Early fluoroscopic realignment for traumatic urethral injuries

ADULT

UROLOGY

ELSEVIER

EARLY FLUOROSCOPIC REALIGNMENT URETHRAL INJURIES THOMAS

A. LONDERGAN,

LINCOLN

H. GUNDERSEN,

AND

FOR TRAUMATIC MARVIN

J. VAN EVERY

ABSTRACT

There are a variety of open surgical and endoscopic approaches to the treatment of traumatic urethral injuries. The objective of our study was to evaluate the efficacy of early fluoroscopic realignment of the urethra following traumatic injury. Methods. Seven patients with urethral rupture injuries (two anterior and five posterior urethral injuries) were treated. Follow-up ranged from 1 to 35 months. Results. Six patients had successful early realignment of the urethra and catheter placement. Two of these required no further treatment, whereas 3 required another procedure or procedures following catheter removal. One patient is presently being treated. In 1 patient, realignment was unsuccessful and subsequent open urethroplasty was required. Conclusions. Early fluoroscopic realignment appears to be a safe and effective method of treatment for severe traumatic urethral injuries. Copyright I997 by Elsevier Science Inc. UROLOGY 49: 10 1- 103, 1997.

Objectives.

T

raumatic injuries to the urethra can cause significant morbidity. Different approaches to treatment include early open repair, early or delayed endoscopic treatment, and cystotomy drainage followed by delayed open or endoscopic repair. Early realignment of the urethra, with placement of a urethral catheter to facilitate healing, would appear to be an excellent method of treatment. We describe 6 casesof severe traumatic urethral injuries treated with early fluoroscopic realignment, followed by endoscopic urethrotomy asnecessary. MATERIAL

AND METHODS

Seven men were treated for severe traumatic urethral injuries. The mean age was 33.6 years. There were two anterior and five posterior urethral injuries. All of the injuries were secondary to blunt trauma! and all of the posterior urethral injuries were associated with multiple pelvic fractures. The two anterior urethral injuries were straddle-type injuries and did not involve pelvic fractures. All of the injuries were defined as complete disruptions with no dye seen going into the bladder on retrograde urethrogram. Six patients had initial retrograde urethrography to diagnose the injury. One patient was transferred to our institution with a urethral catheter; on

From the Gundersen Clinic, La Crosse, Wisconsin Reprint requests: Thomas A. Londergan, M.D., Clinic, 1836 South Avenue, La Crosse, WI 54601 Submitted: June 6, 1996, accepted (with revisions): 1996 COPYRIGHT

1997

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BY ELSEVM

SCIENCE

INC.

Gundersen August

7,

computed tomographic scan, the catheter was noted to be outside the bladder in the pelvis. All patients then had a suprapubic cystotomy placed for bladder drainage, either via an open or trochar cystotomy. Fluoroscopic realignment of the traumatized urethra was then attempted once the patient was medically stable and his other injuries had been addressed. The patients were brought to the interventional radiology suite and given intravenous fentanyl and midazolam for sedation; they were then placed in the supine position. The genitalia and suprapubic site were prepped and draped. A Terumo glide wire (Meditech, Boston) loaded onto a 7F Berenstein hockey-stick configuration catheter (Cook, Bloomington, Ind) was used to cannulate the anterior urethra. Contrast medium was intermittently injected through the catheter to opacify the urethra and identify the site of disruption. The guide wire and catheter were then steered, using multiplanar fluoroscopy, until entrance into the bladder neck was obtained. If this was unsuccessful, the suprapubic tube was removed and a 7F vascular sheath was placed through the suprapubic tract. Through this, a second Berenstein catheter and glide wire could be placed in the bladder; the bladder neck was then entered. Intermittent contrast injection through the catheter could be used to identify the site of proximal disruption. The antegrade catheter could then be used as a guide to probe with the more distal catheter and guide wire, using multiplanar fluoroscopy. A guide wire could then be advanced either retrograde or antegrade out the urethral meatus. After access was obtained through the area of injury, the Berenstein catheter could be placed over the guide wire. A 0.03%inch Amplatz super-stiff guide wire was passed and coiled into the bladder. For several of the initial cases, the traumatic disruption was dilated with an angioplasty balloon catheter at low pressure. No appreciable waist was ever identified during this, and so this maneuver was abandoned. An 18 or 20F council tip catheter was then placed over the wire and into the bladder. The 0090-4295/97/$17.00 PII SOO90-4295(96)00429-3

10 1

TABLE Patient No.

