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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