Surgical Management of Large Foreign Bodies in the Bulbar Urethra
For large foreign bodies in the bulbar urethra requiring open surgery, a "step-up" surgical approach is recommended, starting with attempted transanal extraction under anesthesia and proceeding to open urethrotomy with direct visualization only when less invasive methods fail. 1
Initial Assessment and Approach
- Imaging with lateral and anteroposterior plain X-rays of the pelvis should be performed to identify the foreign body's position, shape, size, and location 1
- For hemodynamically stable patients with suspected perforation, a contrast-enhanced CT scan is recommended 1
- In patients with low-lying foreign bodies without signs of perforation, an initial attempt at bedside extraction should be made 1
- If bedside extraction fails, pudendal nerve block, spinal anesthesia, intravenous conscious sedation, or general anesthesia should be used to improve chances of transanal retrieval 1
Open Surgical Approach for Bulbar Urethral Foreign Bodies
- Open surgical approach is indicated when less invasive methods fail or are contraindicated 1
- The surgical approach should follow these steps:
- Perform a midline perineal incision with the patient in lithotomy position 2
- Expose the bulbar urethra through careful dissection of the subcutaneous tissue and bulbospongiosus muscle 2
- Make a longitudinal urethrotomy directly over the foreign body for optimal visualization and minimal tissue damage 2, 3
- Extract the foreign body under direct visualization, taking care to avoid further urethral trauma 4
- Perform thorough irrigation of the surgical field 5
- Close the urethrotomy with absorbable sutures in a watertight fashion 3
- Consider urinary diversion with a suprapubic catheter rather than a urethral catheter to prevent pressure on the repair 3
Special Considerations
- For patients with extensive urethral damage, consider urethroplasty techniques using oral mucosa as the first choice when grafting is required 1
- Oral mucosa is preferred over skin flaps due to higher patient satisfaction and fewer complications such as post-void dribbling [1, @19@]
- For complex cases with significant tissue damage, a staged approach may be necessary 1
- In patients with extensive damage requiring reconstruction, buccal mucosa graft urethroplasty has success rates greater than 80% for bulbar urethral repairs [1, @16@]
Post-Operative Management
- Perform cystoscopy or flexible sigmoidoscopy after foreign body removal to evaluate urethral wall status 1
- Antibiotic therapy is not routinely recommended after uncomplicated foreign body removal 1
- For cases with signs of infection or perforation, broad-spectrum antibiotic therapy should be administered 1
- Urethral catheter may be safely removed within 72 hours following uncomplicated procedures 6
Potential Complications and Management
- Urethral stricture is a common complication following foreign body removal from the urethra 3
- For short (<2cm) bulbar strictures that develop post-procedure, initial management with urethral dilation or direct visual internal urethrotomy may be attempted 6
- For longer (≥2cm) strictures, urethroplasty should be offered due to low success rates with endoscopic treatments [1, @16@]
- Repeated endoscopic treatments may cause longer strictures and increase the complexity of subsequent urethroplasty 6
Pitfalls to Avoid
- Delaying surgical treatment to perform imaging in hemodynamically unstable patients 1
- Attempting transanal extraction in patients with signs of perforation or hemodynamic instability 1
- Using synthetic materials for urethral reconstruction, which should only be considered under experimental protocols [1, @20@]
- Performing repeated endoscopic procedures for recurrent strictures, as failure rates exceed 80% 6