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ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 47-51  

Endoscopic urethral realignment of traumatic urethral disruption: A monocentric experience


Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Khobar, Saudi Arabia

Date of Submission06-Oct-2017
Date of Acceptance02-Nov-2017
Date of Web Publication15-Jan-2018

Correspondence Address:
Dr. Hamed Mohamed El Darawany
Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al-Khobar
Saudi Arabia
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DOI: 10.4103/UA.UA_151_17

PMID: 29416275

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   Abstract 

Introduction: The optimal management strategy for urethral injuries remains controversial. Suprapubic cystostomy followed by delayed urethral reconstruction or immediate primary urethral injury repair is associated with high complication rate. Early endoscopic realignment for urethral injuries provides early definitive procedure with low complications and avoids the need for further urethral reconstruction.
Materials and Methods: Between April 2007 and March 2016, 27 patients with traumatic posterior urethral disruptions were reviewed. All patients were managed by endoscopic urethral realignment. Patients were followed up every 3 months for 18–36 months regarding incontinence, potency, and urine flow.
Results: Endoscopic urethral realignment was performed immediately in 21 patients and was delayed in 6 patients. It was successful in 24/27 (88.8%) patients. During the procedure, the proximal urethral end was identified directly in four patients, and by the guidance of methylene blue injection, guidewire or endoscopic light in three, nine, and eight patients, respectively. The Foley catheter was removed after 9 weeks in 17/24 (70.8%) patients and after 12 weeks in 7/24 (29.2%) patients. Six months after realignment, minimal urethral stricture was developed in 4/24 (16.7%) patients. All of them were treated successfully with single session of internal urethrotomy without recurrence after 1-year follow-up. After 18–36-month follow-up period, all patients were potent, continent, and with satisfactory voiding pattern.
Conclusions: Endoscopic primary realignment of posterior urethral rupture is less invasive and a safer procedure, without pelvic hemorrhage or additional injuries. It has low incidence of severe urethral stricture and avoids the need for delayed open urethral reconstruction.

Keywords: Urethra, urethral disruption, urethral realignment, urethral stenting, urethral stricture


How to cite this article:
El Darawany HM. Endoscopic urethral realignment of traumatic urethral disruption: A monocentric experience. Urol Ann 2018;10:47-51

How to cite this URL:
El Darawany HM. Endoscopic urethral realignment of traumatic urethral disruption: A monocentric experience. Urol Ann [serial online] 2018 [cited 2020 Oct 1];10:47-51. Available from: http://www.urologyannals.com/text.asp?2018/10/1/47/223145


   Introduction Top


Posterior urethral injury resulting from blunt trauma occurs in 5% to 25% of men who sustain pelvic fractures.[1],[2] The optimal management strategy for urethral injuries remains controversial.[3] Suprapubic cystostomy followed by delayed urethral reconstruction 3–6 months later as advocated by Johanson [4] and later popularized by Morehouse and associates [5] was found to be associated with massive blood loss (500–3150 ml), long hospitalization (22–28 days), and a high (97%) risk of urethral stricture.[6],[7] It also has significant rate of incontinence and erectile dysfunction.[8],[9] Immediate primary open reconstruction of the urethra can be technically challenging as it will invariably require surgical dissection through the site of injury. Dissection through the acutely inflamed tissue, hematoma, and distorted anatomy at the site of urethral injury will increase the potential for further neurovascular damage and may increase the risk of impotence.[3] Early endoscopic realignment as an initial management strategy for acute urethral injuries is an alternative option that provides early definitive transurethral catheter drainage and avoids the need for delayed urethral reconstruction. The endoscopic urethral realignment can be performed with reduced blood loss, shorter hospitalization, and potentially less stricture complication.[10] In this study, patients who were managed by early endoscopic urethral realignment for traumatic posterior urethral rupture were reviewed to determine the incidence of successful realignment and postoperative complications.


   Materials and Methods Top


Between April 2007 and March 2016, 27 patients were presented with traumatic posterior urethral disruptions secondary to road traffic accident. In the emergency unit, after primary and secondary survey, immediate CT urography and retrograde urethrogram were carried out to all patients to assess the upper urinary tract and the integrity of the posterior urethra. The initial urologic management for all patients proved to have posterior urethral disruption was insertion of suprapubic drainage catheter. All patients were evaluated with appropriate genitourinary history, history of potency before and after trauma, and a record of any voiding dysfunction before the urethral disruption. Endoscopic urethral realignment was delayed in cases of hemodynamic instability or life-threatening injuries that precluded urologic manipulation. Urine cultures and appropriate intravenous antibiotics were given before the procedure. Endoscopic urethral realignment was performed under general endotracheal anesthesia either in a dorsal lithotomy or in a modified lithotomy position according to the algorithm shown in [Figure 1]. The aim of the procedure is to visualize the proximal urethral end at the site of disruption. The procedure was started by the introduction of flexible cystoscope along the distal urethra. Identification of the proximal urethral segment was facilitated by the injection of methylene blue in the bladder or simultaneous use of an antegrade flexible cystoscope that was introduced through the suprapubic cystostomy tract. The antegrade cystoscope was advanced through the bladder neck to the proximal urethra, and it was used for antegrade light illumination or advancement of a guidewire to the pelvic cavity. Once the proximal segment was identified, a guidewire was inserted to the proximal urethra then to the bladder followed by insertion of a Foley catheter (14Fr-18Fr) over that wire to the bladder. If the proximal end of the urethra was not identified, the procedure will be stopped.
Figure 1: Algorithm for endoscopic urethral realignment

