Optimising Antegrade Cystoscopy in Urethroplasty for Pelvic Fracture Urethral Injury

Abstract

Introduction:

Intraoperative identification of the proximal limit in pelvic fracture urethral injuries (PFUI) remains challenging. Conventional technique involves dissection over the tip of a metal sound, which is passed through the suprapubic tract. We report our experience with antegrade flexible cystoscopy in localizing the proximal gap. ^{1 –4}

Methods:

The patient is a 50-year-old male with PFUI following a road traffic accident. Antegrade flexible cystoscopy was performed via the suprapubic tract, demarcating the proximal defect on the perioperative urethrogram. The patient was repositioned to lithotomy for posterior urethroplasty. The proximal end of the urethral defect was identified intraoperatively by direct vision antegrade cystoscopy with the Hosseini technique. A non-beveled needle was directed toward the cystoscope light into the bladder from below, receiving a 0.018-inch-wire, which was railroaded via the scope through the needle to the exterior in a rendezvous approach. The proximal end was then circumscribed and resized with the aid of the guidewire reflecting the true lumen.

Results:

Operative time was 370 minutes. Recovery was uneventful, and the patient was discharged on postoperative day 2 following drain removal. A pericatheter ascending urethrogram performed on postoperative day 27 demonstrated no leak, and both indwelling and suprapubic catheters were removed on the same day following a successful trial off catheter with a Qmax of 16.6 mL/s and residual volume of 0 mL/s.

Conclusion:

Antegrade cystoscopy is an effective and easy adjunct in accurately localizing the proximal gap in PFUI by allowing for guidewire passage and a rendezvous approach for identification of the true lumen.

Conflicts of interest/Disclosures:

The authors have no disclosures or conflicts of interest to declare.

Author contributor statement:

C.M.G. drafted and revised the article. W.L. also held a supervisory role in drafting the article as well as implementing critical revisions.

Patient consent statement:

The authors have received and archived patient consent for video recording/ publication in advance of video recording of the procedure.

Runtime of video: 4 mins 47 secs.

Voiceover Script

Timestamp	Script
0:00	Optimizing antegrade cystoscopy in urethroplasty for pelvic fracture urethral injury
0:07	The three key principles of repair of PFUI are localizing the stricture, complete excision of scar tissue and a tension-free anastomosis. However, challenges may arise identifying the proximal gap due to the nature of disruption defects, requiring multiple manouevres including bulbar urethral mobilization, corporal body separation, supracrural rerouting and inferior pubectomy.
0:31	Antegrade cystoscopy has a crucial role in cystoscopic assessment and bladder neck evaluation. In addition, light from the scope can help to identify the proximal limit, facilitating a ‘cut to light’ approach, with the added benefit of antegrade guidewire passage via the scope for more accurate localization in a rendezvous approach, thereby reducing the morbidity and iatrogenic injuries associated with incision onto a urethral sound of fixed curvature. In addition, combined antegrade and retrograde cystoscopy more accurately define the length of the defect in comparison with on-table urethrogram in the setting of acute trauma.
1:06	We present the case of a 50-year-old male polytrauma patient post road traffic accident with a pelvic fracture and multiple other orthopedic and intrathoracic injuries, initially suspected to have PFUI due to inability to void and blood per urethra upon unsuccessful IDC insertion.
1:24	On table urethrogram showed prostatomembranous urethral disruption and a distended bladder.The patient was diverted via SPC and an interval formal MCU and retrograde study was performed, showing a long disruption defect.Delayed urethroplasty was performed 18 months later following full recovery from his other distracting injuries.
1:42	A repeat urethrogram was done on the day of formal urethroplasty assisted by antegrade cystoscopy which accurately defined the proximal defect.
1:52	A midline perineal incision was performed and deepened in layers
1:59	And the bulbospongiosus was identified
2:04	The urethra was identified and freed
2:18	And the bulbar urethra was mobilized
2:31	The distal urethral stump was freed
2:38	And scar tissue was excised distally
2:46	The proximal defect was palpated and localized using light from antegrade cystoscopy. A blunt tip 18G needle was inserted transperineally to the proximal defect and a hydrophilic tipped guidewire was delivered via the scope through the needle at the perineum in a rendezvous approach to define the proximal gap. A single-use cystoscope was used and incision was performed directly onto the scope.
3:17	Dissection continued proximally ensuring all scar tissue was excised. The urethra was then calibrated with Hegar’s dilators.
3:31	And the distal defect was spatulated
3:37	The prostatomembranous anastomosis was performed
3:52	And a urethral catheter was inserted
4:02	A perineal drain was inserted
4:06	And closure was performed in layers
4:23	The results of our operation are as shown. Total operative duration was 370 minutes, and the patient was discharged on postoperative day 2, with a successful trial off catheter on postoperative day 27.
4:36	In conclusion, antegrade cystoscopy is safe and effective in localizing the proximal gap in posterior urethroplasty, hence reducing morbidity associated with blind manouevres in this critical step.