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Endoscopic Treatment of Posttraumatic Urethral Obliteration: Experience in 396 Patients
0022-5347/95/1531-0067$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 153, 67-71, January 1995 Printed in U.S.A.
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION: EXPERIENCE IN 396 PATIENTS SHAWKY A. EL-ABD From the Department of Urology, Tanta University, Tanta, Egypt
ABSTRACT
Of 396 patients with posttraumatic posterior urethral strictures treated endoscopically during 10 years 352 had no vesical displacement (group 1) and 44 had marked displacement (group 2). Group 1patients were treated by suprapubic diversion and delayed optical urethrotomy. Exploration and railroad alignment to the urethra were done in group 2 and followup internal urethrotomy was performed in 33 patients. Eleven patients in group 2 and 68 in group 1 were considered failures due to complete short segment urethral obliteration. These 79 patients who failed initial visual urethrotomy underwent endoscopic resection of the stricture, that is core through optical urethrotomy. After 6 to 55 months (average 2 years) 46 patients (58.2%)were voiding satisfactorily (4 had stress incontinence). The 33 patients (41.8%)with failed minor or major endoscopic treatment due to persistent obstruction were treated with open urethroplasty. We conclude that posttraumatic posterior urethral obliteration can be treated by simple or major endoscopic techniques and that core through optical urethrotomy is a reasonable alternative to urethroplasty in patients with an impassable short stricture. KEY WORDS: urethral stricture, wounds and injuries, endoscopy, urinary catheterization Management of traumatic disruption of the posterior urethra has included primary realignment, primary cystostomy with delayed urethroplasty including scrota1 inlays, free grafts with bladder mucosa, full thickness skin grafts, transpubic repair and modified perineal repairs.', Traditionally, most patients were offered a major operation to establish urethral continuity and in some cases surgical repair in 2 or more stages was necessary. On the other hand, urethral strictures following incomplete urethral disruption have been treated with direct vision urethr~tomy.~ More recently, patients with urethral obliteration following complete rupture of the urethra or as a complication of reconstructive procedures were also treated endoscopically with internal urethrotomy, or with a thin trocar either from below the stricture or with the help of suprapubic light or instrum e n t a t i ~ n . ~Transurethral . ballon dilation andor resection of the fibrous and strictured urethra has also been used in some cases6 PATIENTS AND METHODS
Between 1982 and 1992, 396 patients with posttraumatic urethral obstruction underwent endoscopic management. The mechanism of injury was blunt pelvic and perineal trauma following automobile, industrial or pedestrian accidents. These patients were treated by 2 different methods immediately after the injury according to clinical and radiological evaluation, including retrograde urethrography and excretory urography. Group 1 consisted of 352 patients with no vesical injury or prostatic displacement who underwent suprapubic catheter drainage only. Group 2 included 44 patients who underwent suprapubic exploration and placement of a silicone urethral catheter into the bladder using interlocking sounds or a railroad technique. These patients were explored because of the presence of marked cranial displacement of the bladder and prostate into the sacral promontory, presence of vesical or bladder neck injury andor concomittent rectal injury that mandates abdominal exploration. In this group the urethral catheter was left indwelling for 4 Acce ted for publication May 27, 1994. Reaf at annual meeting of American Urological Association, San Antonio, Texas, May 15-20, 1993.
weeks and then removed to evaluate urethral voiding in the presence of the suprapubic tube. All patients in group 1 had difficulty or inability to void. Similar patients in group 2 with voiding problems after removal of the catheter or during followup underwent combined or retrograde urethrography to demonstrate the degree of bladder neck competence and predict the postoperative continence. This maneuver overestimated the length of obliteration, since it did not always delineate the posterior urethra completely. The most accurate method to estimate the length of the urethral defect is done intraoperatively by insertion of a curved urethral sound through the suprapubic tract into the prostatic urethra, and examining the anterior urethra by visual urethrotomy with concomitant gentle manipulation of the sound by an examining finger in the rectum. Digital rectal examination will demonstrate anal sphincter competence, somatic sacral reflex arc integrity and the level of the prostatic gland. Visual urethrotomy was done in 284 patients in group 1 and 33 in group 2 with a small lumen. A retrograde incision was performed at the 12 o'clock position and extended to the entire length of the stricture until normal proximal mucosa was encountered. The procedure was completed in the presence of a small ureteral catheter routinely placed into the strictured segment before incision. The urethral catheter was left indwelling for 1 to 3 weeks. Core through visual urethrotomy was performed in 79 patients in the explored and nonexplored groups with complete obliteration of the posterior urethra. The procedure was done under C-arm fluoroscopic guidance in 2 planes and in the presence of a suprapubic tube. Manipulation of a curved urethral sound through the suprapubic tract and transrectal palpation of the prostate will allow for transurethral incision towards the tip of the sound and, just before the end of the procedure, to the light of a suprapubic cystoscope. To identify the tip, the operator slightly twists the handle of the sound, wiggling the tip minimally with direct attention paid to the area. When the tip is identified it is held steady and either a ureteral catheter or guide wire is advanced in the direction of the opened proximal urethra until the catheter or guide wire reaches the bladder and is secured through the cystostomy 67
68
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION
tract. Once this guide is in place a wide generous urethrotomy is done and the irregularly floating tags of scar tissues that obscure clear direct vision in the urethral lumen are further excised with the resectoscope. This method will not compromise the integrity of the external sphincter more than it had been by the initial trauma. We usually insert an 18F silicone urethral Foley catheter without a guide wire or occasionally through the half-round sheath of the urethrotome. The procedure is done with antibiotic coverage and the patient usually is discharged from the hospital 2 to 8 days later (mean hospital stay 4 days). The urethral catheter is left indwelling for 4 to 6 weeks according to the length of the bare area noted at the end of the endoscopic procedure (in 1 patient the catheter was left for 16 weeks). Following this period the urethral catheter is removed and the suprapubic tube is closed for a few days before its removal to assist urethral voiding. After removal of the catheter all patients were advised to return sooner than 2 weeks if the stream deteriorated, at which time daily urethral dilation was performed followed by gradual weaning until routine weekly dilation with progressive doubling of the interval was followed. RESULTS