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Postoperatively, the policy used for removal of the Foley catheter according to the algorithm shown in [Figure 2] is based not only on the results of pericatheter urethrogram but also on the degree of the mucosal healing at the site of the realignment as assessed by the flexible urethroscopy. If the pericatheter urethrogram, 6 weeks after endoscopic realignment, showed no extravasation of the contrast, the Foley urethral catheter will be removed followed by immediate flexible urethroscopy to assess the urethral mucosal healing at the site of the trauma. In the presence of any sign of incomplete urethral mucosal healing, the catheter was reinserted again for another 3 weeks. The mucosal healing was reassessed every 3 weeks by flexible urethroscopy until complete healing was observed. At that time, the catheter was not reinserted and was removed permanently. After permanent removal of the urethral catheter, the patients were then followed up for 18–36 months for incontinence, potency, and voiding pattern.
Figure 2: Algorithm for postrealignment catheter removal

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   Results Top


Twenty-seven patients (12–45 years old; mean = 28.9 years) with acute urethral injuries were included during the study. CT urogram was normal in eight patients; however, CT showed elevated bladders base with deformity of the bladder owing to pelvic hematoma in 19 patients, minimal hepatic tear in 3 patients, and 2 patients had grade 2 renal injury. Patients with hepatic tear and renal injury were managed conservatively. All 27 patients underwent retrograde urethrography, which revealed complete prostate-membranous disruption in all of them. Primary endoscopic realignment was done in the same day of trauma in 21 patients, while in 6 hemodynamically unstable patients, the primary endoscopic realignment was delayed ranging from 4 to 7 days. In the primary endoscopic realignment, the proximal urethral end was identified directly in four patients and with the guidance of methylene blue injected in the suprapubic tube in three patients, while in nine patients, the proximal urethral end was detected by following a guidewire and in eight patients by following endoscopic light. The guidewire or the endoscopic light was emerged from the proximal urethral end by the aid of antegrade flexible cystoscope introduced through the suprapubic cystostomy. In the remaining three patients, identification of the proximal urethral end was failed and the procedure converted to immediate closed realignment (railroading procedure). Pericatheter retrograde urethrogram 6 weeks postoperatively showed no extravasation in 19/24 patients. In those patients, urethral catheter was removed followed by immediate flexible urethroscopy that revealed incomplete mucosal healing in all of them. The Foley catheter was reinserted again for more than 3 weeks. In the other 5/24 patients, the pericatheter retrograde urethrogram showed extravasation of the contrast, so the urethral catheter kept for 3 more weeks. According to this policy, the catheter removed permanently after 9 weeks in 17/24 (70.8%) patients and after 12 weeks in 7/24 (29.2%) patients. All 24/27 patients in whom endoscopic realignment was successful, were potent, and voided freely when the urethral stent was removed, with a mean peak urinary flow rate of 15.9 ml/s (range: 12.8–19.7). Six months after realignment, minimal urethral strictures developed in 4/24 (16.7%) patients. All of them were treated successfully with one session internal urethrotomy. After 18–36-month follow-up, all patients voided freely with a mean maximum flow rate of 14.8 ml/s (range: 12.4–17.9 ml/s).


   Discussion Top


Traumatic posterior urethral disruption that occurs at the prostatomembranous junction is a devastating injury and associated with pelvic fractures in approximately 4% to 25% of the time.[1],[2] After diagnosis, the mainstay of treatment for traumatic urethral injuries is to re-establishment the urethral continuity and minimizing the risk of complications mainly incontinence, impotence, and stricture formation.[11] The optimal management strategy for traumatic urethral injuries remains controversial, and the debate regarding immediate versus delayed definitive treatment is currently unresolved. After resuscitation and management of life-threatening associated injuries, the next step in the management of the injured urethra is bladder drainage. This will prevent further soft-tissue infiltration by urine and allow for urinary output monitoring.[12] Once bladder drainage has been achieved, definitive treatment options include either primary realignment of the urethra surgically or endoscopically or suprapubic cystostomy followed by delayed urethroplasty.[11] Suprapubic cystostomy followed by delayed open urethroplasty of the resulting stricture as described by Johansson in 1953[4] was the method of choice for reestablishing urethral continuity. The aim of this type of management is to avoid urethral instrumentations and further urethral trauma at the time of injury.

