螺旋CT尿道三维重建诊断后尿道狭窄或闭锁

目的 探讨螺旋CT尿道三维重建技术在后尿道狭窄或闭锁诊断中的应用价值.方法 对30例创伤性后尿道狭窄或闭锁患者术前行螺旋CT薄层扫描和尿道三维重建、X线尿道造影,观察狭窄或闭锁部位、长度以及尿道周围组织解剖结构的改变,并与开放性手术中发现的结果进行对比研究.结果 X线尿道造影检测狭窄或闭锁段长度为1.0～7.0 cm,平均4.0 cm,狭窄或闭锁长度相关系数为0.92,定位准确率为70%(21/30);螺旋CT尿道三维重建检测狭窄或闭锁段长度为1.2～7.6 cm,平均4.3 cm,狭窄或闭锁长度相关系数为0.96,定位准确率为93%(28/30);术中发现后尿道狭窄或闭锁长度为1.5～7.5 cm,平均4.2 cm.5例合并尿道直肠瘘者螺旋CT尿道三维重建可以清楚显示瘘管位置、长度及大小;X线尿道造影则无法清楚显示.结论 螺旋CT尿道三维重建对了解伤后尿道的解剖结构改变、测量尿道狭窄或闭锁部位和长度、指导手术方式选择有较高价值,尤其对合并尿道直肠瘘者有重要的诊断意义.     

Sonographic staging of anterior urethral strictures

PURPOSE: Although radiographic retrograde urethrography has traditionally been the gold standard for imaging the anterior urethra, sonourethrography has proved to be precise and effective for evaluating urethral strictures. We review the evolution of sonourethrography and demonstrate its practical contemporary applications. MATERIALS AND METHODS: We performed literature reviews on MEDLINE and chart reviews of our patient records from 1988 to 1998. RESULTS: Sonourethrography measures stricture length in the bulbar urethra more accurately than conventional retrograde urethrography. Spongiofibrosis is manifested sonographically by a lack of urethral distensibility during retrograde instillation of saline solution. Posterior shadowing is noted in severe posttraumatic cases. Sonographic staging before treatment of complex or reoperative anterior strictures elucidates complicating features, such as calculi, urethral hair, false passage and stent encrustation. CONCLUSIONS: Sonographic staging of anterior urethral strictures offers clinically important information that may be useful in guiding reconstructive therapy.     

Sonourethrography in the evaluation of urethral strictures: a preliminary report

A total of 17 patients with suspected stricture disease underwent conventional retrograde urethrography and sonourethrography. When the length of the stricture as assessed by each imaging modality was compared to measurements at open urethroplasty in 7 patients, sonourethrography was consistently more accurate. Distension of the urethra with saline during the ultrasound examination enabled classification of the degree of spongiofibrosis, which was confirmed by full depth biopsy in 5 patients. Sonourethrography cannot adequately image the posterior urethra, even when the transcrotal approach is used. However, because it is a dynamic 3-dimensional study and can be repeated without risk of radiation exposure, sonourethrography is preferable to radiographic retrograde urography to evaluate patients with suspected anterior urethral strictures.     

Imaging of the male urethra for stricture disease

Imaging of the urethra for suspected stricture disease should initially consist of conventional imaging with a dynamic RUG. It is easy to perform and detects clinically relevant strictures involving the anterior urethra and those with extension into the membranous urethra. Additional studies, including antegrade imaging, sonographic urethrography, and MRI are best used in conjunction with RUG as clinically indicated to better define the extent of disease and assist in guiding reconstruction. Post-operatively, VCUG is appropriate to evaluate complete healing and adequacy of repair. Sonourethrography is a simple technique that provides a dynamic, precise assessment of anterior urethral strictures. It is best employed as a staging study in men with known symptomatic strictures in whom the need for operative therapy is clear. For short bulbar strictures ultrasound is more accurate in measuring stricture length than conventional radiographic RUG and is therefore helpful in determining whether to excise or graft. For long or complex strictures assessment of the stricture's diameter may be helpful in determining flap width or in identifying the focal urethral segments to be excised. The simplicity, precision, and availability of sonography along with the absence of radiation exposure make sonourethrography a valuable staging tool for the reconstructive urologist. MRI is valuable for defining the distorted pelvic anatomy that is frequently associated with posterior urethral strictures resulting from trauma. By determining the location of the prostate and the length of the prostatomembranous defect, MRI may help determine whether a transperineal or transpubic approach for reconstruction is necessary.     

