Flexible cystoscopy-guided realignment of traumatic urethral disruption in pelvic fracture: A case report.

BACKGROUND: Pelvic fractures from high-energy trauma are frequently complicated by urethral injury. The World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) recommend retrograde urethrogram as the first-line diagnostic test for suspected urethral disruption, performed prior to any catheterization attempt. When urethral injury is confirmed, the American Urological Association advises suprapubic tube placement as the preferred initial management to avoid exacerbating injury, with endoscopic or fluoroscopic techniques reserved for select cases in which standard approaches fail or are not feasible (Coccolini et al., 2019; McCormick et al., 2023; Morey et al., 2021).

CASE PRESENTATION: We report the case of a 43-year-old male involved in a high-speed motorcycle collision who presented in hemorrhagic shock with multiple injuries, including complex pelvic ring fractures and blood at the urethral meatus. A retrograde urethrogram demonstrated urethral extravasation near the pubic symphysis. During emergent operative exploration for associated thoracoabdominal injuries, the urology team performed intraoperative flexible cystoscopy. The disrupted urethral tract was identified at the 12 o'clock position, and a 0.035-inch guidewire was advanced into the bladder under direct vision. A 16 Fr council-tip Foley catheter was successfully placed over the wire, achieving urinary drainage and avoiding further urethral trauma. The patient subsequently underwent interventional radiology-guided bilateral internal iliac artery embolization for ongoing pelvic bleeding and staged orthopedic fixation of pelvic fractures. Urethral healing was supported with long-term catheterization, and the patient was discharged on hospital day 31with the Foley catheter in situ for continued urologic follow-up.

CONCLUSION: This case demonstrates that video fluoroscopy and flexible cystoscopy can facilitate safe guidewire-assisted catheter placement in complex pelvic trauma when conventional methods are unsuccessful. However, current guidelines from the World Society of Emergency Surgery, the American Association for the Surgery of Trauma, and the American Urological Association support suprapubic tube placement as first-line management, with endoscopic realignment reserved for experienced providers and specific indications (Coccolini et al., 2019; McCormick et al., 2023; Morey et al., 2021).