Primary endoscopic realignment following posterior urethral disruption

A Case in Which a Urethral Catheter Could Be Indwelled by an Anterograde Approach After It Was Difficult to Indwell at the Start of Robot-Assisted Laparoscopic Radical Prostatectomy

A case in which a urethral catheter could not be indwelled at the start of robot-assisted laparoscopic radical prostatectomy (RARP) is reported. A 64-year-old man was admitted to the hospital for RARP with a diagnosis of prostate cancer cT2aN0M0. At the start of RARP, a pseudo-urethra was formed by inserting a urethral catheter, so surgery was started with a transabdominal posterior approach without indwelling the urethral catheter. The urethra was opened during bladder neck resection, a guide wire was inserted anterogradely, the urethra was dilated retrogradely, and a urethral catheter was indwelled. After that, the procedure was performed as usual, and the operation was completed. When the urethral catheter could not be indwelled at the start of RARP, it was possible to do so using an anterograde approach during the operation.

Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis

Objective

Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU.

Methods

PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9).

Results

From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82).

Conclusion

For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Traumatic lesions of the posterior urethra

INTRODUCTION

The posterior urethral lesions are associated with pelvis fractures in 5-10% of cases. The posterior urethra is attached to the pelvis bone by puboprostatic ligaments and the perineal membrane, which explains why disruption of the pelvic ring can injure the urethra at this level.

OBJECTIVES

To identify suspected cases of posterior urethral trauma and to perform the diagnosis and its immediate or deferred management.

ACQUISITION OF EVIDENCE

Search in PubMed of articles related to traumatic posterior urethral lesions, written in English or Spanish. We reviewed the relevant publications including literature reviews and chapters from books related to the topic.

SYNTHESIS OF THE EVIDENCE

With patients with pelvis fractures, we must always rule out posterior urethral lesions. The diagnostic examination of choice is retrograde urethrography, which, along with the severity of the condition, will determine the management in the acute phase and whether the treatment will be performed immediately or deferred. Early diagnosis and proper acute management decrease the associated complications, such as strictures, urinary incontinence and erectile dysfunction.

CONCLUSIONS

Despite the classical association between posterior urethral lesions and pelvic fractures, the management of those lesions (whether immediate or deferred) remains controversial. Thanks to the growing interest in urethral disease, there are an increasing number of studies that help us achieve better management of these lesions.

Pro: endoscopic realignment for pelvic fracture urethral injuries

Patients with pelvic fracture urethral distraction injuries may benefit from early endoscopic realignment. Realignment is associated with a low risk of immediate complications and has a high success rate for achieving catheter placement. Review of over thirty studies assessing for subsequent urethral stenosis, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Furthermore, realignment may result in easier subsequent urethroplasty and possibly shorter stenoses.

The management of the acute setting of pelvic fracture urethral injury (realignment vs. suprapubic cystostomy alone)

Background

In patients with pelvic fracture urethral injury there are two options for management: First, to realign as an early primary realignment over a catheter; and second, to place a suprapubic tube with delayed urethroplasty of the inevitable stricture.

Methods

We reviewed previous reports from 1990 to the present, comparing early endoscopic realignment, early open realignment and suprapubic tube placement, to determine the rates of incontinence, erectile dysfunction and stricture formation.

Results

Twenty-nine articles were identified. The rates of erectile dysfunction, incontinence, and stricture formation, respectively, were: for early endoscopic realignment, 20.5%, 5.8% and 43.8%; for open realignment over a catheter, 16.7%, 4.7% and 48.9%; and for a suprapubic tube and delayed urethroplasty 13.7%, 5.0%, and 89.0%. A one-way anova showed no difference in the mean rate of erectile dysfunction (P = 0.53) or incontinence (P = 0.73), and only stricture formation was significantly different (P < 0.1).

Conclusion

The rates of incontinence and erectile dysfunction are similar between the groups. Only the rate of stricture formation was higher in the suprapubic tube and delayed urethroplasty group.

