Controversies in early post-op imaging after urethroplasty Trauma and Reconstructive Urology Working Party of YAU gives overview Ass. Prof. Malte Vetterlein University Medical Centre HamburgEppendorf Dept. of Urology Hamburg (DE) m.vetterlein@uke.de
respondents indicating to omit any evaluation at the time of catheter removal. Of the remaining 89% who opted for any kind of postoperative imaging, 47% and 58% stated to perform pcRUG and VCUG, respectively. [12] Notwithstanding pending surveys from outside the United States, those data suggest that the vast majority of urologists still rely on early postoperative imaging to guide decisions regarding further catheter management, although this practice has been recently challenged.
that extravasation rates were rather low, which is generally used as a core argument to conclude that imaging may be omitted in such patient populations. [4-6] Terlecki et al. published a series of 110 patients with anterior strictures, of which 59 (54%), 28 (25%), and 23 (21%) underwent EPA, augmented anastomotic repair, and ventral onlay flap or graft, respectively. There were no extravasations in the EPA cohort and only 1 (3.6%) after augmented anastomotic repair and 1 (4.3%) after ventral onlay. [6]
institutional algorithm for years now with good results and low extravasation rates.[10] Not only do we have the advantage of physiological voiding pressures during VCUG, but we are also able to evaluate early urethral patency, the healing of the graft, and potential residual urethral narrowness, which is simply not possible with pcRUG as such pathologies would be masked by the catheter.
Discussion Early post-urethroplasty imaging is useful to assess Ass. Prof. Roland extravasation, urethral patency, and potential residual Granieri et al. analysed 407 patients, of which 232 Dahlem narrowness. Such practice is reflected by the recently (57%), 150 (37%), and 25 (6.1%) underwent EPA, University Medical published EAU Guidelines on Urethral Stricture augmented anastomotic repair, and ventral onlay graft Centre HamburgDisease, [3] which strongly recommend postoperative urethroplasty, respectively. [4] At early postoperative Eppendorf imaging at the time of catheter removal. The available imaging, 21 patients (5.2%) had extravasation and Dept. of Urology evidence suggests a particular benefit of imaging there was no statistical difference in extravasation Hamburg (DE) after graft augmentation and more complex rates between EPA (5.6%), augmented anastomotic repair (4.7%), and ventral onlay grafts (4.0%; p > 0.9). procedures, given that extravasation rates are commonly higher after BMGU compared to EPA. One However, patients did benefit from extending r.dahlem@uke.de “The rationales for both pcRUG and [4] particular consideration is quite important in this catheterisation for another week in case of extravasation, given that leakage rate decreased from context. Is it highly likely that everything depends on VCUG are sound.” Over the last couple of years, the information about the appropriate action we take if contrast 5.1% at initial pcRUG to 0.98% at a second optimum surgical strategies in patients with anterior extravasation is detected, or to put it another way: urethrography a week later (p < 0.001). [4] urethral strictures has grown substantially. This has In 2017, Grossgold et al. developed a grading system “Does it even matter if we see a leak?” [5] if we do culminated in the development of well-founded for urethral leakage after buccal mucosal graft not react appropriately? In most cases of Hoy et al. investigated 229 patients, of which 118 treatment guidelines published by renowned urethroplasty (BMGU; grade 0: no leak; grade 1: extravasation, the catheter remains for another 7-14 (52%) and 111 (48%) underwent augmented urological associations and societies. [1-3] Whereas “wisp” leak; grade 2: length of leak >1 .03 cm or anastomotic repair and ventral onlay BMGU, days at the discretion of the individual surgeon but there is more or less consensus on how to treat width of leak > 0.32 cm; grade 3: length of leak > 1.03 respectively. [5] Overall extravasation rate was low determining the severity of extravasation is a very strictures with particular locations, lengths, and cm and width of leak > 0.32 cm). [8] Out of 91 with 3.1% and there were no statistically significant subjective process. We can simply speculate on what aetiologies, short-term post-urethroplasty imaging patients, 31 (34%) had contrast extravasation of any differences in recurrence rates (60% vs. 94%; p = would happen to those patients if we did not know remains controversial. degree on initial postoperative imaging, which 0.0057) and complication rates (29% vs. 7%; p = about the extravasation. It may well be that results translated into 13 (14%), 7 (7.7%), and 11 (12%) 0.087) between patients with versus without after EPA for example are as good as they are, even Guidelines patients with leak grade 1, 2, and 3, respectively. extravasation. [5] However, one could argue that this with extravasation, simply because we know about it There is some evidence promoting the omission of Remarkably, Kaplan-Meier estimates showed a is indeed clinically relevant and statistical and are able to act accordingly by extending the any imaging after urethroplasty. [4-6] On the