Pro: endoscopic realignment for pelvic fracture urethral injuries

Background

In patients with pelvic fracture urethral distraction injury, there are two basic methods of early treatment. The first is early realignment over a catheter, usually using gentle blind or endoscopic techniques. The second is placement of a suprapubic tube, and subsequent open urethroplasty after the nearly inevitable urethral stenosis forms.

The benefits of early realignment over a catheter are potentially many. It is generally simple, avoids the need for placement of a suprapubic catheter, may decrease the overall impact of the urethral injury by promoting earlier return to spontaneous voiding, and may decrease the chance and degree of subsequent urethral obliteration.

Realignment method

There are several methods to place a urethral catheter into the bladder across a disrupted urethra. Most experts start with a simple retrograde catheterization attempt (1-3). If this fails, most modern authors choose retrograde flexible cystoscopy next (4,5). Retrograde flexible or rigid urethroscopy through a suprapubic tube can be attempted next (6). This procedure is claimed to require only 5-10 minutes when successful (5,6), while retrograde rigid cystoscopy has been reported to require an average of 22 minutes (7). If this fails, other authors have used two cystoscopes: one rigid one placed anterograde and a second flexible scope placed retrograde to bridge the gap (8,9).

Despite many documented techniques for realignment, our preferred stepwise approach is a single attempt at gentle blind passage of a catheter followed by retrograde flexible cystoscopy then rigid cystoscopy then suprapubic flexible cystoscopy (with or without simultaneous rigid cystoscopy).

Other techniques described involve placing a wire placed anterograde or retrograde across the defect and then placing a Council-tipped Foley catheter over the wire (10) or using a feeding tube placed in the penis which is placed into the bladder and grasped through a cystotomy (11). Direct placement of a Foley catheter anterograde through a cystostomy (1) or urethral cystoscopy towards a Goodwin sound placed through a cystostomy has also been described (12). Two blindly-placed anterograde and retrograde catheters with strong magnets on the end have been used to safely traverse the defect, but unfortunately these catheters are not commercially available (13). Older reports generally report open techniques using Davis interlocking sounds (2) or a metal sound in the urethra guided by a finger in the bladder neck (14), requiring a mean of 80 minutes to complete in one 1,983 study (2). A technique using anterograde or retrograde placement of catheters required less than 75 minutes (1).

Immediate procedural success of realignment and timing of attempts

The published procedural success rate of any realignment technique is variable depending on the author, and ranges from 70-100% (4,13-18). One series where authors gained experience in the technique over a 5 year period showed an increase in successful realignment rates from 80% up to 93% with time (7).

Most surgeons place the catheter as soon as practically possible (10) and this is generally achievable after a mean of 32 hours from injury (10). A single immediate blind placement of a Foley catheter is attempted at most centers soon after the injury is diagnosed (10). Some have delayed realignment up to 7-19 days (11) with good results. Authors have suggested that after initial failure, realignment can be attempted 2-3 days later with some success (4). A single report of a small number of early (72 hours) and more delayed realignment cases were compared and had similar rates of subsequent stenosis (9).

The recommended time that the catheter should be left in is highly variable, ranging from 3-6 weeks (2,4,10-13,19,20) with some recommend longer catheterization up to 8 weeks (9,19). We leave the catheter 6 weeks before voiding cystourethrogram or peri-catheter retrograde urethrogram is attempted. If there is no extravasation the Foley catheter is removed. If a suprapubic tube is also present, it is capped but left in place for at least 4 weeks to ensure there is no interim stenosis prior to removal.

Incidence of stenosis

Long term success of realignment is most importantly defined by the incidence of subsequent urethral stenosis; however, stenosis outcomes and the screening and diagnoses of urethral stenosis have been variable. A review of the literature demonstrated a wide rate of stenosis among series of patients undergoing realignment ranging from 14-100%; however, realignment appears to be associated with a lower chance of subsequent urethral obliteration by about 40% when compared to placement of a suprapubic tube alone (Table 1) (Figure 1). These findings are consistent with a recent meta-analysis of studies comparing primary realignment to cystostomy, in which, the authors report a significantly lower rate of stenosis among the primary alignment group with an absolute risk reduction of 37% (46).

Table 1 Rate of stenosis (%) by urethral management
Full table

Figure 1 Incidence of urethral stenosis (4,13,15,19,20,31,37-40,43-45).

