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CASE REPORT
Year : 2001  |  Volume : 18  |  Issue : 1  |  Page : 85-86
 

Endovascular treatment of profuse urethral bleeding - following direct vision internal Urethrotomy


Department of Urology and Radiology, Bombay Hospital Institute of Medical Sciences, Mumbai, India

Correspondence Address:
Sushil Shivlal Rathi
c/o Dr. A.G. Phadke, Department of Urology, 14th Floor, New Wing, Bombay Hospital, 19, New Marine Lines,Mumbai - 400 020
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Bleeding; DVIU; Embolisation.


How to cite this article:
Rathi SS, Joshi R, Punamiya S, Phadke A. Endovascular treatment of profuse urethral bleeding - following direct vision internal Urethrotomy. Indian J Urol 2001;18:85-6

How to cite this URL:
Rathi SS, Joshi R, Punamiya S, Phadke A. Endovascular treatment of profuse urethral bleeding - following direct vision internal Urethrotomy. Indian J Urol [serial online] 2001 [cited 2020 Jan 26];18:85-6. Available from: http://www.indianjurol.com/text.asp?2001/18/1/85/37465



   Case Report Top


A 33-year-old man presented with profuse episodic bleeding following direct vision internal urethrotomy (DVIU) for tight stricture at bulbomembranous junction of the urethra. All the conservative methods to control the urethral bleeding failed and suprapubic cystostomy was done. Patient required multiple blood transfusions to maintain his hemodynamic status. On presentation, Hemoglobin was 8.1 gm%. Serum biochemistry & coagulation profile was normal. Sonography revealed normal upper urinary tract and bladder full of blood clots.

19fr cystoscopy sheath could be easily negotiated across the already cut open stricture urethra and there was profuse bleeding from the roof of the urethra near bulbomembranous junction. Attempts of localising and fulgurating the bleeder were unsuccessful. Bladder appeared normal on clot evacuation. Patient was immediately shifted to angiography suite. Using right transformal approach, pelvic angiogram was done which revealed the presence of pseudo aneurysm arising at bulbourethral branch of right internal pudendal artery with contrast extravasation into urethra seen as persistent ring of contrast around the urethral blood clot.

A Microcatheter (Fas Tracker 325) was coaxially introduced & advanced into the bulbourethral artery. The site of urethral bleeding was reconfirmed on selective angiogram and a 1 cm long fibered platinum coil (Target) was deployed into right bulbourethral artery. Post-embolisation arteriogram showed complete occlusion of the offending vessel with no filing of pseudoaneurysm and absence of contrast extravasation. The left pudendal arteriogram showed no evidence of bleeding. There was no further hematuria. Cystoscopy was normal after 8 days. Patient was relieved of obstructive symptoms and had normal erectile function at the time of first follow-up.


   Comment Top


Minor bleeding following a direct vision internal urethrotomy is quite common and generally subsides spontaneously or with pressure dressing. Profuse bleeding following DVIU is an uncommon event though it has been described after a core through optical urethrotomy.[1] Percutaneous embolisation of the offending vessel is the treatment of choice in such type of emergency. Coil embolisation is preferred over gel-foam embolisation as the latter carries a risk of recanalisation and recurrent bleeding. Subselective embolisation avoids risks like erectile dysfunction and ischaemic urethral stricture, associated with embolisation of entire anterior division of internal pudendal artery. Role of rich collaterals from opposite internal pudendal artery in avoiding above-mentioned complications is also speculated upon.[2]

Closely related vessels can be injured during DVIU but can effectively be managed by subselective arterial embolisation. However, there should be no time delay in undertaking this procedure once attempts at controlling the urethral bleeding cystoscopically fail.

 
   References Top

1.Bapuraj JR. Sridhar S, Sharma SK, Suri S. Endovascular treatment of a distal urethral-internal pudendal artery fistula complicating internal optical urethrotomy of a post traumatic urethral stricture. BJU Int 1999: 83: 353-354.  Back to cited text no. 1    
2.Monga M, Puyau FA, Hellstrom WJG. Posttraumatic High Flow Internal Pudendal Artery Urethral Fistula. J Urol 1995; 153: 734-736.  Back to cited text no. 2    


    Figures

  [Figure - 1], [Figure - 2]



 

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