0:02

Hello, and welcome to conferences hosted by MRI Online.

0:05

In response to the changes happening around the world

0:07

right now and the shutting down of in-person events,

0:07

5 00:00:09,570 --> 00:00:11,250 we have decided to provide free daily noon

0:11

conferences to all radiologists worldwide.

0:13

Today, we're joined by Dr. Pauline

0:14

Germaine. As a practicing radiologist,

0:16

she splits her time equally between breast and

0:18

body imaging, with research focus on contrast enhanced

0:21

spectral mammography.

0:22

Her academic focus is on medical

0:24

students and resident education.

0:26

A reminder that there will be time at the

0:27

end of this hour for a Q&A session.

0:29

Please use that Q&A feature to ask

0:30

all of your questions, and we'll get to

0:31

as many as we can before our time is up.

0:33

We'll also be using a few polling questions today, as well

0:36

as a few questions that will respond in the chat feature.

0:39

Uh, so be on the lookout for those and chat

0:40

if you have any questions about that.

0:42

Uh, that being said, thank you so much

0:44

for joining us today. Dr. Germaine,

0:45

I will let you take it from here.

0:47

Hello, everyone, and uh, thank you for

0:49

the opportunity to present to you.

0:51

I will mention upfront that we will end this

0:54

presentation at 12:59 today, as one o'clock marks

0:58

the start of the White Coats, Black Lives Matter.

1:01

You are all leaders in your communities.

1:03

So lead the change and be the change to end the

1:06

social injustice, racism, and healthcare disparities.

1:09

Um, so thank you very much for having me again.

1:12

Uh, today we will talk about retrograde

1:15

ETH, and its current applications.

1:18

Although this examination has been around for a long

1:20

time and used to fall into the scope of radiology.

1:25

These days, most of these studies are performed and, for

1:27

the most part, interpreted by our urology colleagues, with

1:30

their images submitted to, uh, the radiology, predominantly

1:34

for technical aspect and fluoroscopy guidance billing.

1:37

However, some of these studies have a pesky tendency to

1:40

show up on, uh, some important exams that you may encounter,

1:44

so we need to make sure that you're aware of them and

1:47

have a general knowledge about the studies and the disease

1:50

processes that are presented on these examinations.

1:53

At home, when we do this presentation, we usually start

1:57

out with a white blank piece of paper, and I ask the

2:00

residents to draw out the anatomy of male urethra.

2:04

And, uh, I usually receive amazing artworks

2:07

worthy of framing, uh, almost all of them.

2:10

So if you can just take a moment and mentally think of

2:12

the anatomy that you know, um, that would be helpful.

2:16

And then we usually move on to this pre-labeled

2:19

drawing and subsequently to this complete labeled

2:22

drawing just to refresh our anatomy of this small

2:25

body part that we'll be talking about today.

2:28

And speaking of this small body part, um, there's

2:31

an amazing museum in Reykjavik, Iceland that, um,

2:36

houses more than 280 penises and penile parts.

2:40

So if you are ever in Reykjavik, this is the most

2:42

incredible collection, um, that's housed under one roof.

2:46

So take a moment to explore that collection.

2:50

We'll start by reviewing normal anatomy.

2:53

Of the male urethra, it extends from the

2:56

external meatus to the bladder neck, and

2:59

varies in length between 17 and 24 centimeters.

3:03

It is divided into the anterior and posterior segments

3:07

that are separated by the urogenital diaphragm.

3:11

This is the anterior segment that consists

3:13

of the penile part and the bulbous part.

3:17

And this is the posterior segment that

3:20

consists of the prostatic segment.

3:23

The prostatic urethra houses the verumontanum, which is located

3:27

along the posterior wall of the prostatic urethra,

3:31

and in the center of it, there is a prostatic utricle.

3:34

The ejaculatory ducts usually come

3:35

in on either side of the utricle.

3:38

The membranous segment of the posterior urethra

3:42

is on average two centimeters in length

3:44

and houses the external urethral sphincter.

3:49

So these are all the parts of the

3:51

anatomy that we will be discussing today.

3:54

The retrograde examination has

3:56

several important indications.

3:58

The most common indication for us is usually trauma.

4:02

Any patient who comes in with blood in the urethral

4:05

meatus deserves a retrograde examination.

4:07

If there is abnormality on physical examination,

4:10

particularly if they have a mobile prostate

4:12

gland, or they have extensive osseous injuries

4:15

in the pelvis, usually need this examination.

4:19

Another important indication in our setting

4:21

is a postoperative evaluation, particularly

4:24

in the setting of urethral reconstruction.

4:26

Any structural abnormalities such as

4:28

strictures, diverticula, or fistula may also

4:32

be assessed with the retrograde examination.

4:35

Although urethral masses have been

4:38

an important indication for this study.

4:40

This has largely been replaced by resection

4:43

imaging, particularly MRI, and there was a recent

4:45

lecture through the MRI Online on this topic.

4:48

So this hopefully will serve as a complement to this study.

4:52

And then certainly there are other things where people

4:54

put, um, foreign bodies where they don't belong.

4:57

And I'll show you a couple of examples of those at the end.

5:01

There are really no absolute contraindications

5:03

for this study, and the relative contraindication

5:06

is a contrast allergy due to possibility

5:08

of contrast extravasation during the examination.

5:12

Certainly, active urinary infection is a relative

5:15

contraindication if the patient was recently instrumented.

5:18

Again, the possibility of an infection is raised,

5:21

and that can serve as a relative contraindication.

