disruption of the posterior urethra?

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Disponibleenlignesur

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ORIGINAL ARTICLE

When to remove the urethral catheter after endoscopic realignment of traumatic

disruption of the posterior urethra?

Quand retirer le cathéter de l’urètre après le réalignement endoscopique de la rupture traumatique de l’urètre postérieur ?

H.M. El Darawany

FRCSIUrology,ImamAbdulrahmanBinFaisalUniversity,KingFahdHospitaloftheUniversity, DepartmentofUrology,Khobar,SaudiArabia

Received10March2017;accepted22June2017 Availableonline26July2017

KEYWORDS Urethra;

Urethraldisruption;

Urethralrealignment;

Urethralstenting;

Urethralstricture

Summary

Objective.—Todetecttheoptimaltimeforurethralstentremovalafterendoscopicurethral realignmentanditseffectontheincidenceofdevelopmentofurethralstricture.

Patientsandmethods.—Eighteenpatientsunderwentendoscopicurethralrealignmentafter traumaticdisruptionoftheposteriorurethra.Post-operativeurethroscopywasdoneusingthe flexible cystoscopetoassess progress ofurethral healing.The urethral Foley catheterthat served as astent andfor urine drainage was removed only when complete mucosal heal- ingwas observedby flexible urethroscopy. There was apost-operative follow-up period of 12—36months.Uroflowmetrywasperformedattheendofthefollow-upperiod.

Results.—Endoscopy6weeksafterrealignmentshowed50—75%mucosalepithelializationat thesiteofurethraldisruptioninallpatients.Epithelializationwascompleteat9weeksin15/18 patients(83%)andat12weeksintheremaining3patients(17%).Onepatient(5.6%)developed amild symptomaticstricture 5months post stent removalthatwas successfully treatedby asinglesessionofvisual urethrotomy.All 18patients hadnormaluroﬂowmetry readingsat 12—36monthsafterrealignment.

E-mailaddress:heldarawany57@gmail.com http://dx.doi.org/10.1016/j.purol.2017.06.006

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Conclusions.—Urethralstentingshouldbecontinuedtillmucosalhealing atthesiteofure- thral disruptionbecamecomplete. Removalofthestentatthisoptimaltimedecreasesthe incidence ofpost-operative urethral stricture.Flexible urethroscopy was a safe procedure for post-operative follow-upof endoscopicurethral realignmentto assess theprogress and completionofmucosalhealingatthesiteofrealignment.

Levelofevidence.— 4.

MOTSCLÉS Urètre;

Laruptureurétrale; Leréalignementde l’urètre;

Lestenturétral; Lerétrécissementde l’urètre

Résumé

Objectif.—Déterminerletimingoptimalpourl’ablationdelasondevésicaleaprèsréaligne- mentendoscopiquedel’urètreetsoneffetsurl’incidencedessténoses.

Patientsetméthodes.—Dix-huitpatientsontsubiunréalignementendoscopiquedel’urètre aprèsrupturetraumatiquedel’urètrepostérieur.L’urethroscopie postopératoireaétéréal- iséeenutilisantuncystoscopeﬂexiblepourévaluerl’évolutiondelacicatrisationurétrale.Le cathéterdeFoleyurétralquiservaitd’endoprothèseetdedrainagedel’urinen’aétéretiré quelorsquelaguérisonmuqueusecomplèteavaitétéobservée.Ilyaeuunepériodedesuivi postopératoirede12à36mois.Unedébitmétrieaétéréaliséeàlaﬁndelapériodedesuivi.

Résultats.—L’endoscopie6semainesaprèsleréalignementarévéléuneépithélialisationde lamuqueusede50à75%ausitederuptureurétralecheztouslespatients.L’épithélialisation étaitcomplèteà9semaineschez15/18patients(83%)età12semaineschezles3patients restants(17%).Unpatient(5,6%)adéveloppéunesténosesymptomatiquelégère5moisaprès l’ablationdelasondequiaététraitéeavecsuccèsparuneseuleuréthrotomieendoscopique.

Tousles18patientsonteudesdébitnormauxà12—36moisaprèsleréalignement.

