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Rashidov Maksudkhon, Republican research center for emergency medicine, Senior research associate, the department of Urology E-mail: [email protected]
Khadjibaev Abdukhakim, Republican research center for emergency medicine, General director, prof., the department of Surgery E-mail: [email protected]
Khalikov Mukhsim, Republican research center for emergency medicine, Senior urologist, the department of Urology E-mail: [email protected]
A modified open surgical technique for the management of posterior urethral injuries
Abstract: The results of modified urethroplasty of 17 patients with urethral injuries at the age from 18 to 62 years have been retrospectively studied. The authors maintain that new technique is optimal for the repair of posterior urethral injuries and may reduce the incidence of postoperative restructure.
Keywords: Urethroplasty, posterior urethral stricture, operative technique, urethral injury, pelvis fracture.
Introduction
Urethral strictures have always been common. As long ago as in ancient Greece, urethral stricture disease was cited in reports that described bladder drainage through the use of various catheters. Urethral stricture is the result of the development of scar tissue after either traumatic or inflammatory injury of the urethra. The condition has challenged urologists in the past and is still one of the most testing situations for the surgeon [11; 15].
Urethral injuries from external trauma are among the most serious affecting the genitourinary system, with major debilitating complications that include urine retention, impotence, incontinence, stricture, fistula and abscess formation and they lead to the lethal outcomes, long — termed disability and invalidity [5; 13].
Post-traumatic urethral injuries frequently occur as a result of pelvic fractures during vehicular accidents and catatrauma. In the structure of the combined injuries ofpelvis and lower urinary tracts consist from 4.4 to 12.8 % [13]. As the membranous urethra is fixed to the tough perineal membrane, which is attached firmly to the pubic arch, any major force causing pelvic fracture leads the prostate to rise towards the abdominal cavity, stretching and straining the bulbous urethra [6].
The choice of management ofposterior urethral injury remains controversial [17]. Initial supra pubic cystostomy is based on the Johanson principle, and delayed urethral re-construction had been considered as a reference standard for managing anterior urethral injuries [14]. This approach has problems like need of a supra pubic drainage for prolonged period (6 weeks to 3 months) as well as formation of an inevitable urethral stricture requiring reconstructive urethroplasty [10], but it has become widely accepted in the past
three decades, as it avoids surgical interventions in the presence of major pelvic haematomas, therefore implying a greater risk of infection and excessive blood loss [4]. Recent advances in endourologi-cal techniques have made primary realignment feasible to perform with minimal manipulation. But there is great variation in recurrence rates reported after urethral dilatations and urethrotomies with a 50 to 60 % success rate in short strictures without spongiofibro-sis. In longer strictures with spongiofibrosis, the recurrence rate is about 80 % because of scarring contraction [16], so the idea is to use the external metallic frame ring during the immediate urethroplasty for preventing recurrence based on mechanical interference to prevent the scarring process that ends in contraction.
At Republican research center for emergency medicine till 2011 we managed all male patients with urethral disruption from blunt trauma with suprapubic cystostomy and later stricture repair when necessary. And for last 5 years we manage the patients with posterior urethral injuries by using external metallic frame ring during the immediate urethroplasty without supra pubic cystostomy.
We herewith retrospectively analyse our experience with immediate realignment of posterior urethral injuries.
Purpose
The aim of this work is to describe and assess the results of a modified open surgical technique use of the external metallic frame ring in the immediate treatment of posterior urethral injuries.
Materials and methods
We carried out our study in the Urology department of Republican research center for emergency medicine from April 2012 to September 2015. It included 17 male patients with posterior urethral
injuries, who were diagnosed and treated at our center and underwent urethroplasty during this period. The mean age was 32 years (18-62). Of 17 patients presented, 5 (29.4 %) patients had car accident, 8 (47 %) patients fall from high, and 4 (23.5 %) patients had history of urethritis and three of them had history of traumatized catheterization and one experienced internal urethrotomy. Patient with posttraumatic urethral injuries 13 (76.5 %) and 8 (61.5 %) of them had complete and other 5 (38.5 %) patients had partial disruption.
Patients had acute retention of urine and/or bleeding per urethra and were treated on emergency basis. A detailed clinical
evaluation was performed and previous treatment records were reviewed to know the exact pathology in the urethra.
Prior to surgery physical examination, urinalysis, postvoiding residual urine volume measurement, urethroscopy, ultrasound scan of the urinary tract and retrograde urethrography were performed. Patients who had suprapubic catheters also had a micturiting ure-throgram performed. In all cases, the surgeon would be present in the fluoroscopy room during the urethrogram so as to ensure that the radiographic study adequately demonstrates the extent and location of the urethral stricture (Fig.1).
