A case study of a new technique for the primary percutaneous endoscopic realignment of a complete urethral injury.
Abstract: The male urethra is vulnerable to injury with multisystem trauma, especially those that include pelvic fractures. Controversy exists regarding the optimal time to repair urethral injuries and different modalities exist for their treatment. We report the first documented case of percutaneous endoscopic realignment of a urethra using a previous cystostomy site that has been dilated using a balloon dilator.
Article Type: Report
Subject: Fractures (Care and treatment)
Fractures (Case studies)
Urethral diseases (Case studies)
Urethral diseases (Care and treatment)
Endoscopic surgery (Usage)
Endoscopy (Usage)
Cystoscopy (Usage)
Authors: Payne, Faith
Davalos, Julio
Pub Date: 03/01/2010
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: March-April, 2010 Source Volume: 106 Source Issue: 2
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 223908177
Full Text: Case Report

A 40-year-old male presents as a priority two trauma to CAMC General Hospital via HealthNet Aeromedical. The patient was rescued from Nicholas County after he lost control of his vehicle on a patch of ice. He struck a tree and was found unconscious on the scene. The patient was hemodynamically stable during prehospital intervention. He was given IV fluids, placed in full cervical and spinal immobilization, and was transferred to the trauma bay in stable condition. Upon arrival he denied any recollection of the accident. The patient complained of a headache and pain in his left hip, left pelvis, left arm, and left chest. Vital signs were stable. Physical exam revealed an obvious left hip deformity. There was difficulty passing the foley catheter and at that time a retrograde urethrogram was done. This demonstrated complete transection of the urethra with extravasation of contrast both above and below the urogenital diaphragm. Trauma radiographic images were obtained and revealed other injuries including disruption of the diaphragm with abdominal contents displaced superiorly, left rib fractures with pneumothorax, pelvic fracture with hematoma, and a large hematoma anterior and superior to urinary bladder. Consultants were notified. The patient underwent exploratory laparotomy and a suprapubic catheter was placed at that time. After a few days the patient was then given treatment options of delayed repair and open urethroplasty or percutaneous endoscopic urethral realignment. He decided to undergo primary percutaneous endoscopic urethral realignment.

Discussion

Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accidents, falls, or industrial accidents. Pubic diastasis, localized pubic rami fractures, or more complex pelvic fractures may be associated with urethral disruption. "Straddle fractures" involving all four pubic rami, open fractures, and fractures resulting in both vertical and rotational pelvic instability are associated with the highest risk of urologic injury. There are three types of urethral disruptions; a type one injury occurs when the posterior urethra is stretched and elongated but intact. A type two injury is a disruption of the urethra above the urogenital diaphragm (UGD) in the prostatic urethra with the membranous urethra intact. Lastly, a type three injury is disruption of the membranous urethra with extension into the bulbous urethra and/or disruption of the UGD; i.e. complete tear. (1) Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fracture. (2,3)

Immediate suprapubic tube placement remains the standard of care. (4) This is best accomplished through a small infraumbilical incision, which allows inspection and repair of the bladder and proper placement of a large-bore catheter at the bladder dome. An attempt at primary realignment of the distraction with a urethral catheter is reasonable in stable patients, either acutely or within several days of injury. (5) Often a simple technique consisting of passage of a coude catheter antegrade through a cystotomy, then tying it to another that can then be drawn back into the bladder is effective. A variety of more elaborate approaches have been described. If primary urethral realignment is unsuccessful then the suprapubic catheter is placed and the patient will eventually undergo an open urethroplasty. The urethral catheter is then removed after 4 to 6 weeks. Most patients will develop posterior urethral stenosis therefore the suprapubic catheter is kept in place. The suprapubic catheter is removed once the patient is voiding through the urethra with success. (2) Realignment may not prevent symptomatic stenosis; however it may ease the difficulty of an open posterior urethroplasty by bringing the prostate and urethra closer.

We prefer to do a primary realignment using a percutaneous endoscopic approach. It has been our experience that the comorbities of urethral stricture and incontinence is decreased with primary realignment. This is a case report of a complete urethral tear and the repair using a technique that has not been previously described. Percutaneous endoscopic access is achieved through the previous cystostomy site. This is dilated using a balloon dilator. Flexible cystoscopy and flexible urethroscopy is performed and a guidewire is placed antegrade. Realignment is achieved proximally and distally, using guide wires. Once the guide wire is in place, the urethra is then re-approximated by sliding the foley catheter over the guide wires. The injured urethral segment will then heal over the foley. The realignment is confirmed with a cystogram (Figure 1).

[FIGURE 1 OMITTED]

Conclusions

Urethral injuries secondary to trauma are more common today than before. Percutaneous primary realignment using a balloon dilated cystostomy site has not been previously documented. It is our opinion than primary realignment decreases the comorbidities associated with this injury and this is the optimal technique for primary realignment. In our experience, this decreases comorbidities and the need for future operations.

Acknowledgements

Special thanks to Holly Blackwood, RN from CAMC Health Education and Research Institute.

References

1. Rosenstein DI, Alsikafi NF. Diagnosis and Classification of Urethral Injuries. Urologic Clinics of North America. 2006. (33):73-85, vi-vii

2. http://radiographics.rsnajnls.org/cgi/ reprint/23/4/951.pdf (referenced 7-9-08)

3. Wein AJ, Kacoussi LR, Novick AC, Partin AW, and Peters CA. Campbell-Walsh Urology 9th Edition Saunders/Elsevier. Philadelphia, PA. 2007. 879-903

4. Maull K, Sochatello CR, Ernst CB. The deep perineal laceration-an injury frequently associated with open pelvic fractures-a need for aggressive surgical management. J Trauma. 1977; 685-696.

5. Sandler CM, Harris JH, Corriere JN, et al. Posterior urethral injuries after pelvic fractures. AJR 1981;137:1233.

6. Kusminsky RE, Shbeek I, Makos G, Boland JP. Blunt pelvic-perineal injuries: an expanded role for the diverting colostomy. Dis Colon Rectum. 1982;25:787-790.

Faith Payne, DO, PGY3

Charleston Area Medical Center

Julio Davalos, MD

Urology Center of Charleston
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