Harvard Program in Urology Early Endoscopic Realignment of Posterior Urethral Injuries: A New Paradigm of Management Sandy M. Chin, M.D. Department of Urology Harvard Program in Urology

Prostatic urethra Posterior urethra Membranous urethra Bulbous urethra Anterior urethra Pendulous urethra

Posterior Urethral Injury Etiology Blunt trauma from motor vehicle accidents or falls from heights Posterior urethral injury: >90% pelvic fractures present Pelvic fractures: 5% to 25% posterior urethral injury Rupture usually at membranous-bulbous urethral junction

Posterior Urethral Injury Physical findings Blood at urethral meatus Inability to urinate Palpable bladder Triad of symptoms occurs <50% Rectal exam: high riding prostate only if puboprostatic ligaments avulsed Pelvic hematoma mistaken for prostate

Posterior Urethral Injury Diagnosis Suspected by history and physical exam Retrograde urethrogram All patients with blood at the penile meatus Suspected urethral injury

Posterior Urethral Injury Retrograde Urethrogram (RUG) Small bore (14F) urethral catheter Place 1-2cm into urethra Blow up balloon with 1-2cc water, snug fit Gently inject contrast in 10ml increments Lateral decubitus films (static or fluoro)

Posterior Urethral Injury Classification of Posterior Urethral Injury Type I: Urethral stretch injury Type II: Partial or complete posterior urethral disruption. Extravasation limited to below the genitourinary diaphragm. Type III: Partial or complete posterior urethral disruption. Extravasation above and below genitourinary diaphragm.

Posterior Urethral Injury Degree of rupture Partial Contrast extravasates at site of injury but passes through to bladder 27% injuries Stent with urethral catheter Gentle placement of 16-F silicone urethral catheter by a urologist Confirm proper position with cystogram

Posterior Urethral Injury Degree of rupture Complete No contrast enters bladder Contrast extravasation into perivesical space 73% injuries

Posterior Urethral Injury Delayed open urethral reconstruction Standard of care >30 years Immediate suprapubic urinary drainage Delayed urethral reconstruction 3 to 6 months later

Posterior Urethral Injury: Delayed Open Urethral Reconstruction Advantages Avoid OR in acutely injured patients Avoids mobilization of prostate, urethra, and nerves responsible for erectile function Decreased risk pelvic hematoma infection Disadvantages Inevitable stricture formation Commitment to open urethroplasty Postop urethroplasty Strictures 5% Incontinence 5-12% Impotence 16%

Early Endoscopic Realignment of Posterior Urethral Injuries Principle Urethral catheter endoscopically placed 72 hrs after injury Bridges urethral defect Scaffolding for distracted urethral segments to reunite

Early Endoscopic Realignment of Posterior Urethral Injuries Benefits Minimally invasive Without stenting, avulsed urethra and prostate heal far from each other Future urethroplasty inevitable and more difficult Most will not need open urethroplasty No increase in rates of impotence and urinary incontinence

Early Endoscopic Realignment of Posterior Urethral Injuries Comparison Studies of Endoscopic Realignment Adapted from Moudouni S.M. et al.: Early endoscopic realignment of post-traumatic posterior urethral disruption. Urology, 57: 628, 2001. Patients (n) Stricture (n) Incontinence (n) Impotence (n) Patterson et al.10 29 11 1 4 Webster et al.11 19 18 1 10 Follis et al.12 20 3 0 4 Hussman et al.13 17 16 2 8 Elliot and Barret14 53 18 2 4 Koraitim3 23 12 1 5/18 Herschorn et al.15 13 7 NR 5/12 Moudouni et al.5 29 14 0 4 Total (%) 203 97/203 (48.7) 7/190 (4) 44/197 (22)

Early Endoscopic Realignment of Posterior Urethral Injuries Conclusions Comparable rates of continence and potency Minimally invasive Decreased operative time Decreased blood loss Decreased length of hospital stay

Early Endoscopic Realignment of Posterior Urethral Injuries Conclusions Higher stricture rate Successfully treated with endoscopic direct vision urethrotomy Failed endoscopic realignment, open urethroplasty still an option

Early Endoscopic Realignment of Posterior Urethral Injuries SUMMARY Minimally invasive Comparable complication rates New paradigm for treating posterior urethral injuries