Magnetic resonance urethrography in comparison to retrograde urethrography in diagnosis of male urethral strictures: is it clinically relevant?

OBJECTIVE: To compare the clinical relevance of retrograde urethrography (RUG) and magnetic resonance (MR) urethrography in evaluating male urethral strictures. METHODS: Between January and April 2004, 20 men were referred to our institute for management of urethral strictures. The patients were investigated by conventional RUG and multiformat MR urethrography. The patients were examined by urethroscopy under anesthesia to be followed by definitive endoscopic or open operative intervention. The radiologic data were compared by endoscopic as well as operative findings in all the patients. RESULTS: Ten patients were managed by visual internal urethrotomy (VIU) and two by dilatation under anesthesia; two showed normal urethral caliber. Four patients required open urethral reconstructive procedures. Two patients underwent radical cystectomy and cutaneous diversion because of associated bladder or urethral malignancy. Although overall accuracy for diagnosis of urethral strictures was equal between both modalities (85%), MR urethrography provided extra clinical data in seven patients (35%). It was superior to RUG in judging the urethral stricture length in three patients, diagnosing a urethral tumor in one, detecting associated bladder mass in one, characterizing the site of urethra-rectal fistula in one, and accurately delineating the proximal urethra in the last patient. Unlike RUG, MR urethrography provided adequate information about the degree of spongiofibrosis in all patients. CONCLUSION: MR urethrography is a promising tool for defining male urethral strictures and can provide extra guidance for treatment planning that cannot be obtained with RUG.     

Contribution of transcutaneous ultrasonography to the evaluation of urethral strictures

The aim of our study was to investigate the accuracy and sensitivity of ultrasound in detecting urethral strictures. Between 1992 and 1994, 117 patients with stricture of the anterior urethra were evaluated by retrograde urethrography, ultrasonography and urethroscopy.     

Functional evaluation of anterior urethral strictures with combined antegrade and retrograde urethrography

The merits of radiological examination for functional evaluation of urethral strictures of the anterior male urethra were studied by comparing the results of combined retro- and antegrade urethrography with the patient's maximum urinary flow-rate. A correlation was found between stricture diameter and maximum flow-rate (r=0.67) and a still higher correlation between the ratio stricture diameter-prestenotic urethral diameter and the flow-rate (r=0.73). A low but significant (p less than 0.05) negative correlation was obtained between the prestenotic urethral diameter and the flow-rate (r=0.25).     

CAN OUTCOME OF INTERNAL URETHROTOMY FOR SHORT SEGMENT BULBAR URETHRAL STRICTURE BE PREDICTED?

PURPOSE: We predicted the outcome of visual internal urethrotomy (VIU) by measuring the percentage of lumen narrowing at the stricture site on retrograde urethrography (RGU). MATERIALS AND METHODS: From January 1991 to June 2002 patients with primary bulbar urethral strictures who underwent VIU were selected for the study. Patients with a history of intervention, complete block of the urethral lumen and stricture greater than 2 cm were excluded from study. Urethral diameter at the area of maximum stenosis and at the normal distal urethra was measured on RGU with Vernier caliper and percentage narrowing was derived. Patients were followed 3 times monthly with symptoms, calibration and whenever required with RGU. Recurrence of symptoms, failure to self-calibrate and the need for secondary procedure were considered treatment failure. RESULTS: Complete followup data were available in 105 patients (44 grade 1 and 61 grade 2). Mean bulbar urethral stricture length was 0.86 cm. Inflammation was the cause of stricture in 83 (79%) and trauma the cause in 22 (21%) patients. In the Cox proportional hazards model only grade of narrowing had a significant impact on outcome. There were 41 cases of treatment failure in the total followup of 46 +/- 9 months. Mean recurrence-free duration +/- SD was 13 +/- 15 and 44.52 +/- 19 months in cases of treatment failure and success, respectively (p <0.0001). Mean percentage narrowing was significantly higher with treatment failure (69.9% +/- 16.1% vs 48.55% +/- 17.3%, p <0.0001). A cutoff of 74% for urethral narrowing was derived to predict the outcome with 78% probability. CONCLUSIONS: Percentage narrowing of the urethral lumen at the stricture site is a useful predictor of VIU outcome.     

