Trauma / Stricture Flashcards
What are the important steps in ATLS
1) Primary survey with ABCDE first
- airway, cervical spine
- breathing + ventilation
- circulation + control haemorrhage
- disability / CNS
- exposure
2) Secondary survey
- complete history esp AMPLE history ➔ allergy, medication, PMH, last food & drink / LMP, events
- head-to-toe evaluation and physical examination
3) Tertiary survey after management for missed injury or delayed presentation
How is pelvic fracture classified
Tile classification:
A = stable
B = Rotationally unstable, vertically stable
B1 = open book injury (a/w AP compression, usually bladder injury)
B2 = close book injury (lateral compression injury, usually PFUDD)
B3 = bucket handle
C = Rotationally and vertically unstable
What are the classes of hemorrhagic shock
Class I
- <15% blood loss (0.75L)
- BP/P Urine output normal
Class II
- 15-30% (0.75-1.5L)
- Tachycardia
- Narrow pulse pressure (<25% SBP)
- Base deficit -2 to -6
Class III
- 30-40% (1.5-2L)
- Hypotension
- Oliguria
Class IV
- >40% (>2L)
- Profuse hypotension
- Anuria
- Death
➔ need massive transfusion protocol
What is the definitive management for pelvic fracture with bleeding and clinical instability?
Three-in-one protocol with:
1) External fixation (for bone alignment)
2) EOT + Packing (for venous bleeding)
3) Emergency embolisation (for arterial bleeding)
What urological trauma is associated with pelvic fracture?
10% pelvic fracture ➔ PFUDD
5% pelvic fracture ➔ bladder injury
0.5% pelvic fracture ➔ bladder injury and PFUDD
80% bladder injury associated with pelvic fracture
What is the presentation of bladder injury?
Classical triad in 95%:
- haematuria
- lower abdominal pain
- inability to void
Trauma call with bladder trauma, how would you assess the patient?
I would regard it as a urological emergency and immediately attend the patient. The ATLS protocol should be followed with primary survey (ABCDE) and resuscitation first if needed
After stabilisation of patient, I would perform secondary survey with
1) History
a) About the mechanism
- timing
- e.g. straddle injury more likely anterior, pelvic fracture more likely posterior
- any rapid deceleration
- blunt vs penetrating
b) Symptoms
- abd / loin / suprapubic / scrotal pain
- inability to void
- haematuria / blood at urethra meatus
c) Past medical history
- esp transurethral / pelvic surgery / irradiation
- fitness for operation if needed
- drug history of anti platelet or anticoagulant
2) PE
a) Abdomen: any peritonism / loin tenderness / ballotable kidney / palpable bladder
b) Urethra: blood at meatus
c) Penis: any bruising or deformity
d) DRE: high riding prostate, palpable bone fragment, PRB, tone
e) Scrotum: any swelling or tenderness
f) Perineum: any butterfly haematoma
g) Spine: tenderness & neurological exam
3) Immediate Ix
- vitals
- bloods including T&S, CBC, LRFT, clotting
- CXR
- KUB
- Pelvis XR to see any pelvic fracture
4) Cystogram or CT cystogram
- to determine if intra-peritoneal or extra-peritoneal
➔ and then treat accordingly
How would you classify bladder injury?
Based on types:
1) Extraperitoneal (60%)
2) Intraperitoneal (30%)
3) Combined (10%)
AAST Classification:
Grade 1: contusion, partial thickness laceration
Grade 2: Extraperitoneal laceration <2cm
Grade 3:
- Extraperitoneal laceration ≥2cm
- Intraperitoneal laceration <2cm
Grade 4: intraperitoneal ≥2cm
Grade 5: laceration involving bladder neck or UOs
Can also classify by aetiology:
- Non-iatrogenic (blunt and penetrating)
- Iatrogenic (external and internal)
What are the aetiology of bladder trauma?