After coring a channel through the obstructed urethra under vision, 46 patients (58.2%) achieved satisfactory urethral voiding but at least 1 to 3 internal urethrotomies were required for a total of 103 times before the urethra became stabilized following this aggressive endoscopic treatment, that is a rate of 2.2 urethrotomies per patient (table 2). Bleeding requiring blood transfusion was not encountered in any patient. There were no intraoperative complications. Operative time ranged from 45 to 120 minutes (mean 70) and mean hospital stay was 4 days. In 33 patients (41.8%) the urethra was totally obliterated and during endoscopy we observed a more than 2.5 cm. gap with tough scar encasing the urogenital diaphragm preventing negotiation and stabilization of the urethra. These patients underwent open perineal excision and end-to-end urethroplasty, with inferior pubectomy in some. Urinalysis, subjective assessment of the voiding pattern, calibration of the urethra and ascending urethrography were performed to assess the results but flow rate determination was done in some patients. Clinical diminution in the force of the stream was an indication to start routine urethral dilation earlier but this was not followed in time regularly by most patients who underwent recurrent visual urethrotomy. All patients were followed twice in the department for at least 6 months and the majority for approximately 2 years (range 6 to 55 months). A longer followup is mandatory to evaluate the long-term results. No patient had dribbling incontinence after the endoscopic procedures. However, 4 of 46 patients (8.7%)had stress incontinence following core through visual urethrotomy in the presence of a normal bladder neck. One patient had incontinence after transurethral resection for benign enlargement of the prostate performed elsewhere 1.5 years after resection of the stricture. Impotence was noted in 132 patients (37.5%)treated by primary suprapubic cystostomy compared to 35 in the complicated group (79.5%) who underwent the railroad technique. Following injury,potent patients did not show deterioration after endoscopic treatment and have either adequate morning tumescence or vaginal penetration. Therefore, impotence was related to the trauma in 167 patients (42.2%) and none improved after minor or major endoscopic procedures (table 3).
The mechanisms of injury in group 1 patients undergoing suprapubic cystostomy and in complicated group 2 patients undergoing realignment were similar but the difference was in the seventy and associated injuries that mandate exploration in group 2. In the uncomplicated group visual urethrotomy was done 4 to 8 weeks (average 6) following trauma. During the study period the procedure was done once in 12 patients, twice in 98 and 3 times in 174 before satisfactory urethral continuity was achieved (table 1). Strictures recurred after single urethrotomy in 272 patients (95.8%). However, 284 of 352 patients (80.7%)eventually underwent successful simple optical urethrotomy. In the complicated group voiding was possible for a few months and in some cases for years but, unfortunately, late urethral obstruction recurred in all patients. Repeated simple optical urethrotomy for passable strictures at the membraneous urethra was eventually successful in 33 patients (75%) but in 23 (69.7%) retreatment was mandatory due to recurrent obstruction (fig. 1). The rate of visual urethrotomy per patient was 2.6 in group 1 compared to 1.8 in group 2 who underwent initial realignment. DISCUSSION A core through procedure was done in 68 uncomplicated In no area of urology does controversy exist more than in and 11 complicated cases previously treated with realignment (fig. 2) because the obliteration in the posterior urethra the management of posterior urethral injury, with a dichotwas too complete to permit passage of a urethral catheter and omy of opinion making comparisons between different series simple visual urethrotomy. The procedure was done in the difficult. Analysis of the outcome in 15 series of patients presence of a suprapubic tube and the defect in the urethral treated by immediate realignment over a splinting catheter lumen detected intraoperatively was 1 to 3 cm. (mean 2.5 has shown that strictures recurred in 69%,impotence in 44% compared to a mean defect of 4 cm. on the urethrogram). and incontinence in 20%.7Sender et a1 found a 41.6%rate of impotence after catheterization only, and on reviewing many series for 2 types of management (mainly by suprapubic cystostomy alone with delayed urethroplasty versus immediTABLE1. Results of visual urethrotomy following traumatic ate realignment) they reported a 30.3% mean incidence of posterior urethral injury impotence in group 1 compared to 36% in group 2.8 On the other hand Zincke and Furlow observed a 33.3%incidence of Type of Injury Uncomplicated- ComplicatedInitial Management Suprapubic Exploration Totals impotence in already potent patients after open urethroplasCatheter and Railroad ty.9 No cases 352 44 396 ___ When we based our initial management according to the No. visual urethrotomy (%): severity of trauma by suprapubic cystostomy versus immeOnce 12 (3.4) 10 (22.7) 22/317 (7) Twice 98 (27.8) 20 (45.5) 118 (37.2) diate realignment, the incidence of impotence was 37.5%and 3 times 174 (49.4) 3 (6.8) 177 (55.8) 79.5%in both groups. Although the final management in all No. visual urethrotomiedpt. 2.6 1.8 2.5 patients was by endoscopic procedures, impotence related to No. good or acceptable 284 (80.7) 33 (75) 317 (80.1) treatment was not observed and none of the impotent paresults (%I* tients improved later, which supports the observation that No. failures (Q)t 68 (19.3) 11 (25) 79 (19.9) * Patient with good stream, continent and without further urethrotomy or the incidence of impotence is significantly related t o the degree of trauma. Armenakas et a1 clearly documented that dilation. f Patients underwent a core through procedure this type of severe pelvic trauma, which disrupts the perineal ~~
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION
69
FIG. 1. A, ascending urethrogram shows posttraumatic complete posterior urethral injury. B , Ivp in same patient reveals marked displacement of bladder. C, ascending urethrogram 4 years aRer trauma and 3 optical urethrotomies following exploration and realignment procedure.
