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Year : 2019 | Volume : 7 | Issue : 2 | Page : 45 - 49  


Original Articles
Role of Intraoperative Cystoscopy during PFUDD repair

Yaser Ahmad1*, Rouf Khawaja2, Manzoor Ahmad3, Sajad Malik4, Saleem Wani5, Arif Hameed6

1Senior resident; 2Consultant, 3Resident Urology, 4Consultant, 5Consultant &Head of Department,6Consultant SKIMS, Soura, Srinagar, Jammu & Kashmir, India

*Corresponding Author

Dr. Yaser Ahmad                                                                                                               

Email: yasserahmad009@gmail.com                                                                            

Abstract:

Background: Recently, interest has been generated in using cystoscopy as an adjunct in management of urethral stricture disease owing to its diagnostic and therapeutic capabilities. However the feasibility of this technique as an adjunct for diagnosing and management of PFUDD are limited.

Objective: To assess the advantage of performing the antegrade and retrograde cystoscopy during PFUDD repair

Methods: Thirty one perineal urethroplasties combined with antegrade and retrograde cystoscopy was performed on study participants from 2014 to 2018. Informed consent was obtained from all patients. The etiology of lesions, findings of RGU/MCU and operative records of the patients was evaluated, with particular focus on antegrade and retrograde cystoscopy findings during urethroplasty. Data on postoperative outcome were also assessed.

Results: We performed 31 perineal urethroplasties in thirty one patients with mean age of 38 (17- 72) years. The mean defect length was 2.5 cm (range 1-7.5 cm). All the defects were located in posterior urethra however one patient had urethro-cutaneous fistula located in anterior urethra. Lesions were secondary to pelvic trauma in all the patients. Mean duration of follow up was 19 (3-38) months. In 27 patients controlled physiological micturition was achieved without any additional intervention. The mean maximum urine flow was 16.5 ml/s and average flow was 12 ml/s on uroflowmetry (Fig 8). However in 2 patients optical urethrotomy was required at 3 months post procedure and in other 2 patients metallic dilation was needed after three weeks post catheter free trial.

Conclusion: Cystoscopy is an easy to perform adjunctive modality in PFUDD repair and can be used without incurring any considerable additional cost.

Key words:  cystoscopy, modality, PFUDD, repair, cost

INTRODUCTION:

The management of Pelvic Fracture Urethral Distraction Defects (PFUDD) remains one of the most difficult tasks in urological practice particularly in case of complex PFUDD. 1, 2 There are number of different techniques that may be used in imaging the male urethra in such cases. The most widespread methods include retrograde urethrography (RGU) and voiding cystourethrography (VCUG). Evaluation of the stricture, its location, number, and length is invaluable for planning appropriate treatment. Conventional imaging however has certain drawbacks - failure of bladder neck opening, prostatic displacement and other complicating features such as fistulae, cavitation, diverticula, and false passages may be overlooked with conventional imaging modalities. Recently, interest has been generated in using cystoscopy as an adjunct in management of urethral stricture disease owing to its diagnostic and therapeutic capabilities. However the feasibility of this technique as an adjunct for diagnosing and management of PFUDD are limited. We aimed to assess the advantage of performing the antegrade and retrograde cystoscopy during PFUDD repair. 

METHODS:

Number of patients: Thirty one (31)

Duration of study: Four years (2014 to 2018)

Place of study: Department of Urology SKIMS Srinagar.

Type of study: Observational study

Thirty one perineal urethroplasties combined with antegrade and retrograde cystoscopy was performed on study participants from 2014 to 2018. Informed consent was obtained from all patients. The etiology of lesions, findings of RGU/MCU and operative records of the patients was evaluated, with particular focus on antegrade and retrograde cystoscopy findings during urethroplasty. Data on postoperative outcome were also assessed.

