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1. Webster GD, Waxman SW (1995) Strictures of the male urethra. Chapter 35. In Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds) Adult and pediatric urology 3rd edn. Lippincott, Williams, and Wilkins, Philadelphia

2. Chiou RK, Gonzalez R, Ortlip S, Fraley EE (1988) Endoscopic treatment of posterior urethral obliteration: long-term follow-up and comparison with transpubic urethroplasty. J Urol 140:508-511

3. Spirnak JP, Smith EM, Elder JS (1993) Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation. J Urol 149:766-768

4. Pansadoro V, Scarpone P, Emiliozzi P (1993) The endoscopic treatment of membranous urethral strictures. J Endourol 7 [Suppl 1] 111

5. Pansadoro V, Defidio L (1981) Endoskopische Behandlung von Rezidivstenosen der Pars Membranacea der Urethra. Aktuelle Urologie 12:227-231

6. Koraitim MM (1995) The lessons of 145 post-traumatic posterior urethral strictures treated in 17 years. J Urol 153:63-66

7. Jenkins BJ, Badenoch DF, Fowler CG, Blandy JP (1992) Long-term results of treatment of urethral injuries in males caused by external trauma. Br J Urol 70:73-75

8. Mundy AR (1996) Urethroplasty for posterior urethral strictures. Br J Urol 78:243-247

9. Lieberman SF, Barry JM (1982) Retreat from transpubic urethroplasty for obliterated membranous urethral strictures. J Urol 128:379-381

10. Waterhouse K, Laungani G, Patil U (1980) The surgical repair of membranous urethral strictures: experience with 105 consecutive cases. J Urol 123500-505

11. Kehornan RM, Anwar KK, Johnston SR (1990) Complete urethral stricture of the membranous urethra: a different perspective. Br J Urol 65:51-54

12. White JL, Hirsch IH, Bagley DH (1994) Endoscopic urethroplasty of posterior urethral avulsion. Urology 44:100-105

13. Quint HJ, Stanisic TH (1993) Above and below delayed endoscopic treatment of traumatic posterior urethral disruptions. J Urol 149:484-487

14. Wu YA, Huang CH, Liu JH (1994) Transurethral resection in children with urethral stricture and occlusion. J Endourol 8:69-71

15. Goel MC, Mayank K, Kapoor R (1997) Endoscopic management of traumatic posterior urethral stricture: early results and followup. J Urol 157:95-97

16. El-Abd SA (1995) Endoscopic treatment of post-traumatic urethral obliteration: experience in 396 patients. J Urol 153:67-71

11

Endoscopic Realignment

of Post-Traumatic Membranous

Urethral Disruption

V. Pansadoro, P. Emiliozzi

Standard treatment of post-traumatic disruption of the membranous urethra is suprapubic cystostomy and delayed urethroplasty [1]. Other surgical options include primary suturing [2] and early endoscopic realignment. Endoscopic realignment has been gaining popularity in recent reports [3-5].

Endoscopic realignment is a safe and effective procedure for the treatment of post-traumatic membranous urethral disruption. A minority of patients heal without urethral stricture and require no further treatment. The subsequent treatment of patients who develop a stricture is easier because the length of the stricture is short, with a small amount of scar tissue. Early endoscopic realignment in stable patients is our first option. However, larger series are needed before early endoscopic realignment of membranous urethra disruption is accepted worldwide as a standard option. Endoscopic realignment of membranous urethral disruption has several advantages when compared to suprapubic cystostomy, followed by late repair. The procedure is relatively easy to perform, with low morbidity. After placement of suprapubic bladder drainage, preoperative antegrade and retrograde urethrocystograms are performed to evaluate the gap between the two ends of the disrupted urethra. The operation requires a stable clinical condition (usually 2-7 days after trauma).

Preoperative retrograde and antegrade (through suprapubic drainage) urethrocystograms must be performed before the operation. Adequate antibiotic coverage is provided.

With the patient in the lithotomy position, the supra-pubic percutaneous tract is dilated and a metal sound is passed through the bladder neck into the prostatic urethra (O Fig. 11.1). A suprapubic flexible cystoscope, when available, can be used instead of a metal sound. At this point, a 20-Fr urethrotome, with its half sheath, is introduced into the urethra, and carefully advanced through the membranous urethra, into the pelvic hematoma (O Fig. 11.2). Under combined endoscopic and fluoroscopic guidance, the urethrotome meets the tip of the sound (or the light of the flexible cystoscope). Under endoscopic guidance, the urethrotome is further advanced into the prostatic urethra, while the sound is retracted to the bladder neck. The urethrotome is removed, leaving the half sheath in the bladder and urethra. Through the half sheath, an 18-Fr fenestrated silicon catheter is placed into the bladder, and left in place for 4-6 weeks. Hematoma extent and prostate position can be easily monitored by means of transrectal ultrasound. Antibiotic coverage is provided.

The two ends of the disrupted urethra have a gap and they are surrounded by pelvic hematoma. Early drainage of the hematoma through the catheter helps the descent of the dislodged prostate toward the membranous urethra.

All patients are followed with uroflow and urethrocys-togram at 3, 6, and 12 months, and then yearly thereafter.

We have treated ten patients with complete disruption of the membranous urethra, following pelvic fractures, with early endoscopic realignment of the urethra. The mean age was 40 years (15-65 years). The etiology of the urethral disruption was car accident in seven patients and occupational trauma in three patients. The median delay from the acute trauma was 8 days (2-44 days). Mean operative time was 105 min (range, 40-180 min). In all patients, it was possible to pass the urethrotome into the bladder, and to realign the prostate with the membranous urethra.

