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Primary Endoscopic Realignment (PER)

Primary endoscopic realignment (PER) is the early endoscopic placement of a transurethral catheter across a disrupted urethra in order to restore luminal continuity, most often in the setting of pelvic fracture urethral injury (PFUI) and, less frequently, anterior (bulbar) urethral injury from straddle trauma. It is positioned as an alternative or adjunct to suprapubic cystostomy (SPT) alone with delayed urethroplasty, with the theoretical aim of letting the urethra heal over a stenting catheter — potentially reducing stricture severity, shortening any subsequent stenosis, or in selected cases avoiding open reconstruction altogether.[1][2][3]

For the canonical PFUI clinical workflow (epidemiology, MRI, Webster perineal repair, surveillance), see Pelvic Fracture Urethral Injury (PFUI). For obliterative bulbomembranous stricture salvage after failed PER or SPT-only management, see Core-Through Urethrotomy. For the open gold-standard repair, see Abdominoperineal Urethroplasty.

Indications​

  • Posterior urethral disruption from PFUI in a hemodynamically stable patient, particularly partial injuries where retrograde catheter placement has failed.[4][5]
  • Anterior (bulbar) urethral injury from blunt straddle trauma — particularly partial disruptions, where PER has the strongest evidence of benefit over SPT alone.[6]
  • The WSES-AAST 2019 guidelines list endoscopic realignment as an option in hemodynamically stable patients with complete posterior urethral lesions (without other life-threatening injuries) and as a first-line approach for partial anterior blunt urethral injury.[5]

Relative contraindications / situations favoring SPT alone​

  • Hemodynamic instability or polytrauma requiring damage control.[5]
  • Complete posterior urethral disruption in centers without endoscopic expertise — the AUA 2020 Urotrauma Guideline lists SPT as the preferred initial management for most PFUI cases (Grade C).[4]
  • The AUA 2023 Urethral Stricture Guideline Amendment explicitly warns against repeated endoscopic maneuvers (intermittent dilation, blind "cut to the light") after PFUI, as they are rarely successful and may complicate later urethroplasty.[7]
  • Open urethral realignment has no role in PFUI management.[1]

Approach Selection​

Three principal techniques exist; the dual-endoscopic rendezvous is the workhorse, with fluoroscopic and magnetic-catheter variants reserved for selected scenarios.[8][9][10][11]

ApproachSetupStrengthsWeaknesses
Retrograde-onlySingle retrograde cystoscope, blind passage to bladderSimplest; no SPT or antegrade access requiredLow success in complete disruption; proximal stump obscured by hematoma[12]
Combined antegrade + retrograde (dual endoscopic)Flexible scope through SPT + rigid/flexible scope retrograde; "light-to-light" rendezvousWorkhorse for complete disruption; direct visualization of both stumpsRequires SPT, lithotomy, general anesthesia[8][9]
Fluoroscopic-guided (IR)Antegrade + retrograde wires under fluoroscopy; supineNo lithotomy / no GA; concurrent pelvic embolization possible; useful with unstable fracturesNo direct visualization; 87–92% technical success[10][13]
Magnetic catheter rendezvousCoaxial magnetic sounds advanced antegradely + retrogradely; magnetic attraction crosses gapSimple; no cystoscope requiredMagnetic catheters not widely available; limited adoption[11]

Surgical Technique — Dual Endoscopic (Combined Antegrade-Retrograde)​

Prerequisite — suprapubic access​

  • An SPT (≥14 Fr Foley) is placed first — percutaneously under ultrasound or fluoroscopic guidance, or via open cystotomy. An 18-gauge spinal needle for bladder localization is helpful when the bladder is displaced by pelvic hematoma.[4][1]
  • The suprapubic tract should be dilated to accommodate a flexible cystoscope (typically 15.5–16.5 Fr). Some surgeons mature the tract for several days before realignment; others dilate at the time of the procedure.[14]

Antegrade limb​

  1. A flexible cystoscope is introduced through the suprapubic tract into the bladder.
  2. The scope is navigated through the bladder neck into the prostatic urethra to the proximal end of the disruption.
  3. In complete disruption, the proximal stump appears as a blind cavity filled with hematoma; copious irrigation clears clot and improves visualization.[8][9]