Conclusions.—Lestenturétraldoitêtrepoursuivijusqu’àcequelacicatrisationdelamuqueuse ausitederuptureurétraledeviennecomplète.L’ablationdela sondeàcemomentoptimal diminuel’incidencedessténosesurétralespost-opératoires.

Niveaudepreuve.— 4.

Introduction

Endoscopic urethral realignment is a minimally invasive techniquethatwasdescribedfortheearlymanagementof traumaticposteriorurethraldisruption[1—3].Inspiteofits widepopularity,ahighincidenceofpost-operativeurethral stricturedeveloped,sometimesexceeding50%[2,4—8].The high incidence was also reported after surgical urethral realignment[9].

The Foley catheter is commonly removed 3—6weeks post-operatively when pericatheter retrograde ure- thrograms showed no evidence of extravasation [2,3,6—8,10,11]. In this study, endoscopic evidence of complete mucosal healing rather than pericatheter retrograde urethrography was the determining factor for selecting the optimal time of removal of the urethral catheter. The incidence of subsequent development of urethralstricturewasassessed.

Patients and methods

This retrospective study comprised 21 adult males (12—43years old; mean=26.3years) who were presented

bytraumaticurethralruptureandmanagedbyendoscopic urethralrealignmentduringtheperiodfromOctober2008 till January 2016. The procedure was aborted in 3/21 patientsforfailuretoestablishendoscopicurethralrealign- ment. The remaining 18 patients were included in the study. The patients were admitted from the Emergency Roomwithpelvicfracturesandcompletedisruptionofthe prostato-membranous urethra following road trafﬁc acci- dents.Diagnosiswasconﬁrmedbyretrogradeurethrography.

Percutaneous suprapubic cystostomy was performed shortlyafteradmissioninallpatientstorelieveurinereten- tion.Appropriateinvestigationswerecarriedouttoscreen forpossible associatedinjuriesthatweremanaged bythe concernedmedicalteams.Endoscopicurethralrealignment was performed under general anesthesia in 14 patients within3daysfromthedateofadmission.Therewasadelay of5—8daysin4patientstocontrolassociatedrenalinjury, liverinjuryand/orhemodynamicinstability.

A flexible urethroscope was introduced along the distal urethra(retrograde flexible urethroscope) tovisualize the proximalurethral end. If failed,identification of the proximalurethral segmentwas facilitatedby injection of methylene blue in the bladder through the suprapubic catheterwithattempttofollowthedyeemergingfromthe

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proximalurethral end. Simultaneous use of an antegrade flexiblecystoscopethatwasintroducedthroughthesupra- pubiccystostomy tractwas used if the proximalurethral endfailedtobevisualizeddirectlyorbytheaidofmethy- leneblue.Theantegradecystoscope wasadvancedtothe proximalurethra.Itwasusedforantegradelightillumina- tion,injectionofmethyleneblueoradvancementofaguide wire to the pelviccavity andtrial tofollow any of them byretrogradeflexibleurethroscope tovisualizetheproximalurethralend.Oncetheproximalsegmentwasidentified bytheretrograde flexibleurethroscope, aguidewire was advancedtotheproximalurethrathentothebladder.The retrogradeflexibleurethroscopewasthenremovedfromthe urethraandaFoleycatheter(14Fr—18Fr)wasadvancedover thatwiretothebladderandfixed.The antegradeflexible cystoscopeusedtoconfirmthepositionoftheFoleycatheter insidethebladder.Afterremovalofantegradeflexiblecys- toscope, suprapubic catheter was inserted. The urethral catheterserves as a stent while the suprapubic catheter usedforbladderdrainage.

Theendoscopicrealignmentwasterminatedwhenthere wasinability tovisualizetheproximalurethralend either directlybytheretrogradeﬂexibleurethroscopy,orbysimul- taneoususeofretrogradeandantegradeﬂexibleendoscopy withaid of methylene blue, guidewire or light emerging fromtheproximalurethralend.

Pericatheter retrograde urethrogram wasperformed in all patients 6week post-operatively. In the absence of contrast extravasation, the Foley catheter was removed followedby immediateﬂexibleurethroscopy asan outpa- tientproceduretoassessthemucosalhealingatthelevel of the realignment gap between the 2 aligned urethral segments. If mucosal healing was incomplete, the Foley catheterwasre-insertedinthebladderover aguidewire.

