Urologic Radiology

Urol Radiol 3, 107-112 (1981)

Percutaneous Transvesical Antegrade Passage of Urethral Strictures William S.C. Hare, Donald McOmish, and Ian N. Nunn Departments of Radiology and Urology, University of Melbourne, Royal Melbourne Hospital, Victoria, Australia

Abstract. Failure to pass a urethral stricture by retrograde instrumentation is generally accepted as excluding the possibility of closed internal urethrotomy. In 2 patients with impassable strictures percutaneous transvesical antegrade passage of a guide wire through the stricture was successful, paving the way for balloon dilatation of the stricture and visual internal urethrotomy. In view of the success rate of internal urethrotomy in treating strictures, it is recommended that this radiological method of dealing with an impassable stricture from above be used to avoid open operation and to allow internal urethrotomy to proceed. A protocol for the procedure is suggested. Key words: Urethra - Strictures, impassable - Percutaneous antegrade passage

Urethral strictures that are impassable from below using standard urological methods can be managed by antegrade percutaneous transvesical instrumentation using radiological techniques. This procedure, which we believe to be an important advance in the management of such cases, proved successful in 2 patients.

Case Reports

months later the patient was readmitted with a poor urinary stream and incontinence, and a urethrogram (Fig. 1A) showed a tight stricture. Panendoscopy was performed and the passage of filiform bougies attempted. At the stricture site there was a cul de sac with a very fine bore epithelialized lumen lying ventrally making passage of flliforms and a ureteric catheter impossible I Open exploration was contemplated, but it was decided to attempt percutaneous passage of the stricture from above. Under local anesthesia suprapubic puncture was performed, and over a guide wire a slightly curved 14 F dilator-sheath set was introduced into the bladder and directed toward the bladder neck under fluoroscopic control. A guide wire and 8.3 F catheter were passed through the sheath into the posterior urethra (Fig. 2 A) and through the strictured area into the penile urethra and out through the meatus (Fig. 3 B). A Gruntzig dilating balloon catheter was then passed over the guide wire so that the balloon, which measured 3 cm in length and dilated to a diameter of 5 mm, lay within the strictured segment. The balloon was inflated on several occasions (Fig. 2B), and an 8.3 F catheter was introduced passing from the exterior suprapubically through the bladder and along the length of the urethra to drain into a thigh bag (Fig. 3A). Drainage holes were arranged to lie within the bladder cavity, and the external opening of the catheter suprapubically was occluded. Later, on the same day, the drainage catheter was removed and a 4 F ureteric catheter passed into the bladder to allow passage of the urethroscope. The direct vision urethrotome was introduced alongside the catheter, and the stricture was incised ventrally over a 1.5 cm segment of the membranous urethra. Normal intact urethra was noted below the level of the verumontanum for a distance of 0.5 cm. An 18 F Silastic catheter was then passed to the bladder and the ureteric catheter removed. Four days later the catheter was removed and the patient was discharged from the hospital voiding normally. A urethrogram 2 months later (Fig. 1 B) showed a satisfactory lumen through the stricture and an 18 F sound passed to the bladder.

Case 1 S.L., a 22-year-old man, sustained a ruptured membranous urethra when run over by a tractor. Diastasis was present at the symphysis pubis with a fracture through the right pubic bone. At suprapubic cystostomy it was possible to pass a Sylastic 18 F drainage catheter through the ruptured urethra. After 4 weeks of drainage the urethral catheter was removed and the patient voided normally. Seven

Address reprint requests to: William S.C. Hare, Royal Melbourne Hospital, P.O. 3050, Victoria, Australia.

Case 2 N.T., a 56-year-old man with a past history of urethral stricture, was admitted with acute retention of urine. At panendoscopy, there was extensive stricturing of the anterior urethra. Visual internal urethrotomy was possible in the anterior urethra, but the bulbous stricture was impassable and further urethrotomy was abandoned. A suprapubic catheter was inserted percutaneously. Retrograde (Fig. 4A) and voiding (Fig. 4B) urethrograms showed the extent of stricturing.

0171-1091/81/0003-0107 $01.20 © 1981 Springer-Verlag New York Inc.

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Fig. 1. Case 1. A Urethrogram 7 months after ruptured membranous urethra showing tight stricture. B Urethrogram 2 months after visual internal urethrotomy showing lumen of satisfactory width Fig. 2. Case 1. A The guide wire has been passed through the stricture and an 8.3 F catheter lies in the posterior urethra, having been introduced through the sheath in the bladder. B Balloon catheter in the strictured segment Four days later, in the radiology department under general anaesthesia, a Medi-tech 13 F steerable catheter system was introduced into the bladder over a guide wire after removing the suprapubic tube. The guide wire and catheter tip were manipulated into the prostatic urethra where an antegrade urethrogram using

water-soluble contrast medium outlined the fine tract through the stricture (Fig. 5A). The flexible guide wire tip was introduced through the stricture by carefully manipulating the catheter tip. The use of contrast viewed directly with fluoroscopy avoided production of a false passage and allowed safe passage of the wire

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Fig. 3.

