THE ROLE OF AN URGERNT URETHROGRAI’HY IN THE DIAGNOSIS AND OPTIMAL MANAGEMENT OF ANTERIOR URETHRAL INJURY

INTRODUCTION

The wide spread acccpmcc of ureth- rography iis lhc primary diagiioslic proce- cfurc iii patients suspectecf of kwiiig sus- tained urelliral iujurics has iinprwed llie uiKlcrslamliiig of lhc cxtciil ant1 meclia- uisin 0C such iujurics.

Iu pzst the diagnosis was based solely 011 llle classical cliuical triad ol blood al llie urethral meatus, inability lo wid and a palpable bladder. Secondary clinical fca- turns include a high riding prostate ant1

the prescrice of perineal hematorna. (Sari-

tller & Corriere 1080). ‘I’lic diagnoslic catliclerization is now concfcmned aa such proccdur~ may conw~l a partial uix3liral injury inlo a complete one, increases the

risk ol liernorrliagc iii the prohclic ktl

and may infect a prwiously slerile hcmalo- ma, (Corricre & 1 larris 108 1, Santller et al., 1901).

‘I‘lierclhrc urcllirograpliy has become lhc accepletl melliotl Ihr ii diagriosis of sus- pecletl injury. Slratldle injury may result in anlcrior urelliial coutusion, cornpletc or partial rupture 01. the bulbous urethra. Par- lial iujury is dernoiistndecf oii urcllirogra- pliy when there is extrn~wsalion of contrast malerial Ii-orn Ilie mid bulbous urctlira hut- the conlinuily or llic urelllrrr is maintained. Compfctc anlerior urclliral tlisruplion may be diapnosecf when the coutinuily of llic urethra is complelely tlisruplcd (Sandlcr and Carrier 1089).

53

54

. . . . ..ss ---- Ahn~ed Ahoul Scmd h Shehat~ Fmghrri -_________-__________--_---_--___________

‘l’he discussion ovc‘r Ihc years has hecn whellier to operak 011 slraddlc injuries in-

stantly or jusr lo put a cystoslomy k~he and leave them alone Devine el at., 1077, MC Auaich 198 1, I’ontes and Pierce 1078 cmptlasizetl that these injuries are

much better teti atone wiltioul primary rc-

pair, bul with suprapubic cystostomy,

1nost palienls do not devctopcd striclurc urethra (7O%u). and avoid the problem 01 alkrnpling lo repair these ruplure urethra is Ural sevcrc bleeding exk~ds lakratly in

the corpus spongiosum and makes Uie in-

jured area t’riabtc when one explores iI surgically, and failure of prilnary repair wilh subsequent ntriclurc formalion white

Paul and Arthur 1902 reported Uist if here is any question regarding Ihc intcg- rity of Ihe urethra especially if severe

contusion of the aulerior or posterior urc- h-a is present cystoslotny and delayed rc-

couslruction of the urethra arc preferred

lo folly cnrticler urethral drainage. Partial or complete severance of Uic urctlira may be 1nanaged by cxptoration.

PATIENTS AND METHODS

‘I’wcnly one laborers patients exposed lo straddle injury over a period of 3 years 1991 - 1004 were stuttied. ‘heir main clinical presentation was perineal pain : urethral btecding, acute rctcntiou, perineal hemaloma and associared fraclurc femur in one patienl. Clinical cvaluaGc)n inctud- ed, physical signs, abdo1ninat and local cxaminalion, laboratory invesligaliou in the form of CBC, Bhod che1nisrry (Ser- um crca~inine, Blood I Jrca, Sugar). Katti- otogical examinaUo11, “KI 113” for an asso- ciated fracture bone of Uie pelvis or femur. All patients uridcrwunt urgent urelhrography for cvalualion of urethral ituegrity.

?bchrlique of urgent rrrethrogrcrphy :

t+~tly’s caU~elcr IX I?. wiUi balloon 5 ml. Cnthekr was a~lxtied to xi irrigating syringe filled with corm-asI material and

iriserted iulo lhc urelhra for 2 - 3 c1n, otie lo Lwo mittilikrs of saline is iujecktl iulo rtie balloon to seat the cattieler in fossa navicutaris.