Age (Years)

I.

Site of Injury

1 2

39 34

Anterior Anterior

3 4 5 6

38 32 31 39

Posterior Posterior Posterior Posterior

7

22

Posterior

KEY: CDC

= clean daily

Urethral

catheterization;

ED = erect&

injuries

treated

Time to Realignment (Days) 16 42 [unsuccessful) 9 6 2 3 7 dysfunction;

VW = visual

suprapubic catheter was clamped overnight and then removed, leaving the catheter in place. The urethral catheter was left in place for 4 to 6 weeks. A pericatheter urethrogram was then performed to verify healing and continuity of the urethra and rule out extravasation. The catheter was then removed. Patients were followed with frequent examinations and flow-rate studies, with a retrograde urethrogram if necessary. If a stricture was identified, optical internal urethrotomy was performed. This was repeated once if necessary. One patient was maintained on daily clean catheterization for urethral dilation. Telephone follow-up was performed to verify information regarding further procedures and sexual function. Follow-up ranged from 1 to 35 months (mean 16). The need for further urologic intervention and the number of procedures was determined in each case. Impotence was defined as being unable to achieve erection sufficient for sexual intercourse. All of the patients reported normal erections and sexual function prior to the injury. Incontinence was defined as any involuntary loss of urine.

RESULTS Patient data are shown in Table I. The age range of our patients was from 22 to 39 years (mean 33.6). Excluding one unsuccessful attempt at 7 weeks, the mean time to realignment was 7.2 days postinjury (range 2 to 16). The last patient treated has not had his catheter removed at the time of this report. Of the 5 remaining patients, 3 required at least one interval urethrotomy following removal of the catheter. One patient developed a prostatic abscess with his catheter in place; this was treated by endoscopic drainage. No patient required more than two follow-up procedures; the mean number of procedures required was 1.2. Open urethroplasty was not performed, and all 5 patients void spontaneously and are continent. Two of 5 patients were impotent following the injury and treatment, whereas 3 have normal sexual function. One impotent patient underwent penile artery revascularization at another institution, and 1 patient is awaiting further treatment. 102

with

fluoroscopic

Time of Catheterization (Weeks]

internal

realignment

Follow-up (Months)

Additional Procedures/ Complications

2 -

35 28

VIU x 1 VIU x 3, urethroplasty,

6 6 5 7

18 16 12 2

-

-

VIU x 2 VIU x 2, CDC, ED None Pelvic wall abscess, prostatic abscess, ED -

ED

urethrotomy.

COMMENT The optimal form of management for urethral rupture injuries is unknown. Early open realignment via a transpubic or retropubic approach has been advocated in the past.lm3 Concerns about impotence and incontinence associated with early open repair, however, prompted others to favor a conservative approach with suprapubic cystostomy and observation followed by treatment of the inevitable urethral stricture at a later date.4-7 More recent studies have indicated that impotence and incontinence following early realignment of urethral disruption injuries are most likely due to the original injury and not the surgical management. ‘s9 It appears th at early realignment of the traumatized urethra to allow healing might reduce the need for later reconstruction (that is, open urethroplasty) without increasing the risk of impotence or incontinence. Most studies of immediate or early urethral realignment following trauma describe an open technique via a retropubic or transvesical approach directly following the injury. This approach risks entry into a pelvic hematoma and exposes a possibly unstable patient to further intraoperative manipulations. Although the risk of a serious complication is probably low using this approach, it would seem prudent to avoid manipulation directly following a significant injury if possible. Immediate endourologic realignment for traumatic urethral injuries has been reported.“,” This technique uses urethroscopy and placement of a urethral sound from above through a suprapubic cystotomy to re-establish urethral continuity. Results were good, with no patients requiring further surgery other than urethral dilation or internal urethrotomy. However, this approach usually requires a general anesthetic, as well as fluid irrigation for adequate vision. In addition, not all UROLOGY 49 (11,1997

