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