Core Through [Blind] Endoscopic Internal Urethrotomy & Regular Self Calibration: The Cost-Effective Option for Rural Areas

Urethral injuries are common in rural areas especially in mountainous areas like Northeast India where falls from trees and roads are common. Pelvic fractures can contribute to the urethral injuries. Most of them have initial treatment with suprapubic catheter (SPC) drainage placed as an emergency measure. Many of these patients in rural areas are condemned to lifelong catheters as they cannot afford the cost of reconstructive surgical procedures.

We describe our experience in treating these poor rural patients on catheters for very long time.

THE METHOD

The procedures are generally carried out under spinal anesthesia and in lithotomy position. The cleaning and draping is carried out such that both the perineum and the abdomen are exposed and cleaned. If available two sets of camera and light source are used but generally only one set is available.

Scopy is carried out through the SPC first and the proximal urethra is assessed and either a guidewire or depending on the position of the SPC then a Haegar dilator is used to show the position of the proximal urethra.

The working element with the cold knife is then used from the distal end of the urethra. If necessary higher pressure is used for the scopy. If there is total block the stricture is cut with the cold knife using the following principles.

  1. Cutting only white scar tissue [usually there is minimal bleeding if only the scar tissue is cut]
  2. Trying to follow the normal passage in terms of direction for cutting
  3. Using movement from above to guide the direction

It is easily said than done. It needs lots of experience to cut through the scar tissue to reach the normal passage above and once in the bladder a guide wire is placed in the bladder and the cold knife could be used with the half round sheath to cut more.
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If possible a Silastic catheter is placed and if it is difficult to pass the larger catheter a 14F catheter could be initially placed using the half round sheath. We generally leave the catheter in for about a month [for logistic reasons] and in the second sitting replace with a larger catheter and after the third sitting instruct them to do daily self-dilatation with 20F catheter. If they have difficulty in passing the 20F catheter they are instructed to go to the local doctor and pass a 18F catheter and wait for the next sitting of internal urethrotomy.

Figure 1 shows the urethrogram of a patient who had a trial with endoscopic treatment elsewhere and was advised open reconstructive surgery and came to one of the surgical camps since he was unable to afford the treatment and Figure 2 shows the patient after core–through urethrotomy.

Figure 1

Figure 2

RESULTS

Although detailed analysis is not available from the records since 2002, 67 such procedures were performed at the Burrows Memorial Christian Hospital at Alipur in Assam, the surgical camps at various places in Northeast India and the surgical camps of Samiti for Education, Environment, Health and Social Action [SEESHA]. More than ninety percent of them had successful surgery to enter the urinary bladder and have a smaller catheter. The maximum number of repeat procedures on the same patient recorded was 14 over a period of 8 years. Many of them settle down with three to four repeat procedures. Most of them could not afford to go to any other place for reconstructive surgery.

DISCUSSION

A study carried out at Christian Medical College Vellore showed that regular self–catheterization is a better method for follow up treatment following Endoscopic Internal Urethrotomy [2]. It is an excellent option for rural patients as many of them cannot afford to go to hospitals for outpatient urethral dilatations. Even complex reconstructive surgeries for urethral disruption has poor results [3]. In one study it was found that about one third of the patients who did not do self-calibration after reconstructive surgery developed strictures in the operated area [4].

Hence with an experienced team, endoscopic core-through urethrotomy and regular self–calibration is the most cost-effective way of treatment in rural areas for total urethral disruption.

Gnanaraj, J., (2017), Core Through [Blind] Endoscopic Internal Urethrotomy & Regular Self Calibration: The Cost-Effective Option for Rural Areas, mdCurrent-India, Volume 6. Available online at: http://mdcurrent.in/urology/core-blind-endoscopic-internal-urethrotomy-regular-self-calibration-cost-effective-option-rural-areas/ This is a peer-reviewed article.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

http://www.seesha.org/

  1. Devasia A, Pandey AP. Intermittent self – catheterization versus regular outpatient urethral dilatation in urethral stricture: A comparison. Aust N Z J Surg 1999 Jan (1):41-3
  2. B. Ramesh. Management of Pelvic fracture Urethral distraction defect. Journal of Evolution of Medical and Dental Sciences. Vol. 4, Issue 7, January 2015 p 1112-21
  3. Ogbonna (1998), Managing many patients with a urethral stricture:. British Journal of Urology, 81: 741–744. doi:10.1046/j.1464-410x.1998.00638.x

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