5:24

And because a lot of these patients are

5:26

unstable in the setting of trauma, this serves

5:28

as a relative contraindication for the study.

5:32

Although most of these studies are performed by urologists

5:35

these days, I certainly would like you to know and

5:37

be familiar with the technique of the examination.

5:40

In general, a large Foley catheter is utilized

5:43

for this study that has to be primed, um, and

5:46

make sure that all the air bubbles are evacuated

5:49

from the catheter prior to the examination.

5:52

The patient is usually placed in the supine and 45-degree

5:56

oblique angle position with the penis

5:58

stretched out over the lateral thigh.

6:02

Um, to avoid any kinking, the urethral meatus is

6:05

sterilized and the catheter is inserted into the fossa navicularis.

6:10

Although traditionally, the balloon catheter

6:12

inflation was recommended, nowadays our urology

6:15

colleagues recommend against it, uh, to avoid any

6:18

injury to the urethra at the level of the fossa navicularis.

6:24

Additional clamp devices, but most patients,

6:26

most urologists, most physicians just

6:28

stabilize the catheter without any support.

6:32

As with any examination where the contrast is

6:34

injected, the scout examination is a must.

6:38

This is usually hand injection of water-soluble contrast

6:41

through a large-size syringe, and the contrast extends

6:44

from the urethral meatus all the way to the bladder.

6:48

Once that's achieved, the catheter is removed,

6:51

and the patient is asked to void on the table.

6:54

You can imagine how uncomfortable that can be.

6:57

Um, and post-voiding imaging is

6:58

obtained after that's completed.

7:03

The important complication to be

7:05

aware of is contrast extravasation.

7:07

I will show you an example of that in just a minute.

7:10

And this is very similar to ours.

7:13

HSG counterpart where contrast can opacify

7:17

draining veins, allowing immediate access of

7:20

contrast to the intravenous system and the

7:22

possibility of pretty severe contrast reaction.

7:25

So anytime you're dealing with contrast reaction,

7:27

you should be able to deal with possibility

7:29

of contrast reaction of contrast injection.

7:32

You should be able to deal with the

7:33

possibility of contrast reaction.

7:36

Anytime we do any type of procedure, there is a possibility

7:39

of infection, and certainly given that we're dealing with a

7:43

fairly tight spot, there is a possibility of our iatrogenic

7:46

injury to the urethra as a result of catheter manipulation,

7:51

particularly at the tight turn of the bulbous urethra.

7:54

So careful attention to technique

7:57

helps avoid these iatrogenic injuries.

8:00

This is a patient with.

8:03

Contrast extravasation, you can see that the contrast bead

8:06

injected into the penile urethra immediately outlining

8:11

draining veins without extending into the bladder.

8:14

So this is a pretty severe case of contrast extravasation,

8:18

and certainly if the patient has contrast allergy, this

8:21

would be a strong possibility of having a reaction.

8:26

So you should be able to recognize this as a complication.

8:29

Just of note though, though, this is not really

8:31

a complication, you can see that there are wispy

8:35

uh, outlines of contrast material here on the

8:38

different case at the level of the prostate bed.

8:41

And this is normal opacification of the prostatic

8:44

radicals, not an injury or contrast extravasation

8:47

of any kind, just a normal anatomic outline.

8:51

Something to be aware of.

8:54

This is a nice example that I took from the literature,

8:56

really showing the same parts that we just looked

8:59

at together, outlining all of the parts of the male

9:02

urethra, extending from the meatus to the bladder

9:05

base, and a nice correlation with the anatomic drawing.

9:10

Now that we have a solid foundation of normal

9:13

anatomy, let's take a look at a couple of cases.

9:16

This is a 57-year-old man that

9:18

had long-term urinary frequency.

9:22

And he was taken to the operating room for

9:25

a retrograde examination, which is shown here.

9:28

This is certainly not a normal study, doesn't look like

9:31

what I've just shown you under the normal section.

9:35

There are multiple areas of smooth luminal narrowing

9:39

of variable degree extending from the urethral

9:42

meatus, involving the penile and even bulbous parts.

9:46

So this leads us to our first poll question.

9:49

What do you think is the etiology for this stricture?

9:53

So, um, certainly infection is a good thought here.

9:57

However, um, this patient has a pretty long history,

10:01

extensive history of having a catheter for a long time.

10:06

Review of his chart shows that he had a Foley

10:09

catheter on most of his imaging studies, and he

10:12

was hospitalized for quite some time.

10:15

So in this case, this variable-length

10:18

stricture that's long and multifocal

10:21

is related to his prolonged instrumentation.

10:25

This is another case of a 28-year-old person

10:28

who presented with progressively worsening

10:30

lower urinary tract symptoms for a young man.

10:33

You certainly wouldn't expect his prostate to be

10:36

enlarged at this point to account for his symptoms.

10:39

He was treated by one urologist for a urinary

10:41

tract infection, for another by another physician

10:44

for prostatitis, and he presented to us.

10:48

Uh, for another opinion.

10:50

Given the severity of his symptoms, he was taken

10:52

to the operating room, and this is an image, this

10:55

is an image from his retrograde examination.

10:59

You can see that this stricture is much more focal.

11:02

And so in this case, this brings us to our next question.

11:06

What do you think is the etiology for his stricture?

11:09

Wow.

11:09

So we, we were really split.

11:12

So in this case, indeed the injury is related to

11:17

the straddle injury of this, uh, in this patient.

11:21

This was a urethroplasty that this

11:24

patient underwent after the examination.

11:27

Take a note of these bladder diverticula that have formed

11:31

as a result of the longstanding stricture that he's had.