复发性尿道狭窄伴假道的分类与处理

目的 评价复发性尿道狭窄伴假道的诊断方法及长期疗效。方法 1990年3月～2005年12月，我院治疗尿道狭窄或闭锁620例，其中伴假道40例（6．4％）。诊断方法：①尿道造影；②经会阴和直肠联合超声动态观察；③自膀胱造瘘管内注入亚甲蓝，同时行尿道镜观察；④CT或MRI检查；⑤打开膀胱探查。手术方法：尿道冷切开后置记忆合金圈10例，电切7例，强行尿道会师4例，液电冲击波治疗8例，后尿道套入术4例，指导患者自行尿道扩张5例，假道憩室切除术1例，会阴尿道造口术1例。结果 40例随访1～15年，平均9年。32例（80．0％）治愈（排尿正常），8例（20．0％）失败，其中为外伤后骨盆不稳定4例。结论 经会阴和直肠联合超声行动态观察假道与正常尿道关系并分类，操作简单，无放射性，长期效果满童．     

Use of 7.5F flexible pediatric cystoscope in the staging and management of urethral stricture disease

BACKGROUND AND PURPOSE: In the evaluation and treatment of patients with urethral strictures, assessment of the stricture is of paramount importance. To date, urologists have relied on retrograde or antegrade urethrography or both to define stricture length and associated characteristics. Antegrade urethrography typically requires suprapubic access to the bladder, adding to the morbidity of stricture treatment. Herein, we describe the feasibility of using a new method for diagnosing, staging, and managing urethral stricture disease. PATIENTS AND METHODS: Twenty-four men with urethral strictures underwent urethroscopy with a 7.5F, 26-cm "pediatric" flexible cystoscope to stage and manage their disease. Comparison of urethroscopy with retrograde urethrography was made with respect to characterizing the stricture. RESULTS: In all cases, the urethral strictures could be navigated with the 7.5F cystoscope. Documentation of the stricture length and the density of scar tissue and identification and characterization of additional pathology (urethral calculi proximal to the stricture in two patients) were possible in all cases, including four patients with recurrent stricture after complex urethroplasty. CONCLUSION: The 7.5F, 26-cm pediatric flexible cystoscope represents a useful tool in the diagnosis and management of urethral stricture disease. Further studies will be necessary to determine the cost-effectiveness, patient morbidity, and ability to tailor therapy appropriately in comparison with standard retrograde urethrography or voiding cystourethrography.     

Urethral stricture assessment: a prospective study evaluating urethral ultrasonography and conventional radiological studies

OBJECTIVE: To evaluate the accuracy of urethral ultrasonography (sono-urethrography, SUG) in determining the length of anterior urethral strictures, and for predicting the degree of spongiofibrosis. PATIENTS AND METHODS: In all, 52 patients with anterior urethral strictures detected on retrograde urethrography (RUG) were also examined using SUG, to assess the stricture location, length and degree of spongiofibrosis. The findings of both procedures were then compared with the operative findings. RESULTS: The mean (sd) stricture length on RUG, SUG and at surgery was 2 (0.8), 3.8 (1.4) and 3.5 (1.6) cm, respectively. The mean length on SUG was closer to that at surgery. Spongiofibrosis was detected by SUG with an overall accuracy of 42%, 56% and 83% for mild, moderate and severe degrees of fibrosis, respectively. There were no significant complications during the procedure. CONCLUSION: SUG is more accurate for evaluating the length of anterior urethral strictures than RUG, and gives additional information about spongiofibrosis.     

游离黏膜尿道成形治疗硬化性苔藓样病所致尿道狭窄的疗效观察

目的 提高对硬化性苔藓样病( lichen sclerosus,LS)导致尿道狭窄的认识,观察游离黏膜尿道成形治疗LS所致尿道狭窄的疗效. 方法 2007年1月-2010年12月收治LS所致前尿道狭窄患者36例,年龄27～75岁,平均41岁.尿道狭窄段长5.0 ～20.0 cm,平均11.5 cm.根据尿道狭窄段长短和严重程度选择不同的黏膜组织,其中行口腔内黏膜(舌、颊黏膜)尿道成形27例,结肠黏膜尿道成形8例,另1例老年患者行前尿道劈开.在行尿道重建术前对病变累及的阴茎头、尿道口、尿道行病理学检查. 结果 36例患者术后3周拔除导尿管,排尿通畅;活检结果提示上皮基底部特征性病变,过度角化,上皮层变薄,淋巴细胞浸润等.术后随访6 ～ 50个月,平均22个月.出现尿道外口狭窄3例(8.3％),其中口腔内黏膜尿道成形者2例,结肠黏膜重建尿道者1例,行尿道外口切开后排尿通畅.余患者术后排尿通畅,最大尿流率17.2～47.0 ml/s,平均23.4 ml/s. 结论 采用游离黏膜尿道成形治疗LS所致尿道狭窄疗效较好,但需密切随访,因病变迁延可致尿道再狭窄,尤其是尿道口再狭窄.     

