Michael J. Metro, MD discusses the importance of proper diagnosis for urethral reconstruction.
Hello. My name is Michael Metro and I'm an associate professor here at Temple University in philadelphia. I'm the director of Urologic reconstruction and also the fellowship director for our urologic reconstruction and trauma program here at Temple. Um This series is meant to um educate and illustrate the importance of a proper work up for your regional reconstruction including radiographic um diagnosis, symptomatic diagnosis and treatment decisions. And we'll go through today on this component of the discussion the importance of diagnosis for this condition. I did my training at University of Pennsylvania where I finished in 2001, then did a reconstructive fellowship with Jack Mechanic at U. C. S san Fran san Francisco. I've been in practice of philadelphia for 20 years and I've been a temple for about 5.5. My fellowship is uh five years old. Are six fellow is starting this Jilani. So the important things about reconstruction are to figure out what's going on with the patient. And one way of doing that is to obviously get an an atomic discussion and an atomic discussion is important when I describe this. Um anatomy of the urethra to med students, residents and fellow neurologists, some components uh you have to shake off the cobwebs from your training to remember. But the urethra is separated specifically into two separate areas, the anterior and posterior urethra and those are separated by the Euro. General diaphragm, which is roughly at the apex of the prostate, that which is connected to Buick synthesis. This picture here is good because everyone always wonders uh in the interior Aretha where the bulb, our urethra and the penguins urethra are, you know, start and end. And you can't really tell that on a you're a great radiographic urethra graham, this is an an atomic landmark. And the bulb are your ether is that which is covered by the bubbles. Fine joseph's muscle, The anti r pendulous uh portion of the urethra called the penal or pendulous urethra is that which is distal to the ball bar urethra. And there is a dilation in the glands called the faucet. Navicular areas. And then the very uh tip is theory throw me a tous. So this is the interior Aretha. Now everything proximal to. That is the posterior. Through. Now the posterior urethra is basically two parts the member anus urethra which is in the Euro General diaphragm itself which contains this fact eric mechanism. And they're prostatic urethra which is proximal to this. Now strictures themselves are present in the interior re through in the post serie Aretha. These are real more commonly and more correctly referred to as distraction defects in the setting of pelvic trauma or obstructions or stenosis in the setting of some other insult to the lower urinary tracts such as radiation or trauma. And so these are radiation induced strictures, high fu induced strictures, cryotherapy and do strictures of the prostate or bladder neck. So the dogs nation between anterior or posterior urethra is fairly important and it's both an anatomical um difference. And also the treatment of these two um obstructions is vastly different. Also the ideologies for these strictures is also vastly different. Interior strictures. We classically think of infection induced strictures, calamity and gonorrhea. Uh But more commonly with the advent in the antibiotic age, it's traumatic um uh strictures here secondary to either a straddle injury or a catheterization gone awry or act or some sort of i a transgenic instrumentation that from a scope a dilation necessary to complete an emerging catherization um and then also external violence like penetrating injuries and straddle injuries, can also see interior structures from ischemia from a chronic catheter. Now, posterior obstructions are always traumatic. Um 85% of injuries of a post Syrian associated with a pelvic fracture and 15% of pelvic fractures acting associated. Um pelvic fracture, distraction injury. Now more commonly in 2021. The trauma of these posterior injuries is external trauma, such as external beam radiation or other abrasive therapies for prostate cancer, such as high intensity focused ultrasound or cryotherapy. Now to all stenosis aren't the same. Okay. Um so we try to describe these uh and you'll hear a term of urethral stricture and you also hear a term urethral stricture disease. And that's because there are two different entities. A urethral stricture is usually of focal issue. And this this your instagram designates a distal bulb are injury. And this would classically be one you would see after a straddle injury. Now, this is defined, it's treated usually with some sort of excision or augmented urethra plastic and this is the one we like to see in the office or when were sent a urethral stricture. Uh This is usually traumatic or instrumentation and ideology. Now this on the other hand, is a whole different animal. This is urethral stricture disease. Now this is secondary to carcinoma of the urethra, liken sclerosis, ballon itis or multiple repetitive trauma injuries through instrumentation or dilation. And if you can imagine treating the upward stricture versus the one on the bottom image, you can tell the difference of doing that. One is a simple, straightforward procedure and the other is certainly more complex. Mhm. So how do these obstructions or strictures present? Well, they present with extractive complaints. So these are it takes me longer at the bathroom to avoid than all of my friends. I have to push to avoid. I don't feel like I empty, but sometimes these are long term