11:35

Um.

11:36

So he did pretty well.

11:38

After the urethroplasty, we'll use a

11:42

uh, chat feature for this question.

11:44

What do you think is the hobby of this patient?

11:49

Very nice.

11:50

So a lot of you are saying that he's cycling or

11:53

biking, and indeed this patient is an avid cyclist.

11:57

You can see how the bulbous urethra

12:01

can be susceptible to this type of injury with

12:05

compression between the fixed location, between

12:07

the pubic symphysis and the handlebar of the bike.

12:11

And that was certainly a, um, nice

12:13

example of such in this patient.

12:16

So he did fairly well after the

12:19

urethroplasty and, um, recovered.

12:22

So these patients, if they form a focal stricture,

12:27

certainly trauma is a good possibility of the etiology.

12:32

Iatrogenic injuries are another common indication,

12:35

whether the patient had a long-term catheter,

12:38

perhaps under cystoscopy or a corrective surgery.

12:42

And then things that perhaps we didn't ask the right

12:44

questions, so didn't figure out why, um, they formed.

12:48

This is another possibility.

12:50

So if the stricture has formed,

12:53

it can be single and multifocal.

12:54

It can be variable length and commonly

12:57

involves the anterior urethra.

12:59

And as we've seen in the setting of our

13:01

cycling friend, involve the bulbous segment.

13:04

If the stricture involves the posterior urethra, it

13:08

is usually related to pelvic fractures, perhaps prior

13:11

radiation to the pelvis or prior prostatic surgery.

13:17

Let's take a look at another case of a patient

13:20

who was in a motorcycling accident, and

13:24

here are two images from his CT examination.

13:27

So based on these images, you would suspect

13:31

that he might have what type of injury?

13:37

Excellent.

13:38

Given that this is a talk on the urethral

13:40

injury, you would certainly suspect the

13:42

strong possibility of a urethral injury.

13:46

Um, given this appearance,

13:52

what is the genitourinary sign

13:55

that is evident on this coronal image?

13:57

And we'll use the chat feature to answer this question.

14:02

Excellent.

14:03

Excellent.

14:04

So certainly you can see extensive

14:06

osseous injuries, very good.

14:08

But besides that, absolutely very nice.

14:13

Uh, a lot of you have answered nicely.

14:15

This is a nice example of a pie-in-the-sky bladder

14:19

that refers to the appearance of the bladder that's

14:21

floating in the pelvis due to the presence of pelvic

14:25

blood products in the setting of osseous injuries.

14:29

And this sign should really raise a high concern

14:32

regarding the possibility of an underlying bladder injury.

14:36

And so certainly, the more osseous injuries you

14:40

see in the pelvis, the higher the likelihood of the

14:43

urethral injury, and the Malgaigne fracture actually has

14:46

the highest possibility of associated osseous injury.

14:51

A urethrogram is really the best initial diagnostic

14:54

study for these patients with the possibility of

14:57

urethral trauma and for assessment of the possible

15:00

complications in the setting of urethral trauma.

15:05

So our patient was too unstable to undergo a

15:08

conventional urethrogram, so he underwent a makeshift

15:12

urethrogram, so to speak, in the trauma baye.

15:15

And you can see this is a cross table

15:16

lateral view with injection of the penis.

15:21

This is the frontal view from the same examination.

15:23

So this again is another example of pie in

15:26

the sky, urinary bladder, and the contrast.

15:29

The pacified bladder is from the CT examination.

15:33

You can see that there's really no contrast

15:35

extravasation from the bladder itself to suggest either

15:38

intraperitoneal or extra peritoneal bladder injury.

15:43

However, when the conscious is injected through

15:45

the penis, there's no communication between the

15:48

penile urethra and the bladder and neck with

15:51

ification of the draining veins in the pelvis.

15:55

So that tells it that there's definitely an underlying

15:58

urethral injury and the patients with triad of blood

16:03

in the ATU inability to urinate and palpable full

16:06

urinary bladder deserve a retrograde study, um,

16:10

particularly in the setting of extensive osseous injury.

16:13

So how do we grade the urethral injuries?

16:16

There is a classic classification, uh, Goldman

16:19

classification that's used in this case that extends from

16:22

grade one To type one to type five, type one is a uncommon

16:27

type of injury that refers to the stretching of the urethra.

16:31

There is no contrast extravasation during this

16:33

examination and it tends to be, tends to be

16:36

treated conservatively with the cath fo catheter.

16:40

Type two is an isolated injury to the posterior urethra

16:44

with contrast extravasation above the urogenital diaphragm.

16:49

The mild cases tend to be treated again with

16:51

decompression with the catheter, and then the

16:54

more severe cases require a urethra plast.

16:57

Type three injury is by far the most common and is seen

17:01

in up to 85% of cases of the urethral trauma with contrast

17:05

extravasation above and below the urogenital diaphragm.

17:10

It's treated the same way as the about

17:12

previously mentioned type two injury.

17:14

Here's an example of a recent case that we had with

17:17

contrast extravasation above and below the urogenital

17:20

diaphragm and pretty severe injury to the um urethra.

17:26

Type four injury tends to involve the bladder neck,

17:29

uh, with extension into the urethra, and most of

17:32

these patients will present with incontinence.

17:35

Here's an example of one of our patients who

17:38

sustained pelvic trauma with conscious just pouring

17:41

from the bladder neck, and no communication between

17:43

the penile urethra or the rest of the um, bladder.

17:49

Type five is an isolated injury to the anterior urethra.

