Endoscopic re-establishment of urethral continuity after traumatic disruption of the membranous urethra

We report 3 cases of complete traumatic disruption of the membranous urethra treated by transurethral section of the scar tissue with transvesical endoscopic guidance and digital rectal control. Postoperatively, the patients required an average of 3 subsequent urethrotomies. They remain well, continent and free of voiding symptoms for 28, 11 and 14 months after re-establishment of urethral continuity. We suggest that this treatment be considered as an alternative to conventional surgical repair, particularly in elderly and other high risk patients.     

Early endoscopic treatment of a complete traumatic rupture of the membranous urethra

A man presenting complete traumatic disruption of the membranous urethra, with a 1 cm gap between the proximal and distal urethra, underwent successful endoscopic reconstruction ten days after the injury. When the urethral catheter was removed after fifteen days, peak flow rate was 25 cc per second. One internal urethrotomy was necessary 8 months later. Twenty months after the injury, cystography and retrograde urethrography revealed satisfactory restoration of urethral continuity. We suggest that this treatment be considered in complete traumatic disruption without hematoma and with less than a 1 cm gap between the proximal and distal urethra.     

Post-traumatic stenosis of the membranous urethra

Secondary urethral stricture is the most serious complication of traumatic rupture of the membranous urethra, directly related to the treatment of the rupture. In a series of 45 patients treated for urethral rupture with a minimal follow-up of 5 years, 30 developed stricture (66%). An urethral guide, inserted in 31 cases, was responsible for the stricture in 26 of these cases (84%). This stricture developed rapidly (average of 7.4 months), whether the initial rupture was complete or incomplete and was longer (average of 35 mm) in the case of complete rupture. End-to-end urethrorraphy performed between the 15th and 35th day in 14 patients was complicated by 4 secondary strictures (28%). The treatment of the stricture depended on the initial treatment of the rupture and the radiological length of the stricture. In the case of stricture secondary to an urethral guide, end-to-end urethrorraphy for a stricture less than or equal to 40 mm (12 cases) and 2 stage urethroplasty for a stricture greater than 40 mm (4 cases) achieved a good result in 68.8% of cases. The strictures secondary to end-to-end urethrorraphy (4 cases) were treated by direct vision urethrotomy (3 cases) with 100% of immediate good results and by urethral telescoping (1 case) complicated stress urinary incontinence.     

Endoscopic re-establishment of membranous urethral disruption

A total of 17 patients with traumatic membranous urethral disruption underwent urethral reconstruction via a core-through technique. Followup was 1 to 8 years (mean 3.7 years) postoperatively, and included 6 weeks with an indwelling catheter, periodic dilation for 6 months and occasional sounding. Within 1 year postoperatively, 6 patients required additional scar incision, including 3 who underwent scar resection. At 1 to 8 years postoperatively 6 patients had complications: 3 had stricture requiring periodic dilation (including 2 who underwent scar incision), while 2 had mild stress incontinence and 1 had nocturnal enuresis. Traumatic impotence was noted in 7 patients but the operation was not the cause in any. This method of endoscopic management was found to be an acceptable alternative to urethroplasty in cases of membranous urethral disruption.     

The management of strictures of the membranous urethra

We present 40 cases of posterior urethral stricture resulting from pelvic fracture injury or prostatectomy. The strictures were managed according to various factors but most important were stricture length and the absence of pathological conditions in the anterior urethra. Post-traumatic obliterative strictures less than 2 cm. long can be managed with excellent success via a 1-stage perineal bulboprostatic anastomotic repair. Combined abdominoperineal procedures are equally successful but are reserved for patients in whom the stricture is more than 2 cm. long or who have an associated bladder neck pathological condition. When associated anterior urethral disease mitigates against mobilization and extension of the urethra to accomplish an anastomotic repair, the vascularized island flap or 2-stage scrotal inlay procedure appears to be the optimal choice. Of 3 failures with full thickness skin grafts 2 may have been owing to suboptimal graft beds in the scarred pelvic floor and perineum. Direct vision urethrotomy is advocated for nonobliterative posttraumatic strictures, and the rationale for dilation rather than urethroplasty management of postprostatectomy strictures is presented.     

Complete disruption of the female urethra.

PURPOSE: We report a rare condition of complete rupture of the bladder neck with an anterior vaginal laceration secondary to blunt pelvic trauma in a 19-year-old woman. METHODS: Management consisted of a suprapubic cystostomy, followed by end-to-end anastomosis 3 days later. RESULTS/CONCLUSIONS: After 6 months, the patient is continent without any urinary disturbances.     

