Precise pre-operative urethral stricture characterization is important for surgical planning. A period of urethral rest by suprapubic cystostomy tube may aid in stricture characterization and may affect the surgical approach. We compare the radiographic characterization of anterior urethral strictures by fellowship-trained reconstructive urologists before and after a period of urethral rest. We then determine how this changed the planned operative approach.
We queried our prospectively maintained urethroplasty database at the University of Minnesota for men with anterior urethral stricture who had retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) both before and after pre-operative suprapubic cystostomy tube (SPC) placement (n=29). To minimize responder fatigue, 20 pairs of radiographs were selected at random. All pre-SPC and post-SPC images were interpreted in random order by eleven fellowship-trained reconstructive urologists. Interpretation included stricture length, diameter, location and surgeon operative plan. The pre-SPC and post-SPC results were compared; post-SPC stricture lengths were also compared to intraoperative lengths. Intra-class correlation evaluated homogeneity amongst urologists. Linear regression analysis was performed to determine the association between post-SPC radiographic length and intraoperative stricture length.
Imaging agreement among interpreting urologists was satisfactory with intra-class correlation of 0.72. There was no statistically significant difference in pre and post-SPC stricture length. 23% of images were considered obliterative pre-SPC while 58% were obliterative post-SPC (p=0.0005). Mean post-SPC radiographic and intraoperative stricture lengths were 3.0 cm (SD: 2.6cm) and 3.8 cm (SD: 3.3 cm), respectively (p<0.0001). Deviation between radiographic and intraoperative lengths increased with stricture length with a slope of 0.26 (p=0.0023). Surgeon operative plan changed 47% of the time, most commonly to an excisional approach (37%).
Despite optimal urethral imaging with an SPC in men with high-grade strictures, reconstructive urologists underestimate the length by almost 1 cm, on average; this underestimation is less with shorter strictures and increases with stricture length. In addition, a period of urethral rest resulted in more frequent stricture obliteration, which was associated with a change in planned operative approach roughly half the time. If urologists do not place an SPC prior to urethroplasty for high grade strictures then their operative plan should account for account for the stricture being tighter than it may appear.
The Journal of urology. 2017 Dec 05 [Epub ahead of print]
T Moncrief, R A Gor, R A Goldfarb, S Jarosek, S P Elliott, Trauma and Urologic Reconstruction Network of Surgeons
University of Minnesota Department of Urology, Minneapolis, MN., University of Minnesota Department of Urology, Minneapolis, MN; The Trauma and Urologic Reconstructive Network of Surgeons. Electronic address: .