunct in preoperative assessment
• Indications-
• Failure of bladder neck opening on VCUG.
• To know Prostatic displacement on the horizontal or vertical axis
• complicating features such as fistulae, cavitation, diverticula, and false passages
• SIU guidelines also mention the use of MRI and computed CT as useful
adjuncts for the evaluation of urethral stricture, particularly in the setting of
pelvic fracture (SIU; Grade C).
• The AUA guidelines add that in a setting where non-urgent intervention is
appropriate, determining length and location of the urethral stricture is
recommended (AUA; expert opinion)
Chennai
72

MR URETHROGRAM
• first described in 1992
• It is helpful to know density of urethral stricture.(Spongiofibrosis)
• It helps in diagnosis of extension of urethral stricture and complications
associated with stricture.
• Mostly indicated in post traumatic stricture,neoplastic stricture and
recurrent complex urethral stricture.
Chennai
73

• axial and coronal images are most useful for evaluation of the posterior
urethra, whereas sagitally oriented images are most useful for the anterior
urethra.
• A phased array coil is placed over the perineum, and a small field of view
is used.
• If detailed urethral anatomic information is desired, contrast may be
injected into the urethra prior to imaging.
• First, fat- saturated T1-weighted sequences are usually faster to obtain than
most high-resolution T2 sequences, thus minimizing scanning time and
leakage of contrast from the urethra around the catheter.
• Also, any fluid-containing structure will appear hyperintense on T2-
weighted images, which may be confound evaluation of periurethral fluid
collections and make it impossible to differentiate collections which
communicate with the urethra from those that do not.
Chennai
74

Chennai
75

Chennai
76

CT Urethrography
• Three-dimensional spiral computed tomography (CT) cystourethrography
(CTCUG) was first reported for evaluating post-traumatic posterior urethral
defects in 2003.
• Allows multi-plane assessment, and more precise definition of pelvic
anatomy.
• evaluates location and length of the distraction defect, the alignment of the
urethral ends, relationship of bone to the urethra, and associated pathology
such as fistula, diverticula, and false passage.
• better surgical planning
• very rapid scanning time
• ability to perform multiplanar reformatting to lengthen the urethra and determine
stricture length and location accurately.
Chennai
77

Drawbacks – 1) it is can not provide information about the urethra that cannot
be obtained using a less expensive and more conventional technique.
2)the anterior urethra may not be fully distended during voiding, which
may limit evaluation of anterior urethral disease.
3) standard risks when IV contrast: nephrotoxicity and contrast allergy.
4) If the patient triggers the scan but does not actually initiate a full voiding
stream, then adequate opaciﬁcation of the urethra will not be achieved, and the
scan may have to be repeated, thus greatly increasing the gonadal radiation
dose.
5) wait time for initiation of voiding while the patient is occupying the
scanner may be impractical in centers with limited CT resources.
Chennai
78

URETHROSCOPY
• de facto gold standard for most urologists in determining the
presence or absence of a urethral stricture
• very helpful in staging urethral strictures in combination with other
imaging modalities
• chief limitation is - the inability of the instrument to pass through a
significant stricture, which can compromise more proximal
assessment of stricture length, number, and location (overcome by- use
of smaller caliber instruments, such as a pediatric cystoscope, a ureteroscope, or a
flexible hysteroscope)
• urethral distraction after PFUI cases, cystoscopy is required to
accurately assess the length of a stricture. due to completely
obliterated segment and are unable to sufficiently relax the bladder
neck during voiding studies to visualize the posterior urethra. As
such, in conjunction with retrograde urethrogram, contrast-based
assessment alone can result in significant overestimation of the
length of the distraction defect.
Chennai
79

• In these instances, antegrade cystoscopy can be performed through
the suprapubic tract, and the cystoscope can be advanced through
the bladder neck to the level of the stricture.
• In combination with RUG, this maneuver can assist in accurate
identification of distraction length
• Suprapubic tract cystoscopy can allow for direct visual assessment
of bladder neck competence and provide information on bladder
neck fibrosis and tethering, which when present may indicate an
increased risk of incontinence following urethral reconstruction.
Chennai
80

Chennai
81

Chennai
82

SUMMARY
• RUG remains the current gold standard of imaging
• VCUG can provide insight to the degree of functional impairment of
the bladder neck and urethra, and can provide critical staging
information in combination with RUG in complex pelvic fracture
associated urethral injuries.
• Flexible cystoscopy is a useful adjunct as well, allowing for direct
visualization of the stricture and potential complicating features, as
well as improved measurement of distraction length.
• SU remains an adjunctive technique, and may play a role in
intraoperative decision-making.
• Cross sectional imaging via MRI and CT may provide additional
information for complicating features of structures, and can provide
accurate assessment of stricture length, and is most useful in
situations where additional pathology is suspected
Chennai
83

THANK YOU 
Chennai
84

Urethra stricture etiopathogenesis & evaluation

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Urethra stricture etiopathogenesis & evaluation

Similar to Urethra stricture etiopathogenesis & evaluation (20)

More from GovtRoyapettahHospit

More from GovtRoyapettahHospit (20)

Recently uploaded

Recently uploaded (20)