problems and and a man does not specifically complaint of those obstructive symptoms they might present with issues secondary to the instruction, which are urinary tract infections on upstream or in a sending uh infection like an epidemic itis or prostatitis. And then they could present quite acutely with urinary retention. Now, injuries rather than structures can present immediately after a traumatic event, which would be something that occurs after a motor vehicle accident or straddling truth. Now, how do we diagnose you? Re throwing too as well? Certainly in all of medicine, the history is extremely important. And if you diagnosed an acute injury, you almost always have blood at the metis. If they are able to urinate, almost always get blood in the urine and if they are unable to avoid to urinate, that will give you a clue that there's something going on with obstruction. You can also see hematoma in the perineum that is contained within Bucks fashion. Which will give you a hematoma along this penis or if it's in the perineum and tracking north and south like a butterfly that's contained by colleagues fashion. And that's something that you everyone remembers as a resin. Now, this is a classic picture of a straddle injury. A bike post meets urethra meets pubic synthesis. Uh, Distal ball bar injuries are usually resulting from a straddle injury. And this is a classic picture of pinching theory through between two hard objects and the result is disruption of the tunica spun the spongy. Oh, some of the corpus, the tunic of the corpus fungus um which results in bleeding into the scrotum. And this is the colleagues here. The hematoma which is um contained by colleagues fashion. And it can be fairly significant and noteworthy and there's blood at the neatest and oftentimes straddle injury is not completely um 100% disrupted. That is more of a pelvic fracture phenomenon. But the patient can't void because there's clocks in his urethra and he's obstructive from that. So how do we diagnose these injuries? Well there are certain things that can be done invasively, uh certain things that can be done in the office and we'll kind of go through these and this is uh an important component of what reconstructive urologist do is picking the right um study to clarify and diagnose what's going on with an obstruction. Now the classic diagnosis of a urethral strictures that with a retrograde urethra graham and when necessary, avoiding system, your instagram. Those are studies that are done in the radiology department, usually under the direction of uh the Urology service. Now in the office, we do noninvasive things like a europe, which gives you an idea of both the strength and the shape of a flow curve, which could alert you to some obstruction. Now you're arthroscopy in the diagnosis of stricture disease is kind of a binary study. And I say that because it doesn't give you much information about the caliber and character or the length of the structure, because once you meet the distal most component of the structure you have, you stop. This is not a diagnostic and therapeutic event. The earth arthroscopy, it's a diagnostic one. And once you made a stricture, I always tell my residents and colleagues to stop and get your program so we can tell what's going on behind the structure. And it's the phenomenon of the iceberg under the water. The your arthroscopy finding is the tip of the iceberg. And then when you do your program and your radiographic studies, you get the entire picture of the iceberg. And then I'll give you a little bit of information of what a sonar urethra graham can add to the work up um of structures. Now this is a properly um performed retrograde your reprogram um when you start a reconstructive practice or after you are in a academic center as a residency program. Most facilities are very good at doing a wreath program. That is not always the case when you're out and about and starting your practice. And certainly when I came from 13 years of private practice to temple 5.5 years ago I spent the first three months doing all these urethra grams with the text in the Flora Skopje department. And then every month or so I get new radiology residents. So a lot of my time to make sure that I'm not burdened with doing these studies myself in the O. R. Time which in the O. R. Which some people do. But our time is precious of temple. So I want these studies to be done and performed appropriately before that. So I have the text and I spent a lot of time teaching them how to do this study so that I'm convinced that they could do it. And I learned this from my fellowship director Jack Mcinerney too had an entire clinic day which was rugs and he had office right next to the philosophy department and he combined the program with an office user and that's what I do now. So a small caliber urethra which was placed in the in the now in the fastening, vehicular areas, the patient is placed in a lateral to cuba, this position. With the hip on some rolled towels, the reader should be parallel to the femur of several ways to allow the foley balloon to stay into the penis is to put three CCs and then pull lightly. I also instruct uh not blowing up the balloon at all, and just using the tips of your fingers to squeeze the tip of the penis and to give the penis a good pool. And with that technique we can get good pictures that are reproducible. So this is what a normal Uric program would look like um With the penis on stretch, you can see the difference with that between the pendulous and the bulb. Are you read through the boulevard? Aretha has a wider caliber in general, you can see a little turn