From May 1997 to May 2003, seven men were diagnosed at our institute with complete iatrogenic anterior urethral injury. Patients had acute retention of urine and/or bleeding per urethra and were treated on emergency basis. A detailed clinical evaluation was performed and previous treatment records were reviewed to know the exact pathology in the urethra. Patients were subjected to primary endoscopic realignment of their urethral injury. An informed consent was taken for supra pubic cystostomy in all cases.
Under spinal or epidural anaesthesia patients were placed in lithotomy position with the legs on adjustable leg supports. A dynamic ascending urethrogram was performed under fluoroscopic guidance to confirm extravasation of contrast. Complete rupture was suspected when there was failure to delinate proximal urethra during urethrography.
Initial urethroscopy was done with 17 F cystoscopic sheath and a 0° telescope. Normal saline irrigation was kept to as minimum as possible. Clots in the urethra were gently evacuated to reach the site of urethral disruption. Once complete lack of urethral mucosal integrity was confirmed endoscopically following steps were used to delineate proximal urethra:
Step 1- Retrograde endoscopic delineation of proximal urethra
Bladder was punctured suprapubically with 16 F initial puncture needle and methylene blue was injected in bladder. A suprapubic pressure was applied with the simultaneous urethroscopy to identify possible efflux of methylene blue at the site of trauma. An attempt was made to gently negotiate 0.035"hydrophilic glide wire through the area effluxing methylene blue. If attempt succeeded, position of glide wire in bladder was confirmed fluoroscopically. A stiff zebra wire replaced the glide wire. This served as a guide for subsequent urethroscopy.
Step 2- Antegrade fluoroscopic guided delineation of proximal urethra
If the glide wire could not be negotiated retrogradely; an angled tip glide wire was passed from initial puncture needle into the bladder. Under fluoroscopic guidance multiple attempts were made to negotiate glide wire into posterior urethra through bladder neck. Once glide wire reached the posterior urethra a 6 F open-ended ureteric catheter was passed over it into posterior urethra & a glide wire was exchanged for a guide wire.
Step 3- Antegrade endoscopic delineation of proximal urethra
If fluoroscopically guided attempts to negotiate guide wire in to the posterior urethra failed; it was supplemented with endoscopic guidance. The supra pubic tract was dilated up to 24 F using Alken dilators and an Amplatz sheath was than used as a conduit to pass a rigid cystoscope into bladder. Bladder neck was than explored with antegrade cystoscopy and an open ended ureteric catheter was passed into the posterior urethra.
Simultaneous retrograde urethroscopy was used to explore the site of urethral trauma. The glide wire passed through the suprapubically placed open-ended ureteric catheter was pushed down to the site of urethral trauma. This glide wire was easily identified during the retrograde urethroscopy, grasped with cystoscopic grasping forceps and pulled out through the external meatus. The 6 F open-ended ureteric catheter was introduced percutaneously over the glide wire till it appeared at the meatus. Later the glide wire was exchanged with super stiff zebra wire. This zebra wire then acted as a guide for 16 F Foley catheter, which was placed perurethrally in the bladder. If the supra pubic tract was dilated, an 18 F Foley catheter was placed suprapubically as a safety measure.
Postoperative course and follow-up
The suprapubic catheter, if placed was removed on first postoperative day before the patient was discharged from hospital. The urethral catheter was left in place for 1 to 3 weeks, depending on severity of injury. A dynamic urethrogram was performed by the side of catheter to confirm absence of extravasation of contrast before catheter removal. Patients were followed up at 1, 3, 6 and 12-month interval and than yearly. They were monitored with history, physical examination, uroflow rate measurement and ultrasonography guided determination of post void residual urine volume. Development of obstructive urinary symptoms, decrease in flow rate and/or increase in post-void residual urine volume was evaluated by retrograde urethography or Cystoscopy.