17:53

And typically involves the bulbous segment in the

17:56

setting, most commonly in the setting of straddle injury.

18:00

This is an example of one of our patients who had contrast

18:05

extravasation predominantly at the level of the bulbous

18:08

urethra, um, as a nice example of type five injury.

18:14

So let's go back to our patient.

18:16

Clearly, we have a pretty extensive injury here.

18:21

With, um, disruption, these patients tend to be decompressed

18:25

immediately with the suprapubic tube placement unless they

18:29

can undergo a reasonable attempt at primary realignment.

18:33

Unfortunately, these patients, a lot of these

18:35

patients are too unstable, as was our patient,

18:38

and he underwent, uh, suprapubic tube placement

18:41

without the initial attempt at realignment.

18:44

He had a pretty prolonged recovery course,

18:47

underwent multiple exchanges, and then finally

18:50

presented for assessment of the options of.

18:55

Uh, of urethral reconstruction.

18:57

So prior to doing that, we had to assess

18:59

what was the residual sequela of his trauma.

19:02

So he underwent several, uh, he underwent what's referred

19:06

to as an up and down procedure where a cystogram was

19:09

performed in addition to a retrograde examination

19:13

to assess the true extent of residual injuries.

19:16

And so in this case, we see a progressive

19:19

opacification of the bladder and the urethra.

19:23

Outlining several centimeter gap at the

19:26

junction of the penile and bulbous urethra,

19:32

uh, as a sequelae of his original trauma.

19:35

Of note, we noted that there is this outpouching,

19:41

so take a moment to tell me what do you think

19:43

this is, and we'll use the chat feature for this.

19:50

Okay, so in this case, actually, this is a nice example

19:56

of a Cowper's gland, also known as a bulbourethral gland.

20:05

Excellent.

20:05

And many of you did get this right.

20:08

So this gland has a pesky appearance of showing

20:12

up on the exam because of its tricky anatomy.

20:15

Uh, let's, uh.

20:18

Go to the next question, and in this case, I'd

20:22

like you to tell me where this gland is located

20:28

and where does it drain.

20:32

If you could, again, use the chat feature

20:35

to give me your answers for that question.

20:41

So some of you are saying that you can't see the

20:43

other comments, and that's because we're trying to

20:46

preserve your privacy and not to embarrass anyone.

20:49

So I only see the, your answers without

20:52

sharing them with the rest of the chat room.

20:57

But if you could tell me where the gland is located

20:59

that we're at, we in drains, that would be nice.

21:02

Thank you.

21:03

Great.

21:11

Diaphragm in the region of the urogenital.

21:13

Diaphragm, and they drain into the bulbus.

21:17

Segment, into the base of the bulbus segment.

21:20

So, um, that's the reason why they tend to show.

21:24

Up on the exams because of the tricky anatomy.

21:28

Thanks for answering under the chat section.

21:32

So, um, if these patients undergo, if these.

21:35

Patients develop urethral strictures, these.

21:39

Patients tend to undergo urethral reconstruction.

21:44

Uh, urethroplasty if they have a lumen, as we've mentioned,

21:47

They're initially decompressed with a suprapubic catheter.

21:51

And then, if need be, there are lots of.

21:53

Options for continent and incontinent urethral.

21:56

Diversion if this is needed for these patients.

22:00

Uh, in our case, the patient didn't really.

22:02

Have a urethral lumen, so he had to go.

22:05

Undergo a primary urethral reconstruction.

22:10

Although his original repair was significantly delayed,

22:14

He finally underwent urethral reconstruction with the.

22:17

Segment of the scar tissue and the primary end-to-end.

22:20

Anastomosis to bring the two segments together.

22:25

About a month after his original reconstruction, our.

22:29

Patient presented now with pain and fever and scrotal.

22:33

Swelling, and these are, these are the images from his.

22:38

Retrograde examination, and you can see that there's a.

22:42

Prompt extravasation of contrast at the anastomotic site.

22:49

And so in the PO in the chat feature, I would like you.

22:56

To tell me what complication is shown in this example.

23:02

So if you could utilize the chat feature.

23:04

And tell me what your thoughts are on this.

23:09

Complication.

23:13

So excellent answers so far.

23:18

So indeed, we do see a pretty large leak,

23:21

Uh, essentially with iatrogenic injury.

23:24

And it looks like this patient has developed what's.

23:27

Referred to as a urethroscrotal diverticulum, and.

23:33

Given this patient's symptoms of pain and fever.

23:37

This is most likely a superimposed.

23:40

Infection or an abscess in the urethra.

23:43

Scrotal diverticulum.

23:45

This patient was taken to the operating room and.

23:47

Was drained, uh, via the perineal approach and was.

23:52

Sent home on the antibiotics, and he did well for a.

23:55

Little bit, but returned three weeks later again, and.

24:02

These are the images.

24:03

Now this is the image from his repeat examination.

24:10

With contrast all over the perineum.

24:15

So if we, if you could tell me in the.

24:17

Chat feature what term, what classic.

24:21

Uroradiology term is applicable here.

24:26

Okay, so some of you are mentioning a.

24:29

Possibility of Fournier’s infection, gangrene.

24:32

Certainly a good thought here, given the extensive,

24:36

Uh, extravasation of contrast throughout the perineum.

24:39

And certainly having an abscess.

24:41

Previously is a very good thought.

24:44

Um, however,

24:48

Uh, there is another possibility here.

24:52

So in this case, actually the patient has developed.

24:57

What is referred to as water-can perineum, and.

24:59

Many of you have mentioned this in your answer choices.