FIG. 2. A, combined urethrogram in case of complicated posttraumatic urethrorectal fistula (distal arrows) with vesical urinary diversion after failed open repair (proximal arrow). B , voiding cystourethrography after core through urethrotomy and urethral stent placement for 16 weeks with well delineated patent nonfistulous posterior urethra (arrows).
ligaments and muscles, will also cause extensive damage to the neurovascular pathways regulating erection, leading to vasculogenic impotence in 86.7% and neurogenic impotence in 13.3%of the cases." We reserved immediate surgical intervention with realignment, as did others: for the complicated cases with a high riding prostate because of the subsequent lengthy strictures with malalignment, making endoscopic procedures impossible and definitive substitution difficult. The idea of realignment without prostatic traction will avoid urethral angulation and compromise of the proximal continent mechanism. At the same time, it provides a guided descent during hematoma resorption, with subsequent easier and less traumatic endoscopic management. This would be reflected in minimal morbidity rates, and satisfactory functional and anatomical results. The optimal time for endoscopic treatment following urethral trauma was approximately 6 weeks, which allows time for the hematoma to shrink without significant scarring although the procedure can be done a t any late stage. These procedures are not difficult technically but no doubt for correct realignment sufficient experience is necessary. In these cases many auxilliary procedures for orientation are helpful,
and the incision to the light procedure is helpful for short strictures and just before the end of incising a long stricture when the upper and lower cystoscopes are seen overlapping in the C-arm unit without direct communication in the field of vision. An observation worth mentioning is that radiographic studies usually overestimate the actual length of urethral obliteration, making the decision for endoscopic management a remote possibility. After section andor resection of the scar tissue, the actual defect in the urethra was much less than that previously expected depending solely on urethrography . It may be argued that endourological management may jeopardize the process of epithelialization resulting in creation of a lumen within the fibrotic encasement, with a possibility of recurrent stricture. Although this is the main cause of debate with open urethroplasty, the fact is that stenosis of the injured urethra does recur even in the most clean situation." Recently, Roehrborn and McConnell reported the results of different urethroplasty procedures for urethral stricture disease of various etiology during a period of 17 years.12 The poorest results were found in posttraumatic urethral strictures, with 45% excellent results, a 29% recurrence rate
70
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION TABLE2. Results of core through procedure in 79 cases with complete posttraumatic posterior urethral obstruction
No. with good or acceptable results (To) No. undergoing subsequent visual urethrotomy (%I: Once Twice 3 times No. visual urethrotomies done in 46 pts. (mean NoJpt.) Range an. of obstruction (mean): Before'
Group 1 Group 2 (68pts.) (11pts.) 8 38
ARert No. with stress incontinence (To) No. failures with complete obstruction
6 21 11 81
-
2.5 -7 1.5 -3 2 30
2.5 -5 1-3 2 3
2 6 22
Totals
46 (58.2)
6 23 17 103
(13) (50) (37) (2.2)
2.57 (4) 1 3 (2.5) 4 (8.7) 33 (41.8)
(B)i
* Assessed from the urethrogram.
t Assessed endoscopically following the resection. $ Patients underwent open urethroplasty.
TABLE3. Patients with posttraumatic impotence before and after late endoscopic treatment No.mota1 (%I Traumatic Impotence Before visual urethrotomy Before core throueh ARer endoscopy Total impotent pts. related
Group 1
Group 2
Totals
104/284(36.6) 25/33(75.8) 129/317(40.7) 28/68 (41.2) 10/11(91) 38/79 (48.1)
-
-
-
132/352(37.5) 35/44(79.51 167/396(42.2)
foreskin was effective in some difficult cases but the number of cases was few, the experience w a s limited a n d the efficacy of the procedure requires further eva1uati0n.l~Other methods using contact neodymium:YAG laser fibers show less efficient incision than t h e cold knife or electrocautery, with a recurrence rate of 67% within 1year.ls Although management of traumatic posterior urethral inj u r y is still challenging, certainly the number of urologists attaining a 96% success rate following 1-stage delayed urethroplasty with no need for further dilation or urethrotomy is few. l9 The final result depends on the initial assessment of the urethral injury in a multi-trauma patient without jeopardizing the hemodynamic status, long-term incidence of impotence, incontinence a n d the length of stricture. Endoscopic treatment is less traumatic and is cost-effective, with a short hospital s t a y in addition t o being feasible in cases of a short complete posterior urethral obstruction less than 2.5 cm. long. Also, it does not preclude an operation in case of failure. In conclusion, endoscopic treatment is recommended before various forms of urethroplasty are contemplated, particularly in the case of traumatic posterior urethral obstruction when the open procedures (in addition to t h e risk of recurrence) require special expertise a n d may be associated with the risk of impotence and/or incontinence. The complication rate for endoscopic management is low b u t recurrence is common. Therefore, early stenting a n d routine followup dilation are mandatory t o keep the urethra open.