Urethroscopywasrepeatedat 9and12weekstillmucosal healingwascomplete.TheurethralFoleycatheterwasthen removed.Follow-upuroﬂowmetrywasdone12—36months post-operatively.

Results

Noneofthepatientshadanyhistoryofurologicalorsexual problemspriortourethralinjury.Theyallhadpelvicbone fracturesandcompletedisruptionoftheposteriorurethra atthetimeofpresentation.AccordingtoTileclassiﬁcation offracturepelvis[12],12patientshadTileAstablepelvic fracture,6hadTileBverticallystable/rotationallyunstable pelvicfracture,and3hadTileCrotationallyandvertically unstable pelvicfracture. Endoscopic urethral realignment was successful in 18/21 patients. The 3 failures (all of themhadTileCrotationallyandverticallyunstablefracture pelvis),were caused by inability to identify the proximal disruptedurethraendoscopicallyandwerelatertreatedby perinealurethroplasty.Theywereexcludedfromthestudy.

The delay of endoscopic realignment of 5—8days in 4 patientswhohadTileBrotationallyunstable/verticallysta- ble fracture pelvis did not jeopardize the post-operative resultsastheyallhadunremarkableoutcomes.Atthetime ofrealignment,theproximalurethralendwasidentiﬁedby theretrogradeﬂexibleurethroscope in2patients without needforassistedantegradeguidance.Antegradeguidance

usingmethylenebluewasrequiredin3patients,illumina- tionin5andadvancementofaguidewirein8.

The operative time estimated, from insertion of the retrograde ﬂexible urethroscope to ﬁxation of urethral catheter, was 23 to 39mins (mean 30.9mins, median 31mins).

At6weeks,pericatheterretrogradeurethrogramshowed noextravasationofcontrastinanyofthepatients.TheFoley catheterwasremovedandaﬂexibleurethroscopewasthen easily advanced under vision along the entire urethra till thebladder.Therealignmentgapappearedcompletelysur- roundedbyconnectivetissuearoundapatentlumen.None ofthepatientshadcompletemucosalhealing.Themucosa covered 50—75% of thecircumference of the realignment gap (Fig. 1). The remaining non-epithelialized circumfer- encewasstillcoveredbyconnectivetissue.Thoseﬁndings werebasedontheoperator’ssubjectiveassessment.AFoley catheterwasre-insertedandurethralstentingcontinuedfor another3weeks.

A second urethroscopy at 9weeks, after removal of Foleycatheter,showedcompleteepithelializationin15/18 patients(83%)withthemucosacoveringtheentirecircum- ferenceof therealignmentgap.12/15patients previously had Tile A stable fracture pelvisand 3/15 previously had TileBverticallystable/rotationallyunstablefracturepelvis.

So,theurethralcatheterwasnotre-inserted.Inthe 3/18 remaining patients (17%) who had Tile B fracture pelvis, 90—95% of thecircumference of therealignmentgap was coveredby mucosa,leaving5—10%stilllinedonlyby con- nectivetissuewithoutmucosa(Fig.2).Inthose3patients, Foleycatheterdrainagecontinuedfor3moreweekstillcom- plete mucosalhealingwaslaterobservedatweek 12bya 3rdurethroscopy.

All 18 patients were continent and voided satisfacto- rily after catheter removal 9—12weeks post-operatively.

One patient (5.6%) in whom the Foley catheter kept for 12weeks developed symptomatic urethral stricture 5monthsafterremovalofcatheter.Thestricturewasmild

Figure1. Urethroscopyat6weeks:a3×4cmnon-epithelialized area in the realignment gap lined by connective tissue (white arrows).Theblackarrowpointstotheprostaticurethra.

