Role of preoperative sonourethrography in bulbar urethral reconstruction

Purpose: The accuracy of sonourethrography for the evaluation of bulbar urethral strictures has been well documented. Thus, we sought to define the role of preoperative sonourethrography in establishing objective criteria for procedure selection during bulbar urethral reconstruction. Materials and Methods: Sonourethrography was performed preoperatively, just before incision, in 67 men selected for bulbar urethroplasty. All patients had strictures 25 mm. or less in length on preoperative radiographic retrograde urethrography, thus potentially amenable to resection and end-to-end anastomosis. Ultrasonic measurements were prospectively recorded, compared with those on preoperative retrograde urethrography, and used to guide the selection of urethroplasty technique. Results: Overall, a significant trend for retrograde urethrography to underestimate stricture length was demonstrated (r = 0.678, p <0.0001). Indeed, sonographic measurements were frequently twice those of retrograde urethrography, occasionally more. All 26 patients with short strictures on retrograde urethrography (10 mm. or less) were successfully treated by resection and end-to-end anastomosis, and sonographic assessment did not alter management. However, ultrasonic measurement changed the reconstructive procedure selected in 15 of 41 patients (37%, 3 penile flaps, 12 graft procedures) with bulbar strictures of intermediate length on retrograde urethrography (11 to 25 mm.). Conclusions: Sonourethrography has a major influence on selection of therapy in patients with bulbar strictures of intermediate length. By prospectively identifying strictures too long for resection and end-to-end anastomosis, sonourethrography enables quantitative criteria for selection of patients who may be more appropriately treated by flap or graft procedures. We advocate excisional therapy for strictures appearing sonographically to be 25 mm. or less, and substitution urethroplasty for longer strictures.