Complications included hemorrhage requiring transfusion in one patient and persistent (6 and 8 weeks) urinary tract infection in two patients. The mean hospital stay for realignment was 6 days (range, 3-18 days). The median follow-up is now 81 months (40-194 months). Potency was good in seven of ten (70%) patients and moderately impaired in one. Continence was preserved in all patients.

Four of the ten patients are voiding well with a peak flow greater than 15 ml/s and did not require any further treatment. A secondary membranous urethral stricture developed in 6 patients (60%). Five of the six patients with post-traumatic membranous urethral strictures were treated successfully with endoscopic resection of the scar tissue. Three of them required two endoscopic procedures and one required three endoscopic procedures to obtain final stable results. At a median follow-up of 70 months, five out of six patients have good urinary peak flow (above 15 ml/s) with a satisfying urethral caliber. Only one patient required surgical repair with a bulboprostatic anastomosis.

Reducing the amount of scar tissue is mandatory while waiting for the endoscopic [6] or surgical procedure. In a minority of our patients (40%), the urethra healed after realignment without occurrence of a significant stricture, and no further treatment was required. The optimal timing for endoscopic realignment is at 3-4 days after disruption, when the patient is stable and pelvic bleeding has stopped.

After urethral disruption, suprapubic cystostomy alone is almost certainly followed by a membranous urethral stricture. These strictures need repair after a few months in a referral center by a highly specialized urologist [7, 8], where very high success rates, between 95% and 97%, are reported [9, 10]. However, with long-term follow-up, some authors have reported stricture recurrence rates of 20%-31% [11, 12]. For stable patients without additional injuries associated with the urethral disruption, early endoscopic realignment is probably the best option.

The continence and potency preservation rate for early realignment and for delayed urethroplasty has been compared in a review of literature by Herschorn: the incidence of impotence was 30% and 36% and the incidence of incontinence was 6% and 8% for delayed repair and early realignment, respectively [13].

Sound Tube MedicalMetal Sounds For Urethral Dilatation

O Fig. 11.1A-E. Operative technique. A After the acute trauma, a suprapubic tube is inserted. The procedure begins with the substitution of the suprapubic catheter with a metal sound (or flexible cystoscope). B The suprapubic sound (or flexible cystoscope) is gently passed through the bladder neck. A 20-Fr urethrotome with half sheath is carefully advanced along the urethra. C With endoscopic control, the urethrotome meets the tip of the metal sound (or flexible cystoscope) inside the pelvic hematoma. D Fluoroscopic control is used during the procedure. E The urethrotome reaches the bladder following the suprapubic instrument, which is slowly retracted. A fenestrated catheter is inserted through the half sheath. A suprapubic drainage is left

O Fig. 11.1A-E. Operative technique. A After the acute trauma, a suprapubic tube is inserted. The procedure begins with the substitution of the suprapubic catheter with a metal sound (or flexible cystoscope). B The suprapubic sound (or flexible cystoscope) is gently passed through the bladder neck. A 20-Fr urethrotome with half sheath is carefully advanced along the urethra. C With endoscopic control, the urethrotome meets the tip of the metal sound (or flexible cystoscope) inside the pelvic hematoma. D Fluoroscopic control is used during the procedure. E The urethrotome reaches the bladder following the suprapubic instrument, which is slowly retracted. A fenestrated catheter is inserted through the half sheath. A suprapubic drainage is left

In an review of 871 cases, Koraitim [1] evaluated the morbidity of different treatment of post-traumatic urethral disruption. For suprapubic cystostomy, overall the incidence of stricture was 97%, the incidence of impotence was 19%; incontinence occurred in 4% of cases. For early or immediate surgical realignment, overall the incidence of stricture was 53%, the incidence of impotence was 36%;

incontinence occurred in 5%. However, caution must be exercised when comparing retrospective series published over more than 40 years. The treatment of disruption is not related to the incidence of impotence and incontinence, which are rather due to trauma itself [14]. Open surgery performed immediately after the trauma might impair potency because of iatrogenic damage of neurovas-

Open UrethroplastyModerate Stricture Urethra

cular bundles. Endoscopic realignment is minimally invasive and it is unlikely to impair potency. Elliott and Barrett [2] reported 10-year results of immediate primary surgical realignment for membranous urethral disruption in 57 cases. In these patients, 34% had no evidence of stricture and 43% had mild strictures managed by dilatation. Full potency was preserved in 79% of cases. Mild stress incontinence occurred in 4% of cases (O Table 11.1).

In a review of literature, Jepson et al. found 36 cases of endoscopic realignment of posterior urethral disruption, including their series. Successful realignment was achieved in 35 cases (97%); impotence and incontinence rates were overall 7/35 (20%) and 2/36 (6%). Open surgery was

Retrograde Urethrocystography

□ Fig. 11.2. A Combined antegrade and retrograde urethrocystogram after the trauma shows complete urethral disruption. B Retrograde urethrogram 15 days after endoscopy realignment with extravasation of contrast medium into pelvic hematoma. C Retrograde urethrogram 30 days after endoscopic realignment. A slight extravasation is still present. D At 1 year the membranous urethra has healed at a good caliber

1 Tab le 11.1.

Author

cases

days after

stricture

f-up

trauma

(mos)

Londergan [3]

5

7 (2-42)

3

16

Cohen [4]

5

(7-19)

4

Melekos [5]

4

4

Gheiler [15]

3

1

2

Wilbert [16]

8

35 (7-84)

8

40

Benz [17]

9

5

>24

Jepson [18]

8

9 (0-19)

4

50

Moudouni [19]

29

0-8

16

68

Our series

10

8 (2-44)

6

81

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