other significantly lower recurrence-free survival in patients insignificance is probably due to the absolute low catheterisation time. hand, different data indicate the diagnostic benefit with urethral leak grade 3 vs. grade ≤ 2 (p = 0.031). [8] number of urethral leaks in this series. and even prognostic importance of immediate Although the thresholds for length and width of the Inconclusive postoperative urethrography. [7-10] In this regard, the leak to define the grading system were more or less Postoperative urethrography: pcRUG or VCUG? To date, the second question (pcRUG versus VCUG) inaugural European Association of Urology (EAU) arbitrarily calculated by receiver operating Urethral imaging post-urethroplasty can be achieved cannot be answered definitely. Firstly, we would Guidelines on Urethral Stricture Disease were the first characteristic curves, they still suggest a clinically by pcRUG, which is characterised by a feeding tube need a prospective, multi-institutional trial with a lot to strongly recommend “[…] a form of validated relevant impact of the degree of contrast extravasation inserted alongside the catheter and contrast injection of patients to actually compare pcRUG followed by urethrography after urethroplasty to assess for urinary on surgical outcomes after BMGU, which directly under dynamic fluoroscopy. VCUG involves a VCUG versus VCUG followed by pcRUG to allow for a extravasation prior to catheter removal.” [3] The underscores the value of postoperative imaging. technique with the patient voiding under fluoroscopy real comparison of the diagnostic yield of each American Urological Association (AUA) Male Urethral after the bladder has been filled with contrast and the technique. Secondly, the choice of postoperative Stricture Guideline does mention that urethrography Assessment of early urethral patency by VCUG Foley catheter has been removed. imaging modality is directly dependent on catheter is typically performed a couple of weeks following In 2019, we published data from our department on management, which is still highly heterogeneous open urethral reconstruction to avoid inflammation, 513 men who received one-stage BMGU for bulbar among reconstructive referral centres. VCUG in a “Catheter reinsertion may also urinoma, abscess, and fistula formation due to a stricture and underwent a standardised patient with a suprapubic catheter makes sense as persistent urethral leak. However, there is no formal postoperative VCUG. Overall, 54 patients (11%) catheter reinsertion is not required and we can be avoided by using suprapubic recommendation by the AUA that endorses this showed evidence of extravasation, which was, simply uncap the suprapubic catheter. In this context, catheterisation until postoperative practice. [1] however, no predictor of stricture recurrence in the we do not really have any data available to multivariable Cox regression analysis after adjusting determine if catheter reinsertion is really that imaging.” for several stricture characteristics and intraoperative traumatic. Such open research questions call for “Such open research questions call parameters (hazard ratio 1.08; 95% confidence international collaborations that set up prospective comparisons with a focus on catheter management, The rationales for both techniques are sound. for international collaborations that interval = 0.48-2.40; p = 0.9). [10] Interestingly, we found a residual urethral narrowness in nine patients Advocates of pcRUG underline the effort to avoid early postoperative imaging, a standardisation of set up prospective comparisons.” (1.8%), which was predictive of stricture recurrence traumatic catheter reinsertion in case of extravasation grading urethral leaks, and extravasation. Patientin the multivariable model (hazard ratio 4.60; 95% [13,14] and the greater degree of distension to identify reported outcome measures that give more Controversial questions confidence interval = 2.15-9.85; p < 0.001). incompletely healed areas, which could potentially be information about the quality of treatment and the Evidence is scarce when it comes to the question of missed by VCUG. [15] Furthermore, some patients may catheter-related quality of life should also be used. urethrographic modality. In a nutshell, there are Extravasation rate parallels surgical complexity not be able to void during VCUG, which is not relevant This will help to get a better understanding of the currently two main controversial questions regarding In 2020, Giudice et al. presented similar findings in when performing a pcRUG. On the other hand, VCUG options we have and how they impact our patients in post-urethroplasty imaging that are consistently 630 patients undergoing various types of urethral the early post-urethroplasty setting. allows for physiological voiding pressures and by debated and called into question: reconstruction. Overall, 77 (12%) had extravasation at avoiding direct manual injection of contrast towards early imaging, and intriguingly there were significant the renewed anastomosis, traumatic adverse events References (1) Do we need urethrography after urethroplasty at 1. Wessells H, Angermeier KW, Elliott S, et al. Male Urethral differences when looking at stricture location. after VCUG are very unlikely. all? Stricture: American Urological