Procedure: At the start of procedure while the patient is in lithotomy position, a 17 Frcystoscope is advanced into the bladder via SPC tract. An overall examination of the bladder is performed. After the bladder neck is visualized and examined, the cystoscope is advanced into the prostatic urethra and if necessary a guide wire may be used to guide the cystoscope. (Fig 1)

Simultaneously a retrograde cystoscopy is performed with 17 Frcystoscope, the anterior urethra is examined till the level of the obliteration and the level of abnormal urethra is marked with catgut suture. (Fig 2)

While the patient is in lithotomy position, after the surgeon operating in the perineal region reaches the distal end of the posterior urethral stricture the cystoscope is again advanced into the bladder via the supra pubic tract. When the verumontanum is reached, the obliterated urethral level generally becomes visible. Gentle manipulation of the endoscope vertically and horizontally may provide guidance to the surgeon performing urethral/ peri-urethral scar excision on the perineal region, determining the proximal site of anastomosis. By observing the reflection of endoscopic light, the surgeon can adequately open the proximal end of the urethra and create an adequate end to end anastomosis keeping in view the mark on the distal urethra, marked during antegrade urethroscopy. (Fig 3; Fig 4)

In some situations where the endoscopic light is insufficient for guidance of dissection and anastomosis a stiff guide wire is negotiated via the cystoscope and pulled out from the perineum after perforating the proximal end of stricture. 

RESULTS:

Cystoscopic findings

We performed 31 perineal urethroplasties in thirty one patients with mean age of 38 (17- 72) years. All patients underwent tension free end to end anastomosis; however 5 (16.12%) patients needed pubectomy in addition to urethral mobilization and 2 (6.45%) patients needed pubectomy with corporeal rerouting.

The mean defect length was 2.5 cm (range 1-7.5 cm). All the defects were located in posterior urethra however one patient had urethro-cutaneous fistula located in anterior urethra. Lesions were secondary to pelvic trauma in all the patients. Two patients had false passages (8.69%) which had history of failed attempts of open urethroplasty performed in other centres. In these patients RGU/MCU provided only limited information (Fig 5, 6).

Findings on cystoscopy

All patients underwent both antegrade and retrograde cystoscopy before the start of the surgery. Mean time for cystoscopy was 7 minutes. In all patients after completing retrograde cystoscopy we used to mark the level of abnormal urethra with suture on urethra so as to have healthy urethra for anastomosis.

Number of patients with bladder calculi

7 (22.58%)

Number of patient with foreign body

1 (3.22%) not picked by any imaging

Number of patient with false passages

2 (6.45%) limited information on RGU/MCU

Number of patients with recto urethral fistula

1 (3.22%)

Number of patients with urethra-cutaneous fistula

1 (3.22%) not picked by RGU/MCU

Following this antegrade cystoscopy was done. Out of thirty one (31) patients seven patients had bladder calculi, one patient with history of electric torture had piece of electric wire in bladder. (Fig 7) In 27 patients bladder neck was found to be normal and it was possible to advance the cystoscope into proximal urethra and negotiate the verumontanum endoscopically. Once the dissection of the fibrotic tissue was completed, the proximal end of the anastomotic plane was easily visualized. This proximal end was then approximated with the distal end marked with suture. In two procedures in which the bladder neck and posterior urethra were irregular and had false routes, anastomosis was done under guidance of stiff guide wire.

In one of the cases, urethra-cutaneousfistulous opening was noted in bulbar urethra during antegrade cystoscopy. The fistula repair was done along with end to end anastomotic urethroplasty.

Outcome

Mean duration of follow up was 19 (3-38) months. In 27 patients controlled physiological micturition was achieved without any additional intervention. The mean maximum urine flow was 16.5 ml/s and average flow was 12 ml/s on uroflowmetry. (Fig 8) However in 2 patients optical urethrotomy was required at 3 months post procedure and in other 2 patients metallic dilation was needed after three weeks post catheter free trial. 

DISCUSSION:

Evaluation of PFUDD has traditionally been done by RGU and VCUG. Magnetic resonance imaging (MRI) is a valuable technique for defining the length of prostatomembranous defect and distorted pelvic anatomy. 3, 4

However the digital subtraction details of the urethra are not obtainable by MRI. In addition, it is costly and unfamiliar to the urologists. 5, 6

Conventional imaging however has certain drawbacks; failure of bladder neck opening on VCUG can lead to incorrect estimation of length of distraction defect. Prostatic displacement on the horizontal or vertical axis may not be identified. Furthermore complicating features such as fistulae, cavitation, diverticula, and false passages may be overlooked with conventional imaging modalities. In addition RGU/MCU give only a two dimensional idea about stricture and lacks any information on epithelial configuration. However to overcome these limitations multiple authors have advocated use of cystoscopy performed through the cystostomy tract. 7, 8

Intraoperative cystoscopy with a preoperative RGU/MCU gives the reconstructive surgeon a complete picture of actual defect, mucosal health and guides appropriate excision of scar and supple mucosa to mucosa anastomosis.

