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Ascending Urethrogram and Sonourethrogram in Evaluation of Male Anterior Urethra

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Ascending Urethrogram and Sonourethrogram in Evaluation of Male Anterior Urethra Journal of Advances in Medicine and Medical Research 22(3): 1-9, 2017; Article no.JAMMR.33734 Previously known as British Journal of Medicine and Medical Research ISSN: 2231-0614, NLM ID: 101570965 Ascending Urethrogram and Sonourethrogram in Evaluation of Male Anterior Urethra V. N. S. Dola 1, S. Konduru 1, A. Ameeral 2, P. Maharaj 3, B. Sa 4, Ramesh Rao 5 and Suresh Rao 5* 1Department of Medical Imaging, Sangre Grande General Hospital, Trinidad and Tobago. 2Department of Medical Imaging, San Fernando Hospital, Trinidad and Tobago. 3Department of Medical Imaging, EWMSC, Mount Hope, Trinidad and Tobago. 4Department of Medical Education, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago. 5Department of Preclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago. Authors’ contributions This work was carried out in collaboration between all authors. Author VNSD designed the study, wrote the protocol and the first draft of the manuscript. Authors SK, AA and PM managed the analyses of the study. Authors BS, RR and SR performed the statistical analysis and managed the literature searches. All authors read and approved the final manuscript. Article Information DOI: 10.9734/JAMMR /2017/33734 Editor(s): (1) Georgios Tsoulfas, Assistant Professor of Surgery, Aristoteleion University of Thessaloniki, Thessaloniki, Greece. (2) Philippe E. Spiess, Department of Genitourinary Oncology, Moffitt Cancer Center, USA and Department of Urology and Department of Oncologic Sciences (Joint Appointment), College of Medicine, University of South Florida, Tampa, FL, USA. Reviewers: (1) Antonio Augusto Ornellas, Brazilian National Institute of Cancer, Brazil. (2) Josey Verghese, Kerala University of Health Sciences, India. (3) Gajanan Bhat, India General Hospital, India. Complete Peer review History: http://www.sciencedomain.org/review-history/19528 Received 27 th April 2017 th Letter to the Editor Accepted 8 June 2017 Published 14 th June 2017 ABSTRACT Aim: To determine the efficacy and accuracy of detection and characterization of anterior urethral strictures by sonourethrogram compared to retrograde urethrogram. Materials and Methods: A total of 45 patients presented during the 4 months duration of the study. 31 patients qualified for the study; however 2 of these patients were excluded due to technical difficulties encountered during the sonourethrogram. The parameters studied were age, ethnicity, detection of strictures and characterization by length, location and diameter. In the RUG _____________________________________________________________________________________________________ *Corresponding author: E-mail: [email protected], [email protected]; Dola et al.; JAMMR, 22(3): 1-9, 2017; Article no.JAMMR.33734 tapered segments on either side of the stricture were included. Age distribution, Paired t-test and correlation coefficient were examined. Results: Age distribution of the study population was between 18-80 years. Among the study population, 58.6% were East Indian origin and 41.4% were African origin. 10 out of 29 patients showed normal anterior urethra by both RUG and SUG. Also, the two techniques correctly identified normal from abnormal study. The presence of a stricture and its location was correctly identified by both methods which were retrospectively confirmed with optical cystourethroscopy. The stricture length and diameter measured by SUG and RUG showed no statistically significant difference. The Pearson correlation coefficient(r) is 0.95 for length measurement (p<0.01) and correlation(r) is 0.837 for diameter measurement (p<0.01). Periurethral fibrosis and mucosal abnormalities were well shown by sonourethrogram. Among the strictures demonstrated by SUG, 52.6% showed periurethral fibrosis. The presence of periurethral fibrosis varied between the bulbar and penile areas, 77% in bulbar strictures compared to 24% in penile strictures. Conclusion: Both RUG and SUG proved to be equally efficient in detecting the site of stricture and assessing the length and diameter of the stricture. We noticed that by including the tapered segments on either side of stricture in RUG, the length measurements were comparable to SUG. The periurethral fibrosis and mucosal abnormalities were well demonstrated by the SUG, which was not evident by the RUG. Keywords: Sonourethrogram; retrograde urethrogram; anterior urethral strictures; periurethral fibrosis. 