Retrograde Urethrogram and Micturating Cystourethrogram (RGU/MCU) are performed  preoperatively in patients with PFUI. This is a 2 dimensional study .Majority of situations it is helpful for surgical planning .MRI as of now is recommended for complex cases. In academic  units, MRI can  be performed frequently and provides far more information than a conventional RGU MCU. It is most useful in patients with   long gaps, rectourethral fistula, prostato membranous injury , bladder neck trauma and false passages due to prior rail roading or dilatations. MRI is diagnostic in cases with double block (Bladder neck-prostate and bulbo-membranous junction).

There are some controversies in the management of PFUI. These  include

1. Primary realignment versus delayed repair of PFUI,

2. Necessity of inferior Pubectomy

3. Predictability of inferior pubectomy  

4. Spatulation of distal bulbar and proximal urethral ends, 

5. Nomenclature of bulbar urethra. 

We would recommend the members to read our manuscript which highlights on above issues 

The one important question that urologist have is will this patient need inferior Pubectomy or transpubic approach?

Koratim proposed a Gapometery index. In this, we measure the length of bulbar urethra and the gap between the membranous urethra and bulbar urethra. If the gap is more than 1/3 rd the length of bulbar urethra, pubectomy may be needed . 

In our experience  the need of Pubectomy not only depends on length of bulbar urethra but also on the following factors(1).

1.The orientation and relation of posterior urethra (membranous urethra) to the lower  edge of 

pubic bone - If the posterior urethra is above the pubic bone, this patient will need Pubectomy.  If it is high up then a transpubic approach

2.The distance between the posterior urethra and the pubic bone.

If the posterior urethra edge is too close to inferior margin of pubic bone, then we do not have enough access to the anterior wall of urethra to perform anastomosis. In this scenario we may need crural separation and Pubectomy.

3.To shorten the gap to have a tension free anastomosis 

Few studies have highlighted the use of MRI in PFUI. We have recently published a simplified protocol for performing MRI in PFUI. We use the inherent property of water molecules which light up on MRI. We fill the bladder with sterile saline, inject mixture of saline and lignocaine jelly in anterior urethra and tie the glans with gauze piece.

We  perform T2 sagittal images and ask the patient to void in MRI. This protocol takes about 3-4 minutes. We get excellent images mimicking the RGU MCU along with the orientation of posterior urethra, its relation to pubic bone and rectum. This article recently has become the cover page of Turkish Journal of Urology. 

We use the same protocol for imaging of Rectourethral fistulas.

Our Reconstructive colleagues Japan (2) form China recently have published on the use of MRI in PFUI(3)Reconstructive urologist should have all the experience to perform Pubectomy whenever indicated.