Endoscopic Re-Establishment of Membranous Urethral Disruption

0022-534 7 /91/1455-0977$03.00 /0 THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 145, 977-979, May 1991

Printed in U.S.A.

ENDOSCOPIC RE-ESTABLISHMENT OF MEMBRANOUS URETHRAL DISRUPTION K. YASUDA, T. YAMANISHI, S. ISAKA, T. OKANO, M. MASAI

AND J.

SHIMAZAKI

From the Department of Urology, School of Medicine, Chiba University, Chiba, Japan

ABSTRACT

A total of 17 patients with traumatic membranous urethral disruption underwent urethral reconstruction via a core-through technique. Followup was 1 to 8 years (mean 3.7 years) postoperatively, and included 6 weeks with an indwelling catheter, periodic dilation for 6 months and occasional sounding. Within 1 year postoperatively, 6 patients required additional scar incision, including 3 who underwent scar resection. At 1 to 8 years postoperatively 6 patients had complications: 3 had stricture requiring periodic dilation (including 2 who underwent scar incision), while 2 had mild stress incontinence and 1 had nocturnal enuresis. Traumatic impotence was noted in 7 patients but the operation was not the cause in any. This method of endoscopic management was found to be an acceptable alternative to urethroplasty in cases of membranous urethral disruption. KEY WORDS:

urethra, trauma, endoscopy

Since Sachse introduced direct vision urethrotomy for surgical correction of an impassable urethral stricture, including membranous urethral disruption (results not reported), in 19781 several techniques have been reported. 2- 10 These techniques can be divided into 2 groups. Group 1 includes procedures using a light from a previously inserted suprapubic cystoscope, scar resection under the resectoscope, 3 scar incision with a urethrotome 4- 7 and urethral dilation by the balloon method using a guide wire that has been passed previously through the scar tissue. 8- 10 Group 2 involves procedures using a sound as a guide, which is inserted through a suprapubic cystostomy tract. 2 •6 • 7• 10 We improved and simplified our previous endoscopic technique 2 to minimize scar resection or incision and also to avoid a blind interlocking procedure.

Scar tissue

MATERIALS AND METHODS

Patients. From 1980 to 1987, 17 men 20 to 70 years old (mean age 41.1 years) with traumatic membranous urethral disruption were transferred to our department for urethral reconstruction. The causes of injury were an industrial accident in 11 patients and a traffic accident in 6. The interval between injury and urethrotomy ranged from 3 to 6 months. During the period of cystostomy drainage 9 patients were potent and 8 were impotent. Endoscopic management. After the disrupted prostatic urethra is examined and the absence of obstacles is confirmed, such as dislocation of the urethra due to a fractured pubic bone or a prostatitis-caused cavity, a hollow bougie (a modification of a 13F bougie) is inserted to the proximal end of the obstructed prostatomembranous urethra through the suprapubic tract (fig. 1). A pointed guide wire is inserted into the catheter to its tip and then advanced deeper through the scar tissue to the perinea! skin. Then, the catheter is pushed into the scar tissue. A urethrotome is inserted from the distal urethra to incise the scar tissue until the hollow bougie can be seen. The urethrotome is positioned tip-to-tip with the hollow bougie at an angle of 70 to 80 degrees. The pointed guide wire is pushed from the bougie into the urethrotome. Under endoscopic observation the urethrotome is brought down from an angled position to a horizontal level and then pushed through to the bladder. (At this stage the scar tissue is not resected.) An 18F tip-hollowed balloon catheter then is inserted in the urethra and left indwelling for Accepted for publication September 13, 1990. 977

External urinary sphincter FIG. 1. Endoscopic urethrotomy is done with aim of penetrating and following contour of previously existing urethra to urethral cavity.

6 weeks. Total hospital stay was 4 to 6 days. No patient required a blood transfusion. Followup. After 6 weeks of indwelling catheterization, urethral dilation was done periodically for 6 months. When dilation was difficult, scar resection was performed. After 6 months of periodic dilation the patients underwent occasional sounding until a stable stricture was confirmed and urinary flow then was examined by uroflowmetry (fig. 2). Assessment of postoperative results. Postoperative results were considered successful when periodic dilation was not required and there was no incontinence or impotence due to the operation. Complications were recorded. RESULTS

All patients improved with stable stricture. The outcome was successful in 14 patients, while partial failures were noted in 3. Within the first 12 months 6 patients required additional scar incision (3 underwent scar resection). One to 8 years postoperatively 3 patients required periodic dilation for severe stricture, including 2 who underwent scar incision. Eight patients were greatly improved with a good urinary stream and they ceased followup visits. Uroflowmetry was done in the remaining 9 patients. The peak flow rate was greater than 15 ml. per second in these patients (fig. 2).