patients with pelvic fractures are able to be positioned adequately for this procedure. In 1992, Clark et al.” described the case of a 42year-old man with a traumatic membranous urethral disruption who had radiologic realignment of the urethra 21 days following following the injury. Our study is an extension of this approach to 7 patients, 5 with posterior and 2 with anterior urethral disruptions. We were successful on the first attempt in 5 of the 7 cases. In 1 patient, the initial attempt failed 2 days after the injury (probably due to a large hematoma compressing the bladder to one side and separating the ends of the disrupted urethra); however, a second attempt 5 days later was successful. In 1 patient, the technique was not successful, probably due to significant scarring and stricture 7 weeks after the injury. The optimal timing for this approach is not known. We believe that 4 to 10 days following the injury probably affords the best chance for success. By then, the pelvic hematoma should have begun to resolve, while scarring should be minimal. One concern about early fluoroscopic realignment is the possibility of doing harm, either through traumatic manipulation or by introducing infection in the area of injury. We believe that the risk of trauma using the glide wires and catheter is minimal, as long as gentle technique is used and repeated efforts are not made without success. We have had only 1 case in which infection was a problem, where the patient developed an infected lateral pelvic hematoma followed by a prostatic abscess posterior to the area of urethral injury. It is unclear, however, whether the infection in this case was due to our efforts or from other factors, such as a Foley catheter placed outside the urinary tract in the pelvis initially or later angiographic embolization of bleeding pelvic vessels. We believe that every effort should be made in all cases to observe strict sterile technique; consequently, the risk of subsequent infection should be low. Routine antibiotic coverage was not used in our patients, and the possible benefit of antibiotic prophylaxis in these cases is not known. Following urethral realignment and healing, most patients will require at least one internal urethrotomy for recurrent stricture. We believe that this is acceptable, and it has not caused problems

UROLOGY

49 (I), 1997

with incontinence. Open urethroplasty has not been necessary, whereas this is usually required following suprapubic urinary diversion alone. Our impotence rate of 40% is consistent with prior studies of patients with urethral disruption and most likely is secondary to the injury itself, rather than to the treatment.5’7’9 In summary, we describe a noninvasive technique of urethral realignment following traumatic injury to the anterior or posterior urethra. This technique can be performed by urologists and radiologists using multiplanar fluoroscopy, which is available at most institutions. We believe that it offers the advantages of early urethral realignment without some of the risks of an open surgical approach. Further application and study of this technique will be necessary to confirm our results. REFERENCES 1. DeWeerd JH: Immediate realignment of posterior urethral injury. Urol Clin North Am 4: 75, 1977. 2. Glass RE, Flynn JT, King JB, and Blandy JP: Urethral injury and fractured pelvis. Br J Urol 50: 578, 1978. 3. Devine CJ Jr, Jordan GH, and Devine PC: Primary realignment of the disrupted prostatomembranous urethra. Urol Clin North Am 16: 291, 1989. 4. Johanson B: Reconstruction of male urethral strictures. Acta Chir Stand Suppl 176, 1953. 5. Coffield KS, and Weems WL: Experience with management of posterior urethral injury associated with pelvic fracture. J Urol 117: 722-724, 1977. 6. Morehouse DD, and MacKinnon KJ: Management of prostatomembranous urethral disruption: 13-year experience. J Urol 123: 173-174, 1980. 7. Webster GD, Mathes GL, and Selli C: Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol 130: 898, 1983. 8. Herschorn S, Thijssen A, and Radomski SB: The value of immediate or early catheterization of the traumatized posterior urethra. J Urol 148: 1428-1431, 1992. 9. Kotkin L, and Koch MO: Impotence and incontinence after immediate realignment of posterior urethral trauma: result of injury or management. J Uroll55: 1600-1603, 1996. 10. Gelbard MK, Heyman AM, and Weintraub P: A technique for immediate realignment and catheterization of the disrupted prostatomembranous urethra. J Urol 142: 52-55, 1989. 11. Melekos MD, Pantazakos A, Daouaher H, and Papatsoris G: Primary endourologic re-establishment of urethral continuity after disruption of prostatomembranous urethra. J Urol 39: 135, 1992. 12. Clark WR, Patterson DE, and Williams HJ Jr: Primary radiologic realignment of membranous urethral disruptions. J Uro139: 182, 1992.

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