A. Non-iatrogenic
1) Blunt injury
a) Direct blow to lower abdomen with a distended bladder
- e.g. motor vehicle accident or fall
- dome is weakest ➔ usual rupture site ➔ intra-peritoneal injury
b) Pelvic fracture
- usually a/w open book fracture from AP compression ➔ extraperitoneal injury
2) Penetrating injury (more rare)
B. Iatrogenic
1) External
- most commonly O&G (60%) esp hysterectomy and incontinence surgery
- followed by general surgical procedures and then urological procedures
2) Internal
- mainly during TURBT (~3.5%), with majority extraperitoneal
What are the risk factors for bladder rupture in pelvic fracture
More commonly seen with open book fracture from AP compression:
1) Pubic symphysis diastasis
2) Pubic rami fracture
3) SI joint diastasis
4) Disruption of pelvic ring with >1cm displacement
What are the incidence of iatrogenic bladder trauma with various procedures
Based on EAU 2024
A. O&G (60%)
- 4% for lap or robot hysterectomy (malignant)
- 2% for abdominal radical hysterectomy (malignant)
- 2% for benign hysterectomy (TAH vs TVH vs LH similar risk)
- <1% for C-section
B. Surgery
- 4% for abdominal cytoreductive surgery
- <0.5% for rectal surgery
C. Urology
Mid-urethral sling (lower risk with obturator route than retropubic route)
- retropubic route ~5%
- obturator route ~1.5%
How to diagnose bladder injury?
An urgent plain or CT cystogram is needed:
- sensitivity 95%
- specificity 100%
CT cystogram is preferred in trauma due to:
- identification of bone fragments in bladder
- identification of bladder neck injury
- assess concomitant abdominal injury
How to perform a cystogram (plain or CT)
Review the indication
Assess any contraindication (e.g. failed catheterisation in urethral trauma)
1) Pre-contrast plain film
2) Retrograde bladder filling
- by gravity
- with diluted water-soluble contrast
- at least 300-350mL
- XR cystogram: half strength
- CT cystogram: 6:1 dilution
3) Post-drainage film
- to look for posterior leak
4) If XR: multiple views including AP and oblique
How many volume should be instilled into the bladder during cystogram for rupture?
At least 300-350mL (suggested by EAU 2024)
Cass classical study:
1) No false negative if:
- Fill 400mL
- With post drainage film
2) False negative if:
- Fill ≤250mL
- Without post drainage film
What are the cystogram signs of bladder rupture?
Extra-peritoneal:
1) Flame shaped contrast extravasation (over peri-vesical soft tissue)
2) Abdominal molar tooth sign on CT cystogram
- contrast extravasation over pre-peritoneal space and surround the bladder
Intra-pertitoneal:
1) Free contrast in the abdomen, outlining bowel loops or abdominal viscera
What is the management of bladder rupture?
For uncomplicated extraperitoneal (from blunt or iatrogenic trauma):
(can also consider if small intraperitoneal injury after TURBT, or minor penetrating extraperitoneal ➔ but weak evidence)
1) Conservative management by:
- catheterisation for continuous bladder drainage (10-14 days)
- antibiotics
- then re-assessment cystogram in 2/52
For intraperitoneal injury, penetrating bladder injury, or extraperitoneal with bladder neck involvement / bone fragments in bladder wall / concomitant surgery for other injury
1) Surgical repair
- debridement of devitalised bladder wall if needed
- primary bladder repair with absorbable sutures in 2 layers
- post-op with SPC + Foley + Drain
- then re-assessment cystogram in 2/52
Why is intraperitoneal bladder trauma managed by surgical repair?
(EAU 2024): because intraperitoneal urine extravasation causes more complications:
- peritonitis, ileum
- intra-abdominal sepsis
- death
Indications for surgical repair for extraperitoneal bladder rupture
1) Bladder neck involvement
2) Bone fragments in bladder wall
3) Entrapment of bladder wall
4) If surgery is needed for other injuries, e.g.
- open internal fixation for pelvic fracture to prevent urine causing infection of metal plate
- concomitant rectal or vaginal injury, or other abdominal surgery
- open cystotomy is needed for SPC e.g. posterior urethral injury
- clot retention requiring evacuation
5) Persistent extravasation
How would you perform an EOT bladder repair for perforation?
Pre-operative:
- review indication / medical history / drug Hx / bloods
- review CT for surgical planning, any other concomitant injury
- antibiotic prophylaxis
Intra-op:
1) Lower midline incision
2) Identify perforation site, can use methylene blue to rule out other sites
3) If concerns regarding trigone, cystotomy to inspect trigone and UOs
4) Debridement of devitalised bladder wall if needed
5) Two layer primary repair with absorbable suture e.g. Vicryl
6) Insert SPC + urethral catheter + external non-suction drain
Post-op:
- Antibiotics
- Re-assessment cystogram on POD14
What complications should be included in bladder repair consent?