between the ball bar urethra and the pendulous jury throughout the penis scrotal junction, so that which is proximal to the turn is the ball bar Urethra. Number two. In this image is the external sphincter. A lot of patients will ask me if they could go to sleep for their urethra graham and I tell them that it does not allow us to get the proper study because we rely on conclusion at the external sphincter to allow for um the urethra that's behind the obstruction to fill out. And then once the urethra is filled and the external sphincter is by reflex. Close you get the good image that you want. And then with some techniques of deep breathing and relaxation, you'll get that to open up and you can have uh contrast flow into the bladder. Now the second port is avoiding study. Now avoiding study is different than the urethra graham study because the bladder neck is open and you'll see uh it's a more it's a it's a portion of the study that's a little more comfortable for the patient and with proximal strictures, it's super important because sometimes it's hard to tell the difference between a very proximal above our structure and an external year regional sphincter. So this is avoiding study with the bladder. The bladder neck is opened. Environment Montana miz Vm. Or number 12 is the external sphincter which is now open. The boulevard urethra looks less engorged because there's no obstruction behind it. And then the toilet bowl is on the right by the era. And this is what a good urethra graham looks like there's no air bubbles. The urethra is filled, the stricture as well identified, easily identified in the proximal mid bulb. Our urethra there's enough contrast to hit the external sphincter and then there's a contraction of this that shows the peak just under the lower ramos of the beauties. And then the prostate is visualized with the vera Montana um which is a density year, a loose since a year and then the bladder neck, which is old, faithful sign. So this is a retrograde you reprogram. On the other hand, avoiding sister, you're a program of the same patient chose a full bladder and open bladder neck boulevard urethra. And then this is the louis armstrong effect. The distal obstruction leads to dilation and even a little filling of a calpers plan. So this is a nice study of your uncertain where the proximal component of a stricture start is to do avoiding system. Now what you don't want to have the radiology resident or the tech do is to perform the V. C. U. G. By putting something through the stricture and filling the bladder. Which is why this can be somewhat uncomfortable because to fill the bladder and a retrograde fashion under pressure is somewhat uncomfortable for a patient. So I might order a rugby sug, but only about 10 or 15% of the time is the voiding system. You reprogram of critical component of the study. I I will get a picture of the rugs sent to me and I will ask them to do a V. C. G. If necessary. Now I mentioned a so no your instagram in the earlier slide. And this is some pictures of the senate urethra graham and these are studies that are done to kind of give you a little more information about what would be an equivocal structure. So if you're deciding between what would be an ass demotic or a transect NG approach versus that, which is a substitution Urethra plastic, which we'll get into by adding a graft. A sooner urethra game gives you an easy way to exactly measure the scar tissue in the urethra. And that will help you determine if this is going to be a high likelihood of a substitution urethra policy versus that, which can be done within a nasty medical or a transect it repair. So this is done with a small parts transducer in the perineum. I carried some uh an entire tube um Ky jelly with uh an irrigation syringe and a 14 French catheter. And I inject that through while pressing on the bladder to fill up the proximal urethra. So I do this when I do do it in the operating room while the patient is asleep. So this is the sooner you're a program, which I do very uncommonly now. But it is indeed study to show some residents I try to do every few months. I do one so that the residents are comfortable doing them. Mhm. Now. So I will tell you that the diagnosis of urethral stricture is done with clinical decision making in a history, but then careful ordering and actually performance of a good retrograde. Your instagram is vital for picking the right patients to operate on and being prepared to do what you need to do in the operating room to fix that. And she uh in the next component of this discussion will talk about what I do to decide on what technique to fix the patient, whether it's a endoscopic technique, whether it's a one stage repair or whether it's a two stage repair and those things are dependent on character of scar tissue and structure. They are dependent on age of the patient and um goals of therapy. Uh so I hope that this was useful for the vast majority of you are the most important part of this. Uh talk in those of you who are starting a reconstructive practice uh or want to have good studies is to spend some time with your Flora, Skopje department text or radiologists and show them really how to do a urethra graham because you're the one that knows how to do it the best. And if you have a person or a few people that can do this study for you, it allows you to continue seeing patients in the office by the study is being performed. That allows you to be more efficient in that regard. So I hope this was enjoyable. And we'll talk about uh therapy, surgical and and a Luminal surgery. And hopefully this was useful for you. Thank you very much.