Case 1. A An 8.3 F catheter has been passed from the suprapubic puncture through the bladder and urethra to the exterior. Urethrogram outlined from below. B Guide wire enters suprapubicly through an 8.3 F catheter and sheath set and emerges from the external penile meatus

through the stricture and out through the external meatus (Fig. 5B). After removing the Medi-tech catheter, a Gruntzig balloon dilating catheter was passed over the guide wire to the level of the stricture. Kinking was avoided keeping the suprapubic and penile ends of the guide wire taut, facilitating passage of the balloon catheter. The balloon was then distended with contrast medium and the length of the stricture dilated to 6 mm in diameter. After the dilating catheter was removed, a Foley self-retaining balloon catheter with its tip removed was passed over the guide wire to the bladder. The guide wire was then removed and the catheter provided free drainage. The suprapubic puncture wound closed spontaneously. On the following day, a guide wire was passed through the Foley catheter into the bladder and the catheter removed. A further dilatation of the stricture to 6 mm (18 F) was performed by introducing the balloon catheter over the guide wire from below (Fig. 6A). Following this, the Foley self-retaining catheter was again introduced over the guide wire into the urethra. A final urethrogram was performed after partially inflating the Foley balloon to prevent leakage; this urethrogam revealed considerable improvement (Fig. 6B). The catheter was then returned to the bladder.

After a 10-day period of catheter drainage it was possible to perform an internal urethrotomy to 28 F and insert a urethral catheter. The patient is now voiding normally.

Discussion

Compared with blind internal urethrotomy [1], internal urethrotomy under vision [2] is now recognized as an effective method for treating urethral strictures. Until now, failure of retrograde instrumentation to pass the stricture has thwarted attempts at closed visual internal urethrotomy. The application of radiological methods and instrumentation overcame this problem in the 2 cases described and allowed visual internal urethrotomy rather than an open operation.

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Fig. 4. Case 2. A Retrograde urethrogram showing strictures in the anterior urethra and bulbous urethra with a high degree of obstruction. B Voiding urethrogram showing very tight irregular bulbous stricture

Fig. 5. Case 2. A Urethrogram made through Medi-tech steerable catheter with tip lying at the upper extent of the bulbous stricture. B View after manipulation of guide wire and catheter through the stricture

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Fig, 6. Case 2. A Inflated Gruntzig balloon Catheter lying in the strictured segment. B Urethrogram obtained after balloon dilatation

The recent development of the Gruntzig balloon dilating catheter for arterial strictures makes it possible to dilate the stricture so that a drainage catheter can be inserted more easily. It remains to be seen whether balloon dilatation of urethral strictures [3] offers any advantage over conventional methods of dilatation. The radiologically controlled method of crossing urethral strictures, summarized below, uses recent advances in instrumentation and imaging technology, permitting controlled and precise placement of the guide wire through the strictured area, minimizing the likelihood of false passage. The Medi-tech steerable catheter system allows the direction of the guide wire to be varied while permitting continuous visualization of the strictured area by means of antegrade introduction of contrast material through the catheter system. Bleeding, occasionally a problem at endoscopic attempts at crossing urethral strictures, is less of a problem to the radiologist. The ability to control both ends of the guide wire after passage through the stricture is of considerable advantage for introducing dilating catheters through the strictured area, whether performed from above or below.

Experience with these 2 cases suggests the following protocol for performing the procedure: 1. With the patient under general anesthesia or using caudal block with local anesthesia to the abdominal wall, the urologist punctures the bladder suprapubically, introducing the guide wire and dilators to size 14F. 2. The Medi-tech 13 F steerable catheter system is introduced over the guide wire into the bladder. 3. The catheter guide wire system is manipulated into the posterior urethra. The stricture is outlined with contrast medium and under fluoroscopic control the guide wire is passed through the stricture and out through the external urethral meatus. 4. The Medi-tech catheter is exchanged for an appropriate sized Gruntzig polyvinyl or polyethylene arterial balloon dilating catheter, e.g., 3 cm balloon length with 6 mm diameter. The balloon catheter is advanced through the stricture over the guide wire and dilated several times at the appropriate pressure. 5. A 12 F Foley self-retaining catheter is introduced over the distal guide wire into the anterior urethra

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below the stricture. (The tip of the catheter is cut off.) 6. After the dilating balloon catheter is withdrawn to the level of the bladder, a retrograde urethrogram is performed through the Foley catheter in the anterior urethra. This is accomplished by partially inflating the balloon to seal the urethra and hold the catheter in place. Also, the guide wire is positioned so t h a t only 1 or 2 cm project from the outer end of the Foley catheter. This allows an adaptor and syringe with contrast medium to be attached and contrast injected. 7. If the appearance is satisfactory, the Foley catheter is advanced to the bladder and the guide wire and balloon dilating catheter removed, allowing the suprapubic puncture to close.

When urethrotomy is to be performed, a guide wire is passed into the bladder through the drainage catheter, which is then removed to allow introduction of the visual urethrotome. In some cases it may be desirable to plan a combined procedure with the one anesthetic. In that case the visual urethrotome can be introduced beside the guide wire immediately after balloon dilatation.

References 1. Blandy JP: Urethral stricture. Postgrad Med J 56: 383-418, 1980 2. Johnson SR, Bagshaw HA, Flynn JT, Kellett MJ, Blandy JP: Visual internal urethrotomy. Br J Urol 52:542-545, 1980 3. Russinovich NA, Lloyd LK, Griggs WP, Jander HP: Balloon dilatation of urethral strictures. Urol Radiol 2: 33-37, 1980