Long-term outcome of primary endoscopic realignment for bulbous urethral injuries: risk factors of urethral stricture

Purpose

Although endoscopic realignment has been accepted as a standard treatment for urethral injuries, the long-term follow-up data on this procedure are not sufficient. We report the long-term outcome of primary endoscopic realignment in bulbous urethral injuries.

Methods

Patients with bulbous urethral injuries were treated by primary endoscopic realignment between 1991 and 2005. The operative procedure included suprapubic cystostomy and transurethral catheterization using a guide wire, within 72 hours of injury. The study population included 51 patients with a minimum follow-up duration of 5 years.

Results

The most common causes of the injuries were straddle injury from falling down (74.5%), and pelvic bone fracture (7.8%). Gross hematuria was the most common complaint (92.2%). Twenty-three patients (45.1%) had complete urethral injuries. The mean time to operation after the injury was 38.8±43.2 hours. The mean operation time and mean indwelling time of a urethral Foley catheter were 55.5±37.6 minutes and 22.0±11.9 days, respectively. Twenty out of 51 patients (39.2%) were diagnosed with urethral stricture in 89.1±36.6 months after surgery. A multivariate analysis revealed that young age and operation time were independent risk factors for strictures as a complication of urethral realignment (hazard ratio [HR], 6.554, P=0.032; HR, 6.206, P=0.035).

Conclusions

Urethral stricture commonly developed as a postoperative complication of primary endoscopic urethral realignment for bulbous urethral injury, especially in young age and long operation time.

Delayed repair is the ideal management for posterior urethral injuries- FOR the motion

Posterior urethral injuries are seen in trauma cases with pelvic fracture. The time-tested and honored method of management is immediate supra-pubic diversion followed by delayed repair. Immediate alignment as a management option is not new. It was abandoned 30 years ago due to high incidence of incontinence and impotence. However, of late there is a tendency towards immediate management of these injuries with various endoscopic maneuvers. Unfortunately, there is little evidence supporting this. Even these evidences are of limited in number and of limited duration of follow-up.

EAU Guidelines on Urethral Trauma

CONTEXT

These guidelines were prepared on behalf of the European Association of Urology (EAU) to assist urologists in the management of traumatic urethral injuries.

OBJECTIVE

To determine the optimal evaluation and management of urethral injuries by review of the world's literature on the subject.

EVIDENCE ACQUISITION

A working group of experts on Urological Trauma was convened to review and summarize the literature concerning the diagnosis and treatment of genitourinary trauma, including urethral trauma. The Urological Trauma guidelines have been based on a review of the literature identified using on-line searches of MEDLINE and other source documents published before 2009. A critical assessment of the findings was made, not involving a formal appraisal of the data. There were few high-powered, randomized, controlled trials in this area and considerable available data was provided by retrospective studies. The Working Group recognizes this limitation.

EVIDENCE SYNTHESIS

The full text of these guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article comprises the abridged version of a section of the Urological Trauma guidelines.

CONCLUSIONS

Updated and critically reviewed Guidelines on Urethral Trauma are presented. The aim of these guidelines is to provide support to the practicing urologist since urethral injuries carry substantial morbidity. The diversity of urethral injuries, associated injuries, the timing and availability of treatment options as well as their relative rarity contribute to the controversies in the management of urethral trauma.

[Diagnosis and management of posterior urethra disruptions]

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.

THE TREATMENT OF POSTERIOR URETHRAL DISRUPTION ASSOCIATED WITH PELVIC FRACTURES: COMPARATIVE EXPERIENCE OF EARLY REALIGNMENT VERSUS DELAYED URETHROPLASTY

PURPOSE

Urological treatment of the patient with severe mechanical trauma and urethral disruption remains controversial. Debate continues regarding the advisability of early realignment vs delayed open urethroplasty. We analyzed our experience with 96 patients to determine the long-term results of the 2 approaches.

MATERIALS AND METHODS

We retrospectively reviewed the records of 191 men with posterior urethral disruption after severe blunt pelvic injury between 1984 and 2001, of whom 96 survived. Data on 57 patients who underwent early realignment were compared to those on 39 treated with delayed urethroplasty with an average 8.8-year followup (range 1 to 22). All patients were evaluated postoperatively for incontinence, impotence and urethral strictures.