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Figure2. Urethroscopyat12weeks(samepatient):mostofthe non-epithelialized area has been covered by mucosa leaving a 1×0.5cmareawherethedeeperconnectivetissuelayerwasstill exposed(white arrows).The Foley catheter inthis patient was removedatweek15whenepithelializationwascomplete.Theblack arrowpointstotheverumontanumandprostaticurethra.

andwassuccessfullytreatedbyasinglesessionofinternal urethrotomy. Follow-up uroﬂowmetry done 12—36months post-operativelyrevealedameanpeakurinaryﬂowrateof 15.8mL/s(range12.7to18.3).

Discussion

Following complete disruption of the posterior urethra, the distal urethralsegment remains ﬁxed to the urogeni- taldiaphragmwhiletheproximalsegmentretractsbackin thepelviccavity.Awidenon-alignedgapdevelopsbetween bothurethralsegments[13].Thecommoncurrentpractice for managementof post-traumatic completedisruptionof the posterior urethrais suprapubic cystostomy only tobe followedafewmonthslaterbysurgicalurethroplasty.Endo- scopicurethralrealignmenthasrecentlygainedpopularity asanalternative lineoftreatment.Itreducedbutdidnot aborttheneedforsurgicalurethroplasty[7].

Whentraumaticposteriorurethraldisruptionismanaged bysuprapubiccystostomyonly,thesubsequenthealingpro- cessproducesalongobstructedﬁbrousbandwithinthatgap.

Surgicalurethroplastyperformedatalaterstageisoftendif- ﬁcultandchallenging.Ontheotherhand,thegapbetween bothrealignedurethralsegmentsafterendoscopicurethral realignmentis short.It is referred toin this studyas the

‘‘realignmentgap’’. Itwasestimated tovaryfrom1.5 to 4cminlength[14].Thisgapalsohealsbygranulationtissue formationandcanendinstricturedevelopment.

The Foley catheter that is inserted in the urethra at the time of realignment serves 3 important functions. It achievesintra-operativeapproximationwithrealignmentof both disrupted urethral ends, it maintains post-operative urine drainage and it acts as a stent during the post- operativehealingperiod.Unlikeopenurethralrealignment, endoscopicurethralrealignmenthasnosuturestakenatthe timeofrealignmentandthereisnodissectionofdevitalized tissuesatthesiteofthetrauma.

Manystudiesintheliteratureareinfavorofendoscopic urethralrealignmentasaminimallyinvasiveprocedure[7].

Eventhoughitwasfollowedbyahighincidenceofurethral stricture,notallpatientscomplainedofstrictureandmany remainedsymptom-free throughoutthefollow-upperiods.

Urethralstricture isexpected todevelop post-operatively consideringthattherealignmentgapiseventuallyoccluded byﬁbrous tissueduring thecourse of the healingprocess [15]. In their studies on the canine urethra, McRoberts and Ragde reported that healing of the transected ure- thrawassolelybygranulationtissue[16].Inanotherstudy, Hardy reported presence of re-epithelialization together withgranulation tissueduringtheprocessofhealing[17].

Flexibleurethroscopy in this study conﬁrmed presence of epithelializationbymucosalcreepingfrombothalignedure- thraledgestocoverthegranulation tissueatrealignment gap.

The stentingeffectof theFoley catheteris crucialfor propermucosalhealingofthatgap.Thecurrentpracticeas shownintheliteratureistokeeptheurethralstent(Foley catheter)inplacetillpericatheterretrogradeurethrography revealsabsenceofcontrastextravasation[2,3,6—8,10,11].

In these studies, contrast ceased to extravasate 6weeks post-operatively in pericatheter retrograde urethrogram.

Based on these ﬁndings, we used to do retrograde peri- catheterurethrogram6weeksafterendoscopicrealignment thatshowednoextravasationinallpatients.

In the absence of extravasation of contrast by peri- catheterretrogradeurethrogram6weekspost-operatively, ﬂexibleurethroscopy showedthat the gap betweenthe 2 realignedends,inspiteofcompletelycoveredbyconnective tissue,the mucosal covering wasincomplete with patchy areasoftherealignmentgapbeingcoveredbymucosaand otherpatchesbeinguncovered.Thatiswhy,completeheal- ingofurethralwallattherealignmentgapby granulation andconnectivetissuewithoutcompletemucosalhealingcan preventcontrastextravasationinpericatho-urethrogram.

