Adherence to the Right Diagnostic Tools for Best Outcomes in Urethral Reconstructive Surgery

Eur Urol 2006; 50: 424-425.
To collect the right preoperative clinical and radiological investigations is pivotal to perform urethral reconstructive surgery and improve the short and long term outcomes. The term “urethral stricture” refers to different pathologies with regard to anatomy, etiology, pathology, radiology and surgery, and urologists are used to including, in the urethral stricture category, different conditions such as lichen sclerosus, failed hypospadias repair and pelvic trauma. Adherence to proper radiological investigations should result in lower intraoperative and postoperative complications and improvement of functional results at a long-term follow-up. Consequently, the radiological assessment must be tailored according to the clinical history, the etiology and the urethral sites of strictures. In other words the radiological investigation must be tailored according to the peculiar features that the disease shows in any single patient. Patients with lichen sclerosus disease or patients with failed hypospadias repair require clinical and radiological preoperative assessment completely different from patients with pelvic trauma and posterior urethral defects. Basically, the goal of patient’s evaluation is to identify the history, the site, the number and the length of stricture, the extent of spongiofibrosis and the presence of associated conditions such as periurethral abscess or fistula, and to rule out the presence of malignancy. The imaging methods currently available for staging anterior and posterior urethral strictures are retrograde urethrography (RUG), voiding cystourethrography (VCUG), sonourethrography, and MRI. In this issue of European Urology, Osman and colleagues reported an interesting comparison between the use of Magnetic Resonance Imaging (MRI) urethrography and conventional retrograde urethrography in the diagnosis of male urethral strictures. The authors investigated 20 male patients with urethral stricture diseases using conventional retrograde urethrography (RUG) and multiformat MRI urethrography, and conclude that this no-invasive investigation is “a promising tool for defining anterior and posterior male urethral strictures as an alternative to traditional radiographic methods”. The study is founded on a limited series of patients, presents numerous scientific deficiencies that don’t justify the take home message and conclusions reported by the authors. The authors presents a limited series of 20 patients and don’t provide information on the clinical history, etiology, site of the urethral strictures, emphasizing only information on the stricture length, degree of spongiofibrosis and associated pathological conditions. Osman and colleagues did not say if they used MRI in patients with penile urethral strictures or only in patients with bulbar and posterior strictures. They did not state if MRI was used in patients with failed hypospadias repair or lichen sclerosus diseases. The author compare RUG and MRI in a very limited and select group of patients and it is not possible to draw conclusion that the MRI is promising tool for defining anterior and posterior urethral strictures. Urethral stricture disease includes also penile urethra and the authors don’t provide any information about the results of this method in patients with penile disease. Moreover, only 2 patients with posterior urethral strictures are included in the study. The choice of treatment was made according only to the length of stricture? Ten patients were successfully treated by internal urethrotomy, but the authors don’t provide any information about the follow-up length and modalities. The authors compare the clinical relevance of RUG and MRI in evaluating male urethral stricture, but VCUG never was used in patients with anterior urethral stricture, missing an incredible number of information available when the RUG is associated to VCUG. Moreover, the authors compare 2 retrograde techniques (RUG and MRI) that are both fully of limits and pitfalls, without the information obtained by the dynamic study of micturition on VCUG. During the RUG the contrast material is also used to obtain dynamic study of urethra (VCUG), thus obtaining more supplementary information on urethral disease, but this important dynamic study is not possible using MRI, that is no-dynamic investigation. The authors suggested that contrast medium is injected to evaluate the degree of activity in inflammatory lesions where fibrotic alterations of the corpus spongiosum can be seen clearly on T1 and T2 weighted images as hypointense areas, easily distinguishable from normal spongy tissue. But what is the clinical significance of these alterations showed on MRI? The authors use the word “degree of inflammatory lesions”, but histological examination of this tissue is not available and there is no any evidence on the results showed by the MRI in evaluating the spongiofibrosis. The spongiofibrosis is cause of stricture recurrence, but the authors don’t provide any information about the long-term rate of disease recurrence after the treatment, thus it is impossible establish the true clinical significance of the imaging obtained on MRI. We agree with the authors that MRI is useful in the study of pathological conditions associated with urethral stricture, such as tumour, abscess, fistula and others. Urethral stricture disease is rarely associated to bladder tumour or other adverse pathological conditions. Therefore, the indiscriminate use of this method in staging male urethral stricture disease could be unjustified. Moreover, the high cost of the procedure is not comparable with the cost of traditional RUG, VCU and sonourethrography. In conclusion preoperative and postoperative staging of male urethral stricture disease is still an open problem. However any urologist should collect first of all the anamnesis and the clinical history of his patient with suspected urethral strictures and perform an accurate physical examination of genitalia area. RUG and VCUG still represent the fundamental radiological investigations suggested in patients with urethral stricture disease. The role of sonourethrography in detecting the degree of spongiofibrosis is controversial, because studies on correlation between the pathological status of spongiousum tissue and the ultrasonographic findings have never made. MRI don’t provide any supplementary information that cannot obtained by conventional and less expensive RUG-VCUG, and consequently should be suggested only in patients with pathological condition associated with the stricture or in patients with pelvic trauma, to evaluate the lesions involving corpora cavernosa and erectile structures.