General complications: pain, bleeding, infection, abscess formation etc.
Specific:
1) Persistent urine leakage
2) Fistula formation
3) Post-op reduced bladder capacity or compliance
4) Post-op overactive bladder and LUTS
5) Bladder neck injury ➔ incontinence, VVF, vesico-rectal fistula
Explain the anatomy of the male urethra
Anterior:
1) Navicular fossa
- narrowest part of male urethra
2) Penile (aka Pendulous / Spongy) urethra
- lies in the groove ventral to corpora cavernosa
- surrounded by corpus spongiosum
3) Bulbous urethra
- distal: penoscrotal junction
- proximal: within 5cm of membranous urethra at urogenital diaphragm
Posterior:
4) Membranous urethra
- traversing the urogenital diaphragm
- distal: bulbous urethra
- proximal: verumontanum
5) Prostatic urethra
What are the epithelial lining of the male urethra?
Navicular fossa: squamous epithelium
Anterior urethra: pseudo-stratified columnar epithelium
Posterior urethra: transitional epithelium
What are the blood supply of the male urethra?
Urethra is supplied by:
Internal iliac artery which branches into
➔ Internal pudendal artery, which enters perineum via Alcock’s canal (pudendal canal)
➔ Common penile artery divides into 3 branches (“BCD”):
1) Bulbo-urethral artery (urethra)
2) Cavernosal artery (corpus cavernosum)
3) Dorsal penile artery (urethra & spongiosum)
Urethra has dual blood supply by (1) and (3)
What are some differences in anterior vs posterior urethra injury
Different mechanism of injury:
1) Anterior:
- Straddle injury / kick to perineum ➔ bulbous urethra compressed against pubic symphysis
- Penile fracture
- usually associated with spongiosal contusion
2) Posterior
- Shearing effect during pelvic fracture ➔ membranous urethra injured (PFUDD)
- may be associated with bladder injury
Clinical Hx / Sx / signs of urethral injury
1) Injury mechanism:
- straddle injury / perineal trauma ➔ anterior bulbous urethra injury
- pelvic fracture ➔ posterior membranous urethra injury
2) Presentation
- classical triad: Blood at urethral meatus, inability to void, palpable bladder
- haematuria, pain on urination if incomplete rupture
- urinary extravasation causing scrotal / penile / perineal swelling
3) Physical exam:
- DRE: “high riding prostate” in posterior injury
- Perineal ecchymosis / “butterfly haematoma”
- Difficulty or inability to pass a urethral catheter
A&E had a patient was found fallen, and suspected to have an urethral injury. How would you approach this patient?
I would regard it as a urological emergency and immediately attend the patient. The ATLS protocol should be followed with primary survey (ABCDE) first if needed
After stabilisation of patient, I would perform secondary survey with
1) History
a) About the mechanism
- timing
- e.g. straddle injury more likely anterior, pelvic fracture more likely posterior
- any rapid deceleration
- blunt vs penetrating
b) Symptoms
- abd / loin / suprapubic / scrotal pain
- inability to void
- haematuria / blood at urethra meatus
c) Past medical history
- esp transurethral / pelvic surgery / irradiation
- fitness for operation if needed
- drug history of anti platelet or anticoagulant
2) PE
a) Abdomen: any peritonism / loin tenderness / ballotable kidney / palpable bladder
b) Urethra: blood at meatus
c) Penis: any bruising or deformity
d) DRE: high riding prostate, palpable bone fragment, PRB, tone
e) Scrotum: any swelling or tenderness
f) Perineum: any butterfly haematoma
g) Spine: tenderness & neurological exam
3) Immediate Ix
- vitals
- bloods including T&S, CBC, LRFT, clotting
- CXR
- KUB
- Pelvis XR to see any pelvic fracture
- CT if needed
4) Urinary diversion
Explain the anatomical basis for haematoma in urethra injury
Give the boundary of the layers
Classical “butterfly haematoma” is due to breached Buck’s fascia with bleeding & extravasation limited by intact Colles’ fascia
If Buck’s fascia is intact, then haematoma will be confined to penis only:
- distal boundary: coronal sulcus
- lateral boundary: pubic rami, ischial tuberosities and spines
- continuous with urogenital diaphragm
If Buck’s fascia is breached, then haematoma is confined by Colle’s fascia:
- superior boundary: continuous with Scarpa’s fascia up abdominal wall to clavicles
- posterior boundary: urogenital diaphragm, perineal body
- lateral boundary: ischio-pubic rami, fascia lata
What are the fascial layers over the peno-scrotal-perineal region? Please draw them out
From inner to outer = “BCD”
Buck’s fascia:
- innermost
- continuous with deep fascia of abdomen and urogenital diaphragm
➔ distal boundary: coronal sulcus
➔ lateral boundary: pubic rami, ischial tuberosities and spines
Colles’ fascia:
- middle
- continuous with Scarpa’s fascia and dartos fascia of scrotum
➔ superior boundary: continuous with Scarpa’s fascia up abdominal wall to clavicles
➔ posterior boundary: urogenital diaphragm, perineal body
➔ lateral boundary: ischio-pubic rami, fascia lata
Darto’s fascia:
- most superficial
- continuous with Camper’s fascia and dartos muscles of scrotum
How would you classify urethra trauma?