Tausch et al. considered healing by fibrosis inevitably results in occlusion of the urethral lumen [15]. However, there seems to be a correlation between the extent of mucosalhealing and the degree of urethral lumen occlusion.Re-epithelializationcanexertahinderingfactoronthe occlusiveeffectofthegranulationtissue.Themoreisthe epithelializationbyprolongedstenting,thelessistherisk ofstrictureprogression.Based onthat, periurethralfibro- sisisinevitable processandearly removalof theurethral stentbeforecomplete mucosalre-epithelializationcarries the risk of connective tissue to creep toward the lumen throughspacesthathavenotyetbeencoveredbymucosa, whilecompletemucosalre-epithelializationoftherealign- mentgaplimitstheocclusiveeffectofthefibroustissuethat canresultinurethralstrictures.

In 7studies [2,3,6,8,9,18,19] where the urethralstent wasremoved basedonthe resultsof pericathogram,urethralstricture developed in 14 to79% of cases (Table 1).

Inthisstudy,whenurethralstentingcontinuedtillmucosal healingwascompleteasprovedbyﬂexibleurethroscopyat 9—12weekspost-operatively,symptomatic stricturedevel- opmentdroppedto5.6%.

In this study, Flexible urethroscopy was performed in allpatients6weeksafterendoscopicurethralrealignment, twicein83%and3timesin17%.Thefrequentuseofﬂexible

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Table1 Incidenceofstrictureinrelationtodurationofpost-operativeurethralstentingbytheFoleycatheter.

Authors Realignment #ofpatients Postop.

catheterization (weeks)

Stricture(%)

ElliottandBarrett,1997[9] Surgical 53 2—10 66

Moudounietal.,2001[2] Endoscopic 29 4—6 41

Mouravievetal.,2005[18] Endoscopic 57 4—6 49

Hadjizachariaetal.,2008[3] Endoscopic 14 3—6 14

Soferetal.,2010[6] Endoscopic 11 4 45

Leddyetal.,2012[19] Endoscopic 19 2—12 79

Johnsenetal.,2015[8] Endoscopic 27 3—27 63

Thisstudy Endoscopic 18 9—12 5.6

urethroscopyinthisstudyisnotadisadvantage;itisasimple officeprocedurethatisperformedunderlocalanaesthesia withnoside effects.It offeredgreatbenefitfor determi- nation of the extent of urethral mucosal healingand the propertimeofcatheterremoval.Thesubsequentsignificant reductionintheincidenceofpost-operativeurethralstric- turesavedmanypatientsfromtheneedofrepeatedinternal urethrotomyorsurgicalurethroplasty.

Otherfactor thataffectthesuccess ofendoscopicure- thralrealignmentanditsoutcomeisthetypeofassociated fracturepelvis.Inthisstudy,itwasnoticedthatendoscopic urethralrealignmentofthetraumaticruptureurethrawas failedin patients withTile C pelvic fracture. The failure maybeduetowidedisplacementofthetwodisruptedure- thralendssecondarytoassociatedbigpelvic haematoma.

However,therewasnodifferencebetweenTileAandTile Bpelvicfractureregardingtheprocedure itselfor itsout- come.

Limitations tothis studyincluded thesmall numberof patientsnotallowingstatisticalanalysis.Thiswasattributed totheinfrequentcasesofposteriorurethraldisruptionseen in each hospital. In addition, the 12—36month follow-up period was not long enough to predict complete clinical cure.However,theresultsseemedtobefavorable.

Conclusions

Followingendoscopicurethralrealignment,complete cov- erageof therealignmentgap by connectivetissuealways precededcompletecoveragebymucosa.Thestentingeffect oftheindwellingurethralcatheterisimportantforbothcon- nectivetissueandmucosalhealingaroundapatentlumen.

Completemucosalhealingseemstohindertheobstructive effectof peri-urethral ﬁbrosis. The use of a ﬂexibleure- throscopeisimportanttoobservetheprogressofmucosal healingandtodetermine theoptimaltimeforremovalof theFoleycatheterafterendoscopicurethralrealignment.

Disclosure of interest

Theauthordeclaresthathehasnocompetinginterest.

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