Novel method of primary endoscopic realignment for high-grade posterior urethral injuries

BACKGROUND A male urethral disruption injury is a urological emergency. Primary endoscopic realignment (PER) refers to reestablishment of urethral alignment via indwelling urethral catheter by cystoscope, which is recommended as the optimal emergent treatment approach for reducing the likelihood of complications following injury. However, the prior literature suggests the success rate of PER to be relatively low due to complicated urethral disruption. We report a modified PER approach that serves to improve both the success rate and safety of the treatment. CASE SUMMARY A 19-year-old male patient presented with multiple pelvic fractures and complete urethral disruption following a high-velocity traffic accident. The patient's abdominal computed tomography and retrograde urethrography results revealed complete urethral disruption at the bulbar urethra, with hematoma and contrast medium extravasation that extended into the extraperitoneal space. The conventional retrograde PER by cystoscope failed due to severe disruption and considerable hematoma. Modified simultaneous antegrade and retrograde PER was performed by means of semi-rigid ureteroscopy via a suprapubic Foley catheter and cystoscopy via the external urethra. An antegrade guidewire was passed through the bladder neck and then pulled out through the external urethral meatus with a cystoscope. Urethral continuity was achieved after a 16-Fr silicone Foley catheter was indwelled into the bladder along the guidewire. The patient recovered well, achieving voiding continence and avoiding further operation for urethral stricture. CONCLUSION Modified PER via suprapubic Foley catheter represents a promising and safe treatment approach in patients with posterior urethral injuries.