978

YASUDA AND ASSOCIATES

no. cases

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17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2

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y,

1980

1981

1982

1983

1984

1985

1986

1987

1988

FIG. 2. Followup and methods. •, periodic dilation. D, occasional sounding. o, uroflowmetry. 1::J, additional incision

Complications In 1 Yr. Total No. pts. Significant stricture: Periodic dilation Periodic dilation + additional scar incision Mild stress incontinence Nocturnal enuresis

17 17

DISCUSSION From 1-8 Yrs. 6

3 17/17 6/17

3/3 2/3

3

2

1

1

FIG. 3. A, combined preoperative cystogram and urethrogram shows disrupted prostatomembranous urethra. B, postoperative retrograde urethrogram shows continuity achieved by reconstruction.

Complications (see table). Three patients complained of mild stress incontinence within the first 12 months postoperatively, 1 of whom became continent during postoperative year 2. One patient had nocturnal enuresis. A total of 8 patients had traumatic impotence, 1 of whom regained potency 17 months after the trauma. A representative successful case is shown in figure 3.

After reconsidering our previous technique, which caused failures such as rectal perforation and incontinence, we devised a technique using a urethrotome. 2 Subsequently, Fishman et al introduced the Goodwin sound, a catheter similar to ours. Their method, as does ours, permits maximum progression into the anterior lumen and maintains the prostatomembranous urethra.10 Apart from this method, all other techniques reported during the last 10 years used scar incision from the distal urethra to reach a guide wire previously inserted from a suprapubic cystostomy tract. However, these techniques are apt to damage the remaining distal sphincter mechanism. If possible, an operation should not cause damage. There have been some successful cases of endoscopic reconstruction of a disrupted membranous urethra3-10 but the numbers of cases reported are so limited and followup is so short that it is difficult to compare the postoperative results with our present technique and other reported techniques. Since we introduced our method in 19802 the success rate of urethroplasty has increased. Webster and Sihelnik reported a success rate of 97.3%, 11 • 12 compared with our rate of 82.4%. Singh et al reported an impotence rate of 44.4% with suprapubic cystostomy in 45 patients with posterior urethral rupture due to pelvic fracture. 13 This impotence rate was comparable to our rates of 47.1 and 41.2% before and after the operation, respectively. It generally is believed that, after reconstruction of a membranous urethral disruption due to pelvic trauma, the bladder neck should be competent to maintain the mechanism of con tinence. 14 However, of our patients there were 2 whose bladder neck was dilated on cystography. They were continent, although the continence mechanism was not believed to be competent. This finding suggested that the reconstructed membranous urethra had not completely lost the continence mechanism even after reconstruction. This might have been a factor that resulted in the high success rate in our study, although our method of management is not without fault, such as long-term

ENDOSCOPIC RE-ESTABLISHMENT OF MEMBRANOUS URETHRAL DISRUPTION

(6 weeks) catheterization in the urethra for mucosal regeneration and long-term periodic dilation to avoid scar resection. Conventional open urethroplasty has been known to cause excessive blood loss, impotence, incontinence and excessive stricture and requires long-term hospitalization. 15 Endoscopic management of a membranous urethral disruption is a simple procedure and causes much fewer complications. In conclusion, our endoscopic procedure may be a useful alternative to urethroplasty. REFERENCES