The patient is placed in he 2.5 - 35 de- gree oblique position atid a radiographic

T.

exposure made during itie injccliou of 25 IO 30 ml. of coulrast material. I’hc oblique

posirion is grealty preferred because in UW

autcro posterior Uie bulbous urttira is forc-

shortcud arid superimposed on ilsetf on

the rattiogragti. This lallcr position may cause confusion in intcrpreta~ion, cspecial- ly when gross cx1ravasation is present. Out of the 2 I patients, 15 had undcrgonc surgi- cal inlervention white primary urethral re-

conslruclion Ui~~ougti perineal approach had been performed on 10 patients, the other 5

paticnrs were rrearcd inilidty by cystosto- my. l’hc primary reconstrucCon hcgius by exposing Ihc urethral traumalic area with-

out complete tnobilization. ‘I’hc traurna-

tized or ischcmic part of Uic urethra was debridcd, simptc closure of the ureUuA floor outy with suprapubic cystostomy tube. Urcthrat stent was removed afkr IS days md suprapubic tube clamped in the second day aud ask the patienl lo void. As- cending and voiding cytstourcthrogr;un

was performed for all patients afkr one monh

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The role of an urgent . . . . . ~c ...... ~

RESULTS

‘l’hc most commou clinical prcsenta- lion in 21 palients with straddle iujury

were pcrincal hematoma in 6 palients. minimal urthral bleeding in 14 patients

:uid massive imcontrolablc 3nd requires blood transhsion in one patieut, palpable bladder in 4 patients while inability to void in 15 patients.

I+llowing rcsulls of 21 paticnls strad-

dlc injury Cup lo 2 years).

6 patients with urethral contusion were

except two paticuls and dcvcloped relcu- lion and a urclliral catheter was fixed Ihf

IWO clays only.

2 out of 10 palicnts undcrweut primary

reconstruction ol’ urethra required further urethral dilatation. While 3 patients li-om other group of inilial cystostomy required further managcmeut lo cud, one palicnt dc- veloped slricturc bulbous urethral li)r end anastomosis while two palients thr repcat- cd visualised internal uretlirolomy.

passed Free willi conservative treauncnt

Table 1

Synlptouls No. of patients

Perincal Pain 21

lnahility to void 15

Minimal IJrethral Bleeding 14

I’erincal Hcmatoma 06

Palpable Bladder 04

Massive B&ding 01

(2) Urgent Urtileragrapily for 21 patients :

* 06 patients urethral contusion.

* IS patients complete rupture urthra (loss of urethral continuity).

(3) Surgical procedure in 15 patients with complete rupture i~uliw~ urethra :

* 10 paticuts primary repair. T.

* OS patients initial cystostomy.

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c....... r\ltnred Ahoul Sand & Shehntu Furghnl .---_---__-______-__~~-~~~~~~~~~~~~~~~~__-

Figure (1)

Urgent urethrograplly in straddle injury showed complete rupture huli~ous urethra.

Urgen

Figure (2)

t urethrograpliy showed complete ruptur hulhous urel

57 --1111----~ -----

L~..~-...~~~.~~ The role of an urgent ,.... __....._- h ..,... _~

Figure (3)

Surpapubic diversion as a prilimiary procedure in pt.

with complete rupture Imlhar urethra.

Figure (4)

Asending urethrography Qweeks post diversion showed complete chtruction

at the i~~ll~ous urethra requires further dilatation

.____-___________-_____-__-_~_-_-_____- z~ Ahmed Aboul Snnd & Shehntcr I:crrghnl d

Icigure (5) Asending urethrography after delayed urethroplasty of the same pt.

(minimal narrowing required further intervention).

Figure (6)

Asending urethr~raphy of pt. at figure (5) after internal urethrotomy,

requires further intervention

,AStZlll

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[liug uretluwgrqhy slwwcd the result of prima

reconstructive surgery (after 3 m0nthS).

bry

Asending urethrygraphy after primary recunstructive surgery

I’igure (9)

Asending urethrography after primary reconstructive surger?

