Endoscopic repair in 154 cases of urethral occlusion: the promise of guided optical urethral reconstruction

PURPOSE: We determined whether optical urethral reconstruction, with the use of a Béniqué bougie in the proximal urethra and transrectal digital guidance, is effective for the treatment of long and severe urethral occlusions. However, with some skill the procedure can be done without the bougie for the treatment of short occlusions. MATERIALS AND METHODS: During a 9-year period 154 men with complete urethral occlusion underwent core through optical urethrotomy via transrectal digital guidance, using the Béniqué bougie in 89 (58%). A total of 400 urethrotomies was performed. All lesions were in the posterior urethra except 8 in the pendulous portion. There were 64 war related injuries (41.6%). Combined voiding and retrograde urethrography was not useful to measure the length of the occlusion due to failure of proximal urethral filling. Guided optical urethral reconstruction consisted of optical urethrotomy performed with a Béniqué bougie introduced proximally through the suprapubic catheter site and into the proximal urethra with the index finger of the operator in the rectum. The same procedure was performed blindly without use of the bougie in 65 patients (42%), and in 43 with lesions shorter than 1 cm. and 4 with multiple annular lesions. We also used the blind technique successfully to reestablish 18 occlusions longer than 1 cm. For optimal epithelialization of the urethral tract we suggest leaving a silicone catheter indwelling for 3 months. No prophylactic antibiotics were given. RESULTS: Of the patients 54 (35%) were cured after 1 procedure, whereas the remaining 100 (65%) required 1 to 9 additional urethrotomies (mean 3). Patients with an uninstrumented urethra who were treated initially with suprapubic catheterization required 1 to 6 urethrotomies (mean 2), compared to 1 to 10 (mean 3) for those who had undergone a prior procedure. Hematuria occurred in 9% of the patients, symptomatic urinary tract infection in 7% and slight extravasation in 3.2%. One patient had stress incontinence. CONCLUSIONS: Our procedure is effective, simple, safe, repeatable, inexpensive and minimally invasive, and it does not require special or sophisticated guiding instruments, which are necessary for previously described techniques. It can be performed with or without use of a Béniqué bougie depending on the extent of the lesion and skill of the surgeon. The outcome can be judged from the symptomatic response of the patient, and flow studies and urethrography are not mandatory during routine followup.