By anatomy:
- anterior vs posterior
- partial vs complete
By aetiology:
- traumatic (blunt vs penetrating)
- iatrogenic
By AAST grading:
1 - contusion, normal urethrogram
2 - stretch injury, elongation of urethra without extravasation
3 - partial disruption, visualisation of bladder in urethrogram
4 - complete disruption, <2cm urethral separation
5:
- complete disruption, ≥2cm urethral separation
- or extension into prostate or vagina
How would you perform a retrograde urethrogram?
Pre-operative
- review indication
- check stability ➔ if unstable then postpone until patient stabilised
- prophylactic antibiotics
Intra-operative
1) 30 degree oblique position, with bottom hip and knee flexed
- if unable to position then rotate C-arm
2) Fr12 Foley inserted:
- to navicular fossa
- 2mL water to balloon
- fixed with Brodney clamp
3) 20-30mL full strength water soluble contrast injected slowly via Foley
4) Patient instructed to relax sphincter
5) Fluoroscopy
6) See any extravasation or stricture
- length is measured by two artery clamps under fluoroscopy
- if no contrast up to bladder then likely complete urethral injury
What is the fluoroscopy finding for urethral injury?
1) Contrast extravasation outside the urethra
2) Disruption of urethra seen
3) Pie in the sky bladder
- floating bladder seen high in the pelvis due to the presence of a large pelvic haematoma
Common causes of anterior urethral injury
1) Straddle injury ➔ bulbous urethra compressed against pubic symphysis
2) Kick to perineum
3) Penile fracture
4) Instrumentation / traumatic catheterisation
5) Penetrating injury
What is the management of anterior urethral injury?
Need to assess other trauma with ATLS protocol and stabilisation if needed.
Rule out other injury
If blunt injury:
1) Antibiotics
2) Urinary diversion
- SPC or a trial of early endoscopic re-alignment with transurethral catheterisation
➔ Wang retrospective study showed no difference in stricture formation
➔ Zhang series showed 57% patency rate for endoscopic re-alignment
3) Review with up and down urethrogram ± FC intervally:
- EAU: 1-2 weeks for partial rupture, for 3 weeks for complete rupture
➔ to see if any stricture, and manage accordingly (may need delayed DVIU or urethroplasty)
➔ 70% patency rate for partial rupture
➔ 0-25% patency rate for complete rupture
==================
1) Immediate exploration and urethral repair ± reconstruction is needed if:
- penile fracture
- penetrating injury
- degloving
(EAU 2024 guideline commented equal success rate in immediate vs delayed, but data is from expert centre in China, in expertise setting by urethral surgeon)
Would you consider immediate exploration and urethra repair for blunt anterior urethra injury?
I would not for blunt anterior urethral injury, because:
- blunt anterior urethral injury is associated with spongiosal contusion
- the haematoma makes the operation more difficult, and more difficult to identify margin for urethral debridement
Immediate repair is only needed if the anterior urethral injury is associated with:
- penile fracture
- penetrating injury
- degloving
(EAU 2024 guideline commented equal success rate in immediate vs delayed, but data is from expert centre in China, in expertise setting by urethral surgeon)
How would you perform an immediate urethral repair for a blunt anterior urethral injury
It is only needed if the anterior urethral injury is associated with:
- penile fracture
- penetrating injury
- degloving
(EAU 2024 guideline commented equal success rate in immediate vs delayed, but data is from expert centre in China, in expertise setting by urethral surgeon)
1) Simple closure if small laceration
2) Anastomotic repair if complete rupture but short (<1cm)
- mobilise corpus spongiosum
- minimal urethral debridement since spongiosum is well vascularised
- end-to-end anastomosis, water tight, tension free, over catheter, with absorbable suture
- over-closure of corpus spongiosum and skin
- POD14 urethrogram to see any leakage
3) Need staged repair if complete rupture but long (>1cm), or infection
- marsupialisation of urethra, and prepare for 2nd stage repair (~3m later)
- SPC
- acute urethroplasty with flap or graft is not recommended due to contamination and poor blood supply
What are the causes of posterior urethral injury?