tn trauma
REFERENCES
and a 27%failure rate. Also previous studies have noted that 57% a n d 66.6%of t h e patients required internal urethrotomy after perineal and transpubic urethroplasty, respectively.13, 14 Therefore, the technique of resecting the fibrotic tags occluding the urethral lumen with prolonged catheterization may permit rapid epithelialization of a wide caliber urethra, making subsequent treatment of recurrence simple and easy. Furthermore, blood transfusion was not required, and operative time a n d hospital stay were short (4 days), resulting i n good morbidity and cost-effectiveness. Following urethral injury, all patients had early or late urethral stricture and optical urethrotomy was done i n 80.7% of those initially treated with a suprapubic cystostomy tube compared to 75% after realignment. Among patients with a complete posterior urethral obliteration a combined endoscopic procedure was successful in 58.2%, achieving urethral continuity and urethral voiding. Although the recurrence rate was loo%, most of these procedures were done on a short stay basis with the use of local anesthesia. Therefore, endoscopic resection of the scar tissue helps to stabilize the urethral continuity and also downstage t h e degree of obstruction to be amenable for simple dilation or urethrotomy, with mild stress incontinence in 8.7% of the cases. An active followup of these patients is worthwhile and routine dilation is the accepted form of therapy. However, clean intermittent self-catheterization is now regarded a s a new form of intermittent dilation. The long-term result of this combination treatment was not significantly different from t h a t obtained after internal urethrotomy alone, with a 78% and 82% recurrence rate following the 2 methods, respectively.'" The use of a urethral endo-prosthesis following endoscopic incision of the blind end posterior urethra might be a good idea to keep t h e urethra patent until complete epithelialization occurs. Although long-term results are not available, the preliminary results are encouraging.I6 Also, endo-urethroplasty following resection of the scarred urethral segment and grafting of a free patch of full thickness
1. Patterson, D. E., Barrett, D. M., Myers, R. P., DeWeerd, J. H., Hall, B. B. and Benson, R. C., Jr.: Primary realignment of posterior urethral injuries. J. Urol., 129 513, 1983. 2. Webster, G. D. and Sihelnik, S.: The management of strictures of the membranous urethra. J. Urol., 134 469,1985. 3. Sacknoff, E. J. and Kerr, W. S., Jr.: Direct vision cold knife urethrotomy. J. Urol., 123 492, 1980. 4. Spirnak, J. P., Smith, E. M. and Elder, J. S.: Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation. J. Urol., 149: 766, 1993. 5. Leonard, M. P., Emtage, J.,Perez, R. and Moralis, A,:Endoscopic management of urethral stricture: k u t to the light" procedure. Urology, 3 5 117, 1990. 6. Marshall, F. F., Chang, R. and Gearhart, J. P.: Endoscopic reconstruction of traumatic membranous urethral transection. J. Urol., 138 306, 1987. 7. Webster, G. D., Mathes, G. L. 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.,Thijsen, A. and Radomski, S. B.: The value of immediate or early catheterization of the traumatized postenor urethra. J. Urol., 148 1428,1992. 9. Zincke, H. and Furlow, W. L.: Long-term results with transpubic urethroplasty. J. Urol., 133 605,1985. 10. Armenakas, N.A,,Lue, T.F.and McAninch, J. W.: Post-traumatic impotence: use of MRI and duplex ultrasound in diagnosis and management. J. Urol., part 2, 147: 368A, abstract 623,1992. 11. MeRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of repair. J. Urol., 104: 724,1970. 12. Roehrborn, C. G. and McConnell, J. D.: Analysis of factors contributing to success or failure of 1-stage urethroplasty for urethral stricture disease. J. Urol., 151: 869,1994. 13. Chiou, R. K.,Gonzalez, R., Ortlip, S. and Fraley, E. E.: Endoscopic treatment of posterior urethral obliteration: long-term followup and comparison with transpubic urethroplasty. J. Urol., 140 508,1988. 14. Husman, D. A.,Wilson, W.T.,Boone, T. B. and Allen, T. D.: Prostatomembranous urethral disruDtions: manaeement bv suprapubic cystostomy and delayed urethroplasty. J. Urol., 144 76,1990. Y
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION 15. Bgdker, A., Ostri, P., Rye-Andersen, J., Edvardsen, L. and Struckmann, J.: Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: a controlled study of a new therapy. J. Urol., 148 308, 1992. 16. Yachia, D. and Beyar, M.: The use of three types of self-expanding and self-retaining temporary coil stents in the treatment of recurrent strictures in various parts of the urethra. J . Urol., part 2,141:369A,abstract 628,1992.
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17. Chiou, R. K.:Endourethroplasty in the management of complicated posterior urethral strictures. J. Urol., 140 607,1988. 18. Smith, J . A.,Jr.: Treatment of benign urethral strictures using a sapphire tipped neodymium:YAG laser. J. Urol., 142: 1221, 1989. 19. Turner Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries-and from their surgical management. Urol. Clin. N.h e r . , 1 6 335,1989.
