1. 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

2. Prostatic urethra
Posterior urethra
Membranous urethra
Bulbous urethra
Anterior urethra
Pendulous urethra

3. 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

4. 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

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

6. 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)

7. 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.

9. 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

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

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

13. 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%

14. 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

15. 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

17. 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
Webster et al
Follis et al
Hussman et al
Elliot and Barret
Koraitim /18
Herschorn et al NR /12
Moudouni et al
Total (%) /203 (48.7) /190 (4) /197 (22)

18. 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

19. 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

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