Fig. 1. Retrograde urethrography: A. Shows short 0.5 cm. subtotal stricture of bulbar urethra. Patient had endoscopic treatment. B. C. D. Show extravasation typical of prostatomembranous rupture
For 2 (11.7 %) patients with post-traumatic urethral injury we performed cystourethroscopy. Perioperative antibiotic prophylaxis with single dose intravenous 2nd generation cephalosporins were administered in all cases and postoperative antibiotics prescribed routinely.
All patients underwent to the immediate reconstructive urethroplasty with using an external metallic frame ring and urethral repairs were routinely stented with a size 18F siliconised catheter. This innovation was registered at the Patent Bureau of Uzbekistan IAP 20130237 (Fig. 2).
Fig. 2. Titan ring that used as external frame for anastomotic urethroplasty.
Follow-up protocol included urethrograms at 3 and 6 months and 1 year. Subsequently, they were reviewed annually. For patients unable to visit the clinic, telephone interviews were conducted regarding their current voiding symptoms. Descriptive statistical analysis was conducted with MS Excel 2000 (Microsoft).
Operative technique
Under general anaesthesia in lithotomy position with the legs on adjustable leg supports. The patient receives 2nd generation cephalosporins as perioperative antibiotic prophylaxis and also during the formation of anastomosis in patients with post — traumatic
injury of urethra the surgical field irrigated with mixture of antibiotic and solution of furatsilin.
Perform a longitudinal perineal incision as the Y. The bulbo-spongiosus muscle may be incises with the electrocautery (set to "cut") or sharp dissection. Patients with complete disruption of the posterior urethra sometimes the proximal urethral stump is difficult to find because of hematoma and tissue damage. So to find the proximal stump of the urethra we could use 16F or 18F siliconised catheter and also we will solve the retention of the patient. Then if it is necessary the proximal stump of the urethra spatulates without damaging the external sphincter. We have to resect the distal stump of the bulbous urethra economly till the normal urethral mucosa because of ruptured fragments that could not be used for reconstruction. For better preparation, we mobilize the urethra and the spongy body of the penis from the cavernous corpora about 2.0-2.5 cm. If necessary, we mobilize the urethra proximally and distally with sharp and blunt dissection for better anastomosis construction.
Then titan ring placed to the distal side of urethra externally. Then we place 5 sutures at the 10, 12, and 2 o'clock positions to the dorsal urethra and at the 7 and 5 o'clock positions to the ventral urethra of proximal urethra with absorbable sutures. The choice of suture material clearly evolves based on the surgeon's experience and bias; however, absorbable suture is the rule in urethral surgery. Then an 18F transurethral siliconised catheter placed. After all 5 sutures placed, each corresponding suture is placed into its proper spot in the distal urethra (mucosa-to-mucosa). We support two-layer closure of anastomosis: first — layer the urethral mucosa - to-mucosa with multiple interrupted 6-0 PDS sutures. And the second — layer is suturing of muscularis and adventitia of urethra that closed with multiple interrupted 5-0 PDS sutures. After that the titan ring fixes with the sutures of the second-layer as external frame (Fig. 3 and Fig. 4). We advocate performing immediate urethroplasty without suprapubic catheter. In generally the urethral catheter removed about 15-18 days after the operation.
Fig. 3. A — Lithotomy position and longitudinal perineal incision as the Y; B — Excision of damaged area; C — Formation of end-to-end anastomosis with using external frame titan ring (frame titan ring set with arrow); D — Final appearance of urethra-urethra anastomosis with external frame titan ring
Results and discussion
The clinical presentation of patients with urethral stricture were acute urine retention in 9 (53 %) patients, bleeding per external urethral meatus in 13 (76.4 %) patients, and weak urinary stream and straining to void in 8 (47 %) patients. All 17 patients were treated by end-to-end urethroplasty with external metallic frame ring no patients had intraoperative complications. May be the following period is not so much but for that period no patients had recurrent stricture. Urinary continence was achieved in all patients.
The length of strictures ranged from 0.5 cm. to 1.8 cm., and the average length of the stricture was 1.2 cm. In patients with inflammatory urethral strictures mean duration of urethral stenosis was 2.6 years (1.1-5.8). Of the 17 patients 1 patient developed
early postoperative complications inform of wound infection, and dehiscence that healed by secondary intention. Mean blood loss was 350 ml. (range, 200-800 ml). The average operating time was 2.5 h. in the perineal approach. None of our patients required neither intra- operatively nor post-operatively blood transfusion. Mean follow-up has been 2 years, with the shortest 3 months. 3 (17.6 %) of the patients had erectile dysfunction, but 1 regained potency after 5 months and other 2 (11.7 %) regained after 1 year.
Postoperative urethrograms were performed between 1 and 3 months after surgery, depending on the extent of surgery. 2 patients admitted with suprapubic catheters after operation demonstrated satisfactory voiding per urethra then the suprapubic catheters were removed.