RESULTS

The majority of patients had severe concomitant organ injuries (78%) and severe pelvic fractures (76%). The overall mortality rate was 51%. Diagnosis of urethral rupture was based on clinical findings and retrograde urethrography. Strictures developed in 49% of the early realignment group and in 100% of the suprapubic tube group. Impotence (33.6%) and incontinence (17.7%) were less frequent in the early realignment group than in the delayed reconstruction group (42.1% and 24.9%, respectively). Patients with delayed reconstruction underwent an average of 3.1 procedures compared with an average of 1.6 in the early realignment group.

CONCLUSIONS

Early realignment may provide better outcomes than delayed open urethroplasty after posterior urethral disruption. Increased complications are not seen and, although it can be inconvenient in the massively injured patient, it appears to be a worthwhile maneuver.

Posterior urethral injuries and the Mitrofanoff principle in children

OBJECTIVE

To report our experience of children with trauma causing posterior urethral injury who at some stage underwent a Mitrofanoff intervention, as post-traumatic urethral injuries can demand long-term treatment which (regardless of the surgical intervention) requires a period of dilatation of the reconstructed urethra.

PATIENTS AND METHODS

From 1992 to 2001, 14 patients with urethral injuries underwent a Mitrofanoff procedure. Thirteen had been run over by a motor vehicle and had severe hip injuries, and one had a direct non-penetrating perineal impact lesion (13 boys and one girl, aged 2-13 years at the time of the accident). In all cases the Mitrofanoff procedure involved interposing the appendix between the bladder and the umbilicus. Only one of the children (because of extremely high bladder filling pressures) also underwent an augmentation cystoplasty and closure of the bladder neck because there were bony fragments in the urethra.

RESULTS

The Mitrofanoff technique was considered useful in most cases. All patients during a given period used the Mitrofanoff conduit to empty their bladder every 3 h; 10 of the 14 are currently voiding urethrally, with an adequate flow, and four are not, but emptying the bladder periodically via the appendicovesicostomy. The only girl in the group has a major hip deformity and is unlikely to undergo urethroplasty; two patients are expecting definitive treatment and the other, although having a patent urethra, has no urinary flow. He is currently 19 years old and has no erections.

CONCLUSIONS

The treatment of posterior urethral injuries represents a challenge to surgical teams. Although primary suturing of the separated urethral ends is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases.

Reconstruction of posterior urethral disruption

Posterior urethral disruption may be a devastating complication of pelvic trauma. The acute management of these injuries is reviewed as well as the controversy surrounding early versus delayed repair. The various approaches to delayed repair of pelvic fracture urethral distraction defects are presented and the technique of perineal repair is discussed in detail.

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy

BACKGROUND

We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement.

METHODS

We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra.

RESULTS

Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients.

CONCLUSION

Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.

The management of urethral trauma

Urethral trauma is relatively uncommon. It occurs more frequently in young males. Injuries to the a nterior urethra are typically caused by blunt trauma including 'straddle' injuries, athough penetrating injuries do occur. Posterior urethral injurines are usually due to pelvic fractures from automobile or industrial accidents and occur in 10% of patients with a pelvic fracture. In addition to reviewing the management options available in this group of innjuries and highlighting areas of controversy, this article offers clear advice on the initial management of these innjuries on presentation in the emergency department. Subsequent definitive management depends on a variety of factors: the nature and size of the urethral innjury the extent and priorities of treatment of any associated injuries, the availability of local expertise and equipment for dealing with injuries of this type and the management philosophy of the clinical teams involved.

Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up

OBJECTIVES

The management of complete or partial posterior urethral disruption is controversial and much debate continues regarding immediate versus delayed definitive therapy. We further analyze our experience and long-term results using early endoscopic realignment.

METHODS

Between April 1991 and June 1995, 8 men with posterior urethral avulsion, either complete or partial and secondary to blunt trauma and pelvic fractures, presented to our institution. A variety of endourologic techniques were employed to achieve urethral continuity while attempting to minimize stricture formation, incontinence, and impotence.

