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URETHROSCOPIC REALIGNMENT OF RUPTURED BULBAR URETHRA
SUN YING-HAO, XU CHUAN-LIANG, GAO XU, LIAO GUO-QIANG AND HOU JIAN-GUO
From the Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
ABSTRACT
Purpose: We evaluated the efficiency of early endoscopic realignment as primary therapy for
bulbar urethral disruption after straddle injury.
Materials and Methods: From 1990 to 1999 we treated 16 men who had bulbar urethral
disruption with endoscopic realignment. Followup included uroflowmetry and urethroscopy at 39
to 85 months.
Results: All 16 cases were successfully treated at a single session without intraoperative or
postoperative complications. Only 2 patients required intermittent self-dilation once weekly and
all were potent during followup.
Conclusions: The results of this minimally invasive procedure are comparable to those of open
surgery. It may be performed on an outpatient basis using only local anesthesia. Our results
imply that this cost-effective therapy should be done as the initial step in most patients with
bulbar urethral disruption.
KEY WORDS: urethra; wounds, nonpenetrating; endoscopy; rupture
Disruption of the anterior urethra, mostly at the bulbar
urethra, is due to straddle injury in 80% of cases.
1
Today
such injuries are also more rarely caused by penetrating
trauma, such as gunshot or iatrogenic injury. The essential
point of treatment is urethral reunion, for example successful
catheterization for bladder drainage. Pontes and Pierce re-
ported that satisfactory results may be achieved without
primary repair in most patients because the majority of in-
juries involve partial urethral rupture.
2
However, open sur-
gery is always done to form an end-to-end anastomosis if
catheterization fails. This approach is more invasive and is
associated with increased operative time and hospitalization.
Because anterior urethral injuries are rare, accepted treat-
ment methods are commonly based on relatively few pa-
tients. Therefore, to our knowledge definitive therapy for
anterior urethral injury remains controversial. We present
our experience with endoscopic realignment of bulbar ure-
thral disruption in 16 men treated from 1990 to 1999.
PATIENTS AND METHODS
Between April 1990 and June 1999 we treated 16 men 17
to 36 years old with anterior urethral injury on an outpatient
basis at our institution (see table). Patients presented with
urethral hemorrhage and dysuria 1 to 6 hours in duration
after straddle injury. A palpable bladder indicated urinary
retention in 3 cases. There were no associated injuries, such
as traumatic shock or fracture.
Retrograde urethrography revealed bulbar urethral dis-
ruption with no posterior urethral or bladder injury. The
diagnosis of complete and partial disruption in 4 and 12
cases, respectively, was made by urethroscopy during treat-
ment (fig. 1). In 2 patients with complete and 4 with partial
disruption attempted test catheterization was unsuccessful,
and so emergency endoscopic urethral reunion was done.
Endoscopic urethral realignment was performed as soon as
the diagnosis was confirmed in the remaining 10 patients.
We assessed potency, stricture, urinary flow, hospitalization
and intraoperative time. Mean followup was 56 months
(range 39 to 85).
The procedure was performed using superficial lidocaine
anesthesia. Patients were placed in the lithotomy position
and 5% mannitol or normal saline was instilled. Under direct
vision we advanced a 21Fr urethroscope to reach and clearly
reveal the proximal end of the disrupted urethra. A 5Fr
flexible tip guide wire was then introduced across the bulbar
urethral disruption into the bladder via the urethroscope
working channel. The urethroscope was withdrawn and the
guide wire remained in place. The tip of a 22Fr Foley catheter
was pierced with a 12 gauge syringe needle to create a fora-
men. The extracorporeal end of the guide wire was inserted
into the foramen and the catheter was advanced over the
guide wire into the bladder. The guide wire was removed and
the balloon was filled with 15 ml. normal saline.
Mean operative time was 9.5 minutes (range 8 to 12). All
patients were treated with broad-spectrum oral antibiotics
for 3 days postoperatively. The catheter remained indwelling
for 2 to 3 and 6 to 8 weeks in cases of partial and complete
disruption, respectively.
