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Re: Long-Term Results of Early Endoscopic Realignment of Complete Posterior Urethral Disruption
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
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dissatisfied with the postoperative length. Although manual modeling was performed in the majority of these patients, we have not found this maneuver to be helpful. Allen F. Morey, M.D. 1. Dugi DD III and Morey AF: Penoscrotal plication as a uniform approach to reconstruction of penile curvature. BJU Int 2010; 105: 1440.
Re: Long-Term Results of Early Endoscopic Realignment of Complete Posterior Urethral Disruption M. Sofer, N. J. Mabjeesh, J. Ben-Chaim, G. Aviram, Y. Bar-Yosef, H. Matzkin and I. Kaver Endourology Service, Tel Aviv Sourasky Medical Center and Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel J Endourol 2010; 24: 1117–1121.
Purpose: To assess the long-term outcome of early endoscopic realignment (EER) of complete posterior urethral disruption. Patients and methods: The study included 11 consecutive patients with complete posterior urethral disruption secondary to a road accident (n ⫽ 9) or a falling impact (n ⫽ 2). EER was performed using a simultaneous endoscopic transvesical and transurethral approach under fluoroscopic guidance. An 18F Foley urethral catheter was left for 4 weeks. All patients were evaluated postoperatively for incontinence, erectile dysfunction, and urethral strictures. Results: The patients’ mean age was 32 years (range 20 – 62 y). The mean duration of the realignment procedure was 40 minutes (range 30 – 60 min), and it was performed within an average of 48 hours (range 3–72 h) from hospitalization. Efficient erection was maintained in five (45%) patients, and incontinence did not develop in any patient. Five (45%) patients in whom urethral strictures developed were treated initially by endoscopic urethrotomy (EU), which was successful in one patient. Three of the four in the EU failure group remained on periodic urethral dilation, refusing to undergo urethroplasty, and one patient with interposition of a pubic bone fragment underwent successful urethroplasty. There were no other complications during a mean follow-up of 4.3 years (range 2–7 y). Conclusions: EER is a valuable alternative to long-term suprapubic drainage and delayed urethroplasty. Realignment failure did not interfere with the results of open urethroplasty. A further search for prognostic factors should improve the selection of patients for the early or the delayed approach. Editorial Comment: As endourological advances have revolutionized our specialty in the last 3 decades, it is informative to consider the experience of this Israeli group with EER of complete posterior urethral disruption injuries. These procedures were conducted an average of 48 hours after presentation, using flexible cystoscopes above and below the defect to pass an 18Fr Council catheter (average time 40 minutes). Five of the 11 patients (45%) had strictures that required an array of interventions beyond periodic urethral dilation, and the fate of the 6 remaining patients is not specifically reported. I continue to reject the strategy of EER for posterior urethral disruptions—I cannot think of any other urological procedure that I would offer a patient carrying a failure rate as high as 45%. Furthermore, having dealt with literally hundreds of men who have been self-catheterizing or otherwise undergoing periodic urethral dilations after this kind of intervention through the years I can state that they do not enjoy these activities at all. I have yet to hear one tell me that he wished he had not undergone urethral reconstruction, longing instead for the good old days of periodic urethral dilation. Allen F. Morey, M.D.
167
dissatisfied with the postoperative length. Although manual modeling was performed in the majority of these patients, we have not found this maneuver to be helpful. Allen F. Morey, M.D. 1. Dugi DD III and Morey AF: Penoscrotal plication as a uniform approach to reconstruction of penile curvature. BJU Int 2010; 105: 1440.
Re: Long-Term Results of Early Endoscopic Realignment of Complete Posterior Urethral Disruption M. Sofer, N. J. Mabjeesh, J. Ben-Chaim, G. Aviram, Y. Bar-Yosef, H. Matzkin and I. Kaver Endourology Service, Tel Aviv Sourasky Medical Center and Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel J Endourol 2010; 24: 1117–1121.
Purpose: To assess the long-term outcome of early endoscopic realignment (EER) of complete posterior urethral disruption. Patients and methods: The study included 11 consecutive patients with complete posterior urethral disruption secondary to a road accident (n ⫽ 9) or a falling impact (n ⫽ 2). EER was performed using a simultaneous endoscopic transvesical and transurethral approach under fluoroscopic guidance. An 18F Foley urethral catheter was left for 4 weeks. All patients were evaluated postoperatively for incontinence, erectile dysfunction, and urethral strictures. Results: The patients’ mean age was 32 years (range 20 – 62 y). The mean duration of the realignment procedure was 40 minutes (range 30 – 60 min), and it was performed within an average of 48 hours (range 3–72 h) from hospitalization. Efficient erection was maintained in five (45%) patients, and incontinence did not develop in any patient. Five (45%) patients in whom urethral strictures developed were treated initially by endoscopic urethrotomy (EU), which was successful in one patient. Three of the four in the EU failure group remained on periodic urethral dilation, refusing to undergo urethroplasty, and one patient with interposition of a pubic bone fragment underwent successful urethroplasty. There were no other complications during a mean follow-up of 4.3 years (range 2–7 y). Conclusions: EER is a valuable alternative to long-term suprapubic drainage and delayed urethroplasty. Realignment failure did not interfere with the results of open urethroplasty. A further search for prognostic factors should improve the selection of patients for the early or the delayed approach. Editorial Comment: As endourological advances have revolutionized our specialty in the last 3 decades, it is informative to consider the experience of this Israeli group with EER of complete posterior urethral disruption injuries. These procedures were conducted an average of 48 hours after presentation, using flexible cystoscopes above and below the defect to pass an 18Fr Council catheter (average time 40 minutes). Five of the 11 patients (45%) had strictures that required an array of interventions beyond periodic urethral dilation, and the fate of the 6 remaining patients is not specifically reported. I continue to reject the strategy of EER for posterior urethral disruptions—I cannot think of any other urological procedure that I would offer a patient carrying a failure rate as high as 45%. Furthermore, having dealt with literally hundreds of men who have been self-catheterizing or otherwise undergoing periodic urethral dilations after this kind of intervention through the years I can state that they do not enjoy these activities at all. I have yet to hear one tell me that he wished he had not undergone urethral reconstruction, longing instead for the good old days of periodic urethral dilation. Allen F. Morey, M.D.