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Value of Transrectal Ultrasonography in Female Traumatic Urethral Injuries
Female Urology Value of Transrectal Ultrasonography in Female Traumatic Urethral Injuries Tao Ying, Qin Li, Chunjuan Shao, Zhaoling Zhu, Liang Feng, and Bing Hu OBJECTIVES METHODS
RESULTS
CONCLUSIONS
To estimate the value of transrectal ultrasonography (TRUS) in traumatic urethral injuries of various types in females. A total of 30 female patients with symptoms of urethral injuries after trauma underwent TRUS between January 2005 and July 2008. Of them, 28 patients with operative indications undertook operation; the other 2 received conservative management and then a follow-up ultrasonography. All outcomes were used to validate the results of TRUS. Urethral injuries were clearly observed in 30 cases with TRUS. The continuity of urethral wall, unblocking of urethral lumen, and homogeneous echo of surrounding structures had been changed. Urethral injuries varied in types, including urethrovaginal fistula, urethral stricture, urethral rupture, and urethral hematoma. It was common to find several injury patterns simultaneously in 1 patient. The outcomes in 28 cases with operative indications were consistent with results of surgery. The other 2 cases were diagnosed as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months’ conservative management. TRUS is a reliable technique to exhibit abnormalities in injured urethra associated with trauma in female. UROLOGY 76: 319 –322, 2010. © 2010 Elsevier Inc.
I
t is well known that the incidence of urethral injuries resulting from trauma is much lower in females than that in males because urethra of female is short, mobile, and has no significant tight attachments to the pubis.1 To date, it has been unclear what the actual incidence is. The urethral injuries can be easily diagnosed based on typical clinical symptoms, but appropriate management is difficultly achieved because of the complexity of injury patterns.2 So it is common for a patient with urethral injuries to receive further management postoperatively because of the sequelae (such as incontinence, dysuria, etc). Taking into consideration the complexity of injury patterns and the diversity of pathologic lesions in the wound such as fibroplastic proliferation, cicatrization, urethral fistula, and stricture, or even urethral imperforation, the importance of diagnostic imaging should never be neglected in confirming and evaluating the injury. An ideal imaging technique can provide crucial information for the treatment, both about the details of primary injury itself and the status of surroundings. Traditional radiologic examinations perform poorly in providing information about periurethral soft tissue. Magnetic resonance imaging (MRI) has some contraindications besides its high cost. Cystoscopy is an invasive examination
From the Department of Ultrasound in Medicine, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China Reprint requests: Bing Hu, M.D., Department of Ultrasound in Medicine, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai 200233, People’s Republic of China. E-mail: [email protected] Submitted: August 29, 2009, accepted (with revisions): November 24, 2009
© 2010 Elsevier Inc. All Rights Reserved
and has some contraindications, including inflammation, urethral atresia, etc. Transrectal ultrasonography (TRUS), with its advantage of excellent soft-tissue imaging, may be a good option. In this study, we will share our experiences in the observation of traumatic urethral injuries in females, using TRUS.
MATERIAL AND METHODS A total of 30 female patients, mean age 17.27 years (range, 5-42 years), with symptoms of urethral dysfunction after trauma (ie, leakage of urine, bradyuria, dysuria, urinary incontinence, etc), were reviewed between January 2005 and July 2008. The causes were traffic accidents in almost all cases, except for 2 falling from height. The mean examination time was 42.15 months since the trauma (range, 2.5-83 months). Thirteen cases had urethral surgery history for urethral injuries. Others undertook urethral examination for the first time. All agreed to undergo TRUS before further treatment. The patient, in a left lateral lying position with a comfortably full bladder, was examined by sonography carried out with a Hitachi Hv 900 scanner (Hitachi Medical Corporation, Tokyo, Japan) using a 4-10 MHz double-plane probe (4-9 MHz convex array, 5-10 MHz linear array), covered by sheath, placed within rectum at the level of the urethra. During static phase, urethra and surrounding structures were assessed in both sagittal and axial plane. Then, the urinary tract was further evaluated in voiding phase when the patient was required to void in the left lateral lying or supine lying position. For those failing to void automatically as ordered, a soft 6/8F catheter would be inserted under the guidance of TRUS from the urethral external aperture, and saline water would be injected through the catheter to 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.11.044
319
Figure 1. Urethrovaginal fistula (arrow): (A) in statical phase; (B) in voiding phase. B indicates bladder; V, vagina; U, urethra.