RESULTS
Urethral continuity was successfully established at a sin-
gle session in all 16 patients. The procedure was repeated
successfully in 1 man due to balloon rupture after 24 hours of
catheterization. We noted no complications, such as water
intoxication, infection or significant urine extravasation. The
Foley catheter was removed 2 to 8 weeks after treatment.
Urethral continuity was maintained and urethrography was
normal in most patients after catheter removal (fig. 2).
Urethroscopy revealed mild stricture at the traumatic ure-
thral site in only 2 of the 16 patients (12.5%), who complained
of a decreased stream. Urethral disruption was complete and
partial in 1 case each, in which test catheterization had
repeatedly failed after injury. After treatment each patient
performed intermittent urethral self-dilation once weekly for
2 to 4 sessions using an 18Fr catheter and voiding complaints
resolved. During followup uroflowmetry showed a satisfac-
tory voiding pattern in all patients. Maximum urinary flow
was 18.6 to 25.3 ml. per second. All men were potent during
followup.
DISCUSSION
Injury of the anterior urethra, such as that of the bulbar
urethra, is more common than that of the posterior urethra
Accepted for publication June 23, 2000.
0022-5347/00/1645-1543/0
THE JOURNAL OF UROLOGY
®
Vol. 164, 1543–1545, November 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION,INC.
®
Printed in U.S.A.
1543

and is most often due to the blunt trauma of straddle inju-
ry.
1, 3, 4
After establishing the diagnosis the goal of treatment
should be urethral continuity, while minimizing the risk of
complications. Partial and some complete ruptures of the
bulbar urethra may be managed only by several weeks of
bladder drainage.
2, 4
However, the urethral gap and hema-
toma at the injury site always make blind catheterization
difficult. Furthermore, repeat attempts at test catheteriza-
tion may aggravate the severity of injury and increase the
stricture rate.
5
Thus, after failed catheterization patients
with bulbar urethral disruption have traditionally been
treated with emergency open surgery to realign the urethra
and decrease the incidence of urethral stricture or with su-
prapubic cystostomy tube placement followed by secondary
urethral reconstruction. At our hospital these more invasive
approaches are associated with a long operative time of about
2 hours, an extended hospital stay of 1 to 2 weeks and a cost
of about RMB 4,000.
In the procedure that we describe the Foley catheter may
be advanced through the external sheath of the internal
urethrotomy endoscope, which has a C-shaped cross section.
However, catheter caliber is limited to 14Fr or less by sheath
size. In addition, the success of this procedure depends on
introducing the endoscope into the bladder via the disrupted
urethral site, which may increase urethral injury.
We were led to develop this treatment by reports of pri-
mary endoscopic realignment as early intervention in cases
of posterior urethral injury, which may alleviate the need for
open surgery. Most others believe that early realignment not
only decreases the incidence of stricture, but also decreases
stricture length and, thus, facilitates later repair. A number
of techniques of so-called railroading to manipulate the cath-
eter across the posterior urethral gap have been described,
such as direct vision, sound-to-sound, sound-to-finger and so
forth.
6–8
Since results are best after primary endoscopic re-
alignment of posterior urethral injuries, we thought to use a
similar technique to achieve anterior urethral continuity.
Furthermore, unlike the disruption gap in cases of posterior
urethral disruption, the gap in the anterior urethra is rela-
tive short and the proximal end of the disrupted anterior
urethra is more immobile. Therefore, we think that combined
suprapubic intervention is not required to reestablish ante-
rior urethral continuity.
We previously reunited ruptured bulbar urethras with a
Foley catheter under urethroscopic guidance with satisfac-
tory results. This technique is simple and no significant
urethral stricture or impotence was observed postopera-
tively. Furthermore, because treatment may be performed
using local anesthesia on an outpatient or emergency basis,
hospital stay and cost are significantly decreased. In our
series no patients required hospitalization and the average
cost of treatment was RMB 450.
Several points require attention during this procedure.
Isotonic solutions are recommended during instillation to
avoid water intoxication. To visualize clearly and prevent
infection and urinary extravasation instillation must be
maintained at an appropriate pressure of 40 cm. water or less
and at an appropriate flow rate. We do not recommend that
the urethroscope be advanced across the urethral gap, which
may cause a high risk of further urethral injury.