The success rate of open urethroplasty in treating posterior urethral stricture has been reported as 70% to 90%. 9

The wide variation in success rate is partly attributable to the technique employed in addition to the surgical expertise and patient characteristics. The two most important prerequisites for a successful urethroplasty are; an adequate scar debridement and a healthy tension free end to end anastomosis. Several techniques have been proposed by different authors to satisfy these requirements including advancement of bougie, sound, endoscope or endoscopic light through the supra-pubic cystostomy tract to gain the advantage of antegrade guidance for anastomoses. 10-15

During the present study perineal urethroplasties were aided byantegrade plus retrograde cystoscopy and endoscopic manipulation was used to create a healthy, tension free and safe anastomoses under vision. During perineal urethroplasty, after determining the distal end of stenotic urethral segment, it is necessary to accurately define the proximal end and thus the stricture length. Most urologists prefer to use a hard bougie introduced from the cystostomy towards the prostatic urethra as a guide for the proximal urethra to define the anastomosis site. In most complicated cases like ours (cases with traumatic etiology, redo cases and sometimes accompanied by pelvic fracture), the lesion may involve an unexpectedly longer segment of prostatic urethra and may be severely fibrotic. In addition, VCUG may be of limited value in determining the anatomy of bladder neck and the length of stricture pre operatively. Using a hard bougiein such situations, to ascertain the proximal end of the stricture during the operation, in a blinded manner carries the potential risk of advancing through a false passage instead of the prostatic urethra. 12, 13

Antegrade cystoscopy via supra-pubic cystostomy during urethroplasty gives the surgeon an opportunity to inspect the proximal end of stricture and to avoid causing a false passage or mal-alignment during the anastomoses. 12, 13

In addition, the anatomic integrity of the bladder neck can easily be visualized, and on traversing the prostatic urethra into the membranous urethra, the proximal extent of stricture can be ascertained. In our study we simultaneously performed retrograde cystoscopy to mark the healthy distal mucosa so as to perform healthy anastomosis under vision. When the endoscope is in contact with this end, moving the endoscope slightly in all directions can guide the surgeon operating in the perineal side for debridement of the fibrosis and excision of obliterated proximal urethral tissue. The surgeon can then define the appropriate site for anastomosis by both following the light of the endoscope and by palpating the hard tip of endoscope through the perineum.

However despite these modifications, advancing to the proximal end may not be possible, or we may not be confident of the direction of the dissection prior to the anastomosis in patients with heavy fibrosis. In such difficult situations, while the obliterated segment is being antegradely visualized with supra-pubic cystoscopy, the direction of the anastomosis can be guided by inserting a stiff guide wire through the cystoscope and palpated through perineum. Alternatively some authors advance a needle through from the perineal side into the bladder until the tip of the needle is visualized with the endoscope.

The success rate in our study was 87% which is fairly good when compared with the reported success rate of 70-95% in the literature. 9, 12, 16-19

The better success in our cohort of complex cases is partly attributable to the intra-operative useof antegrade and retrograde endoscopy and direct visualization of bladder neck, posterior urethra and the proximal extent of stricture. 

CONCLUSION:

Cystoscopy is an easy to perform adjunctive modality in PFUDD repair and can be used without incurring any considerable additional cost. Cystoscopy combined with RGU and VCUG may provide more accurate and more immediate information of diagnosis. We believe that it offers significant advantages to a surgeon, including the benefits of supplementary endoscopic findings and the potential use of certain manoeuvres while performing both the debridement and the anastomosis during perineal urethroplasty. Thus intraoperative endoscopic assessment is a viable approach which allows direct visualization of complex portion of posterior urethral transection and subsequent tension free anastomotic urethroplasty. 

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