Accepted Manuscript Title: A Critical Evaluation of the Utility of Imaging after Urethroplasty for Bulbar Urethral Stricture Disease Author: Michael A. Granieri, George D. Webster, Andrew C. Peterson PII: DOI: Reference:
S0090-4295(16)00207-7 http://dx.doi.org/doi: 10.1016/j.urology.2015.12.086 URL 19648
To appear in:
Urology
Received date: Accepted date:
29-9-2015 12-12-2015
Please cite this article as: Michael A. Granieri, George D. Webster, Andrew C. Peterson, A Critical Evaluation of the Utility of Imaging after Urethroplasty for Bulbar Urethral Stricture Disease, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2015.12.086. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 A Critical Evaluation of the Utility of Imaging after Urethroplasty for Bulbar Urethral Stricture Disease
Michael A. Granieri1, George D. Webster1, Andrew C. Peterson1 1. Department of Surgery, Division of Urology, Duke University Medical Center Durham, North Carolina
Corresponding Author: Michael A. Granieri, M.D. Division of Urologic Surgery Duke University Medical Center DUMC 3707 Durham, NC 27710 Phone: +1.847.224.1260 Fax: +1.919.668.0321 Email: [email protected]
Key words: urethroplasty, urethral stricture disease, imaging, bulbar
Abstract Word Count: 232 Manuscript Word Count: 2426
Financial Disclosures:
Page 1 of 22
2 Dr. Michael A. Granieri has no disclosures to report.
Dr. George D. Webster has no disclosures to report
Dr. Andrew C. Peterson has a grant from American Medical Systems to train a fellow for urology and an unrestricted grant for research into the mechanism of action for the male sling. ABSTRACT
PURPOSE: To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type.
MATERIALS/METHODS: We performed a retrospective review to collect stricture related and post-operative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week with a repeat pcRUG if extravasation was noted.
RESULTS: We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons; GDW, ACP). We identified 437 patients and 407 (93%) had follow up data.
Page 2 of 22
3 The mean stricture length was 1.97cm ± 1.2cm. In those patients who underwent excision and primary anastomosis (EPA) (n=232, 57%), we performed the1st pcRUG one week earlier compared to those who underwent augmented anastomotic repair (AAR) (n=150, 37%) or onlay repair (n=25, 6%). There was no difference in extravasation rates among all repair types at 1st pcRUG. The overall rate of extravasation on the 1st post-operative pcRUG significantly decreased in all patients (0.98% vs 5%, p=0.0008) and in those who underwent EPA (5.6% vs 0.4%, p=0.0016) when the Foley catheter remained for an extra week.
CONCLUSIONS: Men who undergo bulbar urethroplasty have a low extravasation rate (2.2 %) three weeks post-operatively and those who underwent EPA benefited from an additional week of catheterization. INTRODUCTION Currently there are no guidelines for imaging after urethroplasty for bulbar urethral stricture disease (BUSD). The options for postoperative imaging to ensure healing include retrograde urethrogram (RUG), voiding cystourethrogram (VCUG) and pericatheter retrograde urethrogram (pcRUG). Among major tertiary referral centers, imaging is commonly performed 2-3 weeks post operatively and used to evaluate for extravasation and the integrity of repair.
The incidence of extravasation when pcRUG is performed after urethroplasty for BUSD is not well established; prior studies utilizing VCUG have reported extravasation rates
Page 3 of 22
4 ranging from 0-20%1, 2. The identification and subsequent management is important as urinary extravasation may possibly lead to fistula, abscess or urinoma formation, repair breakdown and stricture recurrence3, 4.
Recently, some centers of excellence have anecdotally abandoned the use of postoperative imaging in select patient groups instead opting for non-invasive symptomsbased follow up1, 5. With low detections rates in select populations, post-operative imaging may pose an unnecessary financial burden to the patient and health care system6, 7, cause patient discomfort8, and expose the patient to unnecessary radiation9. Further, patients often have to travel long distances to reconstructive centers of excellence for their follow up visits5.
The objective of this study is to determine the incidence of extravasation during pcRUG after bulbar urethroplasty, examine the relationship to repair type, and critically evaluate the role of pcRUG in follow up protocols.
MATERIALS AND METHODS Patient Selection We performed an institutional review board-approved retrospective review of the Duke Urethroplasty Database for patients who underwent urethroplasty for BUSD by two surgeons (GDW, ACP). Included repair types were excision and primary anastomosis (EPA), augmented anastomotic repair (AAR), and Onlay repair. This review was performed from January 1996 through December 2012.
Page 4 of 22
5 Data Collection We recorded patient demographics, stricture related information including etiology, operative stricture length and location, type of repair and any type of post-operative complications or stricture related recurrence. All stricture lengths were measured intraoperatively by defining the distal portion with a 20 French catheter and using a measuring tape to mark the proximal portion after urethrotomy. Transection was then performed on the tip of the catheter and measurements were taken in the operating room using a ruler defining the length of the stricture aided by transurethral injection of methylene blue dye. A 12 or 14 Fr Foley catheter was placed postoperatively for all cases.
All patients had a pcRUG at the initial post-operative follow up appointment. All pcRUGs were performed by a dedicated urologic radiology technician using our standardized protocol: placing patient in right lateral oblique, injecting 20-25 mL on Isovue® contrast (Bracco Diagnostics Inc., Singen, Germany) through butterfly tubing with sustained pressure over 30 seconds.