1. INTRODUCTION dependent on the preoperative evaluation of the strictures. The assessment of the morphology of Urethral strictures in males are either anterior or stricture such as the length of the stricture, posterior. Generally, the term urethral stricture diameter of the stricture, site of the stricture and applies to the stenosis of the urethra caused by presence or absence of periurethral fibrosis, etc. fibrous scarring of the anterior urethra secondary is a very important determinant for the method of to collagen and fibroblast proliferation [1,2]. The management of the stricture. Hence, imaging scarring process usually starts in the lumen and forms one of the integral parts in the extends to involve the corpus spongiosum and management of the urethral strictures. adjacent structures. The scarring of the corpus spongiosum is called spongiofibrosis. Ultimately, Retrograde urethrography (RUG) and the scarring leads to retraction and contraction micturatingcystourethrography (MCUG) have resulting in reduced diameter of the urethral long been used as the standard procedures for lumen. the evaluation of the anterior urethra and posterior urethra respectively. Strictures are The etiology of the anterior urethral strictures more common in the anterior urethra and RUG is may be secondary to inflammatory (e.g. the standard imaging technique used to evaluate infectious urethritis, balanitis xerotica obliterans) the anterior urethra, not only for strictures but and traumatic (straddle injury, iatrogenic also for other diseases like diverticulae, fistula or instrumentation) or congenital in origin. The tumours. However, the RUG has certain infectious strictures from gonococcal urethritis disadvantages and limitations such as use of were a major cause in the past. The other radiation and contrast media [5]. infectious causes include Chlamydia urethritis and tuberculosis. In recent years the most The sonourethrogram (SUG) for the study of common cause of urethral stricture is secondary anterior urethra is an alternative and safer to trauma, either from instrumentation or method of evaluation of the anterior urethra. The accidents (like straddle injury and pelvic SUG has been shown by many studies to be fractures) [3]. Management of urethral strictures accurate and reliable in measuring the stricture are aimed at reducing the morbidity and length compared with RUG [6-11]. The use of enhancing the quality of life. There are many sonourethrogram for the evaluation of strictures options like simple dilatation, internal has long been studied and popularized for the urethrotomy, stenting and various reconstructive last 2-3 decades [6,12,13]. These types of surgeries available for the treatment of the studies are however limited in our knowledge in urethral strictures [4]. The selection of the the Caribbean region and the procedure is not appropriate type of treatment is largely well known. Hereby we undertook the study of 2 Dola et al.; JAMMR, 22(3): 1-9, 2017; Article no.JAMMR.33734 sonourethrogram at the SFGH to evaluate the using high frequency (VF 5-10 MHz) linear array anterior urethra and compare the results with transducer. The saline filled anterior urethra RUG. appeared as an echo free dark area on ultrasound. The anterior urethra (penile and 2. MATERIALS AND METHODS bulbar urethra) was scrutinized in both longitudinal and transverse views. The presence A total number of 45 patients were presented to of stricture, the site of stricture, length and the department. Among these, 10 patients were diameter of stricture was assessed thoroughly. known to have posterior urethral strictures, 2 The presence or absence of periurethral fibrosis patients had recent history of trauma and 2 was evaluated, which appeared as increased patients had urethral fistula and hence were periurethral echogenicity with or without posterior excluded from the study. Furthermore, 2 of the acoustic shadowing. 31 patients were excluded from the study due to the technical difficulties encountered while The measurement of stricture length and performing sonourethrogram. The RUG was diameter was done with the aid of an electronic initially performed by an independent radiologist calliper available on the imaging monitor. The other than the investigator which was then length of the stricture was measured in followed by the SUG performed by the sonourethrogram from the transition of normal to investigator. The results of the retrograde abnormal urethral mucosa on either end of urethrogram were blinded to the investigator stricture as shown in Fig. 1. In measuring the performing sonourethrogram. The results stricture on retrograde urethrogram, we followed obtained by the two methods were compared by the technique that includes the tapered ends of two independent radiologists in order to avoid the the stricture. The imaginary lines drawn bias. The various parameters like normal or connecting the normal urethra outlined in RUG abnormal study, site of the stricture, length of the on either side of the stricture was taken
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