Intra-Operative Sonourethrography and the Management of Anterior Urethral Strictures

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Background: Intra-operative ultrasonourethrography has previously been described as an effective and
precise imaging modality for determining the length of anterior urethral strictures. We routinely perform intra-operative urethral sonography to better interrogate the character and length of urethral stricture to guide our reconstructive approach. To demonstrate its utility, we sought to quantitate how often intra-operative sonourethrography either determined or changed our operative approach in complex anterior urethral reconstructions.
Methods: A retrospective review of 500 patients receiving anterior urethroplasty from 1985 to 2007 was conducted. 232 patients met the inclusion criteria of documented pre-operative clinical assessment, retrograde urethrogram (RUG), intra-operative sonourethrogram, and measured operative stricture length. Immediately prior to urethral reconstruction, an intra-operative sonourethrography was preformed and the operative approach was selected based on these findings. To determine the extent and usefulness of intra-operative sonourethrography in anterior urethral stricture reconstruction, we compared the pre-operative planned reconstructive approach to the preformed reconstructive procedure. Continuous and categorical data were compared using Mann-Whitney U and Chi-squared tests for significance, respectively, with p<0.05 considered significant.
Results: Of the 232 patients in our review, 115 (50%), 88 (38%), and 16 (7%) received end-to-end anastomosis, buccal mucosa graft, and fasciocutaneous flap procedures, respectively. Mean RUG length was 2.9 cm (range 0.3 to 15 cm). Intra-operative ultrasonography changed surgical approach in 44 (19%) patients, and was integral in deciding between two equally possible approaches in an additional 61 (26%) patients. In patients whose approach was changed from end-to-end anastomosis to buccal mucosa graft, mean RUG length was 2.0 cm, while mean ultrasound length was significantly longer at 3.4 cm (p=0.02). When surgical approach was changed from buccal mucosa graft to end-to-end anastomosis, mean RUG length was 2.7 cm, but mean ultrasound length was significantly shorter at 1.9 cm (p<0.005).
Conclusions: Intra-operative sonourethrography of the anterior urethra directly influenced reconstructive operative approach in 45% of patients. It is a simple, quick procedure that adds valuable clinical and radiographical data
that can be instrumental in selecting the optimal urethral reconstructive approach.

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