In a recent case series of 19 patients undergoing primary endoscopic realignment, the authors report a failure rate of 79%, but of those failures three only required a single urethrotomy such that only 58% of the cohort went on to require urethroplasty (18). While we do not advocate for management with repetitive urethrotomies, these data imply that realignment allows for a less severe stenosis in some patients.

Time to voiding and length of stenosis

In one series, the patients who underwent realignment had a significantly shorter time to spontaneous voiding (35 vs. 229 days) than those who had cystostomy (4).

Furthermore, some authors have suggested that realignment also aligns the urethral ends so that any subsequent urethroplasty is technically easier (6). While there is not much evidence to support claims of less severe stenosis, one series did find significantly shorter stenoses among the cohort treated with early realignment as compared to cystostomy (42).

Complications of realignment

While most authors report good results from endoscopic realignment, some studies suggest that they decrease the success of any future urethroplasty. A report of 7 patients reported that in those that required urethroplasty, it was 1/2 as successful (43% for realigned group vs. 85% for uninstrumented group); however, this trend has not been demonstrated in other series. The authors hypothesized that endoscopic realignment causes inflammation and then fibrosis of the torn ends of the urethra, although no proof for this is given (47).

Confirmed early complications from endoscopic realignment are rare and sporadic. Most series that actually analyzed complications report no significant complications from the procedure (1). Attempting and failing to get realignment with a catheter is not believed to harm the patient (14). One series report a 1/34 (3%) incidence of pelvic abscess (2). A single urethro scrotal fistula appeared in a series of 14 (7%) realigned patients (10) and a perineal abscess developed in 1/6 (16%) and1/4 (35%) patients in other studies (22,23). Malposition of the catheter (including inadvertently “jumping” the catheter over the prostate and placing into the bladder via a bladder rupture) is a rare possibility and has been personally witnessed by the authors. Delayed realignment at a mean of 10 days caused septicemia in 15% of cases in one series (7) prompting us to avoid late attempts at realignment.

One series has reported that realignment was associated with increased need for multiple endoscopic procedures (48). Algorithmic approaches to any urethral stenosis/stricture patients should take into account the high likelihood of failure with repeated endoscopic procedures. As urethral disruption is associated with a high rate of stenosis, close follow-up after realignment is essential. If treated with a similar algorithm to any other urethral stenosis/stricture, that is, timely transition to urethroplasty after failed endoscopic management, there should not be a need for multiple interventions among urethral stenosis after realignment.

Erectile dysfunction and incontinence have been commonly reported following urethral distraction injuries; however, primary realignment does not appear to increase the baseline incontinence or erectile dysfunction rate (Tables 2,3). Variation seen in a variety of series with regard to erectile dysfunction and continence likely reflects the diversity of the initial injury rather than the method of urethral management (Figures 2,3).

Table 2 Rate of incontinence (%) by urethral management
Full table

Table 3 Rate of erectile dysfunction (%) by urethral management
Full table

Figure 2 Incidence of incontinence (3,14,15,41-45).

Figure 3 Incidence of erectile dysfunction (3,14,15,41-45).

Limitations

Almost all reports used different methods of achieving urethral alignment, making direct comparisons difficult. Outcomes from old reports describing open, often highly invasive, techniques (e.g., removing hematoma or cutting the puboprostatic ligaments) cannot be properly compared to modern endoscopic techniques.

It is also possible that patients in whom realignment is possible may have less serious injuries that those in which it fails. In some series the patients managed with suprapubic cystostomy had previously failed alignment attempts, and these patients probably have more significant injuries and longer urethral distraction distances than those in whom alignment was successful. One report of 16 patients determined that partial urethral tears as determined by urethrography were present in 33% of those in whom realignment was not possible and 46% of those in whom realignment was possible (15). The incidence of partial versus total urethral disruption found partial injuries to be much more common in the cystostomy group (7%) than the alignment group (39%) (15).

Conclusions

Review of over thirty studies, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Secondary benefits of realignment may include easier subsequent urethroplasty, when necessary, and possibly shorter stenoses. Endoscopic realignment is not associated with a higher rate of immediate or delayed complications. While the rate of subsequent urethral stenosis after realignment remains high, the potential to eliminate the need for complicated urethroplasty in up to a third of patients cannot be ignored.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

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