Figure 2. Urethral stricture: (A) in statical phase; (B) in voiding phase; (C) scar tissue (arrow) close to the urethral stricture in voiding phase. observe the urinary tract. These actions were performed under sterile conditions.
RESULTS All 30 patients undertook TRUS, result of which prompted with operative indications in 28 cases. The postoperative diagnosis was consistent with the TRUS results preoperatively. The other 2 cases were regarded as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months’ conservative management. In all 30 cases, urethral injuries varying in patterns were all visualized clearly in TRUS. It was not uncommon that several kinds coexisted in 1 patient. Different urethral injury types performed in different ways are listed as follows. 1. Urethrovaginal fistula (20 cases): Urethrovaginal fistula was demonstrated not only by discontinuity of posterior urethral wall and anterior vaginal wall but by a narrow hypoechoic or anechoic zone called fistula between them (Fig. 1). In the voiding period, urine was seen flowing from bladder to urethra, then through fistula to vagina, which sometimes dilated with urine accumulated inside. 2. Urethral stricture (18 cases): Urethral stricture was suggested by restrained opening of urethra lumen and dilated proximal urethra in voiding phase (Figs. 2A, and B). Injured urethra also appeared with harsh cavity surface. 320
3. Urethral rupture (5 cases): Urethral ruptures were ensured in TRUS through urethral continuity breaking, disordered echo for urethral muscular layer in the injured place, distal urethra disappearing in some patients, and sometimes scar tissue inserting. In addition, catheterization under ultrasound failed to insert to the bladder (Fig. 3). 4. Urethral hematoma (2 cases): In our research, the 2 patients falling from height suffered from pain and deteriorating dysuria. It showed a mixed echo mass in the surrounding of urethra, suggesting a hematoma. After 3 months’ conservative treatment, the hematoma vanished in ultrasonography and the symptoms were also markedly relieved. 5. Scar tissue (13 cases): Scar tissue presented an irregular hyperechoic or hypoechoic zone, involving the retropubic space and the surrounding of urethra and vagina (Fig. 2C). The extent and degree of fibrosis was different according to the magnitude of trauma.
COMMENT Urethral injuries in females after trauma, mostly induced by direct laceration from sharp edges of fractured fragments in pelvic fracture, are usually a partial and longitudinal urethral anterior wall laceration and vary in degrees.3 In addition, urethra is so close to vagina that it is difficult to avoid injury to vagina. Owing to plenty of venous plexus around, it is not rare that bleeding of UROLOGY 76 (2), 2010
Figure 3. Urethral rupture (arrow): (A) in statical phase; (B) in voiding phase. PS indicates pubic symphysis.
urethra results in hematoma. As time goes by, most injuries will lead to stricture or fistula. In our study, urethral injuries took different patterns, among which stricture and fistula were the most. Furthermore, it was not surprising to find different injury patterns coexisting in 1 patient. The procedure remains controversial because of the complex injury patterns and the incidence of late sequelae reported with a disappointing rate.2,4-7 Thereby, the importance of the diagnostic imaging cannot be denied. Radiological examination and MRI are the most common available techniques for female urethral imaging.8-12 Some traditional radiological examinations, such as retrograde urethrography and micturition cystourethrography, are considered as the standard imaging techniques for the morphologic and functional study of urethra. However, they are insufficient to become an ideal technology as they are radioactive and provide poor information for periurethral soft tissue. Relatively speaking, MRI can provide anatomic details of both the urethra and periurethral tissue. However, the contraindication to patients with metal in body and high cost of the examination cannot be ignored. Cystoscopy, a traditional and inexpensive method, has been widely applied in urology for lower urinary tract diseases. It can be used for both diagnosis and treatment.13,14 However, for those of severe urethral stenosis or even atresia, this approach is often difficult to implement. Though it can be very good at observing cavity of the urethra and bladder, cystoscopy is limited when it comes to evaluation for damage of soft tissue around urethra. Ultrasound, a cheap, convenient, and repeatable imaging method, is an ideal tool for urethral evaluation, with its advantage in soft-tissue imaging and without radiation. TRUS can reveal urethra and structures around it clearly. Normal ultrasonographic characteristics of female urethra perform with continuity of wall, unblocking of lumen, smoothness of inner surface, and uniformity of muscular layer echo. Meanwhile, TRUS can identify and determine abnormalities for the urethra and other relevant structures presenting with following characteristics. UROLOGY 76 (2), 2010
