Management of iatrogenic urethral injury.
The risk of urethral injury due to improper catheterization during a hospital stay is estimated to be 3.2 per 1000.  Urethral catheterization in males to be done only if necessary, especially patients who have previously underwent surgery for hypospadias. If required fine caliber catheters to be used. Transurethral resection of the prostate (TUR-P), and similar Transurethral procedures are other common cause of iatrogenic urethral lesions. Prolonged catheterization primarily affects the anterior urethra, the bladder neck is rarely affected.  Stricture formation with concomitant incontinence is possible due to sphincter damage.
Depending on the treatment used for prostate cancer, incidence of iatrogenic urethral trauma is estimated to be around 1.1-8.4%, highest risk being with radical prostatectomy or brachytherapy plus external beam radiotherapy.  Robotic assisted radical prostatectomy also have similar rate (2%) of urethral injury as open radical prostatectomy.  Abdominal and pelvic procedures also result in iatrogenic injuries to the urethra. Bladder catheterizations prior to surgery prevents or reveals these injuries if any. 
Diagnosis of iatrogenic urethral injury: The symptoms of urethral injury caused by improper catheterization or use of instruments are penile and/or perineal pain (100%) and urethral bleeding (86%). 
MANAGEMENT: Prevention of urethral injuries is better than the management of the complications. Proper urethral catheterization technique under aseptic precautions is a must. Junior doctors and the nursing staff to be trained and supervised during their initial period of catheterization.
Acute false passage is treated by urethral stenting with an indwelling catheter with or without endoscopic assistance for a short period of time.  If urethral catheterisation is not possible, suprapubic catheter to be placed. 
Endoscopic management successfully treats the iatrogenic strictures after radical prostatectomy. Patient may need multiple sessions. Placement of urethral stents at the bladder neck together with the placement of an artificial sphincter has also been reported as a valid option in recurring strictures, but should be performed only in selected patients. [11,12] The alternatives are a permanent indwelling catheter, urethral dilatation, intermittent self-catheterization, or open procedures.
Open vesicourethral reanastomoses carry increased morbidity and are also associated with incontinence requiring an artificial sphincter.  endoscopic management, either by incision or resection Alternative procedures in recalcitrant cases and in post-TUR-P double sphincteric lesions (incontinence + stricture) are procedures that abandon the urethral outlet, such as urinary diversions, continent vesicostomy or permanent suprapubic catheter. [14,15]
Recommendations for avoiding iatrogenic urethral trauma:
* Avoid traumatic catheterization.
* Keep the length of time an indwelling catheter is present to a minimum.
* Major abdominal and pelvic surgery should be undertaken with a urethral catheter as a guide and protective structure.
[1.] Jordan GH, Schlossberg SM. Surgery of the penis and urethra. In: Walsh PC, Retik AB, Vaughan Jr ED, Wein AJ, editors. Campbell's Urology. 8th ed. Philadephia, PA: WB Saunders; 2002. p. 3886-952.
[2.] Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral stricture: etiology and characteristics. Urology 2005; 65: 1055-8.
[3.] Hammarsten J, Lindqvist K. Suprapubic catheter following transurethral resection of the prostate: a way to decrease the number of urethral strictures and improve the outcome of operations. J Urol 1992; 147: 648-51.
[4.] Kashfi L, Messer K, Barden R, Sexton C, Parson JK. Incidence and prevention of iatrogenic urethral injuries. J Urol 2008; 179: 2254-7 discussion 2257-8.
[5.] Hammarsten J, Lindqvist K, Sunzel H. Urethral strictures following transurethral resection of the prostate. The role of the catheter. Br J Urol 1989; 63: 397-400.
[6.] Elliott SP, Meng MV, Elkin EP, McAninch JW, Duchane J, Carroll PR. CaPSURE investigators. Incidence of urethral stricture after primary treatment for prostate cancer: data from CaPSURE. J Urol 2007; 178: 529-34.
[7.] Msezane LP, Reynolds WS, Gofrit ON, Shalhav AL, Zagaja GP, Zorn KC. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol 2008; 22: 97-104.
[8.] Polat O, Gu" l O, Aksoy Y, Ozbey I, Demirel A, Bayraktar Y. Iatrogenic injuries to ureter, bladder and urethra during abdominal and pelvic operations. Int Urol Nephrol 1997; 29: 13-8.
[9.] Go"kalp A, Yildirim I, Aydur E, Go"ktepe S, Basal S, Yazicioglu K. How to manage acute urethral false passage due to intermittent catheterization in spinal cord injured patients who refused insertion of an indwelling catheter. J Urol 2003; 169: 203-6.
[10.] Maheshwari PN, Shah HN. Immediate endoscopic management of complete iatrogenic anterior urethral injuries: a case series with long-term results. BMC Urol 2005; 5: 13.
[11.] Eisenberg ML, Elliott SP, McAninch JW. Preservation of lower urinary tract function in posterior urethral stenosis: selection of appropriate patients for urethral stents. J Urol 2007; 178: 245-660 discussion 2460-1.
[12.] Elliot DS, Boone TB. Combined stent and artificial urinary sphincter for management of severe recurrent bladder neck contracture and stress incontinence after prostatectomy: a long-term evaluation. J Urol 2001; 165: 413-5.
[13.] Elliott SP, McAninch JW, Chi T, Doyle SM, Master VA. Management of severe urethral complications of prostate cancer therapy. J Urol 2006; 176 (6 Pt 1): 2508-13.
[14.] Chrouser KL, Leibovich BC, Sweat SD, Larson DW, Davis BJ, Tran NV, et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol 2005; 173: 1953-7.
[15.] Marguet C, Raj GV, Brashears JH, Anscher MS, Ludwig K, Mouraviev V, et al. Rectourethral fistula after combination radiotherapy for prostate cancer. Urology 2007; 69: 898-901.
Shreeharsha Mallappa Awati (1), Nataraj Naidu R (2)
(1.) Shreeharsha Mallappa Awati
(2.) Nataraj Naidu R.
PARTICULARS OF CONTRIBUTORS:
(1.) Assistant Professor, Department of Urology, Sanjay Gandhi Institute of Trauma & Orthopaedics, Byrasandra, Jayanagar, Bangalore.
(2.) Assistant Professor, Department of General Surgery, Sanjay Gandhi Institute of Trauma & Orthopaedics, Byrasandra, Jayanagar, Bangalore.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Shreeharsha Mallappa Awati, No. 1442, 1st main 11th Cross, Kengeri Satellite Town, Bangalore-560060.
Date of Submission: 10/03/2015. Date of Peer Review: 11/03/2015. Date of Acceptance: 23/03/2015. Date of Publishing: 06/04/2015.
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|Author:||Awati, Shreeharsha Mallappa; Nataraj, Naidu R.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Apr 6, 2015|
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