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The Glidewire Technique for Overcoming Urethral Obstruction
0022-5347/96/1561-0164$03.00/0
Vol. 156, 164-165, July 1996 Printed in U.S.A.
THE JOURNAL OF UROIQGY
Copyright 0 1996 by AMERICANUROL~CICAL. ASSOCIATION, INC
THE GLIDEWIRE TECHNIQUE FOR OVERCOMING URETHRAL OBSTRUCTION RUSSELL M. FREID AND ARTHUR D. SMITH From the Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York
ABSTRACT
Purpose: Using the hydrophilic Terumo Glidewire* we developed a less traumatic, yet effective alternative method to filiforms and followers for cases of urethral obstruction. Materials and Methods: The initial step and cornerstone of our method is the passage of the Glidewire per urethra in a manner similar to a filiform. After the appropriate intravesical location of the Glidewire is confirmed using a ureteral catheter, it is exchanged for a standard polytetrafluoroethylene (Teflon) coated guide wire. Urethral dilation and/or catheter placement is then performed. Results: This technique was successful in 19 of 20 attempts, several of which followed unsuccessful passage of filliform catheters. Urethral obstruction due to strictures, bladder neck contractures and benign prostatic hyperplasia in our group was treated effectively. Furthermore, no complications occurred due to the technique. Conclusions: The Glidewire method is safe and effective for treating most cases of urethral obstruction. Therefore, we recommend this technique over standard filiforms and followers when flexible or rigid cystourethroscopy is not immediately available. KEY WORDS:urethral obstruction, surgical instruments
A frequent reason for urological consultation is inability to pass a Foley catheter. Filiforms and followers are often successful in achieving catheter drainage but they are far from ideal and are a potential cause of urethral trauma. Beaghler et a1 demonstrated a high degree of safety and efficacy using flexible cystoscopy under these circumstances.l However, despite its appeal flexible cystoscopy is not always feasible. We devised an alternative technique using the Glidewire, which achieves catheter drainage safely and effectively. Therefore, we recommend using this technique unless direct visualization urethroscopy is immediately available. The necessary guide wires and catheters should be readily available in all cystoscopy suites (see figure). TECHNIQUE
The patient is prepared and draped for catheter insertion with a n additional sterile drape over the lower extremities to Urethral access technique requires 0,038-inch Glidewire, 7F ureprovide a larger field, minimizing the chance for contamina- teral catheter, 0,038-inch polytetrafluoroethylene coated guide wire, tion of guide wires or catheters. The Glidewire (preferably 18F Graham (or Councill) Foley catheter, lidocaine jelly and sterile with an angled or floppy tip) is prepared by injecting 5 cc saline. sterile saline through the syringe port of the holder, thus activating the hydrophilic coating. After injecting lidocaine jelly, the Glidewire is introduced per urethra and advanced meatus. Since this length is double that of a standard Foley with a gentle steady pressure using a gauze pad to aid in grasping it. When resistance is felt the Glidewire is still catheter (approximately 40 cm.) a long portion of Glidewire advanced until it seems to have overcome the obstruction and remains in the bladder for safety and it is extremely unlikely entered the bladder or has doubled back and the tip appears that the bladder has not been reached. An open ended ureteral catheter (preferably 7F with a tapered tip) is advanced at the meatus. In the latter situation the entire Glidewire is withdrawn and reintroduced. When resistance is again felt over the Glidewire while maintaining tension on the free end the Glidewire is advanced and withdrawn in an alternating of the wire. The catheter is advanced to 60 cm. leaving 10 cm. fashion similar to a filiform until passage is achieved. Suc- protruding a t the meatus. At this point, the Glidewire is cess will typically be obtained rapidly so that persistence removed and urine dripping from the ureteral catheter confirms proper positioning. Occasionally the catheter may need usually is not warranted. Entry into the bladder can be inferred by passage of ap- to be pulled back 5 to 10 cm. to undo a kink within the proximately half the length (150 cm.) of the Glidewire into bladder and allow urine flow. If this does not work we irrigate the urethra without reappearance of the tip or a coil at the the apparatus with 20 cc sterile saline to eliminate lidocaine jelly or sediment from the catheter lumen as a source of obstruction. The procedure was completed successfully in all Accepted for publication January 26, 1996. * Microvasive, Watertown, Massachusetts. of our patients in whom a ureteral catheter was passed. 164
GLIDEWIRE TECHNIQUE FOR OVERCOMING URETHRAL OBSTRUCTION
Once the intravesical location of the catheter tip is confirmed a standard 0.038-inch polytetrafluoroethylene coated guide wire (145 cm.) is advanced through the ureteral catheter until half its length has been introduced. At this point excellent transurethral bladder access has been obtained and a variety of techniques can be used to dilate the urethra, if necessary, and pass a catheter. Our preference is to pass a n 18F Graham catheter directly over the ureteral catheterguide wire unit. This catheter has a central lumen larger than that of a Councill Foley catheter, and it easily accommodates the 7F ureteral catheter. Furthermore, the catheter is constructed of a more rigid material, allowing it to pass through most obstructions and performance of simultaneous dilation. The ureteral catheter-guide wire unit is stiff and, therefore, resists kinking. Alternatively, one may proceed with dilation of the urethra followed by catheter placement. Any of the currently available urethral dilators may be passed sequentially over the standard guide wire. However, one must keep in mind the potential complications that may result from overzealous dilation. Therefore, we recommend dilating only to 16 or 18F and then inserting a 16F Councill catheter. RESULTS
Our technique has been successful in 19 of 20 attempts to date. The etiology for urethral obstruction was urethral stricture in 8 patients, bladder neck contracture in 7, benign prostatic hyperplasia in 3 and unknown in 2. There were no complications due to the technique.
