Early Endoscopic Management of Posttraumatic Posterior Urethral Stricture

ABSTRACT

INTRODUCTION: Some studies of primary realignment of urethral stricture show higher long-term complication rates than those observed in patients treated with delayed repair, but the results are not thoroughly documented. The purpose of this study was to evaluate the results of early endoscopic management of posttraumatic posterior urethral stricture by visual internal urethrotomy (VIU).

METHODS: Participants were 14 males with posterior urethral strictures following a car accident. All patients had partial injuries to the urethra. The strictures were 1-2 cm long. Participant mean age was 21 years (range, 18-26 years). Patients were evaluated by medical history, clinical examination, laboratory investigations, and radiological imaging. VIU was done within 2 weeks of trauma. Follow-up examinations were done at 1, 3, 6, 12, and 24 months after surgery. Outcome measures were flow rates and postoperative complications.

RESULTS: All patients were continent with satisfactory flow rates. One patient had impotence, but his condition was improved at the 6-month follow-up. Other complications included dysuria (n = 5), urinary tract infection (UTI) (n = 2), and urge incontinence associated with UTI (n = 1). After 12 months, 1 patient required surgical intervention due to a decrease in flow rate and recurrence of stricture.

CONCLUSION: Based on this report of 14 patients, early endoscopic urethral realignment surgery is a safe procedure with few complications. Endoscopic restoration of urethral continuity may be considered for early treatment of posttraumatic posterior urethral stricture.


Ahmed Shelbaia

Submitted March 15, 2011 - Accepted for Publication April 8, 2011


KEYWORDS: Stricture posterior urethra; Early management; Visual internal urethrotomy

CORRESPONDENCE: Dr.Ahmed Shelbaia, MD, Borg Elatbaa, Faisal Street, 5th Floor, Flat 5, Giza, Egypt ().

CITATION: UroToday Int J. 2011 Jun;4(3):art43. doi:10.3834/uij.1944-5784.2011.06.13.

ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection; VIU, visual internal urethrotomy.

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INTRODUCTION

Posterior urethral injuries in males usually occur in conjunction with a fracture of the bony pelvis [1,2,3,4]. Approximately 90% of these injuries are caused by motor vehicle accidents; the other 10% are due to falls from high places, crushing trauma, and sports-related accidents [5]. Posterior urethral injuries are caused by the shearing force of the bone disruption. The prostate (attached by the puboprostatic ligaments) is pulled in one direction while the membranous urethra (attached to the urogenital diaphragm) is pulled in another.

Some previous studies of primary realignment of a posterior urethral stricture showed higher long-term complication rates than those observed in patients treated with delayed repair [6,7,8,9]. However, there are some advantages to immediate direct urethral alignment [9] and the effects of early endoscopic repair are not thoroughly documented.

The purpose of the present study was to evaluate the results of early endoscopic management of posttraumatic posterior urethral stricture by visual internal urethrotomy (VIU).

METHODS

This was a prospective study conducted at Cairo University Hospital between June 2008 and June 2010. The protocol was approved by the Cairo University Hospital Research Committee. All patients provided informed consent.

Participants

The participants were 14 males with a posterior urethral stricture following a car accident. Their mean age was 21 years (range, 18-26 years). The patients had unilateral fracture of the pubic ramus (n = 9), multiple bilateral fractures of the pubic rami (n = 3), and comminuted fracture of the coccyx (n = 2). All patients had partial injuries to the urethra; there were no complete ruptures.

Evaluation Procedure

All patients presented with suprapubic catheters when they were referred to our department. They were evaluated by medical history, clinical examination, and laboratory investigations. Imaging consisted of x-rays of the pelvis, retrograde urethrography combined with antegrade cystourethrography, and abdominal and pelvic sonography.

Surgical Procedure

Consent was taken from all patients for early endoscopic management of the urethral stricture. Surgery was conducted within 2 weeks from the time of the accident.

The patients were placed in a modified lithotomy position. General anesthesia was administered. Cystoscopy was done using a 20 Fr sheath and a guide (3 Fr ureteric catheter or .36 inch floppy guidewire). Visual internal urethrotomy was done in the prostatomembranous urethral stricture until the cystoscope reached the bladder. If the ureteric catheter or the guidewire could not pass the stricture area to reach the bladder, methylene blue was inserted through the suprapubic catheter as a guide to reach the bladder from the urethra. At the end of the procedure, an 18 Fr Foley catheter was placed. The suprapubic catheter was also left in place at the end of the operation.

Postoperative Follow-up and Data Analysis

The urethral catheter was removed after 1 week to help the patient micturate normally. The suprapubic catheter was closed and removed 1 day later.

Follow-up examinations were done by abdominal and pelvic sonography, flowmetry, and urethrography at 1, 3, 6, 12, and 24 months after surgery. The outcome measures were flow rates and postoperative complications.

RESULTS

All 14 patients had posttraumatic prostatomembraneous posterior urethral strictures that measured 1 cm to 2 cm in length. All strictures were passable during surgery.

All patients were continent on follow-up examinations. Their mean flow rates at each postoperative evaluation are contained in Table 1. The mean flow rates decreased over time, but they were considered clinically satisfactory.

One patient had impotence and his condition was improved at the 6-month follow-up examination. Other complications that occurred in the first 2-week postoperative period were dysuria (n = 5), urinary tract infection (UTI) (n = 2), and urge incontinence associated with UTI (n = 1). These early complications were resolved in the first postoperative month of follow-up. After 12 months, 1 patient required surgical intervention due to a decrease in flow rate and recurrence of stricture.

DISCUSSION

The success rate of early stricture management in the present study was higher than that reported previously [6,7,8,9]. All patients were continent with satisfactory flow rates and only 1 patient had impotence (not related to the procedure). A third patient had stricture recurrence that required surgical intervention with resection anastomosis; this procedure has a very high success rate. Based on this small sample, it appears that primary endoscopic realignment offers an effective method for treating traumatic urethral injuries.

Goel et al [10] reported that endoscopic treatment should be considered the first procedure of choice for all posttraumatic posterior urethral strictures. They said that the morbidity of open surgery can be avoided in 61% of patients. The length of the hospital stay is also decreased with endoscopic therapy. Moudouni et al [11] and Ikuerowo et al [12] reported that primary endoscopic realignment offers an effective method for treating traumatic urethral injuries without an increased incidence of impotence, stricture formation, or incontinence. Koritim [13] reported that optical urethrotomy was successful in 58% of patients with mild strictures and a persistent opening between the bulbar and prostatic areas of the intact urethra. Therefore, the author recommended that this procedure should be reserved for such cases. In the present study, the success rate was very high with few complications. The complications that occurred were comparable to those reported previously [6,7,8,10,11].

The present study has a number of limitations. We had a small number of patients. Our outcome measures were limited to flow rate and reported complications. The 2-year follow-up period was relatively short. Finally, we did not have a comparison group that received delayed repair. Therefore, further study is needed to confirm the results.

CONCLUSION

Based on this report of 14 patients, early endoscopic urethral realignment surgery is a safe procedure with few complications. Endoscopic restoration of urethral continuity may be considered for early treatment of posttraumatic posterior urethral stricture.

Conflict of Interest: none declared.

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