1) Pelvic fracture due to shearing effect of bone disruption
- especially in lateral compression injury (Tile B2 close book fracture) with pelvic ring disruption
➔ membranous urethra is injured, as it has the least support being attached to the urogenital diaphragm
➔ prostate is not affected as it is well supported being attached to the puboprostatic ligaments
i.e. PFUDD (pelvic fracture urethral distraction defect)
How would you manage a suspected posterior urethral injury?
Need to assess other trauma with ATLS protocol and stabilisation
Usually associated with severe injuries and pelvic fracture
In general no urgency to treat urethral injury during first hour of resuscitation
Specific Mx include:
1) Antibiotics
2) Urinary diversion
a) 1 attempt of gentle passage of urethral catheter
- if successful and easy, and no urethral bleeding before and after ➔ safe to assume no urethral injury ➔ can consider TWOC once patient start mobilising
- if successful, but suspicion of urethral injury e.g. bleeding ➔ peri-catheter urethrogram
b) SPC insertion
- either USG guided or open cystostomy
=== the following only if stable patient ===
3) Perform urethrogram ± urethroscopy to determine if partial or complete
4) Early endoscopic re-alignment
- in partial injury or in complete injury requiring surgery for associated injuries
- if failed then SPC insertion
➔ Elshout Systematic review showed stricture rate reduced from ~90% (SPC) to ~45% (early re-alignment)
5) Review with up and down urethrogram ± FC intervally:
- 3 weeks for partial
- 6 weeks for complete
6) Deferred Urethroplasty >3 months
- standard by Mundy
-) Immediate (<48h) is not recommended by Mundy and EAU, except:
- penetrating injury
- injury to bladder neck / prostate / rectum
- perineal degloving
-) Early urethroplasty (48h to 6 weeks) can be considered to shorten SPC duration, with Scarberry retrospective cohort reporting similar outcomes
What is the indication of early endoscopic re-alignment in urethral injury?
What are the benefits?
For anterior urethral injury:
- Is an option of urinary diversion (SPC vs trial of re-alignment + Foley)
➔ Wang retrospective study showed no difference in stricture formation
➔ Zhang series showed 57% patency rate for endoscopic re-alignment
For posterior urethral injury
- only in stable patient
- in partial injury or in complete injury requiring surgery for associated injuries
➔ Elshout Systematic review showed stricture rate reduced from ~90% (SPC) to ~45% (early re-alignment)
========================
Proposed benefits in posterior disease:
1) Lower stricture rate
- usually for partial rupture, it can reduce urine extravasation, thus reduced inflammation
- Elshout Systematic review showed stricture rate reduced from ~90% (SPC) to ~45% (early re-alignment)
2) Shorter stricture if occurred (controversial)
- ~50% stricture after endoscopic re-alignment are short and can be treated endoscopically first with DVIU
3) In complete injury, it can correct severe distraction, but unlikely to prevent stricture
- thus easier urethroplasty if needed
How would you perform endoscopic re-alignment?
Pre-op
- review indication
- antibiotic prophylaxis
Intra-operative:
1) SPC tract dilatation and Amplatz sheath inserted to bladder
2) Retrograde and antegrade FC
3) Alignment of the two FCs on AP and oblique fluoroscopy
4) Through and through guidewire insertion, Foley railroaded up
(EAU: can also consider with 1 retrograde FC and fluoroscopy, guidewire is placed into bladder under direct vision, then Foley inserted)
Post-op:
- Keep SPC and Foley
- Avoid traction of bladder neck as may damage sphincter
What is the prognosis for early endoscopic re-alignment for posterior urethral injury?
