One of the options for patients with urethral stricture, bladder-urethral anastomosis stricture and neurological patients with detrusor-sphincter dyssynergia could be the urethral stent.
The gold standard procedure in neurological patients is the sphincterotomy, an invasive and irreversible procedure not free of complications; which we should consider: bleeding, infertility, erectile dysfunction, strictures and a high rate of reinterventions. In addition, it does not allow the patient a period of adaptation to the new voiding pattern.
Urethral stents offer a reversible alternative, and an effective and well tolerated procedure which causes minor complications in its majority, such as urinary infection and migration or calcification of the stent. More serious complications, such as sepsis, are very rare.
Using this alternative, we allow patients to preserve their fertility and erectile function, in addition to offering a time of accommodation to their new situation.
This treatment gives all the professionals a time to think about the best alternative in an individualized way, so we can decide the best therapeutic attitude according to the results and tolerance of the stent. We can choose either to make a temporary replacement or place a definitive one, do not perform any procedure or choosing to perform a sphincterotomy.
To use this procedure, we have always required fluoroscopic control. We propose to replace the use of fluoroscopy with the use of transrectal ultrasound. It offers a radiation-free method that allows direct visualization of the procedure and the location of the stent in real time.
Currently, it is not possible to talk about the cost-utility of the procedure since there are no studies with this purpose.
We present the case of a 70-year-old man with a complete traumatic spinal cord injury at level C6-C7 with detrusor-sphincter dyssynergia, who required the placement of an Allium TPS urethral stent type of 6 cm in length, so that the distance between the length between the bladder neck and the external sphincter was 5.7 cm.
To perform the procedure, we needed an ultrasound scanner with a transrectal transducer, an endoscopic delivery tool with 0-degree optics, a stent to place and two specialists in Urology. Before starting the procedure, it is important to identify the following anatomical references in the transrectal ultrasound image (Image 1).
Image 1. (B) Spongiosus bulb, (U) Urethra, (E) External sphincter, (P) Prostate, (V) Bladder.
Once the patient is placed in supine position with legs and anesthetized (epidural or general anesthesia) we proceed to the placement of the stent.
An urologist will be in charge of managing the transrectal transducer and being able to detect the movement of the cystoscope in the most coordinated possible way, to identify the exact place of placement of the stent.
Once we are in the correct position we must remove the safety of the endoscopic delivery tool and press the trigger repeatedly to release the stent.
Once released, it is important to remove the endoscopic delivery tool slowly, while performing circular movements. We must pay attention to the ultrasound image to detect any displacement of the stent in real time to correct its position before ending the procedure.
Urethral stents are an alternative to sphincterotomy in patients with detrusor-sphincter dyssynergia. It is an effective, reversible and well tolerated procedure, with minor complications in its majority.
The use of fluoroscopy can be replaced by transrectal ultrasound, avoiding the patient to be radiated and allowing us to directly visualize the procedure and the location of the stent in real time.