165
DISCUSSION
We devised a safe and effective alternative method to filiforms and followers when obtaining urethral access in difficult cases. The Glidewire was a logical choice for our technique. On numerous occasions it has proved able to pass even the most narrow and tortuous lumens of obstructed ureters. Our initial few attempts with this Glidewire technique were done after failed attempts with filiforms and followers, and successful passage was achieved rapidly in each case. In subsequent cases we initially used the Glidewire technique and no longer used filiforms and followers. To date the technique has been safe and reliable with only 1 failure in a patient who subsequently underwent cystourethroscopy and internal urethrotomy for a pinhole urethral stricture. CONCLUSIONS
Our technique has been effective in overcoming urethral obstruction from stricture disease, bladder neck contractures and benign prostatic hyperplasia. Furthermore, the safety and efficacy are superior to filiforms and followers. Therefore, we recommend this technique instead of filiforms and followers when significant urethral obstruction is encountered and cystoscopy is not immediately available. REFERENCE
1. Beaghler, M.,Grasso, M., I11 and Loisides, P.: Inability to pass a urethral catheter: the bedside role of the flexible cystoscope. Urology, 44:268, 1994.
Vol. 156, 164-165, July 1996 Printed in U.S.A.
THE JOURNAL OF UROIQGY
Copyright 0 1996 by AMERICANUROL~CICAL. ASSOCIATION, INC
THE GLIDEWIRE TECHNIQUE FOR OVERCOMING URETHRAL OBSTRUCTION RUSSELL M. FREID AND ARTHUR D. SMITH From the Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York
ABSTRACT
Purpose: Using the hydrophilic Terumo Glidewire* we developed a less traumatic, yet effective alternative method to filiforms and followers for cases of urethral obstruction. Materials and Methods: The initial step and cornerstone of our method is the passage of the Glidewire per urethra in a manner similar to a filiform. After the appropriate intravesical location of the Glidewire is confirmed using a ureteral catheter, it is exchanged for a standard polytetrafluoroethylene (Teflon) coated guide wire. Urethral dilation and/or catheter placement is then performed. Results: This technique was successful in 19 of 20 attempts, several of which followed unsuccessful passage of filliform catheters. Urethral obstruction due to strictures, bladder neck contractures and benign prostatic hyperplasia in our group was treated effectively. Furthermore, no complications occurred due to the technique. Conclusions: The Glidewire method is safe and effective for treating most cases of urethral obstruction. Therefore, we recommend this technique over standard filiforms and followers when flexible or rigid cystourethroscopy is not immediately available. KEY WORDS:urethral obstruction, surgical instruments
A frequent reason for urological consultation is inability to pass a Foley catheter. Filiforms and followers are often successful in achieving catheter drainage but they are far from ideal and are a potential cause of urethral trauma. Beaghler et a1 demonstrated a high degree of safety and efficacy using flexible cystoscopy under these circumstances.l However, despite its appeal flexible cystoscopy is not always feasible. We devised an alternative technique using the Glidewire, which achieves catheter drainage safely and effectively. Therefore, we recommend using this technique unless direct visualization urethroscopy is immediately available. The necessary guide wires and catheters should be readily available in all cystoscopy suites (see figure). TECHNIQUE
The patient is prepared and draped for catheter insertion with a n additional sterile drape over the lower extremities to Urethral access technique requires 0,038-inch Glidewire, 7F ureprovide a larger field, minimizing the chance for contamina- teral catheter, 0,038-inch polytetrafluoroethylene coated guide wire, tion of guide wires or catheters. The Glidewire (preferably 18F Graham (or Councill) Foley catheter, lidocaine jelly and sterile with an angled or floppy tip) is prepared by injecting 5 cc saline. sterile saline through the syringe port of the holder, thus activating the hydrophilic coating. After injecting lidocaine jelly, the Glidewire is introduced per urethra and advanced meatus. Since this length is double that of a standard Foley with a gentle steady pressure using a gauze pad to aid in grasping it. When resistance is felt the Glidewire is still catheter (approximately 40 