25:03

Classically was described with advanced infections.

25:06

Uh, such as tuberculosis and gonorrhea, but we can.

25:10

See it worldwide with just a ionis and certainly, uh,

25:13

With Crohn’s disease is one of the common indications,

25:17

But unfortunately in our case, this was sequela of.

25:20

His surgeries and infections, uh, as a, as a result.

25:25

Of his prior injury and reconstructive surgery.

25:28

So certainly, um, this patient has been through a lot.

25:33

So three years after trauma in his original reconstruction,

25:37

This is his repeat examination, and so you can see now.

25:42

That the contrast outlines more normal caliber urethra.

25:47

And there's really no contrast extravasation.

25:49

And ultimately he did.

25:51

He did well.

25:52

Um, it took a long time for this recovery as.

25:55

It may happen with many of these patients.

25:58

Also make a mental note of, again,

26:00

Our friend, uh, Cowper’s gland.

26:02

And in this case, we can actually see.

26:03

A Cowper’s duct as it leads down to, um.

26:07

Inferior, pretty classic appearance here.

26:10

So, uh, finally a success story, but it took a little while.

26:14

And this patient demonstrated a lot of the complications.

26:17

That we can see on the urography, um, especially in the.

26:22

Setting of extensive osseous injury as was seen here.

26:27

So let's move on to the next case.

26:29

Uh, this is a patient who underwent a radical prostatectomy.

26:35

And you may say, well, why would they need this examination?

26:39

And on occasion, uh, it may be necessary to.

26:43

Reconstruct the bladder neck in the patients who.

26:45

Have, uh, who have undergone radical prostatectomy.

26:50

These patients, um,

26:52

undergo this examination on the table, on the table before.

26:56

They leave the operating room to assess for any leak.

26:59

And the leak may be, uh, at the bladder neck,

27:02

Or it may even result in the communication

27:05

Between the bladder, uh, and the adjacent rectum.

27:09

So it's a very important complication that

27:11

If identified intraoperatively will be

27:14

Immediately repaired by our colleagues.

27:19

Before the patient leaves the operating room, so

27:21

This patient underwent such examination to assess

27:25

For a possibility of the leak because they were

27:27

Concerned that there might have been a urethral

27:29

Injury, and you can see that there are some air

27:32

Bubbles along the path, but there's really no

27:35

Contrast extravasation on this original examination.

27:40

So the patient went home and unfortunately

27:44

Returned three weeks later with pain and fever.

27:48

Um, given his symptoms and his presentation,

27:52

The patient underwent cross-sectional imaging,

27:55

And in particular he had an MRI examination.

27:59

So in this case, uh, this is a select coronal image.

28:03

You can see that there, the, there is a catheter in place

28:06

In the bladder, decompressing the bladder, but there is.

28:10

A fluid collection that extends inferior and it looks

28:14

Like continues into the medial thigh on the right side and

28:21

Following contrast administration, there is rim enhancement

28:25

Of both collections that are in direct communication.

28:30

And, um, this is certainly a, uh, an example of what

28:35

Is referred to as a, uh, urethrocutaneous fistula.

28:41

Um, most of these are acquired.

28:43

And we tend to see them, see them in the setting

28:47

Of trauma, uh, prior surgery or infection, or

28:50

Perhaps prior radiation treatment to the pelvis.

28:54

The most common types that we encounter are the urethra,

28:58

Rectal urethrocutaneous, and urethral diverticulum.

29:02

We've already seen an example of the urethroscrotal

29:04

Diverticulum, and like I said, this was

29:06

A nice example of the urethrocutaneous fistula.

29:11

Uh, I don't have a good example of my own urethrorectal

29:14

Fistula, but I wanted to include one in this presentation.

29:18

Uh, so I borrowed one from the same article

29:21

By our colleagues, uh, at Temple University.

29:23

And this is a nice example of a patient who you

29:26

Can see sustained the gun, uh, injury to, uh,

29:29

The penis with the retained bullet fragment.

29:32

And the contrast outlines the.

29:35

Urethra with the opacification of the rectum.

29:39

Uh, so this is a nice example of the urethrorectal fistula.

29:42

This, uh, arrow is pointing to a small amount of contrast

29:47

In the urinary bladder, uh, related to the original CT.

29:53

This is another example from the literature of the urethra,

29:57

Scrotal diverticulum, but they look pretty similar.

30:00

Um, they all look pretty similar to

30:01

What I've just shown you already.

30:03

Um, as nice examples.

30:07

So these fistulas, uh, if, uh, uncovered, they're

30:10

Obviously treated with urethroplasty and removal of the tissue.

30:15

Um, some of these patients require allograft,

30:19

Interposition, and, um, to resolve any obstruction that may

30:23

Cause may happen as a result of the fistula formation.

30:29

Let's take a look at another example here.

30:31

This is a young man who underwent a

30:34

Stabbing injury to the penile shaft.

30:39

And presented with venous oozing at the site of

30:44

Injury along with the blood of the meatus.

30:48

The Foley catheter was inserted without difficulty,

30:53

And this was his original examination.

30:58

Although on the first glance, this

31:01

Is a pretty normal retrograde.

31:03

Remember I said that, um, post-evacuation

31:07

Images are done upon completion of the

31:09

Study, and this was done in this case.

31:12

So in this case, we noted that there was contrast retention

31:15

In somewhat of an unusual configuration, unusual at the,

31:20

Uh, base of the penis, looks like in the bulbar segment.

31:24

And so.

31:25

The question arose whether there may be a fistula

31:31

Between the urethra and perhaps the corpus spongiosum

31:34

Or the corpus cavernosum.

