Immediate endoscopic management of complete iatrogenic anterior urethral injuries: A case series with long-term results

Anterior urethral rupture is rare and is usually iatrogenic, during catheterisation or urethral dilatation. Trauma resulting from inflating a Foley balloon in the urethra occurs frequently. It may also result from blunt trauma e.g. saddle injury.

The definitive management of anterior urethral injury remains controversial [1]. Initial supra pubic cystostomy and delayed urethral re-construction had been considered as a reference standard for managing posterior urethral injuries [2]. This approach has problems like need of a supra pubic drainage for prolonged period (6 weeks to 3 months) as well as formation of an inevitable urethral stricture requiring reconstructive urethroplasty.

Recent advances in endourological techniques have made primary realignment feasible to perform with minimal manipulation. This technique realigns the urethra over a urethral catheter that splints the urethra till the healing occurs [3]. We herewith retrospectively analyse our experience with immediate endoscopic realignment of iatrogenic complete anterior urethral injuries.

All patients had complete loss of urethral continuity. Bulbar urethra was affected in four patients and the remaining three patients had proximal penile urethral rupture. Glide wire was negotiated retrogradely only in one patients & the remaining six patients needed antegrade (suprapubic) access. Rigid antegrade cystoscopy was needed through suprapubically placed Amplatz sheath in five patients.

Procedure was successful in all the seven patients. Suprapubic catheter kept in five patients was removed on first post-operative day. Per urethral catheter was kept for one week in three patients, two weeks in two patients and for three weeks in remaining two patients. No patient had extravasation of contrast during dynamic retrograde urethrogram performed before catheter removal. All patients were asymptomatic and had insignificant post-void residue on sonography during 1-month follow-up. The peak uroflow rate was 19.7 ml/sec. (range 15–24 ml/sec) & the post-void residual urine was 38 ml (range 10 to 55 ml) on ultrasonography measurement. By six months of follow-up three patients developed stricture at the site of trauma. Of these two patients had injury during dilatation for the stricture urethra. All these three patients were treated by optical urethrotomy and were taught self-calibration of urethra for an average period of 6 months. With the average follow-up of 49.2 months (range 7–74 months) all, except one patient are asymptomatic with no further recurrence of stricture urethra. Only one patient developed multiple recurrences & was offered open end-to-end urethroplasty at twenty months after third recurrence. Hence four of our patients (57.14%) were disease free during their follow-up after their immediate endoscopic realignment for urethral trauma. After an additional optical urethrotomy, urethroplasty could be avoided in six patients (87.2%).

Controversy continues regarding proper management of traumatic urethral disruption. The suggested surgical treatment modalities include a) immediate primary simple realignment over a stenting catheter b) immediate primary suture repair c) immediate suprapubic cystostomy alone, with delayed elective urethroplasty for the resulting stricture. Many urologists believe that delayed urethral reconstruction is the safest method [2]. However, placement of suprapubic catheter significantly impairs the patient's quality of life.

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. In a recent review on management of urethral trauma, it is stated that a stenting urethral catheter may be useful in management of anterior urethral injury in some cases [4]. However the exact role of primary endoscopic realignment in management of complete iatrogenic urethral injury was not specified.

Towler JM et al initially described realignment of traumatic urethra over a splinting catheter by instrumentation and endoscopy via both suprapubic and urethral routes in an effort to decrease patient morbidity [5]. Moudouni SM et al described early endoscopic realignment of posterior traumatic urethral disruption [6]. On follow up of 68 months they concluded that the urethral continuity could be established without any increase in the incidence of impotence, stricture formation or incontinence. In case of failure, endoscopic realignment doesn't compromise the results of secondary urethroplasty. In another study Jepson BR et al employed a variety of endourological techniques to achieve urethral continuity in 8 patients [3]. The average time to realignment was 9.5 days. With a mean follow up of 50.4 months four patients required subsequent internal urethrotomies with eventual voiding stabilisation over the course of 11 months. Olapede J et al used either both antegrade & retrograde cystoscopy (with or without fluoroscopy), or flexible retrograde urethroscopy alone for primary endoscopic realignment of posterior urethral trauma [7]. Similar good results were reported in various studies from different institution [8–11]. Thus the technique of immediate endoscopic realignment of urethral injuries is widely employed for management of posterior urethral injuries.