Based on EAU 2024:
1) Stricture rate ~45% in contemporary study (Elshout Systematic review)
No evidence suggesting it will increase incontinence (~5%) or ED (~20%)
What is the timing for urethroplasty in posterior urethral injury? Why?
1) Deferred Urethroplasty >3 months ➔ standard
- traditional teaching based on Mundy: results at 1 year > 6 month > 3 month
- allow patient to recover from major trauma with optimised nutrition etc
- allow pelvic haematoma and urine extravasation to resolve
- allow prostate to descend into more normal position
- allow scar tissue to stabilise
- patient can lie down in lithotomy position
- Only 14% stricture rate (86% success rate)
2) Early Urethroplasty (2 days to <6 weeks) ➔ can be considered
- in selected cases with short defect, short perineum, and able to position
- in order to shorten SPC time
- Scarberry retrospective cohort reporting similar outcomes as deferred urethroplasty
3) Immediate urethroplasty / repair (<48 hours) ➔ not recommended
- poor visualisation in acute setting
- traumatised tissue does not hold suture well
- risk of release of pelvic haematoma and losing tamponade
- EAU: higher rate of stricture (54%), incontinence (14%), ED (23%), and bleeding than delayed
(except):
- injury to bladder neck / prostate / rectum
- penetrating injury
- perineal degloving
➔ to prevent incontinence, infection, fistula
➔ if bladder neck not repaired, the circular sphincter muscle fibres will stay open
What is the right term for urethral narrowing? Why?
Anterior urethral Stricture:
- scarring involves the corpus spongiosum i.e. spongiofibrosis, therefore stricture only occurs at anterior urethra
- absence of muscularis mucosae or sub-epithelial layer in urethra ➔ therefore once epithelium is breached, urine extravasate to spongiosum
Posterior urethral Stenosis:
- no spongiosal tissue and therefore not stricture
- just obliteration of posterior urethra
What is the pathophysiology of urethral stricture?
Spongiofibrosis, therefore only in anterior urethra:
1) Noxious stimulus breaching the epithelium
2) Squamous metaplasia
3) Develops fissure
4) Urine extravasation
5) Spongiofibrosis
6) Coalesce of fibrotic plaques
7) Stricture develops if circumferential
What size of urethral narrowing is considered significant?
How to classify the degree of urethral narrowing?
Based on Joe Smith’s classical paper, the effective diameter of male urethra is Fr11
EAU classify urethral narrowing by French gauge:
0 - normal
1 - subclinical stricture ≥Fr16 ➔ no need intervene
2 - low grade Fr11-15 ➔ not flow significant
3 - high grade Fr4-10
4 - Nearly obliterative Fr1-3
5 - Obliterative Fr0
Patient presents with history compatible with urethral stricture ➔ how would you approach this patient?
(Very similar to LUTS approach) I will see him in the clinic
1) History taking
i) Clarify Sx
- LUTS Sx esp voiding / duration / severity / QoL
- Can use USS-PROM (urethral stricture surgery - patient reported outcome measures)
ii) Complications e.g. AROU / haematuria / dysuria / UTI / stone
iii) Causes
- trauma (straddle injury, penile fracture)
- infection i.e. gonorrhoea
- lichen sclerosis
- iatrogenic (TURP / Foley / hypospadias)
- pelvic fracture
iv) Medical condition and drug history, to see fitness for intervention
2) Physical exam:
- uraemic or fluid overload
- ballotable kidneys
- palpable bladder
- external genitalia (phimosis, meatal stenosis, chordee)
- DRE
- neurological exam
3) Simple Ix:
- RFT, KUB
- urine dipstix & urinalysis
- Uroflowmetry to see plateau shape + PVRU
- USG urinary system
4) FC
5) Urethrogram
±6) VCUG ➔ to adequately assess proximal site
What assessment form for urethral stricture do you know?
USS-PROM (urethral stricture surgery - patient reported outcome measures) which covers:
1) Weak stream
2) Intermittency
3) Incomplete emptying sensation
4) Straining
5) Hesitancy
6) Post micturition dribbling
0-4 score for each item
What are the causes of anterior urethral stricture?
1) Post-traumatic (straddle injury, penile fracture)
2) Infection (gonorrhoea, ~20 years after initial infection)
3) Inflammation (Lichen sclerosis)
4) Iatrogenic
- transurethral intervention e.g. TURP
- Foley insertion
- RARP
- Hypospadias repair
5) Idiopathic / congenital
- Cobb’s collar / Moorman’s ring in adolescent
What is the risk of urethral stricture with Foley? Where is it at?