31:39

And so in order to answer this question, the

31:44

Uh, some of an unusual examination was performed.

31:47

Called renogram.

31:50

Believe it or not, these studies used to be performed in

31:53

Radiology, and if you look up the images, if you look up

31:57

The journals of radiology, uh, and/or Radiographics dating

32:01

Back to the 1970s, you'll see lots of articles by esteemed

32:06

Radiologists describing this procedure and its applications

32:10

In the treatment and assessment of the male symptoms.

32:16

I'm thankful that we no longer perform these studies.

32:18

Um, hope you're as well.

32:20

But in this case, this young

32:21

Man did undergo a, uh, renogram.

32:24

And on the image on the left, you can see that, uh,

32:28

There was an injection initially into the right corpus

32:32

Cavernosum outlining a normal corpus cavernosum with no

32:36

Communication with this retained contrast material that

32:40

Was fairly persistent at the level of the bulbous urethra.

32:45

Following removal of the needle.

32:48

It looks like there's a little bit of contrast

32:49

Extravasation here at the site, but this is

32:52

Normal, so we're not going to worry about this.

32:55

And then subsequently another, uh, injection

32:58

Was performed now into the left corpus cavernosum.

33:02

And it looks like, again, there's

33:05

Really no communication with this.

33:08

Uh, retained contrast in the segment of the bulbous urethra.

33:12

So ultimately, uh, it was decided that this patient

33:16

Probably has either a small diverticulum or perhaps

33:19

A focal injury to the bulbous urethra with a probable

33:24

Small fistula at the, uh, bulbar urethra and spongiosum.

33:31

Uh, the Foley catheter was placed and remained in place

33:35

And on repeat examination, this finding completely resolved,

33:38

And there was no, uh, retained contrast anywhere else.

33:42

And he did well after that.

33:44

Somewhat of an unusual study.

33:46

But, uh, it's interesting to see how, um,

33:50

You know, our practice has evolved over time.

33:54

Um, so, uh, patients with penetrating injuries

33:58

Deserve whether it's knife or firearm.

34:01

Um, usually this affects the anterior urethra, and these

34:05

Patients definitely need a retrograde examination as up

34:10

To 50% of them will have an underlying urethral injury.

34:14

So, pretty extensive, uh, pretty high number.

34:17

So retrograde examination still has a

34:19

Significant applicability in this case.

34:23

These patients, as late complications, may develop

34:26

Periurethral abscess, post-traumatic stricture, or fistula

34:30

Formation, as we've seen in some of the examples already.

34:37

Uh, if the injury is a complete transection with

34:40

Extravasation, um, they undergo usually anastomosis.

34:45

Um, and in the setting of a firearm injury,

34:50

The injury repair is usually delayed

34:54

Due to the possibility of thermal injury.

34:57

So these repairs are delayed in men.

35:00

Now, in contrast, the female repairs are tended to be done

35:05

Immediately to avoid the possibility of a urethrovaginal

35:09

Fistula and development of underlying vaginal stenosis.

35:13

So just a slight distinction between the

35:15

Males and females in this type of setting.

35:21

I didn't have a good example to show

35:23

You, so I took one from the literature.

35:25

This is a pretty gnarly example of a gunshot

35:28

Injury, and you can see that there is pretty

35:30

Extensive contrast extravasation over the catheter

35:34

From the region of the penile urethra with

35:37

Multiple fragments in the surrounding tissues.

35:39

These patients are treated with the Foley catheter,

35:43

Which usually remains in place, as was done in this case.

35:47

A month later, this patient came back and repeat

35:50

Examination showed a nice healing of this, uh, initial

35:54

Injury, with just a little bit of contour irregularity

35:58

At the site of previously noted contrast extravasation.

36:03

Um, people tend to do funny things in their spare time.

36:07

So this is one of our examples, um, where a

36:10

Foreign body was identified in the wrong place.

36:14

So in this case, uh, this is actually a

36:17

Lithium battery that wasn't inserted, um,

36:20

Retrograde was not really helpful in this case.

36:24

The, uh, battery could not be

36:27

Retrieved, uh, through the scope.

36:30

So unfortunately, this patient had to undergo

36:33

A resection of this foreign body with a primary

36:37

Anastomosis of the involved penile segments, and he

36:42

Ultimately did well, but certainly funny things can

36:45

Be placed in the wrong places where they don't belong.

36:48

So something else to keep in mind, um, and, uh.

36:54

As you can see, retrograde examination is the gold

36:58

Standard for initial examination of male patients

37:01

With acute trauma and post-traumatic pathologies, as

37:05

I showed you, with formation of the strictures and

37:08

Fistulas, and still has a lot of applications in the

37:12

Modern day and age, and certainly lots of utility.

37:16

And as we're involved more and

37:18

More in the reconstructive, uh.

37:21

Uh, surgeries.

37:22

It remains an important indication

37:25

For this study to assess for.

37:27

Reconstructive complications.

37:30

This is one of the images from the

37:32

Philological Museum in the, uh, Reykjavík, Iceland.

37:36

So if you have a chance, certainly take

37:38

A look, uh, at other examples there.

37:41

And, uh, uh, I will answer any questions you may have.

37:45

Thank you to the MRI Online for giving

37:47

Me an opportunity to talk today.

37:49

Um, I try to speak slowly, as Dr. Collins

37:53

Suggested, but I tend to run them all a minutes.

37:55

So I think that's, uh, the best I can do.

37:59

Perfect.

37:59

Thank you so much.