Association Guideline. J Extravasation rates were lowest in bulbar strictures (2) If we choose to perform postoperative Urol 2017;197:182-190. (7.9%), followed by multifocal (18%), and penile POIROT trial urethrography, should we opt for peri-catheter 2. Lumen N, Campos-Juanatey F, Greenwell T, et al. (20%) strictures. Maybe the most interesting finding The only study which has looked into this clinical retrograde urethrography (pcRUG) or voiding European Association of Urology Guidelines on Urethral from this study was the increasing extravasation rate question prospectively is the POIROT trial from Ghent cystourethrography (VCUG)? Stricture Disease (Part 1): Management of Male Urethral paralleling the surgical complexity. Extravasation was (Belgium). An interim analysis was published in Stricture Disease. Eur Urol 2021;80:190-200. seen in 6.0% after excision and primary anastomosis 2020.[14] Overall, 25 patients underwent sequential Current practice patterns 3. Campos-Juanatey F, Osman NI, Greenwell T, et al. (EPA): in 13% after one-stage grafting, in 14% after pcRUG followed by VCUG in case of no extravasation We do not have a lot of data showing if and how European Association of Urology Guidelines on Urethral augmented anastomotic repair, and in 22% after a on pcRUG. Extravasation was detected in 3 patients urologists perform post-urethroplasty imaging on a Stricture Disease (Part 2): Diagnosis, Perioperative combination of flap and graft. [7] (12%) and VCUG did not unfold any new leakages not regular basis, but there is novel evidence from the Management, and Follow-up in Males. Eur Urol previously diagnosed by pcRUG. Interestingly, 20% of United States providing useful information on current High predictive value 2021;80:201-212. patients were not able to void at all during VCUG. practice patterns, at least in North America. Members Finally, in 2020 Patino et al. published a large series 4. Granieri MA, Webster GD, Peterson AC. A Critical Furthermore, radiation exposure was higher after of the Society of Genitourinary Reconstructive Evaluation of the Utility of Imaging After Urethroplasty of 1,101 patients with early post-urethroplasty imaging VCUG compared to pcRUG (203 vs. 122 mGy/cm2; Surgeons (GURS) were surveyed on several questions and found an extravasation rate of 4.9%. Similarly to p < 0.001). [14] While the final results from POIROT for Bulbar Urethral Stricture Disease. Urology regarding perioperative management in patients will be published soon, there are some things to 2016;91:203-207. Giudice et al., [7] extravasation was more common undergoing urethroplasty. 142 out of 248 urologists deduct from the interim analysis. Indeed, the 5. Hoy NY, Wood HM, Angermeier KW. The Role of after graft urethroplasty (6.1%) compared to EPA responded (response rate 57%) and 68% indicated diagnostic yield of pcRUG regarding contrast Postoperative Imaging after Ventral Onlay Buccal Mucosal (2.2%). [9] Importantly, functional recurrence was they routinely perform urethral imaging at the time of 9.3% with extravasation versus 3.2% without extravasation seems comparable to VCUG and Graft Bulbar Urethroplasty. J Urol 2020;204:1270-1274. catheter removal, whereas 13% and 20% stated to catheter reinsertion can be avoided in some cases. 6. Terlecki RP, Steele MC, Valadez C, Morey AF. Low Yield of extravasation (p = 0.04) and the positive predictive omit imaging completely or only selectively perform The proportion of patients not being able to void Early Postoperative Imaging After Anastomotic value of extravasation for predicting anatomic urethrography, respectively. [11] Such patterns during the examination appears quite high and, in Urethroplasty. Urology 2011;78:450-453. recurrence was high (78%). Furthermore, infectious corroborate the precursor study with a similar study such cases, pcRUG may be the solution at hand. complications were more frequently reported in design from 2013. Overall, 90 of 184 surveyed However, it should be noted that catheter reinsertion patients who had extravasation on early imaging urologists responded (49%). There were 11% of may also be avoided by using suprapubic The full references of this article are available from (p ≤ 0.04). catheterisation until postoperative imaging. [5,7,10] the EUT Editorial Office. Please send an e-mail to: In patients undergoing urethroplasty-naïve, primary EUT@uroweb.org with reference to the article Contrary evidence – overall low number of leaks EAU Section of Genito-Urinary Reconstructive BMGU, we have been using a Foley for 10 days plus “Controversies in early post-op imaging” by There are some studies attesting a low yield of Surgeons (ESGURS) Ass. Prof. Vetterlein, Aug/Sep issue 2021. post-urethroplasty imaging. They all have in common a suprapubic catheter for 21 days as per our Need for urethrography after urethroplasty? There are two considerations to reinforce the usefulness of post-urethroplasty urethrography. First, it is deemed important to evaluate the condition of the urethral anastomosis and to rule out significant urethral leak as represented by contrast extravasation. Second, urethrography may aid in assessing early postoperative urethral patency and identify a potential residual narrowness in the area of the anastomosis.
August/September 2021
European Urology Today
35