(minimal constructing band)

A k’igure

,sending ur~thrography after primary reconstructive surge

(minimal constructing hand)

61 ___-----

-- The role of an urgent . . . . . _____..-. _,__

Figure (11)

Asending urethrography after 6 weeks of priliminary supra pubic diversion

Figure (12)

Asending urethrography of same pt. of figure (11) after gradual dilatatiou and further internal urethrotomy (one month later)

,:

62 c<<<<<< Ahnwd Ahoul Sand & Shehnta Fmghal

--_____________--______________I______ a-

DISCUSSION

I Jrgent urclhrography is certainly a simple non invasive proccdurc for diagno- sis of urelhral injury as well as lhc cxtcul of such injury, tlc~cntling 011 lhc finding of cxlrvasalion ;uid llic prcscncc of urc- lhral conlinuily. (lorrier & IIarris 1981 concluded (hat (tie tliqnosis of ruplurc urclhra by calhclcrization is now con- dcrnncd due IO high risk of complicalion, lhcreforc urclhrography has lake lhc prior- ity niclhod for a diagnosis of our palienls. In our sludy lhe mosl common clinical prcscnlation was pcrincal paiu with he- maloma and inabilily lo void, similar rc- snlls wcrc ohlainetl in olhcr series (Sandli- c’r antI (‘orricr IO89 - (‘orricr and I larris r0riIj.

In 2 I palicnlk unclerwcnl urclhrogra- phy. abscul urelhral coulinuily will1 peri- Iical cxlravasnlion was reporlcd in I5 pa- lienls indicating complclc ruplurc urcthm, while normal urelhral continuily in 6 pa- ticnls wilh sirnplc urelhral Conlusion.

‘l’hc controversy exisled about lhe idcal rnnnagcmcnl of slratltllc bulbous urclhral injury: in Ihc pas1 eslablislicd the ad\;arttagc~ of sqrapubic cysloslomy di- version over ;I primary urclhral rccon- slruction as crnphasizcd by many aulhors Ikvin et al., 1077. Poilles and l’iercc 1c)7X, McAnich 1081, while .farncs and Picrcc 100 I rcporlctl lhal if one has lricd lo cslablish urclhral continuily surgically

there ccrlainly more: involvcrncnt of urclhra may be present hecausc of tissue being lost secondary Lo the cxploralion. I Iowevcr such rcsull in lhc absccncc of accurale di- aglioslic procedure for lhc cxlcnl of urc- lhral injury consitlcrctl unreliable because of Ihe stautlard use of urclhral catheteriza- lion wilh ils well known sequcnccs in 111c

diagnosis of urclhral injury lhal might af- feel Ihc outcome of primary repair (infcc- lion, hernaloma formalionj.

In our 10 patictils opcralcd upon wilh primary urthral rcconslruclion lhc success ralc aboul 60% (cxclutling 2 palicnls re- quired furllicr dilalNion) in comparison lo 5 palicnls wcrc managed by preliIninauy su-

pranubic cysloslomy, in whom 2 palienls required further proccdurc as i~iler~ial visu- ali7ctl urclhromlomy and dilalalion, out p;i- licnl has requirctl excision of slriclurc parl and end IO end urclhraplasly. WC lhink lhal lhc compariscn~ is more reliable as il quile depending 011 fixed paranelers from urgcnl nrelbrography, also fruitful rcsulls of primary urclhrat rcconslruclion wcrc in- proved by careful ascplic lcchuiquc of’ ur- oeul urcrhroganhy, trimming Ihc conrused 3 or ischcmic c&e of urethra, lhc use of fin: sulurcs Innlcrial 5 / 0 Ikkson, suprapuhic ClivCrsiou ant1 use of small scliconired I2 Ch. fcnslmlcd urelhralslenl antI finally rc- slricled mobilizaliou of urclhral cul cud and lhe avoidance of’ sulurcs in lhc supporl- cd parI of urelhral roof.

CONCLUSION

I irgent urclhrography is well cslab- jury is uow favoured by urgent urcthrogra- Iishetl and accc~lctl noii invasive tliagios- phy and simple modificalion of Ihc surgical lit procctlurc for uretlir;d iujury. Prirn:\ry tcchniquc provide exccllcnl rcsulls with Ihc urelhral rcconslruction cd lhe slnwldle in- lowcsl morbidity.

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r....... u- ..xm..~...-2--~. The role of itn nrgent . . . . . ki .,..... h:

REFERENCES

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