Around 15-30%
Silicone catheter may reduce stricture
Usually located at meatus / pendulo-bulbous
Management overview of anterior urethral stricture
Consider site and length
Bulbous stricture
A. <2cm
1) Endoscopic Tx (DVIU / dilatation)
- Can retry up to 2 times according to EAU
±2) Optilume (for <3cm)
- if failed 2 endoscopic Tx, but urethroplasty is not an option
3) Urethroplasty if failed (Anastomotic EPA)
B. 2-4cm
1) Can consider 1 trial of endoscopic Tx with DVIU / dilatation
±2) Optilume (for <3cm)
- if failed 2 endoscopic Tx, but urethroplasty is not an option
3) Urethroplasty (Free Graft FGU, or augmented anastomotic e.g. Barbagli Dorsal On-lay)
C. >4cm
1) Urethroplasty (Free Graft FGU, or augmented anastomotic e.g. Barbagli Dorsal On-lay)
Penile stricture
1) Urethroplasty
- Patch urethroplasty e.g. Orandi’s procedure / Jordan procedure
- Two stage substitution urethroplasty
±2) Only consider trial of endoscopic Tx (consider dilatation) if not fit for operation
- very low success rate
- DVIU is not suggested, as might provoke venous leakage from the corpora cavernosa with ED risk
Management overview of posterior urethral stricture
Depends on cause / length / obliteration
Non-traumatic
1) Endoscopic treatment as first line if non-obliterative
- DVIU / dilatation for radiation induced bulbo-membranous stricture
- TUR for bladder neck stenosis or prostatic urethral stenosis
2) Reconstruction if failed endoscopic Tx or obliterative
- urethroplasty for radiation induced bulbo-membranous stricture
- bladder neck reconstruction (Y-V plasty or T plasty) for bladder neck stenosis or prostatic urethral stenosis
Traumatic
A. Short <1.5cm, non-obliterative
1) One trial of Endoscopic treatment (DVIU or dilatation)
- do not repeat
2) Urethroplasty if failed
B. >1.5cm, or obliterative
1) Urethroplasty
What is the principle of endoscopic management of urethral stricture?
Breach the urethral mucosa at the site of stricture
➔ re-epithelialisation should occur faster than wound contraction
What is the indication of endoscopic therapy for urethral stricture?
DVIU / dilatation
1) Definitive treatment
- first time treatment of short (<2cm) bulbous urethral stricture
- first line for non-traumatic non-obliterative posterior urethral stenosis
2) Trial of treatment
- repeat treatment of short (<2cm) bulbous urethral stricture
- trial of treatment of 2-4cm bulbous urethral stricture
- trial of treatment of traumatic short (<1.5cm) non-obliterative posterior urethral stricture
3) Palliative treatment
- for any other strictures (not recommended)
How to perform urethroplasty for post-traumatic posterior urethral stricture?
Bulbo-prostatic anastomotic urethroplasty
Timing: Deferred >3 month is standard
Based on Mundy: results at 1 year > 6 month > 3 month
Pre-op:
- review indication and contra-indication
- assess anatomy with urethrogram (up and down if possible) ±VCUG + FC
- informed consent
- antibiotic prophylaxis
Intra-op
1) Perineal approach usually (sometimes abdomino-perineal approach)
2) Exaggerated lithotomy position
3) Ischiocavernosus muscle is divided, bulbospongiosus opened
4) Complete bulb mobilisation
5) Excision of stricture with Haygrove sound from cystotomy tract
6) Open triangular ligament to control dorsal penile vein
**7) Transperineal progressive approach with 4 manoeuvre to gain length:
a) Bulbar urethra mobilisation
b) Crural separation (of corpora cavernosa) ➔ to create intra-crural space
c) Inferior tubectomy
d) Supra-crural re-routing (around the corporeal body)
➔ 2cm each manoeuvre
➔ defect up to 7-8cm can be managed
8) Anastomosis
- water tight / tension free / over Foley catheter / absorbable suture**
Post-op:
- keep SPC and FC for 4/52
- antibiotics and anti-muscarinics
- voiding cystogram after 4/52
Explain the operative steps for acquiring a buccal mucosa graft
Pre-op
- indication and contraindication
- informed consent
- antibiotic prophylaxis
Intra-op
1) Identify the Stensen duct ➔ next to upper 2nd molar
2) Harvest 1.5cm from Stensen duct and 1.5cm from external cheek
3) Harvest area = 4cm x 2.5cm
4) Bupivacaine + epinephrine injection to facilitate dissection and haemostasis
5) Can consider closure of donor site
What are indications for angiogram ± SAE in renal trauma?