38:00

Uh, before we move into that Q&A, I do see some

38:02

Questions in there if you want to open that feature.

38:04

I just wanted to thank all of you for participating

38:06

In this noon conference and remind you that it'll

38:07

Be made available on demand at mrionline.com,

38:11

In addition to all previous noon conferences.

38:13

These are made complimentary,

38:14

Available complimentary to you.

38:15

Um, and join us.

38:16

On Monday, we'll be with

38:18

Dr. Asim Mian, uh, for a noon conference on

38:20

Infections of the spine and spinal cord.

38:23

All right.

38:23

If you don't mind opening up that Q&A feature

38:25

And answering some of those, and, uh, we'll

38:27

Respect your time to hop off in about 12–16 minutes.

38:33

That sounds good.

38:33

So let's take a look.

38:35

Um, so the first question is, uh, how many films

38:38

Do we take in the standard retrograde examination,

38:42

And what is the total amount of contrast injected?

38:44

Is retrograde cystography always done?

38:47

Um, so we'll start from the top.

38:49

How many films?

38:50

It will depend on your injection.

38:52

On average, the urologists tend to take about five or six

38:56

Images, but it will depend on how much contrast is, uh, how.

39:01

The urethra is being opacified.

39:03

And if there is any pathology, obviously

39:05

You want to go back to that segment.

39:07

And remember, you always want to take a scout and

39:10

You always want to take a post-evacuation image.

39:13

So there's really no, um, exact

39:16

Number of images that's needed.

39:19

But at the very least, you want to take the pre-,

39:22

The evacuation and several images in between,

39:26

Showing progressive opacification of the urethra.

39:29

As far as the amount of contrast, on average,

39:33

Uh, about 20 cc, 20 to 30 cc of contrast is used.

39:37

But because they're, they're usually, um, the contrast

39:40

Is usually placed into a large syringe of about 60

39:43

mL, um, just to allow that nice and steady injection.

39:48

And then, is retrograde cystography always done?

39:52

Uh, no, cystography, um, the up-and-down

39:55

Approach is usually done in the setting

39:58

Uh, if there's pretty extensive injury,

40:01

And sometimes you can't really, uh.

40:03

Uh, there are multiple sites of injury, so it's helpful

40:07

To do a combined or up-and-down approach to identify

40:11

A true extent, especially if the repair is planned.

40:15

The urologist certainly will want to know the

40:17

Length of the segment and/or segments that are

40:20

Involved, um, in the setting of the injury.

40:24

So up-and-down may be helpful in planning the procedure.

40:29

Um.

40:31

Can contrast extravasation cause necrosis?

40:35

Um, good question.

40:37

I'm, I'm not exactly sure, uh, as to the,

40:40

Uh, true, uh, answer to this question.

40:43

Uh, but, um, yeah, I'm not sure.

40:46

Uh, I'm not sure of the answer to this question,

40:48

So I will skip that if, uh, you're okay with that.

40:52

Um, one structure.

40:56

I'm not sure what that means.

41:00

Um, sorry.

41:01

We will, um, move on.

41:05

How to mention an enlarged prostate.

41:08

So really, because you're looking at a, um,

41:11

Intraluminal, sorry, the feature, um, keep skipping.

41:15

How, um, because we're assessing

41:17

The intraluminal, um, pathology.

41:21

Um, unless you see deviation of the prostatic

41:25

Urethral segment, and sometimes it is deviated, you may

41:28

Certainly raise possibility of an enlarged prostate.

41:32

Um, and also if you see really deviated course, um,

41:37

Other than that, you have other, many other examinations

41:40

To tell you if the prostate gland is enlarged.

41:42

And certainly most of the time

41:43

Urologists will perform a, um,

41:46

Digital rectal examination, and certainly that gives

41:49

Them a good indication of a prostate gland enlargement.

41:54

So how do we identify various

41:56

Segments on the retrograde study?

41:59

Well, uh, certainly if we're at the level of the

42:01

Pubic symphysis, for the most part, that you're

42:04

Going to be, uh, above, at or above the level

42:08

Of the prostatic urethra. If you're at the

42:11

Level of the pubic symphysis, and just below

42:13

That tends to correspond to the membranous

42:15

Segment. The bulbar segment has a little bit of

42:19

The sagging to it and perhaps a bit of a dilatation.

42:22

And as I've mentioned, urologists tend

42:24

To classify the bulbar segment in the

42:27

Anterior, mid, and posterior segments.

42:30

And then the penile segment tends to be pretty long and

42:33

Uniform in caliber, uh, extending from the bulbar segment.

42:37

So hopefully that, um, helps you

42:39

Figure out the urethral segments.

42:44

Um, so, uh, retrograde studies in females may be performed,

42:50

But, um, this is, this tends to be a tricky examination

42:55

'Cause the female urethral segments are pretty short.

42:58

And so this is going to be a challenging examination.

43:02

A good look to go.

43:03

Uh, a good way to look at the, uh, female urethra

43:06

Is actually during the voiding cystourethrogram.

43:10

Because during the voiding part, you can nicely

43:12

See several centimeters of the female urethra

43:16

As another option to look at the female urethra.

43:19

Um, you can look at the, um, MRI, and MRI is particularly

43:25

Helpful at looking at the female urethra and classic anatomy.

43:29

Um, some of the female, uh, urethral diverticula will house the,

43:35

Uh, calcifications.

43:37

And so that may also be helpful with, um, just, uh,

43:42

Scout imaging, uh, prior to a voiding examination to

43:46

See if there are any abnormal calcifications in the

43:48

Perineum, uh, to suggest the possibility of diverticula.