First, it can present the anatomic changes, such as whether the urethra is injured and which pattern the injury is. Different urethral injury patterns were shown distinctly including urethral stricture, urethrovaginal fistula, urethral rupture, urethral hematoma, scarring, and so on. Most patients suffered from more than one injury pattern. Second, TRUS can identify details of urethral injuries. Taking fistula and stricture as examples, the site, number, diameter, and length of all were displayed clearly. For those with urethral rupture, the site and range of the rupture were assessed. In addition, the length of the remained urethra is another important part of assessment. It is related to operation style: if the residual urethra is long enough it can be used in the surgery; if it is not, a flap or graft is needed. It is also associated with the urinary control function postoperatively. Patients with too short remaining urethra tend to have postoperative urinary incontinence and should also undergo further urethral suspension procedure to avoid the sequelae besides single urethral reconstruction. Third, evaluation of the status of periurethral structures (if there are vaginal injuries or scar tissue) gives the clinician a more general view and a greater possibility for sufficient preoperative preparation, for example, the right size of pedicle graft. For example, we had to find out the accurate site of scarring to ensure the complete removal of the whole scar tissue to recreate a urethral bed with good blood supply. All the elements mentioned earlier are critical to the success of surgery. Ultrasonography of different approaches has been described for assessing various urethral diseases.15-18 However, transabdominal sonography is not good at urethral imaging as the approach requires an overdistended bladder and what is worse ultrasound penetration is diminished by obesity and excessive intestinal gas. Though transperineal approach is better to visualize urethra, it is not the best choice as its beam is nearly paralleled with axis of urethra. We believe that transrectal approach may be the best choice for urethra observation considering the fact that the axis of urethra, vagina, and rectum is almost paralleled; when the probe is located in the rectum, the beam launched from side of the probe is nearly vertical to 321
the axis of urethra, allowing a much better visualization. With this method, the disturbing influence of pubis can also be avoided and imaging of the whole urethra can be required. TRUS has been widely used in male prostate ultrasonography, but only a few cases have been reported about its application in female urethra. In 1996, Rasines et al15 reported 2 cases about the use of TRUS in diagnosis of female urethral diverticula, appreciating the transrectal approach an excellent alternative imaging method. In 1997, Vargas SB et al18 reported 4 cases of urethral diverticula diagnosed by transrectal ultrasound.16 In these articles, authors concluded that TRUS was the most useful diagnostic method after comparing it with other imaging methods. Although transvaginal approach is also an available method in urethral observation,16 we prefer transrectal approach in this study. For severe urethral injuries cases with vagina injured simultaneously, it is not strange that missed diagnosis happens because of the placement of probe in vagina pressing vaginal wall which is possibly injured. In addition, the vagina lumen of young girls is too small for the probe to be placed in, especially if there is a vaginal stricture. Furthermore, it is not permitted ethically to have a transvaginal ultrasonography for virgins. Relatively speaking, transrectal approach is more widely used and more effective in detecting urethral injuries. In our study, urethra as well as the adjacent organs, that is, vagina, rectum, and other surrounding structures, were observed clearly with TRUS in all cases. Besides, we also supplemented voiding ultrasonography with TRUS in this study. In the voiding phase, urinary went into all spaces it could, including urethral lumen, fistula, false urinary tract, etc. Because urinary is the natural contrast agent of ultrasonography, it is effective to observe urinary tract during voiding period. In our study, most patients were able to void automatically. The fistula and stricture can be visualized in voiding ultrasonography more clearly. For those failing to void, a soft 6/8F catheter under the guidance of ultrasound is acquired to detect the tract as it can be imaged distinctly on ultrasound too. In addition, injection of saline water through the catheter can further help in urinary tract imaging. As the catheter is thin and soft, the examination was not very uncomfortable and patients undertaking catheterization found it acceptable.
CONCLUSIONS In summary, we consider TRUS an excellent alternative imaging method for female traumatic urethral injuries
322
and it could play an important role in the diagnosis and evaluation. It is inexpensive, convenient, repeatable, and without any radiation harm. TRUS can definitely reveal abnormal performances in injured urethra with different types. Consequently, TRUS has significant values in the diagnosis and treatment of traumatic urethral injuries.