cm.) a long portion of Glidewire advanced until it seems to have overcome the obstruction and remains in the bladder for safety and it is extremely unlikely entered the bladder or has doubled back and the tip appears that the bladder has not been reached. An open ended ureteral catheter (preferably 7F with a tapered tip) is advanced at the meatus. In the latter situation the entire Glidewire is withdrawn and reintroduced. When resistance is again felt over the Glidewire while maintaining tension on the free end the Glidewire is advanced and withdrawn in an alternating of the wire. The catheter is advanced to 60 cm. leaving 10 cm. fashion similar to a filiform until passage is achieved. Suc- protruding a t the meatus. At this point, the Glidewire is cess will typically be obtained rapidly so that persistence removed and urine dripping from the ureteral catheter confirms proper positioning. Occasionally the catheter may need usually is not warranted. Entry into the bladder can be inferred by passage of ap- to be pulled back 5 to 10 cm. to undo a kink within the proximately half the length (150 cm.) of the Glidewire into bladder and allow urine flow. If this does not work we irrigate the urethra without reappearance of the tip or a coil at the the apparatus with 20 cc sterile saline to eliminate lidocaine jelly or sediment from the catheter lumen as a source of obstruction. The procedure was completed successfully in all Accepted for publication January 26, 1996. * Microvasive, Watertown, Massachusetts. of our patients in whom a ureteral catheter was passed. 164
GLIDEWIRE TECHNIQUE FOR OVERCOMING URETHRAL OBSTRUCTION
Once the intravesical location of the catheter tip is confirmed a standard 0.038-inch polytetrafluoroethylene coated guide wire (145 cm.) is advanced through the ureteral catheter until half its length has been introduced. At this point excellent transurethral bladder access has been obtained and a variety of techniques can be used to dilate the urethra, if necessary, and pass a catheter. Our preference is to pass a n 18F Graham catheter directly over the ureteral catheterguide wire unit. This catheter has a central lumen larger than that of a Councill Foley catheter, and it easily accommodates the 7F ureteral catheter. Furthermore, the catheter is constructed of a more rigid material, allowing it to pass through most obstructions and performance of simultaneous dilation. The ureteral catheter-guide wire unit is stiff and, therefore, resists kinking. Alternatively, one may proceed with dilation of the urethra followed by catheter placement. Any of the currently available urethral dilators may be passed sequentially over the standard guide wire. However, one must keep in mind the potential complications that may result from overzealous dilation. Therefore, we recommend dilating only to 16 or 18F and then inserting a 16F Councill catheter. RESULTS
Our technique has been successful in 19 of 20 attempts to date. The etiology for urethral obstruction was urethral stricture in 8 patients, bladder neck contracture in 7, benign prostatic hyperplasia in 3 and unknown in 2. There were no complications due to the technique.
165
DISCUSSION
We devised a safe and effective alternative method to filiforms and followers when obtaining urethral access in difficult cases. The Glidewire was a logical choice for our technique. On numerous occasions it has proved able to pass even the most narrow and tortuous lumens of obstructed ureters. Our initial few attempts with this Glidewire technique were done after failed attempts with filiforms and followers, and successful passage was achieved rapidly in each case. In subsequent cases we initially used the Glidewire technique and no longer used filiforms and followers. To date the technique has been safe and reliable with only 1 failure in a patient who subsequently underwent cystourethroscopy and internal urethrotomy for a pinhole urethral stricture. CONCLUSIONS
Our technique has been effective in overcoming urethral obstruction from stricture disease, bladder neck contractures and benign prostatic hyperplasia. Furthermore, the safety and efficacy are superior to filiforms and followers. Therefore, we recommend this technique instead of filiforms and followers when significant urethral obstruction is encountered and cystoscopy is not immediately available. REFERENCE
1. Beaghler, M.,Grasso, M., I11 and Loisides, P.: Inability to pass a urethral catheter: the bedside role of the flexible cystoscope. Urology, 44:268, 1994.