RESULTS

After a mean of 50.4 months (range 35 to 85) of follow-up, 7 men (87.5%) are continent, with 2 of those requiring intermittent self-dilation ranging from once every 7 days to once a month. One patient required conversion to an open perineal urethroplasty. Of the 8 patients, 5 (62.5%) are potent, and 2 others achieve adequate erections for intercourse using intracorporeal injections. Four of the 8 have required subsequent internal urethrotomies with eventual voiding stabilization over the course of 1 2 months. Average time to realignment was 9.5 days (range 0 to 19).

CONCLUSIONS

Primary endoscopic realignment offers an effective method for treating traumatic urethral injuries. Our long-term follow-up provides further support for use of this technique by demonstrating that urethral continuity can be established without increased incidence of impotence, stricture formation, or incontinence. By achieving early and minimally invasive realignment, we seem to lessen the severity of stricture disease that almost uniformly afflicts those patients who undergo delayed repair. If a minimally invasive technique should fail, it does not seem to delay nor does it preclude further management using open techniques.

Immediate primary realignment of prostatomembranous urethral disruptions using endourologic techniques

OBJECTIVES

A new technique is described for primary realignment of prostatomembranous urethral disruptions using endourologic techniques.

METHODS

Realignment was achieved in 3 patients on the day of injury. Primary urethral realignment is achieved by passing a council-tip catheter over a guidewire inserted during antegrade flexible cystourethroscopy.

RESULTS

Three patients underwent successful realignment on the day of injury. With an average follow-up of 6 months, 2 patients are voiding spontaneously without evidence of a urethral stricture; 1 patient developed a structure necessitating delayed urethroplasty. All patients have retained their potency and continence.

CONCLUSIONS

Our technique provides an expeditious, simple, and atraumatic means of obtaining primary realignment of acute prostatomembranous urethral disruptions.

Pelvic fracture urethral injuries: evaluation of various methods of management

PURPOSE

The results of various immediate treatments of urethral injuries complicating a fractured pelvis were evaluated.

MATERIALS AND METHODS

The records of 100 male patients with pelvic fracture urethral injury were reviewed, 73 of whom were treated by suprapubic cystostomy and delayed repair, 23 by primary realignment and 4 by primary suturing. Also, the findings of 771 patients reported in the literature were reviewed.

RESULTS

Urethral stricture was an almost inevitable consequence (97% of the cases) after suprapubic cystostomy. Primary realignment decreased the incidence of stricture to 53% but produced a 36% impotence rate. Primary suturing also decreased the incidence of stricture to 49% but produced the greatest complication rates for impotence (56%) and incontinence (21%).

CONCLUSIONS

Suprapubic cystostomy alone is indicated for incomplete urethral rupture, slight urethral distraction and critically unstable patients, and when there are inadequate facilities or inexperienced surgeons. Primary realignment is advised if there is wide separation of the urethral ends, or associated injury of the bladder neck or rectum. Primary suturing is not recommended for any condition.

Alternative endoscopic management in the treatment of urethral strictures

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.

Antegrade-retrograde urethrotomy for treatment of severe strictures of the urethra: experience and literature review

In cases of urethral stricture that are nonpassable when using conventional internal urethrotomy, open urethroplasty can be avoided by performing combined antegrade-retrograde urethrotomy (ARUT). A rigid cystoscope is guided through a dilated suprapubic cystostomy channel toward the stricture in the membranous or bulbar urethra. A urethrotome is inserted in retrograde fashion, and the "cut to the light" procedure is performed. Using the ARUT method, realignment was achieved in nine patients; four of whom had strictures induced by trauma or urethritis and five of which were the result of previous transurethral management. Recurrent stricture in four of seven cases necessitated further urethrotomy. There was no recurrence in five of seven patients for at least 5 months subsequent to the last treatment. All patients were spared open surgery. The antegrade-retrograde technique was described in 1978, but to date, only 70 cases have been reported in the literature. The primary success rate is 25%. Successful retreatment following recurrence was observed in 65%. We recommend ARUT as a first-choice treatment for severe strictures of the bulbar and membranous urethra.