Imaging of urethral stricture disease

Accurate imaging of urethral strictures is critical for preoperative staging and planning of reconstruction. The current gold standard, retrograde urethrography (RUG), allows for accurate diagnosis, staging, and delineation of urethral strictures, and remains a cornerstone in the management of urethral stricture disease. In complex situations, the RUG can be combined with voiding cystourethrogram (VCUG) in order to better visualize the posterior urethra or complex distraction defects. Direct visualization of the stricture by cystoscopy, either retrograde or antegrade, can provide additional information as to the location and appearance of stricture, as well as precise location on fluoroscopic imaging. Sonourethrography (SU) is a useful adjunct to allow for three-dimensional assessment of stricture length and location, and can be a useful intraoperative assessment tool, however, its use remains limited to a second-line setting. Cross-sectional imaging in the form of computed tomography (CT) or magnetic resonance urethrography can provide additional three-dimensional information of anatomic structures and their relations, and can serve as a useful adjunct in complex clinical scenarios.     

阴茎头硬化性苔藓样变及并发前尿道狭窄的临床分析

目的：提高对阴茎头硬化性苔藓样变（LS）及由此引起的前尿道狭窄的认识,并探讨合理的手术治疗方法。方法：15例LS并发前尿道狭窄的患者,年龄27～75岁,尿道狭窄段长4～16cm。采用舌黏膜尿道成形11例、结肠黏膜尿道成形2例;尿道外口切开及前尿道劈开术各1例。所有患者手术同时行LS病变组织病理学检查。结果：术后随访6～12个月（平均10．07个月）。1例游离结肠黏膜尿道成形患者术后2月发生尿道外口狭窄。行尿道外口切开后排尿道通畅;余者术后排尿通畅,Qmax：17．2～32ml／s（平均18．70ml／s）。结论：采用游离黏膜尿道成形治疗LS性尿道狭窄可取得较好效果,但需密切随访病变迁延致尿道再狭窄。     

Diagnostic in stricture of urethra – whats necessary?

Summary For therapy of strictures of the urethra several procedures are available. The choice of the adequate strategy requires a rational diagnostic, answering questions about localisation, length, shape and funktional effect of the stricture. The most important method is the miction-cyst-urethrography (MCU). Statements about the dimensions of scarred alterations in the corpus spongiosum urethrae are to receive from urethral ultrasonic. In addition you can perform the retrograde urethrography. The functional effects of the urethral stricture should be investigated by uroflowmetry and examinations of the upper urinary tract (ultrasonic/urography).      

Risk factors for the development of prostate brachytherapy related urethral strictures

PURPOSE: We identified clinical, treatment and dosimetric parameters associated with the development of urethral strictures following permanent prostate brachytherapy. MATERIALS AND METHODS: From April 1995 through April 2003, 1,186 consecutive patients underwent prostate brachytherapy for clinical stage T1b-T3a NxM0 (2002 American Joint Committee on Cancer) prostate cancer. The treatment plan included supplemental XRT in 625 patients (52.7%) and androgen deprivation therapy in 465 (39.2%). Median followup was 4.3 years. Multiple clinical, treatment and dosimetric parameters were evaluated in univariate and multivariate analyses to identify independent predictors for urethral stricture disease. RESULTS: A total of 29 patients had brachytherapy related urethral strictures. All strictures involved the BM urethra with a 9-year actuarial risk of 3.6% and a median time to development of 2.4 years. The mean radiation dose to the BM urethra was significantly greater in patients with vs without stricture (p = 0.002). On multivariate analysis the BM urethral dose and supplemental XRT predicted urethral stricture. All except 3 patients were successfully treated with urethral dilation or internal optical urethrotomy. CONCLUSIONS: Brachytherapy related urethral stricture disease correlates highly with the radiation dose to the BM urethra. Careful attention to brachytherapy preplanning and intraoperative execution along with the judicious use of supplemental XRT is essential to minimize the incidence of stricture disease.     

