Department of Urology, Clinical Hospital Split, Croatia
In February 2010. a 63 years old male was brought to emergecy room at Clinical Hospital Split in hemorrhagic shock. He fell down from heigt of 10 metres and susteined multiple and life threatening injuries: contusion of rigt lung with hemato and pneumothorax , serial fracture from III to XII rib on th right side, fracture of right forearm and right lower leg ,multifragmental fracture of sacral bone with dislocation of superior rami of pubic bone , avulsion of tubera of ischial bone and diasthasis of symphisis of more than 2 centimetres. MSCT with contrast revealed right kidney rupture with perirenal hematoma without contrast extravasation and minor extraperitoneal bladder rupture. We decided to treat bladder and renal rupture conservatively with urinary catheter inserted in the bladder. Measures for resuscitation were undertaken. After stabilizing patient was transfered to Zagreb in the Hospital Sestre Milosrdnice at surgical departement. Multiple surgical procedures were undertaken including osteosynthesis of fractured pelvic bones. Control urethrography revealed extravasation of contarst media from posterior urethra. Consulting urologyst suggested urinary catheter as a permanent solution. He assumed that surgery of posterior urethra would be very difficult to perform either approach ( transsymphyseal or perineal) owing to character of bonoe fractures and type of osteosynthesis that was performed.
The patient stayed in hospital for 6 monts suffering from many complications: wound infection, multiple decubitus, osteomyelitis, uroinfection. After discharge from the hospital process of rehabilitation was conducted in specialized institution. All that time he had urinary catheter that was changed regularly every two weeks. In June 2011. he complained on difficulties carrying urinary catheter, so we removed it.
Two months later he was addmited to our urological departement in the emergency service with absces formation in the left groin. He also complained on the weak urinary stream. We made incission in the left groin and evacuated pus. Attempt to place urinary catheter in the bladder was unsuccessfull because of the stricture of the anterior urethra. We placed urethroscopically 3 Ch ureteral catheter in the bladder and secured urinary drainage. The next day we performed internal urethrotomy: with Sacheʹs urethrotome we incised scar tissue; afterthat an orthopedic screw was visible traversing through urethra. The screw was tightly lodged in the urethra and we could not mobilize it. So we placed urethral catheter 18 Ch in the bladder. Plain film of lower abdomen showed multiple screws and plate after ostheosynthesis of pelvic bones. Retrograde urethrography helped us to localize screw that was traversing urethra.
The dilemma was to extract screw immediately by transperineal approach or to place catheter in the bladder for some time in hope that screw position in the urethra will relax. We choose the second solution and wait until January 2012. when we tryed again to remove screw endoscopically. Using cystoscope with working element we managed to dislodge the screw with forceps and then to remove it from urethra. Urinary catheter 18 Ch was placed in bladder for next 6 weeks. Afterthat control uretrography showed irregular outline of urethral lumen with contrast promptly filling the bladder, so urinary catheter was removed. The patient voids with good caliber stream occasionaly with elements of urgency.
- This was unusual situation for us because we had no experience in dealing with such a problem
- Someone may question our approach in favor of urethroplasty with perineal appproach
- Close follow-up is mandatory in order to prevent recurrent urethral stricture
- So far the patient is doing well and is satisfied with quality of his voiding