References 1. Chapple CR. Urethral injury. BJU Int. 2000;86:318-326. 2. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161:1433-1441. 3. Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol. 1992;147:139-143. 4. Xu YM, Qiao Y, Sa YL, et al. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection. Eur Urol. 2007;51:1093-1099. 5. Xu YM, Sa YL, Fu Q, et al. Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture. Eur Urol. 2009;56:193-200. 6. Brandes S, Borrelli JJ. Pelvic fracture and associated urologic injuries. World J Surg. 2001;25:1578-1587. 7. Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol. 1996;156:1288-1291. 8. Steinhardt GF, Landes RR. Countertraction retrograde urethrography in women: an improved diagnostic technique. J Urol. 1982; 128:936-937. 9. Golomb J, Leibovitch I, Mor Y, et al. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol. 2003;13: 536-542. 10. Siegelman ES, Banner MP, Ramchandani P, et al. Multicoil MR imaging of symptomatic female urethral and periurethral disease. Radiographics. 1997;17:349-365. 11. Yoshida S, Fujii Y, Yokoyama M, et al. Female urethral diverticular abscess clearly depicted by diffusion-weighted magnetic resonance imaging. Int J Urol. 2008;15:460-461. 12. Han DH, Jeong YS, Choo MS, et al. Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging. Eur Urol. 2007;51:1664-1670. 13. Lawrentschuk N, Ooi J, Pang A, et al. Cystoscopy in women with recurrent urinary tract infection. Int J Urol. 2006;13:350-353. 14. Sato K, Ishikawa S, Tsutsum M, et al. Flexible cystoscopy. Diagnosis and treatment. Jpn J Urol. 1988;79:1769-1773. 15. Rasines GL, Gutierrez MR, Abascal FA, et al. Female urethra diverticula: value of transrectal sonography. J Clin Ultrasound. 1996;24:90-92. 16. Fontana D, Porpiglia F, Morra I, et al. Transvaginal ultrasonography in the assessment of organic diseases of female urethra. J Ultrasound Med. 1999;18:237-241. 17. Martensson O, Duchek M. Translabial ultrasonography with pulsed colour-Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol. 1994;28:101-104. 18. Vargas SB, Cortina MB, Rodríguez RR, et al. Transrectal ultrasonography in the diagnosis of urethral diverticula in women. J Clin Ultrasound. 1997;25:21-28.
UROLOGY 76 (2), 2010
RESULTS
CONCLUSIONS
To estimate the value of transrectal ultrasonography (TRUS) in traumatic urethral injuries of various types in females. A total of 30 female patients with symptoms of urethral injuries after trauma underwent TRUS between January 2005 and July 2008. Of them, 28 patients with operative indications undertook operation; the other 2 received conservative management and then a follow-up ultrasonography. All outcomes were used to validate the results of TRUS. Urethral injuries were clearly observed in 30 cases with TRUS. The continuity of urethral wall, unblocking of urethral lumen, and homogeneous echo of surrounding structures had been changed. Urethral injuries varied in types, including urethrovaginal fistula, urethral stricture, urethral rupture, and urethral hematoma. It was common to find several injury patterns simultaneously in 1 patient. The outcomes in 28 cases with operative indications were consistent with results of surgery. The other 2 cases were diagnosed as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months’ conservative management. TRUS is a reliable technique to exhibit abnormalities in injured urethra associated with trauma in female. UROLOGY 76: 319 –322, 2010. © 2010 Elsevier Inc.
I
t is well known that the incidence of urethral injuries resulting from trauma is much lower in females than that in males because urethra of female is short, mobile, and has no significant tight attachments to the pubis.1 To date, it has been unclear what the actual incidence is. The urethral injuries can be easily diagnosed based on typical clinical symptoms, but appropriate management is difficultly achieved because of the complexity of injury patterns.2 So it is common for a patient with urethral injuries to receive further management postoperatively because of the sequelae (such as incontinence, dysuria, etc). Taking into consideration the complexity of injury patterns and the diversity of pathologic lesions in the wound such as fibroplastic proliferation, cicatrization, urethral fistula, and stricture, or even urethral imperforation, the importance of diagnostic imaging should never be neglected in confirming and evaluating the injury. An ideal imaging technique can provide crucial information for the treatment, both about the details of primary injury itself and the status of surroundings. Traditional radiologic examinations perform poorly in providing information about periurethral soft tissue. Magnetic resonance imaging (MRI) has some contraindications besides its high cost. Cystoscopy is an invasive examination
From the Department of Ultrasound in Medicine, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China Reprint requests: Bing Hu, M.D., Department of Ultrasound in Medicine, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai 200233, People’s Republic of China. E-mail: [email protected] Submitted: August 29, 2009, accepted (with revisions): November 24, 2009
© 2010 Elsevier Inc. All Rights Reserved
and has some contraindications, including inflammation, urethral atresia, etc. Transrectal ultrasonography (TRUS), with its advantage of excellent soft-tissue imaging, may be a good option. In this study, we will share our experiences in the observation of traumatic urethral injuries in females, using TRUS.