1) CT findings of:
- active contrast extravasation / blush
- AV fistula
- pseudo-aneurysm
2) Can be considered if haemodynamically unstable
What is the blood supply of the ureters?
The blood supply is segmental:
1) upper ureter is from the renal artery’s ureteric branches
➔ supplied from medial
2) middle ureter from direct branches of the abdominal aorta
- also branches from gonadal and iliac arteries
➔ supplied from medial
3) distal ureter from the superior and inferior vesical arteries.
➔ supplied from lateral
How can the ureter be injured during Gynaecology operations? Explain the anatomical basis
Not uncommon:
- lap hysterectomy 6%
- abdominal hysterectomy 2%
- vaginal hysterectomy 0.5%
Mechanism:
1) Ligation of ovarian vessels
- injury at pelvic brim
- “water under the bridge” as distal ureter is posterior to gonadal vessels
2) Ligation of uterine vessels
- during hysterectomy
- ureter crosses under the uterine artery
3) Pelvic dissection
- during pelvic LN dissection
- injury near the apex of obturator fossa
- ureter crosses anterior to iliac vessels
4) Dissection of vagina away from bladder
- injury of VUJ at the anterior fornix
- ureter crosses the anterior vaginal fornix before entering bladder
- ureter lies 1.5cm lateral to cardinal ligament (lateral transverse cervical ligament)
5) Infundibulo-pelvic ligament
- injury of mid ureter
- ureter runs lateral to infundibula-pelvic ligament
Explain and compare techniques for uretero-neocystostomy
i.e. ureteric re-implantation
1) Lich Gregoir
- extravesical
- anti-reflux by submucosal tunnelling
- less mucosal bleeding
- more pelvic dissection may cause bladder dysfunction
Steps:
- detrusor is incised extravesically, creating a submucosal groove
- transmural cystostomy at neo-UO
- spatulate ureter and placed in submucosal tunnel (Parquin rule 5:1) and anastomosis
- detrusor muscle is closed to create the submucosal tunnel
2) Modified Politano-Leadbetter
- transvesical
- anti-reflux by submucosal tunneling
- more bleeding
- additional cystostomy wound
Steps:
- anterior cystotomy
- neo-UO is selected superior and medial to UO
- submucosal tunnel developed by sharp dissection by Parquin rule (5:1)
- cystotomy over posterior bladder wall, and ureter is mobilised into bladder through the submucosal tunnel
- ureter is spatulated and anastomosed interruptedly at neo-UO
3) Cohen Cross-trigonal technique (usually not used)
- transvesical
- anti-reflux by submucosal tunneling
- allow longer tunnel length, but very hard for retrograde cannulation
Steps:
- anterior cystostomy
- submucosal tunnel developed with neo-UO above contralateral UO
Explain the indication and steps of Boari flap
Indication: distal / mid ureter stricture, can gain up to 15cm length
Steps initially are the same as Psoas hitch:
1) Lower midline incision
2) Distend bladder with 300mL water
3) Mobilise bladder:
- some suggest division of contralateral bladder pedicle to improve fundal mobility
- however some prefers not to ligate as may impair flap blood supply
4) Mobilise ureter while preserving adventitial and peri-ureteric fat with atraumatic handling
5) Blandy Cystostomy (right angle to the long axis of ureter)
6) Hitch bladder above iliac vessels on Psoas Minor Tendon
- with 3 non-absorbable sutures e.g. prolene
- avoid genitofemoral nerve damage
+7) Creation of Boari flap
- U-shape incision
- base at least 4cm, tip of flap at least 3cm width for patent anastomosis
- with length to base ratio = 3:1 (to minimise flap ischaemia)
- Flap is reflected upwards and opened
7) Uretero-neocystostomy by modified Politano-leadbetter
- tension free
- water tight
- mucosa to mucosa
- absorbable suture
- over stent
- Parquin rule of 5:1 for submucosal tunnel
8) Close the flap in a tubularised manner, and close the bladder
9) External drain + Foley ± SPC