Fig. 4. Steps of anastomotic urethroplasty: А — Longitudinal perineal incision as the Y; B — Catheterization the proximal stump of the urethra to solve the retention of the patient; C — First layer closure (mucosa-to-mucosa); D — Second layer closure with fixation of titan ring as external frame of anastomosis
There were no cases of urethral fistula, urethral, diverticulum, hair growth or penile curvature/shortening. Other minor complications included epididymo-orchitis (1) and wound infection (1).
Controversy continues regarding proper management of traumatic urethral disruption. The suggested surgical treatment modalities include: a) immediate primary simple realignment over a stenting catheter; b) immediate primary suture repair; c) immediate suprapubic cystostomy alone, with delayed elective urethroplasty for the resulting stricture. Many urologists believe that delayed urethral reconstruction is the safest method [1; 5; 14]. However, placement of suprapubic catheter significantly impairs the patient's quality of life. With respect to urethral stricture, immediate management with realignment of a complete disrupted urethra is supported by the data of Ku et al. [7], who found a stricture rate of 31 % when immediate management was performed, compared with 69 % in patients in whom management was delayed. In addition, the degree of urethral stricture in patients who underwent delayed management was more severe than in those with immediate realignment.
The advantage of immediate careful urethral catheter realignment was underlined by Herschorn et al. [4]. They found it to be a safe maneuver that obviated urethral closure. If posttraumatic ure-thral obliteration of less than 2 cm. develops, it can be managed successfully with a one-stage perineal bulboprostatic anastomotic repair. An overall long-term success rate of up to 97 % has been reported after that procedure. Problems generally arise when the urethral defect is not subjected to anastomosis without tension; for such patients, urethral substitution tissue is necessary.
Elliot and Barret [3] followed 56 patients with posterior ure-thral disruptions who underwent primary urethral realignment within 6 h. of injury; the pelvis was fractured in 52, and 53 were available for the long-term follow-up. In all, 36 patients (68 %) had strictures after re-alignment and 13 (25 %) had more significant strictures that required a repeat procedure under general anaesthesia.
Moudouni S. M. et al. described early endoscopic realignment of posterior traumatic urethral disruption [9]. On follow up of 68 months they concluded that the urethral continuity could be established without any increase in the incidence of impotence, stricture formation or incontinence. In case of failure, endoscopic realignment doesn't compromise the results of secondary urethroplasty.
Fig. 5. Retrograde urethrography 6 months after primary reconstruction for urethral trauma
Due to low success rates of internal urethrotomy and difficulty in the urethroplasty technique, clinicians searched for alternative methods which can be used in the treatment of urethral strictures including metallic urethral stents. Milroy et al. reported a 63 % success rate at long term follow-up of the permanently implantable "Urol-ume" stent [8]. Also Sertcelik et al. reported their clinical experience with urethral stent. In that study they reported an 87 % success rate at a mean of 3.8-year follow-up in 60 patients who had recurrent bulbar urethral stenosis [12].
Based on our experience we feel that immediate reconstructive urethroplasty with using an external metallic frame ring realignment of post-traumatic posterior disruption is feasible, safe and effective. The major drawback of our study is small number of patients and lack of comparison with patients who were managed by delayed method and immediate urethroplasty without external metallic frame ring.
Conclusion
Immediate open reconstructive surgery realignment with external metallic frame ring posterior urethral disruption is a feasible, safe and effective treatment modality for management of these patients. Our suggested technique is optimal for the repair of posterior urethral injuries and may reduce the incidence of postoperative restricture and we believe that it will find a place in reconstructive surgery ofurethra.
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Rozukulov Vahid Ubaydullaevich, Republican Specialized Center of Eye Microsurgery, MD, PhD, Deputy Director for Clinical Work, Tashkent, Uzbekistan
E-mail: [email protected]
Phacoemulsification of diabetic cataract with pseudoexfoliation syndrome
Abstract: It is carried out the analysis of intraoperative and postoperative course of diabetic cataract phacoemulsification combined with pseudoexfoliation syndrome, depending on the methodology used by phacoemulsification. Keywords: diabetic cataract, Pseudoexfoliation syndrome, phacoemulsification.
Relevance
Today significantly expanded the indications for phacoemulsification of diabetic cataract, in connection with the increased attention to the prognostically unfavorable situations in terms of occurrence of intraoperative and postoperative complications. Pseudoexfoliation syndrome — the age-associated pathology of the extracellular matrix, accompanied by excessive production and accumulation of abnormal extracellular material in various intraocular and extraocular tissues. These ultrasound biomicroscopy in
the preoperative examination of the patient adequately assess the degree of damage Zinn ligaments [2, 27-38]. This situation is exacerbated when combined with diabetic cataract, which has its own characteristics: localization of opacities in the posterior subcapsular layers, a sharp increase in the core, the rigidity of the front lens capsule, opacification posterior lens capsule and so on, as well as concomitant diabetic changes in the surrounding tissue: rubeosis of the iris, the presence of mooring in the vitreous humor, diabetic retinopathy, increased fragility of blood vessels eye, bleeding tendency