Visual urethrotomy in the management of the obliterated membranous urethra

Delayed direct-vision internal urethrotomy is a reasonable first treatment of the traumatically obliterated posterior urethra. Postoperative continence is achieved if the bladder neck is competent on preoperative cystogram. Simultaneous suprapubic and transurethral instrumentation most accurately define the length of obliterated urethra, and rectal examination determines any prostatic displacement. Half the patients will require repeat endoscopic surgery for significant stricture, and all require long-term follow-up to assure urethral patency. Potency is not affected by the procedure. Urethrotomy failure should not preclude a subsequent open procedure.     

Delayed retropubic urethroplasty of completely transected female membranous urethra

Injuries to the female urethra, especially in childhood, are rarely seen with pelvic trauma. Complete transection of the membranous urethra was sustained by a ten-year-old girl in a car accident. A delayed retropubic urethroplasty after suprapubic cystostomy drainage was accomplished. The technique of the repair is described. Delayed repair in a female child is an excellent alternative to primary realignment if a primary repair cannot be accomplished.     

Urethral duplication and complete bladder exstrophy

Urethral duplication is a rare anomaly that has been classified into epispadiac, hypospadiac, spindle, Y-duplications and collateral varieties. We report a case of an accessory urethra associated with complete bladder exstrophy in which the accessory urethra was integrated into the epispadias repair. To our knowledge this is the first case reported of urethral duplication associated with bladder exstrophy.     

The characteristics of the membranous part of the urethra]

The membranous part of the urethra has anatomic specificity influencing its trauma mechanism and allowed for in the trauma treatment policy. In 239 patients with an injured membranous part of the urethra described in the paper, the rupture was mainly due to the hip fracture. 85% of the patients developed a complete rupture with subsequent obliteration, 15% had strictures. Cicatrization involved the whole membranous part in 74% of the cases. In relevant traumas common are severe rectourethral and peritoneal fistulas surgical treatment of which as well as obliterations involves great technical difficulties. There is a variety of operative approaches and techniques (perineal, original anteropubic and anorectal). Urethral reconstruction should not be followed by bougienage. Typical are also frequent renal and genital complications (phlegmons, nephroliths, ureteroliths, epididymitis, orchitis, prostatitis, pyelonephritis). The number of complications depends on the choice of the adequate operative technique and due consideration of anatomical characteristics of the membranous part of the urethra.     

The transpubic approach for strictures of the membranous urethra.

Strictures of the membranous urethra following pelvic fractures pose a challenge in management because of their relatively inaccessible position above the urogenital diaphragm and behind the pubic symphysis. The corrective procedures the pass up from the perineum through the urogenital diaphragm to reach the stricture have the real or theoretical disadvantage of defunctionalizing the external urethral sphincter and leaving continence dependent solely upon the competency of the bladder neck. On the other hand, transpubic surgery allows a direct attack upon the stricture without violating the sphincter. Our experience with 4 such cases has convinced us of the superiority of this approach.     

介入尿道会师术治疗男性尿道断裂

目的:探讨用介入方法对尿道断裂的患者行急诊尿道会师治疗.方法对17例骨盆骨折和骑跨伤伴尿道断裂患者,采用经尿道外口送入超滑导丝,或经耻骨上膀胱穿刺置入导管鞘,自导管鞘逆入超滑导丝,送至尿道外口;不能通过者通过尿道外口送入抓捕器,将导丝自尿道外口抓出.沿导丝送入尿管,行尿道会师牵引术,通过随访1、3、6、12个月至3年.结果术后3～4周拔除导尿管,17例患者中5例患者出现尿道狭窄,术后3例使用尿道金属探子扩张,2例使用球囊扩张尿道,保留导尿管3～4周,随访1～3年患者均自行排尿通畅.结论介入尿道会师术,操作简便,创伤小,并发症少,可重复操作,康复快等优点.     

Urethral diverticula surrounding the urethra in women: report of 2 cases

We report two cases of female urethral diverticula. A 49-year-old woman (case 1) complained of perineal pain when she voided urine. A 36-year-old woman (case 2) complained of perineal pain. In both cases, intravenous pyerography and urethrography revealed diverticula around their urethra, and we diagnosed them with urethral diverticula which surrounded their urethra by magnetic resonance imaging. We treated them by transvaginal diverticulectomy. Case 2 was successfully treated, but the diverticulum recurred after one year in case 1. There are over 200 reported cases of female diverticula in the Japanese literature, but a urethral diverticulum surrounding the urethra is rare.