1. Sachse, H.: Die Sichturethrotomie mit scharfem Schnitt: Indikation-Technik-Ergebnisse. Urologe A, 17: 177, 1978. 2. Yasuda, K., Murakami, M., Hama, T., Nakayama, T., Sanada, T., Kitamura, Y. and Shimazaki, J.: Endoscopic management of posterior urethral disruption. Jap. J. Urol., 71: 952, 1980. 3. Gonzalez, R., Chiou, R.-K., Hekmat, K. and Fraley, E. E.: Endoscopic re-establishment of urethral continuity after traumatic disruption of the membranous urethra. J. Urol., 130: 785, 1983. 4. Lieberman, S. F. and Barry, J. M.: Retreat from transpubic urethroplasty for obliterated membranous urethral strictures. J. Urol., 128: 379, 1982. 5. Gupta, N. P. and Gill, I. S.: Core-through optical internal urethrotomy in management of impassable traumatic posterior urethral strictures. J. Urol., 136: 1018, 1986. 6. McCoy, G. B., Barry, J. M., Lieberman, S. F., Pearse, H. D. and Wicklund, R.: Treatment of obliterated membranous and bulbous urethras by direct vision internal urethrotomy. J. Trauma, 27: 883, 1987. 7. Barry, J. M.: Visual urethrotomy in the management of the obliterated membranous urethra. Urol. Clin. N. Amer., 16: 319, 1989. 8. Marshall, F. F., Chang, R. and Gearhart, J.P.: Endoscopic reconstruction of traumatic membranous urethral transection. J. Urol., 138: 306, 1987. 9. Stillwell, T. J., Patterson, D. E. and LeRoy, A. J.: Endoscopic urethroplasty with balloon dilatation for traumatic disruption of the prostatomembranous urethra. J. Endourol., 2: 257, 1988. 10. Fishman, I. J., Hirsch, I. H. and Toombs, B. D.: Endourological reconstruction of posterior urethral disruption. J. Urol., 137: 283, 1987. 11. Webster, G.D. and Sihelnik, S.: The management of strictures of the membranous urethra. J. Urol., 134: 469, 1985. 12. Webster, G.D.: Perinea! repair of membranous urethral stricture. Urol. Clin. N. Amer., 16: 303, 1989. 13. Singh, P. B., Karmakar, D., Gupta, R. C., Dwivedi, U. S. and Tripathi, V. N. P.: Result of suprapubic cystostomy only as primary management of posterior urethral rupture following pelvic fracture. Int. Surg., 73: 59, 1988. 14. Turner-Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries and from their surgical management. Urol. Clin. N. Amer., 16: 335, 1989. 15. Waterhouse, K., Laungani, G. and Patil, U.: The surgical repair of

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membranous urethral strictures: experience with 105 consecutive cases. J. Urol., 123: 500, 1980.

EDITORIAL COMMENTS There continues to be enthusiasm for the endoscopic management of pelvic fracture urethral disruption defects, ostensibly in an attempt to decrease the morbidity of posterior urethroplasty. However, it is important to recognize that posterior urethroplasty has come of age with predictable success rates in excess of 90%, without the need for subsequent dilation and without any compromise to potency or continence. Such procedures can now invariably be performed through the perineum alone, are adaptable for long urethral defects and, in our experience, rarely require blood transfusion. It is appropriate to note that while a successful surgical urethroplasty requires 1 procedure, a 5day hospitalization and 3 weeks of catheterization, the endoscopic procedures reported, while having the same hospitalization, did require reincision in approximately 50% of the cases and all patients required at least periodic dilation during the first 6 months of management. The merits of the nonoperative approach to any disorder cannot be denied. However, it is important to analyze objectively the inconveniences and results of the new method against the track record of the old technique before it can be enthusiastically embraced. We must establish which disruption defects are appropriate for such management with a minimum of morbidity, re-dilation and re-stricture, and I believe that presently only the short uncomplicated defect should be considered. George D. Webster Division of Urology Duke University Medical Center Durham, North Carolina We also have found that endoscopic reconstruction of total traumatic membranous urethral disruptions can be successful. We have evolved to a slightly different technique. A flexible cystoscope is placed through the proximal prostatic urethra. A rigid nephroscope is used as a urethroscope and with C-arm verification a hollow needle is passed accurately to the apex of the prostatic urethra. A guide wire is passed and balloon dilation is performed. We have not resected abundant tissue but we have tried to sculpt the urethra in its normal position. Resection does not appear to have affected potency. Most patients have required 1 or 2 additional endoscopic procedures but we have usually not had to rely on frequent dilations or further manipulations after 6 to 12 months. I believe most endoscopic procedures probably will require multiple manipulations. We have also used this technique for bulbous urethral injuries but I believe they are probably more easily repaired with open surgical techniques. Endoscopic techniques offer a viable, attractive alternative to an open operation in patients with short, traumatic, membranous urethral transections. Fray F. Marshall Department of Urology The Johns Hopkins Hospital Baltimore, Maryland