43:52

But MRI will probably be most helpful in this setting.

43:58

Uh, let's see.

43:59

Uh.

44:01

Cowper’s glands, um, look pretty high.

44:05

Well, so, uh, the Cowper’s gland and their

44:08

Ducts, because they take an oblique course.

44:10

Uh, the ducts take an oblique course inferior

44:13

To the level of the bulbous urethra.

44:16

They may project superior.

44:18

And remember that the membranous urethra

44:20

Is usually, uh, a couple of centimeters long.

44:24

So, uh, the Cowper’s gland will sit a little bit high.

44:28

Um.

44:28

With respect to the bulbous urethral segment and may

44:32

Seem like they're, um, projecting superior. The way

44:36

To figure them out from contrast extravasation,

44:39

Which sort of flows into the next segment, is

44:41

That they're usually oval, almond-shaped, as we've

44:44

Seen in the couple of examples that I showed you.

44:48

Um.

44:49

It would be an unusual spot to form for a

44:52

Diverticulum, but certainly could happen.

44:55

And sometimes the distinction is purely academic.

44:59

Um, and, but otherwise, um, it's

45:02

A normal anatomic structure.

45:06

Um, many times the posterior urethra is not opacified.

45:11

Is it normal?

45:12

So certainly, um, with handheld injection,

45:15

You need to provide sort of steady pressure

45:18

During the injection, and it may be normal.

45:21

And for that reason, sometimes

45:23

The superior approach, the up approach from the cystogram,

45:27

May be needed to help figure things out a little bit.

45:30

And even when the patient voids, that will

45:33

Also open up the internal urethral sphincter to

45:36

Help you take a look at the posterior urethra.

45:40

Um, but yes, it can be a normal finding.

45:44

Um, let's see how.

45:48

How to differentiate extraperitoneal bladder

45:51

Rupture and bulboprostatic urethral injury,

45:54

Given contrast extravasation in either case.

45:57

Well, so hopefully with extraperitoneal rupture,

46:00

As most of these patients will undergo trauma,

46:04

Uh, CT imaging, you will see contrast in the pelvis.

46:08

If the injury is isolated to the bulboprostatic urethra,

46:14

You will not have any contrast, uh, truly in the pelvis,

46:18

But you will have contrast localizing to the perineum.

46:23

So that should give, that should really be a clue as to the

46:28

Site of injury, um, but certainly retrograde examination

46:32

Will again help you delineate if you have injury.

46:36

If you have contrast extravasation at the perineum

46:39

During the retrograde study, that's most likely

46:42

The, uh, injury to the, uh, posterior urethra.

46:47

But if there is frank contrast extravasation in

46:50

The pelvis, that is usually related to the bladder.

46:55

Um,

46:58

Let's see.

47:03

Um,

47:04

Do I, do we have any experience with urethral ultrasound?

47:08

Um, uh, no.

47:10

I would say not much.

47:12

We tend to do a lot of penile, uh, ultrasound,

47:15

Not necessarily with attention to the urethra.

47:18

A lot of it nowadays

47:19

Comes under the, uh, urology territory, and the, uh,

47:24

Venogram that I have shown you an example of actually is

47:28

Currently performed as a third-line assessment of patients,

47:33

Um, with impotence and some of the other symptoms.

47:37

And in the urology office, that tends to be combined with,

47:41

Uh, pressure measurements, um, and urethral ultrasound.

47:45

So, um, that falls outside of the urology territory.

47:49

Uh, sorry.

47:50

Radiology territory.

47:52

Uh, when can we report prostate reflux, and what's the cause?

47:56

Um, you can always report it.

47:58

There's really no limitation.

48:00

However, it's not a pathologic finding.

48:03

Uh, it's a normal, just a normal opacification.

48:07

Uh, very similar to, um, HSG examination, if you.

48:14

If you extend, uh, pressure for a long period of time,

48:17

You can opacify, uh, glands, uh, paracervical glands.

48:22

And so it's really not a pathologic

48:25

Finding, just a function of the technique.

48:30

Uh, have you come across paraphimosis?

48:32

Yes.

48:33

Uh, so I actually had a case that I

48:35

Removed from this presentation, but yes.

48:37

And, um, it can, um, so the question was,

48:41

Have you come across paraphimosis as a

48:43

Complication of a retrograde examination?

48:46

So the answer is yes.

48:47

And like I said, I did have a case, um, that I took out

48:50

Because I thought it was going to be hard, uh, to show.

48:54

But, um,

48:56

It can be seen.

48:57

And one of the patients that we recently had, um, had

49:01

Developed actually a stricture at the level of the glans

49:05

Penis that had to be treated with urethroplasty and dilatation.

49:10

Um, so definitely something that

49:13

We do see, um, how to manage it.

49:16

Be careful, and certainly your urologist should

49:18

Be pretty experienced in these techniques.

49:23

Um, and, uh, I think, um, this is

49:27

Probably all, um, that we have.

49:32

Perfect, as it brings us to a close.

49:33

I wanted to thank you for your time, Dr. Jermaine,

49:34

And thanks to all of you for

49:36

Participating in this noon conference.

49:37

Again, it will be made available on

49:38

Demand, complimentary, at mrionline.com.

49:41

In addition to all previous noon conferences, please

49:44

Follow us on social media for updates and reminders

49:46

On upcoming noon conferences, and join us next week.

49:48

We have a great lineup.

49:50

Uh, you can check that out at mrionline.com.

49:52

Thanks, and have a wonderful day.