Vol. 153, 67-71, January 1995 Printed in U.S.A.
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION: EXPERIENCE IN 396 PATIENTS SHAWKY A. EL-ABD From the Department of Urology, Tanta University, Tanta, Egypt
ABSTRACT
Of 396 patients with posttraumatic posterior urethral strictures treated endoscopically during 10 years 352 had no vesical displacement (group 1) and 44 had marked displacement (group 2). Group 1patients were treated by suprapubic diversion and delayed optical urethrotomy. Exploration and railroad alignment to the urethra were done in group 2 and followup internal urethrotomy was performed in 33 patients. Eleven patients in group 2 and 68 in group 1 were considered failures due to complete short segment urethral obliteration. These 79 patients who failed initial visual urethrotomy underwent endoscopic resection of the stricture, that is core through optical urethrotomy. After 6 to 55 months (average 2 years) 46 patients (58.2%)were voiding satisfactorily (4 had stress incontinence). The 33 patients (41.8%)with failed minor or major endoscopic treatment due to persistent obstruction were treated with open urethroplasty. We conclude that posttraumatic posterior urethral obliteration can be treated by simple or major endoscopic techniques and that core through optical urethrotomy is a reasonable alternative to urethroplasty in patients with an impassable short stricture. KEY WORDS: urethral stricture, wounds and injuries, endoscopy, urinary catheterization Management of traumatic disruption of the posterior urethra has included primary realignment, primary cystostomy with delayed urethroplasty including scrota1 inlays, free grafts with bladder mucosa, full thickness skin grafts, transpubic repair and modified perineal repairs.', Traditionally, most patients were offered a major operation to establish urethral continuity and in some cases surgical repair in 2 or more stages was necessary. On the other hand, urethral strictures following incomplete urethral disruption have been treated with direct vision urethr~tomy.~ More recently, patients with urethral obliteration following complete rupture of the urethra or as a complication of reconstructive procedures were also treated endoscopically with internal urethrotomy, or with a thin trocar either from below the stricture or with the help of suprapubic light or instrum e n t a t i ~ n . ~Transurethral . ballon dilation andor resection of the fibrous and strictured urethra has also been used in some cases6 PATIENTS AND METHODS
Between 1982 and 1992, 396 patients with posttraumatic urethral obstruction underwent endoscopic management. The mechanism of injury was blunt pelvic and perineal trauma following automobile, industrial or pedestrian accidents. These patients were treated by 2 different methods immediately after the injury according to clinical and radiological evaluation, including retrograde urethrography and excretory urography. Group 1 consisted of 352 patients with no vesical injury or prostatic displacement who underwent suprapubic catheter drainage only. Group 2 included 44 patients who underwent suprapubic exploration and placement of a silicone urethral catheter into the bladder using interlocking sounds or a railroad technique. These patients were explored because of the presence of marked cranial displacement of the bladder and prostate into the sacral promontory, presence of vesical or bladder neck injury andor concomittent rectal injury that mandates abdominal exploration. In this group the urethral catheter was left indwelling for 4 Acce ted for publication May 27, 1994. Reaf at annual meeting of American Urological Association, San Antonio, Texas, May 15-20, 1993.
weeks and then removed to evaluate urethral voiding in the presence of the suprapubic tube. All patients in group 1 had difficulty or inability to void. Similar patients in group 2 with voiding problems after removal of the catheter or during followup underwent combined or retrograde urethrography to demonstrate the degree of bladder neck competence and predict the postoperative continence. This maneuver overestimated the length of obliteration, since it did not always delineate the posterior urethra completely. The most accurate method to estimate the length of the urethral defect is done intraoperatively by insertion of a curved urethral sound through the suprapubic tract into the prostatic urethra, and examining the anterior urethra by visual urethrotomy with concomitant gentle manipulation of the sound by an examining finger in the rectum. Digital rectal examination will demonstrate anal sphincter competence, somatic sacral reflex arc integrity and the level of the prostatic gland. Visual urethrotomy was done in 284 patients in group 1 and 33 in group 2 with a small lumen. A retrograde incision was performed at the 12 o'clock position and extended to the entire length of the stricture until normal proximal mucosa was encountered. The procedure was completed in the presence of a small ureteral catheter routinely placed into the strictured segment before incision. The urethral catheter was left indwelling for 1 to 3 weeks. Core through visual urethrotomy was performed in 79 patients in the explored and nonexplored groups with complete obliteration of the posterior urethra. The procedure was done under C-arm fluoroscopic guidance in 2 planes and in the presence of a suprapubic tube. Manipulation of a curved urethral sound through the suprapubic tract and transrectal palpation of the prostate will allow for transurethral incision towards the tip of the sound and, just before the end of the procedure, to the light of a suprapubic cystoscope. To identify the tip, the operator slightly twists the handle of the sound, wiggling the tip minimally with direct attention paid to the area. When the tip is identified it is held steady and either a ureteral catheter or guide wire is advanced in the direction of the opened proximal urethra until the catheter or guide wire reaches the bladder and is secured through the cystostomy 67
68
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION
tract. Once this guide is in place a wide generous urethrotomy is done and the irregularly floating tags of scar tissues that obscure clear direct vision in the urethral lumen are further excised with the resectoscope. This method will not compromise the integrity of the external sphincter more than it had been by the initial trauma. We usually insert an 18F silicone urethral Foley catheter without a guide wire or occasionally through the half-round sheath of the urethrotome. The procedure is done with antibiotic coverage and the patient usually is discharged from the hospital 2 to 8 days later (mean hospital stay 4 days). The urethral catheter is left indwelling for 4 to 6 weeks according to the length of the bare area noted at the end of the endoscopic procedure (in 1 patient the catheter was left for 16 weeks). Following this period the urethral catheter is removed and the suprapubic tube is closed for a few days before its removal to assist urethral voiding. After removal of the catheter all patients were advised to return sooner than 2 weeks if the stream deteriorated, at which time daily urethral dilation was performed followed by gradual weaning until routine weekly dilation with progressive doubling of the interval was followed. RESULTS
