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Ureteroscope in managing difficult urethral problems
URETEROSCOPE DIFFICULT LARRY
URETHRAL
C. MUNCH,
LEONARD BRUCE
IN MANAGING
M.D.
G. GOMELLA,
A. LUCAS,
PROBLEMS
M.D.
M.D.
From the Department of Surgery, Division of Urology, University of Kentucky Medical Center, Lexington, Kentucky
Management of urethra1 problems encountered under local anesthesia with previously available urologie instrumentation can be difficult. With recent additions to the urologie armamentarium, especially the ureteroscope, some of these problems may be more easily managed in a single stage procedure without the use of regional or genera1 anesthesia. A fifty-four-year-old man with a long history of urethra1 stricture disease in the past refused any surgical intervention. He had been managed with a chronic suprapubic catheter. He presented to our clinic with fever, malaise, pyuria, and drainage from a scrotal fistula. A cystogram through the suprapubic catheter demonstrated a urethrocutaneous fistula (Fig. 1, open arrow). To better evaluate this finding, the patient was taken to the cystoscopy suite for urethroscopy under local anesthesia. Because of panurethral stricture disease, standard panendoscopes would not pass through the lumen. A 12-F pediatrie panendoscope was carefully passed, but on entering the bulbous urethra encountered multiple obstructing calculi, (Fig. 1, solid arrow). The pediatrie alligator forceps passed through the scope did not open sufficiently to grasp the calculi, and other forceps or baskets would not pass either within or alongside the sheath. The Wolf ureteroscope has an 11.5-F sheath with a larger working Channel than a 12-F peThere are many availdiatric panendoscope. able baskets and grasping forceps designed for use with the Wolf instrument. Stone extraction was attempted through the ureteroscope. A three-prong grasping forceps and four-wire helical basket were used to easily extract the
UROI,OCY
/ NOVEMBER
1988
/
VOLUME
FIGURE 1.
Cystogram
demonstrating
urethrocuta-
neous fistula. multiple urethra1 calculi under direct vision. After stone removal, the ureteroscope was successfully advanced to the proximal bulbous urethra where the origin of the fistula was confirmed with the injection of methylene blue into the scrotal sinus. NO evidente of periurethral abscess was detected, and the patient was returned to his room. NO additional anesthesia was required, and the procedure was wel1 tolerated. With accurate definition of the problem, appropriate treatment could be instituted. This unusual application of the ureteroscope for urethra1 surgery made diagnosis and treatment of this patient possible under local anesthesia.
XXXII,NUMBER 5
Lexington,
Kentucky 40536 (DR. MUNCH)
451
URETHRAL
C. MUNCH,
LEONARD BRUCE
IN MANAGING
M.D.
G. GOMELLA,
A. LUCAS,
PROBLEMS
M.D.
M.D.
From the Department of Surgery, Division of Urology, University of Kentucky Medical Center, Lexington, Kentucky
Management of urethra1 problems encountered under local anesthesia with previously available urologie instrumentation can be difficult. With recent additions to the urologie armamentarium, especially the ureteroscope, some of these problems may be more easily managed in a single stage procedure without the use of regional or genera1 anesthesia. A fifty-four-year-old man with a long history of urethra1 stricture disease in the past refused any surgical intervention. He had been managed with a chronic suprapubic catheter. He presented to our clinic with fever, malaise, pyuria, and drainage from a scrotal fistula. A cystogram through the suprapubic catheter demonstrated a urethrocutaneous fistula (Fig. 1, open arrow). To better evaluate this finding, the patient was taken to the cystoscopy suite for urethroscopy under local anesthesia. Because of panurethral stricture disease, standard panendoscopes would not pass through the lumen. A 12-F pediatrie panendoscope was carefully passed, but on entering the bulbous urethra encountered multiple obstructing calculi, (Fig. 1, solid arrow). The pediatrie alligator forceps passed through the scope did not open sufficiently to grasp the calculi, and other forceps or baskets would not pass either within or alongside the sheath. The Wolf ureteroscope has an 11.5-F sheath with a larger working Channel than a 12-F peThere are many availdiatric panendoscope. able baskets and grasping forceps designed for use with the Wolf instrument. Stone extraction was attempted through the ureteroscope. A three-prong grasping forceps and four-wire helical basket were used to easily extract the
UROI,OCY
/ NOVEMBER
1988
/
VOLUME
FIGURE 1.
Cystogram
demonstrating
urethrocuta-
neous fistula. multiple urethra1 calculi under direct vision. After stone removal, the ureteroscope was successfully advanced to the proximal bulbous urethra where the origin of the fistula was confirmed with the injection of methylene blue into the scrotal sinus. NO evidente of periurethral abscess was detected, and the patient was returned to his room. NO additional anesthesia was required, and the procedure was wel1 tolerated. With accurate definition of the problem, appropriate treatment could be instituted. This unusual application of the ureteroscope for urethra1 surgery made diagnosis and treatment of this patient possible under local anesthesia.
XXXII,NUMBER 5
Lexington,
Kentucky 40536 (DR. MUNCH)
451