Urethral Rest with Suprapubic Cystostomy for Obliterative or Nearly Obliterative Urethral Strictures: Urethrographic Changes and Implications for Management.

PURPOSE: Precise preoperative characterization of urethral stricture is important for surgical planning. A period of urethral rest by a suprapubic cystostomy tube may aid in stricture characterization and affect the surgical approach. In this study fellowship trained reconstructive urologists compared the radiographic characterization of anterior urethral strictures before and after a period of urethral rest. We then determined how this changed the planned operative approach.

MATERIALS AND METHODS: We queried our prospectively maintained urethroplasty database at our institution for men with an anterior urethral stricture who underwent retrograde urethrogram and voiding cystourethrogram before and after preoperative suprapubic cystostomy tube placement. A total of 29 men were identified for analysis. To minimize responder fatigue 20 pairs of radiographs were selected at random. All images before and after suprapubic tube placement were interpreted in random order by 11 fellowship trained reconstructive urologists. Interpretation included stricture length, diameter, location and surgeon operative plan. Preplacement and post-placement results were compared. Post-placement stricture length was also compared to intraoperative length. ICC was used to evaluate homogeneity among the urologists. Linear regression analysis was performed to determine the association of post-radiographic length after tube placement with intraoperative stricture length.

RESULTS: Imaging agreement among interpreting urologists was satisfactory (ICC 0.72). There was no statistically significant difference in stricture length before vs after suprapubic tube placement. Of the images 23% were considered obliterative before tube placement while 58% were obliterative after placement (p = 0.0005). Mean ± SD post-placement radiographic and intraoperative stricture length was 3.0 ± 2.6 and 3.8 ± 3.3 cm, respectively (p <0.0001). Deviation between the radiographic and intraoperative lengths increased with stricture length (slope 0.26, p = 0.0023). The surgeon operative plan changed 47% of the time, including to an excision approach in 37% of cases.

CONCLUSIONS: Despite optimal urethral imaging with a suprapubic tube in men with high grade stricture reconstructive urologists underestimated length by an average of almost 1 cm. This underestimation was less for shorter strictures and it increased with stricture length. In addition, a period of urethral rest resulted in more frequent stricture obliteration, which was associated with a change in the planned operative approach about half of the time. If urologists do not place a suprapubic cystostomy tube prior to urethroplasty for high grade stricture, the operative plan should account for the stricture being tighter than it may appear.