MATERIAL AND METHODS A total of 30 female patients, mean age 17.27 years (range, 5-42 years), with symptoms of urethral dysfunction after trauma (ie, leakage of urine, bradyuria, dysuria, urinary incontinence, etc), were reviewed between January 2005 and July 2008. The causes were traffic accidents in almost all cases, except for 2 falling from height. The mean examination time was 42.15 months since the trauma (range, 2.5-83 months). Thirteen cases had urethral surgery history for urethral injuries. Others undertook urethral examination for the first time. All agreed to undergo TRUS before further treatment. The patient, in a left lateral lying position with a comfortably full bladder, was examined by sonography carried out with a Hitachi Hv 900 scanner (Hitachi Medical Corporation, Tokyo, Japan) using a 4-10 MHz double-plane probe (4-9 MHz convex array, 5-10 MHz linear array), covered by sheath, placed within rectum at the level of the urethra. During static phase, urethra and surrounding structures were assessed in both sagittal and axial plane. Then, the urinary tract was further evaluated in voiding phase when the patient was required to void in the left lateral lying or supine lying position. For those failing to void automatically as ordered, a soft 6/8F catheter would be inserted under the guidance of TRUS from the urethral external aperture, and saline water would be injected through the catheter to 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.11.044
319
Figure 1. Urethrovaginal fistula (arrow): (A) in statical phase; (B) in voiding phase. B indicates bladder; V, vagina; U, urethra.
Figure 2. Urethral stricture: (A) in statical phase; (B) in voiding phase; (C) scar tissue (arrow) close to the urethral stricture in voiding phase. observe the urinary tract. These actions were performed under sterile conditions.
RESULTS All 30 patients undertook TRUS, result of which prompted with operative indications in 28 cases. The postoperative diagnosis was consistent with the TRUS results preoperatively. The other 2 cases were regarded as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months’ conservative management. In all 30 cases, urethral injuries varying in patterns were all visualized clearly in TRUS. It was not uncommon that several kinds coexisted in 1 patient. Different urethral injury types performed in different ways are listed as follows. 1. Urethrovaginal fistula (20 cases): Urethrovaginal fistula was demonstrated not only by discontinuity of posterior urethral wall and anterior vaginal wall but by a narrow hypoechoic or anechoic zone called fistula between them (Fig. 1). In the voiding period, urine was seen flowing from bladder to urethra, then through fistula to vagina, which sometimes dilated with urine accumulated inside. 2. Urethral stricture (18 cases): Urethral stricture was suggested by restrained opening of urethra lumen and dilated proximal urethra in voiding phase (Figs. 2A, and B). Injured urethra also appeared with harsh cavity surface. 320
3. Urethral rupture (5 cases): Urethral ruptures were ensured in TRUS through urethral continuity breaking, disordered echo for urethral muscular layer in the injured place, distal urethra disappearing in some patients, and sometimes scar tissue inserting. In addition, catheterization under ultrasound failed to insert to the bladder (Fig. 3). 4. Urethral hematoma (2 cases): In our research, the 2 patients falling from height suffered from pain and deteriorating dysuria. It showed a mixed echo mass in the surrounding of urethra, suggesting a hematoma. After 3 months’ conservative treatment, the hematoma vanished in ultrasonography and the symptoms were also markedly relieved. 5. Scar tissue (13 cases): Scar tissue presented an irregular hyperechoic or hypoechoic zone, involving the retropubic space and the surrounding of urethra and vagina (Fig. 2C). The extent and degree of fibrosis was different according to the magnitude of trauma.