排尿期尿道超声显像在男性尿道疾病诊断中的应用

目的探讨排尿期尿道超声显像在男性尿道疾病诊断中的临床应用价值。方法对58例尿道疾病患者及8例正常尿道行排尿期尿道的经会阴及经阴茎超声检查。其中膀胱颈口尿道梗阻8例，良性前列腺增生（BPH）致尿道梗阻16例，急性尿道炎19例，慢性尿道炎7例、合并狭窄2例，尿道外伤性狭窄2例，尿道瘘2例，假性尿道、尿道炎性息肉、尿道尖锐湿疣和尿道癌各1例。结果排尿期尿道超声显像可动态观察膀胱颈口开放及后尿道顺应性扩张情况，膀胱颈口梗阻及良性前列腺梗阻表现为随着膀胱底及基底部下降，尿道内口被挤压形成颈口狭窄，而其以下水平尿道扩张正常或降低，患者愈用力排尿，梗阻愈加重。对急慢性尿道炎可明确炎症部位、范围、程度、有无脓栓附着等，同时对尿道慢性炎性狭窄或外伤性狭窄以及假性尿道、尿道瘘、尿道赘生物及恶性肿瘤等显像良好。结论排尿期尿道超声检查为非侵入性检查、可重复性强，对尿道疾病的诊断及治疗效果评价具有重要的临床意义。     

The role of urethrography in urethral disease. Part II. Indications for transphincter urethroplasty in patients with primary bulbous strictures.

We herein outline the radiological and clinical criteria that will aid the surgeon in deciding whether transphincter urethroplasty is required in patients whose primary stricture is in the proximal bulbous urethra. Sinc proximal bulbous urethral strictures are common the urologist frequently is called upon to make this important decision. The criteria described herein will help him to do so and, thus, avoid urethroplasty failure because of proximal stenosis in the membranous urethra. The concept of paradoxical dilatation of the membranous urethra on voiding urethrography also is described. Paradoxical dilatation means that in the presence of a primary obstructive bulbous urethral stricture the membranous urethra, although containing significant scar tissue, is dilated on the voiding study because of the distal obstruction. Relief of the bulbous urethral stricture alone may result in rapid contraction and stenosis of the previously dilated membranous urethra.     

BARCELONA RETROGRADE URETHROGRAPHY: A NEW DEVICE AND TECHNIQUE

PURPOSE: We describe a new device and technique for retrograde urethrography without instrumentation of the male urethra. MATERIALS AND METHODS: We performed retrograde urethrography with a vacuum uterine cannula in 160 patients. Stricture of the distal tip of the urethra and iatrogenic damage to the urethra were evaluated. RESULTS: No patient sustained iatrogenic damage to the urethra and stricture of the distal tip of the urethra was visualized in 12 patients. CONCLUSIONS: We recommend the use of this technique of retrograde urethrography without instrumentation to determine urethral disease when manipulation of the urethra must be avoided or is impossible due to meatal stenosis.     

Porcine small intestinal submucosa graft for repair of anterior urethral strictures

OBJECTIVES: We evaluated porcine small intestinal submucosa (SIS) used in the treatment of inflammatory, iatrogenic, posttraumatic, and idiopathic strictures of bulbar and penile urethra. Midterm maintenance of urethral patency was assessed. METHODS: Fifty patients aged 45-73 yr with anterior urethral stricture underwent urethroplasty using a porcine SIS collagen-based matrix for urethral reconstruction. Stricture was localized in the bulbar urethra in 10 patients, the bulbopenile area in 31 cases, and in the distal penile urethra in nine patients. All patients received a four-layered SIS patch graft in an onlay fashion. A voiding history, retrograde and antegrade urethrography, and cystoscopy were performed preoperatively and postoperatively. Failure was defined as stricture confirmed on urethrogram. RESULTS: After a mean follow-up of 31.2 mo (range: 24-36 mo), the clinical, radiological, and cosmetic findings were excellent in 40 (80%) patients. Restricture developed in one of 10 bulbar, five of 31 bulbopenile, and four of nine penile strictures. These all occurred in the first 6 mo postoperatively. All patients with recurrences needed further therapy, but there has been no additional recurrence observed to date. No complications such as fistula, wound infection, UTI, or rejection were observed. CONCLUSIONS: Use of inert porcine SIS matrix appears to be beneficial for patients with bulbar and bulbopenile strictures. Midterm results are comparable to skin flaps and mucosal grafts.