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Year : 2011  |  Volume : 27  |  Issue : 3  |  Page : 431-432
 

Long-term results of early endoscopic realignment of complete posterior urethral disruption


Department of Urology, CSM Medical University (Upgraded King George's Medical College), Lucknow, Uttar Pradesh, India

Date of Web Publication26-Sep-2011

Correspondence Address:
Apul Goel
Department of Urology, CSM Medical University (Upgraded King George's Medical College), Lucknow, Uttar Pradesh
India
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How to cite this article:
Kathpalia R, Mandal S, Goel A. Long-term results of early endoscopic realignment of complete posterior urethral disruption. Indian J Urol 2011;27:431-2

How to cite this URL:
Kathpalia R, Mandal S, Goel A. Long-term results of early endoscopic realignment of complete posterior urethral disruption. Indian J Urol [serial online] 2011 [cited 2014 Jul 26];27:431-2. Available from: http://www.indianjurol.com/text.asp?2011/27/3/431/85462

Sofer M, Mabjeesh NJ, Ben-Chaim J, Aviram G, Bar-Yosef Y, Matzkin H, et al. Long-term results of early endoscopic realignment of complete posterior urethral disruption. J Endourol 2010;24:1117-21.



   Summary Top


The traditional approach to the management of patients with complete posterior urethral disruption has been suprapubic drainage followed by delayed open surgical repair. [1] However, this is complicated with prolonged suprapubic drainage and obliteration of stricture segment. With the popularization of endo-urologic techniques, successful early endoscopic realignment (EER) has been reported. [2] Mario Sofer et al . carried out a study that included 11 consecutive patients who presented with grade III complete posterior urethral disruption and who were treated by EER. [3] Their mean age was 32 years (range, 20-62 years). The posterior urethral ruptures were caused by a motor vehicle accident (n = 9) or an impact of a fall (n = 2). Urethral rupture was suspected based on the clinical signs and confirmed by retrograde urethrography and antegrade cystography. The posterior urethral realignment was performed under general anesthesia after stabilization of other life-threatening injuries. Flexible 15F cystoscopes were simultaneously introduced transurethrally and transvesically under fluoroscopic multiplanar guidance. The transurethral scope was advanced to the distal edge of the disruption, while the transvesical scope was used to pass a guide wire through the bladder neck into the retropubic space. The cystoscopes were gradually advanced towards each other to enable endoscopic controlled passage of a guide wire through the disrupted urethral segment down to the urethral orifice. An 18F Councill catheter was railroaded on the guide wire into the bladder and left for 4 weeks. The realignment was accomplished in an average of 48 hours (range, 3-72 hours) from hospitalization, with complementary orthopedic interventions in 4 (36%) patients. The average time of the intraoperative urethral manipulation was 40 minutes. There were no complications related to the procedure. Urethral patency and functionality were evaluated by retrograde urethrography performed immediately after removal of the catheter and by flowmetry and urinary residual scanning every 3 months thereafter. Continence was maintained in all patients. Erectile function was preserved in 5 (45%) patients. Urethral strictures developed in 5 (45%) patients; the urethral stricture was shorter than 5 mm in 3 patients and measured an average of 15 mm (range, 10-20 mm) in the remaining 2 patients. All occurred within an average period of 8 months (range, 3-12 months) from the occurrence of the traumatic event. These patients were treated initially by holmium laser urethrotomy, which was successful in 1 (20%) patient. Three of the 4 patients in the failure group remained on periodic urethral dilation, refusing to undergo urethroplasty; and 1 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 years). Thus, it is seen that immediate surgical realignment in comparison with delayed repair provides equivalent or better outcome without the need for multiple surgical procedures.


   Comments Top


Most posterior urethral injuries are caused by blunt trauma that is associated with a pelvic fracture or straddle injury. The mechanism of these injuries involves major shearing forces at the prostatomembranous junction, resulting in avulsion of the urethra from the fixed urogenital diaphragm.

Other potential mechanisms of posterior urethral injury are shearing forces between a fixed prostate and a mobile bladder, resulting in bladder neck injury and direct laceration by pelvic bone fragments or urethral distraction/compression between the symphysis and pubic rami. [4] The definitive management options include primary suture repair, primary surgical or endoscopic realignment, and suprapubic cystostomy with delayed repair. The aim is to reestablish urethral continuity while maintaining continence and sexual function. The historic approach of pelvic exploration and primary repair was associated with significant complications, including bleeding from disruption of contained pelvic hematoma, infection, aggravation of the initial urethral injury and high rates of incontinence and erectile dysfunction. [1],[5] Today, this approach is reserved only for rare cases of bladder neck laceration (grade IV injury) associated with severe dislocation of the prostatomembranous urethra, and pelvic vascular or rectal injury. The introduction of endoscopic instrumentation significantly reduces the invasiveness of the treatment. It avoids the risks that accompany complex open urethral manipulation while preserving its advantages of reducing stricture rates, shortening the time to spontaneous voiding, and eliminating the morbidity that is associated with suprapubic cystostomy. [2],[4] Thus this procedure offers a valuable alternative to suprapubic drainage and delayed urethroplasty; and realignment failure did not interfere with the results of open urethroplasty.

 
   References Top

1.Koraitim MM. Pelvic fracture urethral injuries: The unresolved controversy. J Urol 1999;161:1433-41.  Back to cited text no. 1
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2.Hadjizacharia P, Inaba K, Teixeira PG, Kokorowski P, Demetriades D. Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. J Trauma 2008;64:1443-50.  Back to cited text no. 2
    
3.Rosenstein DI, Alsikafi NF. Diagnosis and classification of urethral injuries. Urol Clin North Am 2006;33:73-85.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Brandes S. Initial management of anterior and posterior urethral injuries. Urol Clin North Am 2006;33:87-95.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Koraitim MM. Pelvic fracture urethral injuries: Evaluation of various methods of management. J Urol 1996;156:1288-91.  Back to cited text no. 5
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