Procedure Selection and Operative Technique Our preference is to perform EPA whenever possible. We commonly perform EPA for BUSD
S0090-4295(16)00207-7 http://dx.doi.org/doi: 10.1016/j.urology.2015.12.086 URL 19648
To appear in:
Urology
Received date: Accepted date:
29-9-2015 12-12-2015
Please cite this article as: Michael A. Granieri, George D. Webster, Andrew C. Peterson, A Critical Evaluation of the Utility of Imaging after Urethroplasty for Bulbar Urethral Stricture Disease, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2015.12.086. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 A Critical Evaluation of the Utility of Imaging after Urethroplasty for Bulbar Urethral Stricture Disease
Michael A. Granieri1, George D. Webster1, Andrew C. Peterson1 1. Department of Surgery, Division of Urology, Duke University Medical Center Durham, North Carolina
Corresponding Author: Michael A. Granieri, M.D. Division of Urologic Surgery Duke University Medical Center DUMC 3707 Durham, NC 27710 Phone: +1.847.224.1260 Fax: +1.919.668.0321 Email: [email protected]
Key words: urethroplasty, urethral stricture disease, imaging, bulbar
Abstract Word Count: 232 Manuscript Word Count: 2426
Financial Disclosures:
Page 1 of 22
2 Dr. Michael A. Granieri has no disclosures to report.
Dr. George D. Webster has no disclosures to report
Dr. Andrew C. Peterson has a grant from American Medical Systems to train a fellow for urology and an unrestricted grant for research into the mechanism of action for the male sling. ABSTRACT
PURPOSE: To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type.
MATERIALS/METHODS: We performed a retrospective review to collect stricture related and post-operative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week with a repeat pcRUG if extravasation was noted.
RESULTS: We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons; GDW, ACP). We identified 437 patients and 407 (93%) had follow up data.
Page 2 of 22
3 The mean stricture length was 1.97cm ± 1.2cm. In those patients who underwent excision and primary anastomosis (EPA) (n=232, 57%), we performed the1st pcRUG one week earlier compared to those who underwent augmented anastomotic repair (AAR) (n=150, 37%) or onlay repair (n=25, 6%). There was no difference in extravasation rates among all repair types at 1st pcRUG. The overall rate of extravasation on the 1st post-operative pcRUG significantly decreased in all patients (0.98% vs 5%, p=0.0008) and in those who underwent EPA (5.6% vs 0.4%, p=0.0016) when the Foley catheter remained for an extra week.
CONCLUSIONS: Men who undergo bulbar urethroplasty have a low extravasation rate (2.2 %) three weeks post-operatively and those who underwent EPA benefited from an additional week of catheterization. INTRODUCTION Currently there are no guidelines for imaging after urethroplasty for bulbar urethral stricture disease (BUSD). The options for postoperative imaging to ensure healing include retrograde urethrogram (RUG), voiding cystourethrogram (VCUG) and pericatheter retrograde urethrogram (pcRUG). Among major tertiary referral centers, imaging is commonly performed 2-3 weeks post operatively and used to evaluate for extravasation and the integrity of repair.
The incidence of extravasation when pcRUG is performed after urethroplasty for BUSD is not well established; prior studies utilizing VCUG have reported extravasation rates
Page 3 of 22
4 ranging from 0-20%1, 2. The identification and subsequent management is important as urinary extravasation may possibly lead to fistula, abscess or urinoma formation, repair breakdown and stricture recurrence3, 4.
Recently, some centers of excellence have anecdotally abandoned the use of postoperative imaging in select patient groups instead opting for non-invasive symptomsbased follow up1, 5. With low detections rates in select populations, post-operative imaging may pose an unnecessary financial burden to the patient and health care system6, 7, cause patient discomfort8, and expose the patient to unnecessary radiation9. Further, patients often have to travel long distances to reconstructive centers of excellence for their follow up visits5.
The objective of this study is to determine the incidence of extravasation during pcRUG after bulbar urethroplasty, examine the relationship to repair type, and critically evaluate the role of pcRUG in follow up protocols.
MATERIALS AND METHODS Patient Selection We performed an institutional review board-approved retrospective review of the Duke Urethroplasty Database for patients who underwent urethroplasty for BUSD by two surgeons (GDW, ACP). Included repair types were excision and primary anastomosis (EPA), augmented anastomotic repair (AAR), and Onlay repair. This review was performed from January 1996 through December 2012.
Page 4 of 22
5 Data Collection We recorded patient demographics, stricture related information including etiology, operative stricture length and location, type of repair and any type of post-operative complications or stricture related recurrence. All stricture lengths were measured intraoperatively by defining the distal portion with a 20 French catheter and using a measuring tape to mark the proximal portion after urethrotomy. Transection was then performed on the tip of the catheter and measurements were taken in the operating room using a ruler defining the length of the stricture aided by transurethral injection of methylene blue dye. A 12 or 14 Fr Foley catheter was placed postoperatively for all cases.
All patients had a pcRUG at the initial post-operative follow up appointment. All pcRUGs were performed by a dedicated urologic radiology technician using our standardized protocol: placing patient in right lateral oblique, injecting 20-25 mL on Isovue® contrast (Bracco Diagnostics Inc., Singen, Germany) through butterfly tubing with sustained pressure over 30 seconds.
Procedure Selection and Operative Technique Our preference is to perform EPA whenever possible. We commonly perform EPA for BUSD