COMMENT Urethral injuries in females after trauma, mostly induced by direct laceration from sharp edges of fractured fragments in pelvic fracture, are usually a partial and longitudinal urethral anterior wall laceration and vary in degrees.3 In addition, urethra is so close to vagina that it is difficult to avoid injury to vagina. Owing to plenty of venous plexus around, it is not rare that bleeding of UROLOGY 76 (2), 2010
Figure 3. Urethral rupture (arrow): (A) in statical phase; (B) in voiding phase. PS indicates pubic symphysis.
urethra results in hematoma. As time goes by, most injuries will lead to stricture or fistula. In our study, urethral injuries took different patterns, among which stricture and fistula were the most. Furthermore, it was not surprising to find different injury patterns coexisting in 1 patient. The procedure remains controversial because of the complex injury patterns and the incidence of late sequelae reported with a disappointing rate.2,4-7 Thereby, the importance of the diagnostic imaging cannot be denied. Radiological examination and MRI are the most common available techniques for female urethral imaging.8-12 Some traditional radiological examinations, such as retrograde urethrography and micturition cystourethrography, are considered as the standard imaging techniques for the morphologic and functional study of urethra. However, they are insufficient to become an ideal technology as they are radioactive and provide poor information for periurethral soft tissue. Relatively speaking, MRI can provide anatomic details of both the urethra and periurethral tissue. However, the contraindication to patients with metal in body and high cost of the examination cannot be ignored. Cystoscopy, a traditional and inexpensive method, has been widely applied in urology for lower urinary tract diseases. It can be used for both diagnosis and treatment.13,14 However, for those of severe urethral stenosis or even atresia, this approach is often difficult to implement. Though it can be very good at observing cavity of the urethra and bladder, cystoscopy is limited when it comes to evaluation for damage of soft tissue around urethra. Ultrasound, a cheap, convenient, and repeatable imaging method, is an ideal tool for urethral evaluation, with its advantage in soft-tissue imaging and without radiation. TRUS can reveal urethra and structures around it clearly. Normal ultrasonographic characteristics of female urethra perform with continuity of wall, unblocking of lumen, smoothness of inner surface, and uniformity of muscular layer echo. Meanwhile, TRUS can identify and determine abnormalities for the urethra and other relevant structures presenting with following characteristics. UROLOGY 76 (2), 2010
First, it can present the anatomic changes, such as whether the urethra is injured and which pattern the injury is. Different urethral injury patterns were shown distinctly including urethral stricture, urethrovaginal fistula, urethral rupture, urethral hematoma, scarring, and so on. Most patients suffered from more than one injury pattern. Second, TRUS can identify details of urethral injuries. Taking fistula and stricture as examples, the site, number, diameter, and length of all were displayed clearly. For those with urethral rupture, the site and range of the rupture were assessed. In addition, the length of the remained urethra is another important part of assessment. It is related to operation style: if the residual urethra is long enough it can be used in the surgery; if it is not, a flap or graft is needed. It is also associated with the urinary control function postoperatively. Patients with too short remaining urethra tend to have postoperative urinary incontinence and should also undergo further urethral suspension procedure to avoid the sequelae besides single urethral reconstruction. Third, evaluation of the status of periurethral structures (if there are vaginal injuries or scar tissue) gives the clinician a more general view and a greater possibility for sufficient preoperative preparation, for example, the right size of pedicle graft. For example, we had to find out the accurate site of scarring to ensure the complete removal of the whole scar tissue to recreate a urethral bed with good blood supply. All the elements mentioned earlier are critical to the success of surgery. Ultrasonography of different approaches has been described for assessing various urethral diseases.15-18 However, transabdominal sonography is not good at urethral imaging as the approach requires an overdistended bladder and what is worse ultrasound penetration is diminished by obesity and excessive intestinal gas. Though transperineal approach is better to visualize urethra, it is not the best choice as its beam is nearly paralleled with axis of urethra. We believe that transrectal approach may be the best choice for urethra observation considering the fact that the axis of urethra, vagina, and rectum is almost paralleled; when the probe is located in the rectum, the beam launched from side of the probe is nearly vertical to 321