Retrograde limb​

  1. A rigid or flexible cystoscope is advanced retrogradely from the meatus to the distal blind end of the bulbar or membranous urethra.
  2. Hematoma and disrupted spongiosum are inspected; irrigation is again used to improve visibility.[2]

Rendezvous and guidewire passage​

  1. Light-to-light visualization — the antegrade scope's transilluminated light is used as the target for the retrograde scope (or vice versa) to orient toward the gap.[15]
  2. A 0.035-inch hydrophilic guidewire is passed through the disruption, most commonly antegradely from the suprapubic tract through the prostatic urethra and out the meatus, establishing through-and-through wire access.[2][8]
  3. Forceful or blind wire passage is avoided — false passages into the rectum or periurethral tissues may complicate later urethroplasty.[2]

Catheter placement​

  1. A Council-tip Foley catheter (16–18 Fr) is railroaded over the guidewire across the injury site; the end-hole accommodates the wire.[8]
  2. The balloon is inflated in the bladder, the wire is removed, and irrigation through the catheter confirms intravesical position.

Fluoroscopic-Guided (IR) Variant​

This variant is particularly useful when lithotomy positioning is impossible because of pelvic hardware, unstable fractures, or lower-extremity injury.[10]

  • The patient remains supine — no lithotomy, no general anesthesia required.
  • Through the existing SPT, a catheter and guidewire are advanced antegradely into the bladder, through the bladder neck, and into the prostatic urethra under fluoroscopy. A simultaneous retrograde catheter / guidewire is advanced from the meatus.
  • The two wires are manipulated until they cross the disrupted segment; through-and-through access is then converted to a Foley.
  • Technical success: 87% (13 of 15) in Jeon's series, mean procedure time 66 minutes; concurrent pelvic embolization for arterial hemorrhage was performed in 73% of patients in the same session — a unique advantage of the IR-guided approach.[10] Lee's IR series reported 92% technical success and a mean procedure time of 20 minutes.[13]

Magnetic Catheter Rendezvous​

Coaxial magnetic urethral catheters are introduced simultaneously antegradely (through the SPT) and retrogradely (through the meatus). The magnetic attraction between the two catheter tips guides them across the disrupted segment without endoscopic visualization. In Porter's original series, technical success was 85% (11 of 13) with a 50% stricture rate at mean 6.1 months — the technique is simple but constrained by limited availability of magnetic catheters and has not been widely adopted.[11]

Timing and Catheter Protocol​

WindowPractical considerations
Day 0–2 (immediate)Some Level 1 centers perform PER on the day of injury, often concomitantly with orthopedic fixation or laparotomy — avoiding a second OR trip. Median time to realignment was 2 days in one Level 1 series, with 72% performed simultaneously with another surgical service.[16]
Day 3–14 (early delayed)Hematoma partially organizes, anatomy is more identifiable. The ACS 2025 Best Practices recommend PER "within a few days of injury" once stable.[1]
>2–3 weeksFibrosis begins, making endoscopic passage progressively more difficult; some series have nonetheless realigned successfully up to 11–19 days.[3][17]

Catheter duration and post-removal​

  • Catheter indwelling time is 4–10 weeks (mean ≈5–6 weeks) across endoscopic series; the IR literature reports shorter durations (mean 25–52 days).[10][13][16][17]
  • After catheter removal, a VCUG or retrograde urethrogram is performed before voiding trial.
  • Some protocols incorporate clean intermittent self-catheterization for ~3 months after removal to maintain patency.
  • Mean time to failure after catheter removal was 79 days in Leddy's Level 1 series — close surveillance with uroflowmetry, post-void residual, and cystoscopy is essential.[18]

Outcomes — Posterior (PFUI)​

The evidence for PER in complete PFUI is mixed and increasingly questioned. The two largest contemporary datasets — TURNS prospective and Owen's 2025 meta-analysis — show no benefit over SPT alone, while older retrospective series and Barrett's 2014 meta-analysis suggested lower stricture rates.