After coring a channel through the obstructed urethra under vision, 46 patients (58.2%) achieved satisfactory urethral voiding but at least 1 to 3 internal urethrotomies were required for a total of 103 times before the urethra became stabilized following this aggressive endoscopic treatment, that is a rate of 2.2 urethrotomies per patient (table 2). Bleeding requiring blood transfusion was not encountered in any patient. There were no intraoperative complications. Operative time ranged from 45 to 120 minutes (mean 70) and mean hospital stay was 4 days. In 33 patients (41.8%) the urethra was totally obliterated and during endoscopy we observed a more than 2.5 cm. gap with tough scar encasing the urogenital diaphragm preventing negotiation and stabilization of the urethra. These patients underwent open perineal excision and end-to-end urethroplasty, with inferior pubectomy in some. Urinalysis, subjective assessment of the voiding pattern, calibration of the urethra and ascending urethrography were performed to assess the results but flow rate determination was done in some patients. Clinical diminution in the force of the stream was an indication to start routine urethral dilation earlier but this was not followed in time regularly by most patients who underwent recurrent visual urethrotomy. All patients were followed twice in the department for at least 6 months and the majority for approximately 2 years (range 6 to 55 months). A longer followup is mandatory to evaluate the long-term results. No patient had dribbling incontinence after the endoscopic procedures. However, 4 of 46 patients (8.7%)had stress incontinence following core through visual urethrotomy in the presence of a normal bladder neck. One patient had incontinence after transurethral resection for benign enlargement of the prostate performed elsewhere 1.5 years after resection of the stricture. Impotence was noted in 132 patients (37.5%)treated by primary suprapubic cystostomy compared to 35 in the complicated group (79.5%) who underwent the railroad technique. Following injury,potent patients did not show deterioration after endoscopic treatment and have either adequate morning tumescence or vaginal penetration. Therefore, impotence was related to the trauma in 167 patients (42.2%) and none improved after minor or major endoscopic procedures (table 3).
The mechanisms of injury in group 1 patients undergoing suprapubic cystostomy and in complicated group 2 patients undergoing realignment were similar but the difference was in the seventy and associated injuries that mandate exploration in group 2. In the uncomplicated group visual urethrotomy was done 4 to 8 weeks (average 6) following trauma. During the study period the procedure was done once in 12 patients, twice in 98 and 3 times in 174 before satisfactory urethral continuity was achieved (table 1). Strictures recurred after single urethrotomy in 272 patients (95.8%). However, 284 of 352 patients (80.7%)eventually underwent successful simple optical urethrotomy. In the complicated group voiding was possible for a few months and in some cases for years but, unfortunately, late urethral obstruction recurred in all patients. Repeated simple optical urethrotomy for passable strictures at the membraneous urethra was eventually successful in 33 patients (75%) but in 23 (69.7%) retreatment was mandatory due to recurrent obstruction (fig. 1). The rate of visual urethrotomy per patient was 2.6 in group 1 compared to 1.8 in group 2 who underwent initial realignment. DISCUSSION A core through procedure was done in 68 uncomplicated In no area of urology does controversy exist more than in and 11 complicated cases previously treated with realignment (fig. 2) because the obliteration in the posterior urethra the management of posterior urethral injury, with a dichotwas too complete to permit passage of a urethral catheter and omy of opinion making comparisons between different series simple visual urethrotomy. The procedure was done in the difficult. Analysis of the outcome in 15 series of patients presence of a suprapubic tube and the defect in the urethral treated by immediate realignment over a splinting catheter lumen detected intraoperatively was 1 to 3 cm. (mean 2.5 has shown that strictures recurred in 69%,impotence in 44% compared to a mean defect of 4 cm. on the urethrogram). and incontinence in 20%.7Sender et a1 found a 41.6%rate of impotence after catheterization only, and on reviewing many series for 2 types of management (mainly by suprapubic cystostomy alone with delayed urethroplasty versus immediTABLE1. Results of visual urethrotomy following traumatic ate realignment) they reported a 30.3% mean incidence of posterior urethral injury impotence in group 1 compared to 36% in group 2.8 On the other hand Zincke and Furlow observed a 33.3%incidence of Type of Injury Uncomplicated- ComplicatedInitial Management Suprapubic Exploration Totals impotence in already potent patients after open urethroplasCatheter and Railroad ty.9 No cases 352 44 396 ___ When we based our initial management according to the No. visual urethrotomy (%): severity of trauma by suprapubic cystostomy versus immeOnce 12 (3.4) 10 (22.7) 22/317 (7) Twice 98 (27.8) 20 (45.5) 118 (37.2) diate realignment, the incidence of impotence was 37.5%and 3 times 174 (49.4) 3 (6.8) 177 (55.8) 79.5%in both groups. Although the final management in all No. visual urethrotomiedpt. 2.6 1.8 2.5 patients was by endoscopic procedures, impotence related to No. good or acceptable 284 (80.7) 33 (75) 317 (80.1) treatment was not observed and none of the impotent paresults (%I* tients improved later, which supports the observation that No. failures (Q)t 68 (19.3) 11 (25) 79 (19.9) * Patient with good stream, continent and without further urethrotomy or the incidence of impotence is significantly related t o the degree of trauma. Armenakas et a1 clearly documented that dilation. f Patients underwent a core through procedure this type of severe pelvic trauma, which disrupts the perineal ~~
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION
69
FIG. 1. A, ascending urethrogram shows posttraumatic complete posterior urethral injury. B , Ivp in same patient reveals marked displacement of bladder. C, ascending urethrogram 4 years aRer trauma and 3 optical urethrotomies following exploration and realignment procedure.