Urethroscopic urethral reunion has the advantages of min-
imal invasion and low cost, which is about 10% that of open
FIG. 1. Endoscopy in patient 13. A, complete anterior urethral disruption 65 minutes after injury. B, 6 months later urethral continuity
is maintained.
Patient data and treatment results
Pt. — Age
No.
Hrs. After
Injury Presentation Injury Type Test
Catheterization Self-Dilation
Urine Flow 6 Mos. or
More After Treatment
(ml./sec.)
1 — 24 2 Urethral hemorrhage ⫹dysuria Partial No No 21.5
2 — 31 1.5 Urethral hemorrhage, dysuria ⫹perineal hematoma Partial Yes 2 18.6
3 — 25 1 Dysuria Partial No No 22.6
4 — 32 1.5 Urethral hemorrhage, dysuria ⫹palpable bladder Complete Yes 4 21.2
5 — 31 2 Urethral hemorrhage ⫹dysuria Partial No No 19.0
6 — 17 3 Urethral hemorrhage ⫹dysuria Partial Yes No 24.3
7 — 20 1 Urethral hemorrhage ⫹dysuria Partial Yes No 21.8
8 — 33 1 Urethral hemorrhage ⫹dysuria Partial No No 19.5
9 — 25 2.5 Urethral hemorrhage ⫹dysuria Complete Yes No 21.3
10 — 18 2 Urethral hemorrhage Partial No No 25.3
11 — 26 1 Urethral hemorrhage, dysuria ⫹palpable bladder Complete No No 20.1
12 — 28 1.5 Urethral hemorrhage ⫹dysuria Partial No No 20.8
13 — 36 6 Urethral hemorrhage ⫹dysuria Complete No No 19.6
14 — 22 4 Urethral hemorrhage Partial No No 23.8
15 — 32 2 Urethral hemorrhage ⫹dysuria Partial Yes No 22.0
16 — 27 3 Urethral hemorrhage, dysuria, palpable bladder ⫹
perineal hematoma
Partial No No 22.1
URETHROSCOPIC REALIGNMENT OF RUPTURED BULBAR URETHRA1544

surgery. In addition, it may be performed on an outpatient
basis. Bladder drainage and the establishment of urethral
continuity at 1 stage may be successful using this procedure.
It may be performed using superficial lidocaine but not dy-
clonine anesthesia since absorption from the wound surface
may result in systematic toxicity. Urethral stricture in only 2
of our cases may have been associated with repeat blind test
catheterization.
Because our patient number was relatively low, we iden-
tified no significant association of stricture with the extent of
injury. In addition, no other significant complications were
due to the procedure. Potential complications include an in-
creased probability of urethral injury as well as an increased
incidence of infection and urethral stricture after treatment
but there were none in our study. To our knowledge we report
the initial cases of endoscopic treatment of anterior urethral
disruption. More experience with a sufficient number of pa-
tients and longer followup are needed to confirm our early
results and compare this approach with conventional methods.
CONCLUSIONS
The trend in medicine continues to be toward nonoperative
or minimally invasive surgery. Often minimally invasive en-
doscopic procedures replace open surgical procedures. Our
experience indicates that test catheterization always fails in
cases of bulbar urethral disruption. As an ideal cost-effective
treatment of the ruptured bulbar urethra, ureteroscopic ure-
thral reunion should be considered at the earliest opportu-
nity. Retrograde urethrography did not clearly differentiate
partial from complete urethral disruption. Thus, we think
that when endoscopic realignment is appropriate for sus-
pected anterior urethral injury, retrograde urethrography is
not necessary. The diagnosis of the severity of injury is made
more precisely using urethroscopy. In most patients with
anterior urethral injury this treatment is sufficient.
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Grayhack, S. S. Howards et al. St. Louis: Mosby Year Book,
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4. Sagalowsky, A. I. and Peters, P. C.: Genitourinary trauma. In:
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realignment of the disrupted prostatomembranous urethra.
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solved controversy. J Urol, 161: 1433, 1999
FIG. 2. Normal studies in patient 13 after catheter removal 6
months after treatment. A, retrograde urethrography. B, voiding
urethrography.
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