Early open realignment of acute urethral disruption is not new. Since it was first described in 1934 by Ormond and Cothran, several techniques have been used to pass a stent across the urethral injury.[13],[14],[15],[16] Primary open realignment has lost its popularity for many years because surgical intervention soon after injury converts a closed hematoma into an open hematoma and can potentially lead to infection with increased risk of urethral necrosis,[17] and it was thought to increase the risk of postoperative impotence, incontinence, and stricture formation.[18],[19]

Early closed realignment (railroading) was used as initial line of treatment for urethral disruption with data showed that this technique did not change the incidence of impotence.[20],[21],[22],[23] These data also demonstrated that, with early closed alignment of the ruptured urethra, some patients did not develop stricture at all and that stricture, if formed in other patients, it would be short and easily managed by internal urethrotomy or dilatation without the need for open surgery.

Kamal [12] in his study reported that early closed realignment (railroading) of the urethra was successful in 9 out of 12 patients. Two patients were impotent, none was incontinent, and four developed short segment urethral stricture that required visual urethrotomy. On the contrary in other studies, urethral injury managed by early realignment (railroading) of the urethra showed that the cumulative incidences of stricture in 320 cases were 54% (range from 14% to 75%).[20],[21],[22],[23],[24],[25],[26],[27],[28]

With the advances and improvements in endourologic techniques and equipments, primary endoscopic realignment has been evolving and has made possible the safe approach to posterior urethral injuries. It has the potential advantage of reducing stricture rates, shortening the time to spontaneous voiding, and eliminating the morbidity associated with suprapubic cystostomy and reconstructive urethral stricture repair.

Jepson et al.[29] evaluated eight patients that were managed by early primary endoscopic realignment after a mean of 50.4 months (range: 35–85) of follow-up, two of the patients required intermittent self-dilation ranging from once every 7 days to once a month. One patient required conversion to an open perineal urethroplasty. Seven men (87.5%) are continent, five (62.5%) are potent, and two others achieve adequate erections for intercourse using intracorporeal injections.

Hadjizacharia et al. in their study [30] showed that the stricture rate was significantly lower in patients undergoing immediate endoscopic realignment (IER) when compared with delayed treatment (DT) (14% vs. 100%, P = 0.001). He also stated that the failed attempted of IER has no effect on future urethral reconstruction surgery. For patients who had initial successful IER and developed stricture later, delayed reconstruction is potentially made easier.

Similar results were observed in a study comparing 65 patients managed with primary endoscopic realignment to 30 patients managed with DT. This study showed a significantly reduced rate of urethral strictures in the primary endoscopic realignment group (19% vs. 40%, P = 0.025).[31] When they do occur, strictures after realignment were less severe and more amenable to minimally invasive treatment and infrequently requiring formal urethroplasty.

Even with long-term follow-up (mean follow-up of 83 months) as in Moudouni et al. study,[10] endoscopic urethral realignment is associated with minimal morbidity, and moreover, the failure of endoscopic realignment did not compromise delayed formal urethral reconstruction.

Park et al.[32] analyzed the long-term results of treatment for urethral injury with performing immediate primary endoscopic realignment in 19 patients. The author concluded that the endoscopic primary realignment of urethral injury is a simple, safe, rapid, and nontraumatic technique. It reduces the incidence and extent of the complications such as stricture, erectile dysfunction, and incontinence.

In this study, endoscopic realignment succeeded to re-establish the urethral continuity in 24/27 (88.9%) patients, no patients developed incontinence or impotence, and four patients developed minimal ureteral stricture that was managed by visual internal urethrotomy.

The proper timing for permanent urethral stent removal postoperatively has a crucial affect in the incidence of the postrealignment urethral stricture. Healing of the transected urethra occurs in two synchronized processes, granulation tissue formation in the periurethral tissues,[33] and re-epithelialization of the disrupted urethral mucosa as well.[34] The formation of the granulation tissue occurs earlier than complete re-epithelialization of disrupted mucosa. These granulation tissues, when developed, can prevent contrast from extravasation during postoperative pericatheter urethrogram in spite of incomplete mucosal healing. The removal of urethral stent based on pericatheter urethrogram before complete mucosal healing allows the granulation tissue to grow through the mucosal defect resulting in urethral stricture. Keeping the stent till complete mucosal healing seems to exert a barrier effect that can prevent granulation tissue from infiltrating and obstructing the urethral lumen and subsequently decrease the incidence of urethral stricture. In this study, the urethral stent was kept in place depending on complete re-epithelialization of the urethral mucosa as assessed by flexible urethroscopy rather than the results of postoperative pericatheter urethrogram.


   Conclusions Top


Advancement in endoscopic technology has made the primary endoscopic realignment an effective and successful alternative option for immediate repair of posterior urethral disruption without adverse effect on erectile function or continence mechanism. Primary endoscopic realignment seems to lessen the severity of stricture disease and the need for delayed reconstructive urethral surgery and decreased its associated morbidity. Primary endoscopic realignment if failed, it neither delays nor precludes further management using open techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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