the axis of urethra, allowing a much better visualization. With this method, the disturbing influence of pubis can also be avoided and imaging of the whole urethra can be required. TRUS has been widely used in male prostate ultrasonography, but only a few cases have been reported about its application in female urethra. In 1996, Rasines et al15 reported 2 cases about the use of TRUS in diagnosis of female urethral diverticula, appreciating the transrectal approach an excellent alternative imaging method. In 1997, Vargas SB et al18 reported 4 cases of urethral diverticula diagnosed by transrectal ultrasound.16 In these articles, authors concluded that TRUS was the most useful diagnostic method after comparing it with other imaging methods. Although transvaginal approach is also an available method in urethral observation,16 we prefer transrectal approach in this study. For severe urethral injuries cases with vagina injured simultaneously, it is not strange that missed diagnosis happens because of the placement of probe in vagina pressing vaginal wall which is possibly injured. In addition, the vagina lumen of young girls is too small for the probe to be placed in, especially if there is a vaginal stricture. Furthermore, it is not permitted ethically to have a transvaginal ultrasonography for virgins. Relatively speaking, transrectal approach is more widely used and more effective in detecting urethral injuries. In our study, urethra as well as the adjacent organs, that is, vagina, rectum, and other surrounding structures, were observed clearly with TRUS in all cases. Besides, we also supplemented voiding ultrasonography with TRUS in this study. In the voiding phase, urinary went into all spaces it could, including urethral lumen, fistula, false urinary tract, etc. Because urinary is the natural contrast agent of ultrasonography, it is effective to observe urinary tract during voiding period. In our study, most patients were able to void automatically. The fistula and stricture can be visualized in voiding ultrasonography more clearly. For those failing to void, a soft 6/8F catheter under the guidance of ultrasound is acquired to detect the tract as it can be imaged distinctly on ultrasound too. In addition, injection of saline water through the catheter can further help in urinary tract imaging. As the catheter is thin and soft, the examination was not very uncomfortable and patients undertaking catheterization found it acceptable.
CONCLUSIONS In summary, we consider TRUS an excellent alternative imaging method for female traumatic urethral injuries
322
and it could play an important role in the diagnosis and evaluation. It is inexpensive, convenient, repeatable, and without any radiation harm. TRUS can definitely reveal abnormal performances in injured urethra with different types. Consequently, TRUS has significant values in the diagnosis and treatment of traumatic urethral injuries.
References 1. Chapple CR. Urethral injury. BJU Int. 2000;86:318-326. 2. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161:1433-1441. 3. Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol. 1992;147:139-143. 4. Xu YM, Qiao Y, Sa YL, et al. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection. Eur Urol. 2007;51:1093-1099. 5. Xu YM, Sa YL, Fu Q, et al. Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture. Eur Urol. 2009;56:193-200. 6. Brandes S, Borrelli JJ. Pelvic fracture and associated urologic injuries. World J Surg. 2001;25:1578-1587. 7. Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol. 1996;156:1288-1291. 8. Steinhardt GF, Landes RR. Countertraction retrograde urethrography in women: an improved diagnostic technique. J Urol. 1982; 128:936-937. 9. Golomb J, Leibovitch I, Mor Y, et al. Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula. Eur Radiol. 2003;13: 536-542. 10. Siegelman ES, Banner MP, Ramchandani P, et al. Multicoil MR imaging of symptomatic female urethral and periurethral disease. Radiographics. 1997;17:349-365. 11. Yoshida S, Fujii Y, Yokoyama M, et al. Female urethral diverticular abscess clearly depicted by diffusion-weighted magnetic resonance imaging. Int J Urol. 2008;15:460-461. 12. Han DH, Jeong YS, Choo MS, et al. Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging. Eur Urol. 2007;51:1664-1670. 13. Lawrentschuk N, Ooi J, Pang A, et al. Cystoscopy in women with recurrent urinary tract infection. Int J Urol. 2006;13:350-353. 14. Sato K, Ishikawa S, Tsutsum M, et al. Flexible cystoscopy. Diagnosis and treatment. Jpn J Urol. 1988;79:1769-1773. 15. Rasines GL, Gutierrez MR, Abascal FA, et al. Female urethra diverticula: value of transrectal sonography. J Clin Ultrasound. 1996;24:90-92. 16. Fontana D, Porpiglia F, Morra I, et al. Transvaginal ultrasonography in the assessment of organic diseases of female urethra. J Ultrasound Med. 1999;18:237-241. 17. Martensson O, Duchek M. Translabial ultrasonography with pulsed colour-Doppler in the diagnosis of female urethral diverticula. Scand J Urol Nephrol. 1994;28:101-104. 18. Vargas SB, Cortina MB, Rodríguez RR, et al. Transrectal ultrasonography in the diagnosis of urethral diverticula in women. J Clin Ultrasound. 1997;25:21-28.
UROLOGY 76 (2), 2010