FIG. 2. A, combined urethrogram in case of complicated posttraumatic urethrorectal fistula (distal arrows) with vesical urinary diversion after failed open repair (proximal arrow). B , voiding cystourethrography after core through urethrotomy and urethral stent placement for 16 weeks with well delineated patent nonfistulous posterior urethra (arrows).
ligaments and muscles, will also cause extensive damage to the neurovascular pathways regulating erection, leading to vasculogenic impotence in 86.7% and neurogenic impotence in 13.3%of the cases." We reserved immediate surgical intervention with realignment, as did others: for the complicated cases with a high riding prostate because of the subsequent lengthy strictures with malalignment, making endoscopic procedures impossible and definitive substitution difficult. The idea of realignment without prostatic traction will avoid urethral angulation and compromise of the proximal continent mechanism. At the same time, it provides a guided descent during hematoma resorption, with subsequent easier and less traumatic endoscopic management. This would be reflected in minimal morbidity rates, and satisfactory functional and anatomical results. The optimal time for endoscopic treatment following urethral trauma was approximately 6 weeks, which allows time for the hematoma to shrink without significant scarring although the procedure can be done a t any late stage. These procedures are not difficult technically but no doubt for correct realignment sufficient experience is necessary. In these cases many auxilliary procedures for orientation are helpful,
and the incision to the light procedure is helpful for short strictures and just before the end of incising a long stricture when the upper and lower cystoscopes are seen overlapping in the C-arm unit without direct communication in the field of vision. An observation worth mentioning is that radiographic studies usually overestimate the actual length of urethral obliteration, making the decision for endoscopic management a remote possibility. After section andor resection of the scar tissue, the actual defect in the urethra was much less than that previously expected depending solely on urethrography . It may be argued that endourological management may jeopardize the process of epithelialization resulting in creation of a lumen within the fibrotic encasement, with a possibility of recurrent stricture. Although this is the main cause of debate with open urethroplasty, the fact is that stenosis of the injured urethra does recur even in the most clean situation." Recently, Roehrborn and McConnell reported the results of different urethroplasty procedures for urethral stricture disease of various etiology during a period of 17 years.12 The poorest results were found in posttraumatic urethral strictures, with 45% excellent results, a 29% recurrence rate
70
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION TABLE2. Results of core through procedure in 79 cases with complete posttraumatic posterior urethral obstruction
No. with good or acceptable results (To) No. undergoing subsequent visual urethrotomy (%I: Once Twice 3 times No. visual urethrotomies done in 46 pts. (mean NoJpt.) Range an. of obstruction (mean): Before'
Group 1 Group 2 (68pts.) (11pts.) 8 38
ARert No. with stress incontinence (To) No. failures with complete obstruction
6 21 11 81
-
2.5 -7 1.5 -3 2 30
2.5 -5 1-3 2 3
2 6 22
Totals
46 (58.2)
6 23 17 103
(13) (50) (37) (2.2)
2.57 (4) 1 3 (2.5) 4 (8.7) 33 (41.8)
(B)i
* Assessed from the urethrogram.
t Assessed endoscopically following the resection. $ Patients underwent open urethroplasty.
TABLE3. Patients with posttraumatic impotence before and after late endoscopic treatment No.mota1 (%I Traumatic Impotence Before visual urethrotomy Before core throueh ARer endoscopy Total impotent pts. related
Group 1
Group 2
Totals
104/284(36.6) 25/33(75.8) 129/317(40.7) 28/68 (41.2) 10/11(91) 38/79 (48.1)
-
-
-
132/352(37.5) 35/44(79.51 167/396(42.2)
foreskin was effective in some difficult cases but the number of cases was few, the experience w a s limited a n d the efficacy of the procedure requires further eva1uati0n.l~Other methods using contact neodymium:YAG laser fibers show less efficient incision than t h e cold knife or electrocautery, with a recurrence rate of 67% within 1year.ls Although management of traumatic posterior urethral inj u r y is still challenging, certainly the number of urologists attaining a 96% success rate following 1-stage delayed urethroplasty with no need for further dilation or urethrotomy is few. l9 The final result depends on the initial assessment of the urethral injury in a multi-trauma patient without jeopardizing the hemodynamic status, long-term incidence of impotence, incontinence a n d the length of stricture. Endoscopic treatment is less traumatic and is cost-effective, with a short hospital s t a y in addition t o being feasible in cases of a short complete posterior urethral obstruction less than 2.5 cm. long. Also, it does not preclude an operation in case of failure. In conclusion, endoscopic treatment is recommended before various forms of urethroplasty are contemplated, particularly in the case of traumatic posterior urethral obstruction when the open procedures (in addition to t h e risk of recurrence) require special expertise a n d may be associated with the risk of impotence and/or incontinence. The complication rate for endoscopic management is low b u t recurrence is common. Therefore, early stenting a n d routine followup dilation are mandatory t o keep the urethra open.
