Post traumatic stricture and diverticulm

• 11 Feb 2021 09:28:36 AM
• |Reconstructive Urology

40 year male having history of vehicular accidents before 1 year, exploratory laparotomy done at civil hospital for bladder rupture. Following removal of catheter develop LUTS. some endoscopy done twice by general surgeon in year. Presented to me with total incontinence, with poor streem and high residual urine. All serial urethrogram attached 

Comments(11)

• 

  Dr Sanjay Balwant Kulkarni

  15 Feb 2021 02:20:06 PM

  Dear Ashvinkumar 

  Interesting case.

  This patient had road traffic accident with pelvic fracture urethral injury and bladder rupture. The first RGU and MCU shows dilated prostatic urethra indicating double transection of the urethra. Bladder neck- prostate and bulbo membranous trauma. During laparotomy the surgeon closed the bladder injury and manipulated the urethral catheter from below and drained the bladder with Urethral and suprapubic catheter. After urethral catheter removal the both ends of prostatic urethra narrowed and semen collection in the prostatic urethra had no escape route and developed dilated prostatic urethra. Endoscopy was used to dilate the two narrow sites so subsequent RGU shows  non dilation of the prostatic urethra. He is incontinent as both sphincters are not functioning. His bladder looks like neurogenic and needs evaluation. MRI  and endoscopy will clinch the diagnosis. This patient needs urethroplasty in expert hands to preserve continence.

  
  

  
  

  Sanjay B. Kulkarni, Sandesh Surana, Devang J. Desai, Hazem Orabi, Subramanian Iyer, Jyotsna Kulkarni, Ajit Dumawat, Pankaj M. Joshi,

  Management of complex and redo cases of pelvic fracture urethral injuries,

  Asian Journal of Urology, Volume 5, Issue 2,2018,Pages 107-117,

• 

  Venugopal P

  16 Feb 2021 07:51:27 AM

  Dear All,

  I have hopefully placed the pictures provided by Ashvinkumar in the proper order.

  Sanjay has provided useful comments of Complex redo cases of posterior urethral injury from which all of us will have to learn.

  For those interested in reading the article provided by Sanjay, I am providing the link for easy access.

  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934510/pdf/main.pdf

  With warm regards

  Venu

  

• 

  Dr. Ashvinkumar Motilal Gami

  16 Feb 2021 07:36:03 PM

  Here by I am sending link for cystoscopy,  suggest of stricture at prostate apex

  
  

  https://www.youtube.com/watch?v=YQUXmsxEiigyst

• 

  Dr. Anil Takvani

  16 Feb 2021 10:32:30 PM

  So if we conclude problems are:

  No sphinters-  so incontinence 

  Diverticulum

  Stricture 

  Ashwin, which size sheath you used for urethrocystoscopy?

  Thanks 

• 

  Dr. Ashvinkumar Motilal Gami

  17 Feb 2021 09:17:45 AM

  It is done with 6 f ureteroscope, cystoscopy not possible due to stricture. 

• 

  Dr. Anil Takvani

  17 Feb 2021 09:30:24 AM

  On behalf of Dr. Ashvin, I am posting all images again. 

  Time line: Feb 2020, May 2020 & December 2020.

  Thanks 

  

• 

  Dr. Anil Takvani

  17 Feb 2021 09:43:27 AM

  Timeline for above three images is:

  First is the most recent- December 2020

  2nd was done - May 2020

  3rd at the start  of treatment- February 2020

• 

  Dr Sanjay Balwant Kulkarni

  21 Feb 2021 06:16:06 PM

  Dear Anil

  Thanks for rearranging RGU and MCU according to the timeline.

  If you look at the endoscopy carefully the entry point is on the posterior wall of urethra!

  We need an MRI by Dr Pankaj Joshi Protocol to check the anatomy.

  As I wrote in my previous comment the patient had double trauma at the BN-Prostate and Bulbo membranous or Membrano-Prostatic junction.

  We still have to identify the veru montanum properly.

  As both sphincters are not working properly he is incontinent.

  Distal obstruction led to dilated prostatic urethra,

  Sanjay Kulkarni

• 

  Dr. Anil Takvani

  21 Feb 2021 06:30:54 PM

  Agree  MRI by Dr. Pankaj Joshi protocol will be of great help.

  Dear Asvin,  can you please more details on management of this very interesting case? Thanks 

• 

  Dr. Ashvinkumar Motilal Gami

  25 Feb 2021 11:31:32 AM

  Thanks for suggestions,  MRI will be good option. I have decided to do cystoscopy under local Anesthesia to assess his external sphincter.  Cystoscopy done with ureteroscope suggestive of stricture just proximal to sphincter with diverticulum, normal bladder neck, partial damaged veru.
  
  Next day under Anesthesia I gave hot cut at 5,7 and 12 o'clock ; taking care of distal sphincter.  Whole of diverticulum fossa fulgurated. Preoperative consent for incontinence taken.
  
  2 months post operation patient is continent and no LUTS. 
  
  I think that First injury will be partial at prostate apex. Later on stricture at injury site and proximal diverticulum.  As first RGU suggestive of disturbed posterior urethra but no diverticulum.
  Latest preop and post op RGU attached.
  
  Link of operative video
  
  https://youtu.be/2o3YRRpgp4c
  
  

  

• 

  Lalit Shah

  08 Mar 2021 01:13:31 PM

  In the given circumstances wonderful clinical outcome. 

  Continence in the instant case is almost like miracle.

  Now what would be long term plan??

  Stricture proximal to distal sphincter with intact bladder neck,

  Would EEA work??

  Would he need regular CIC with endoscopic management sos??