Since the anterior urethral injuries are rare, accepted treatment methods are commonly based on relatively few patients. Benchekroun A et al on reviewing their 23 patients with anterior urethral trauma recommended delayed end to end anastomosis for total rupture, reserving immediate repair in patients with associated penile fracture [12]. Dobrowlski ZF et al in their series of 255 patients with anterior urethral injury found iatrogenic trauma during catheterisation or cystoscopy to be commonest (206 patients) [13]. The treatment was conservative in 193 patients and surgical in 62. Partial rupture of anterior urethra will heal after urinary diversion alone with excellent results [14]. However the most common complication of complete urethral rupture is development of urethral stricture [15]. The goal of immediate primary realignment lies in the ability to perform the procedure in as timely a fashion as possible with minimal disruption to the already traumatized tissue. Realignment of the urethra will produce more anatomically aligned stricture and obviate the need for long-term suprapubic tube drainage [15]. Londergan TA et al employed early fluoroscopic realignment for traumatic urethral injury [9]. Of 2 patients with anterior urethral trauma, the procedure was successful in one patient. The patient later required visual internal urethrotomy at 35-month follow-up. Keeping the results of primary endoscopic realignment of posterior urethral injuries in mind, Ying-Hao S et al were first to employ technique of urethroscopic realignment for treating 16 patients with ruptured bulbar urethra [1]. They felt that since the gap in the anterior urethra after disruption is relatively short and the proximal end of disrupted anterior urethra is more immobile, a combined suprapubic intervention was not required to re-establish anterior urethral continuity. However only 4 patients in their series had complete injury. They found procedure feasible in all these patients with only 1 patient requiring intermittent self-dilatation once weekly. They treated all patients on outpatient basis under local anaesthesia. Based on their results, they recommended primary endoscopic urethral reunion as an ideal, cost effective treatment in treating male patients with bulbar urethral disruption. Nakajima et al employed a thin trocar needle for endoscopic realignment of complete disruption of bulbar urethra resulting from a straddle injury [16]. They confirmed exact suprapubic trocar position with flexible antegrade cystoscopy and placed a guide wire in proximal urethra and found the procedure safe, simple and reproducible. Ku JH et al supplemented above results by comparing immediate versus delayed treatment [15]. Of 95 patients studied, 46 had complete disruption. Primary endoscopic realignment was successful in 65 patients. The remaining patients underwent delayed repair. In their experience, the incidence of urethral stricture after complete disruption was statistically low in patients undergoing immediate realignment as compared with those patients treated with delayed repair (31.3% vs. 68.8%). They suggested that better outcomes could be obtained when immediate urethral realignment is successful in patients with bulbar urethral disruption.

In view of encouraging results of primary endoscopic realignment of posterior urethral disruption, we employed the similar technique for treating our patients with iatrogenic anterior urethral injuries from May 1997 onwards. Our results are encouraging and except for three patients who developed stricture at 6 months follow-up, rest all patients had a patent urethra without any urinary symptoms. We believe that the development of stricture in these three patients was attributable to presence of urethral stricture before urethral trauma rather than the long-term result of immediate endoscopic realignment that they underwent for urethral trauma. Two out of these three patients had documented stricture for which they had undergone dilatation in past. During dilatation, trauma resulted causing urethral disruption. Patients who developed stricture during follow-up were easily managed by optical urethrotomy, avoiding the need for open urethroplasty &/or long-term supra-pubic urinary diversion. Based on our experience we feel that immediate endoscopic realignment of iatrogenic anterior urethral disruption is feasible, safe and effective. The major drawback of our study is small number of patients and lack of comparison with patients who were managed by delayed method. A prospective randomised trial with larger number of patient is necessary to evaluate definitive role of immediate endoscopic realignment in management of complete anterior urethral injuries.

Immediate endoscopic realignment of complete iatrogenic urethral disruption is a feasible, safe and effective treatment modality for management of these patients.