tn trauma
REFERENCES
and a 27%failure rate. Also previous studies have noted that 57% a n d 66.6%of t h e patients required internal urethrotomy after perineal and transpubic urethroplasty, respectively.13, 14 Therefore, the technique of resecting the fibrotic tags occluding the urethral lumen with prolonged catheterization may permit rapid epithelialization of a wide caliber urethra, making subsequent treatment of recurrence simple and easy. Furthermore, blood transfusion was not required, and operative time a n d hospital stay were short (4 days), resulting i n good morbidity and cost-effectiveness. Following urethral injury, all patients had early or late urethral stricture and optical urethrotomy was done i n 80.7% of those initially treated with a suprapubic cystostomy tube compared to 75% after realignment. Among patients with a complete posterior urethral obliteration a combined endoscopic procedure was successful in 58.2%, achieving urethral continuity and urethral voiding. Although the recurrence rate was loo%, most of these procedures were done on a short stay basis with the use of local anesthesia. Therefore, endoscopic resection of the scar tissue helps to stabilize the urethral continuity and also downstage t h e degree of obstruction to be amenable for simple dilation or urethrotomy, with mild stress incontinence in 8.7% of the cases. An active followup of these patients is worthwhile and routine dilation is the accepted form of therapy. However, clean intermittent self-catheterization is now regarded a s a new form of intermittent dilation. The long-term result of this combination treatment was not significantly different from t h a t obtained after internal urethrotomy alone, with a 78% and 82% recurrence rate following the 2 methods, respectively.'" The use of a urethral endo-prosthesis following endoscopic incision of the blind end posterior urethra might be a good idea to keep t h e urethra patent until complete epithelialization occurs. Although long-term results are not available, the preliminary results are encouraging.I6 Also, endo-urethroplasty following resection of the scarred urethral segment and grafting of a free patch of full thickness
1. Patterson, D. E., Barrett, D. M., Myers, R. P., DeWeerd, J. H., Hall, B. B. and Benson, R. C., Jr.: Primary realignment of posterior urethral injuries. J. Urol., 129 513, 1983. 2. Webster, G. D. and Sihelnik, S.: The management of strictures of the membranous urethra. J. Urol., 134 469,1985. 3. Sacknoff, E. J. and Kerr, W. S., Jr.: Direct vision cold knife urethrotomy. J. Urol., 123 492, 1980. 4. Spirnak, J. P., Smith, E. M. and Elder, J. S.: Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation. J. Urol., 149: 766, 1993. 5. Leonard, M. P., Emtage, J.,Perez, R. and Moralis, A,:Endoscopic management of urethral stricture: k u t to the light" procedure. Urology, 3 5 117, 1990. 6. Marshall, F. F., Chang, R. and Gearhart, J. P.: Endoscopic reconstruction of traumatic membranous urethral transection. J. Urol., 138 306, 1987. 7. Webster, G. D., Mathes, G. L. 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.,Thijsen, A. and Radomski, S. B.: The value of immediate or early catheterization of the traumatized postenor urethra. J. Urol., 148 1428,1992. 9. Zincke, H. and Furlow, W. L.: Long-term results with transpubic urethroplasty. J. Urol., 133 605,1985. 10. Armenakas, N.A,,Lue, T.F.and McAninch, J. W.: Post-traumatic impotence: use of MRI and duplex ultrasound in diagnosis and management. J. Urol., part 2, 147: 368A, abstract 623,1992. 11. MeRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of repair. J. Urol., 104: 724,1970. 12. Roehrborn, C. G. and McConnell, J. D.: Analysis of factors contributing to success or failure of 1-stage urethroplasty for urethral stricture disease. J. Urol., 151: 869,1994. 13. Chiou, R. K.,Gonzalez, R., Ortlip, S. and Fraley, E. E.: Endoscopic treatment of posterior urethral obliteration: long-term followup and comparison with transpubic urethroplasty. J. Urol., 140 508,1988. 14. Husman, D. A.,Wilson, W.T.,Boone, T. B. and Allen, T. D.: Prostatomembranous urethral disruDtions: manaeement bv suprapubic cystostomy and delayed urethroplasty. J. Urol., 144 76,1990. Y
ENDOSCOPIC TREATMENT OF POSTTRAUMATIC URETHRAL OBLITERATION 15. Bgdker, A., Ostri, P., Rye-Andersen, J., Edvardsen, L. and Struckmann, J.: Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: a controlled study of a new therapy. J. Urol., 148 308, 1992. 16. Yachia, D. and Beyar, M.: The use of three types of self-expanding and self-retaining temporary coil stents in the treatment of recurrent strictures in various parts of the urethra. J . Urol., part 2,141:369A,abstract 628,1992.
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17. Chiou, R. K.:Endourethroplasty in the management of complicated posterior urethral strictures. J. Urol., 140 607,1988. 18. Smith, J . A.,Jr.: Treatment of benign urethral strictures using a sapphire tipped neodymium:YAG laser. J. Urol., 142: 1221, 1989. 19. Turner Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries-and from their surgical management. Urol. Clin. N.h e r . , 1 6 335,1989.