StudyDesign / NPER outcomeSPT outcomeComment
McCormick 2023 (TURNS)Multicenter prospective, complete PFUI, n = 69Obstruction 97%; urethroplasty 87%Obstruction 94%; urethroplasty 91%No significant difference (p = 0.471, p = 0.784)[19]
Owen 2025 meta-analysis11 studies, 769 patientsStricture OR 1.23 vs SPT (p = 0.80); incontinence OR 1.02 (p = 0.94); ED OR 0.97 (p = 0.88)—No advantage in any domain[20]
Zou 2017Retrospective, n = 522Stricture 83%; mean stricture length 3.2 cm; simple anastomotic urethroplasty 51%Stricture 100%; length 3.7 cm; simple anastomotic 35%PER associated with shorter, simpler strictures[21]
Barrett 2014 meta-analysisSystematic reviewStricture rate significantly lower (OR 0.12, 95% CI 0.04–0.41, p < 0.001)—Older studies; selection bias likely[22]
Johnsen 2015Single-center retrospectiveDefinitive therapy in 37%; only 26% required urethroplasty79% required urethroplastyTime to urethroplasty longer with PER (14.6 vs 5.8 mo, p = 0.003)[2]

Erectile dysfunction rates (≈14–47%) and incontinence rates (≈2–4%) do not differ significantly between PER and SPT, reflecting that these are largely driven by the initial pelvic trauma rather than the realignment procedure itself.[20][23]

Outcomes — Anterior (Bulbar) Straddle Injury​

PER has a more favorable role in partial bulbar disruption:

  • In a propensity-matched study by Peng et al., patients with partial bulbar disruption managed by PER required no further urethral surgery in 41.5% of cases, vs only 14.6% with cystostomy alone (p < 0.001).[6]
  • For complete bulbar disruption, the same group found that emergency primary anastomotic repair outperformed both PER and cystostomy.[6]
  • A modified single rigid ureteroscopy technique for severe bulbar injury achieved 100% technical success, with mild post-PER strictures (53%) manageable by dilation alone.[3]

Impact on Subsequent Urethroplasty​

A frequently raised concern is whether prior endoscopic manipulation worsens the stricture pattern or reduces success of later anastomotic urethroplasty.

  • Potential benefit: PER may shorten stricture length and increase the proportion amenable to simple perineal anastomosis (Zou 2017: 51% vs 35% simple anastomosis).[21]
  • Potential harm: Two studies have shown that previous urethral manipulation (including PER and intervening DVIU) decreases the success rate of subsequent anastomotic urethroplasty for post-traumatic stricture, with higher rates of complicated strictures (34.1% vs 17.1%, p = 0.003).[24][25]
  • Long-term equipoise: A single-surgeon series of 119 patients found no difference in long-term reconstruction outcomes when comparing initial PER vs SPT.[26]

Guideline Summary​

GuidelinePosition
AUA Urotrauma 2020SPT is the preferred initial management for most PFUI; PER is an alternative associated with a longer clinical course due to repeat procedures.[4]
AUA Urethral Stricture Amendment 2023Repeated endoscopic maneuvers (CIC, blind cut-to-the-light) after PFUI should be avoided; delayed urethroplasty is preferred over delayed endoscopic procedures.[7]
ACS Best Practices 2025No strong evidence that PER significantly impacts stenosis rate or complexity for complete PFUI; for partial injuries, successful PER may lower the stenosis rate. Open realignment has no role.[1]
WSES-AAST 2019Endoscopic realignment preferred over immediate urethroplasty in stable patients with complete posterior lesions; first-line for anterior blunt injury.[5]

Technical Pearls and Pitfalls​

  • Avoid false passages. Forced wire passage through hematoma can create rectal or periurethral tracts that complicate later urethroplasty. Gentle, atraumatic technique with copious irrigation and direct visualization is mandatory.[2]
  • Use a small flexible scope through the SPT. A 15.5 Fr flexible cystoscope minimizes tract trauma compared with rigid instrumentation; serial dilation of a percutaneous tract may be required.[4]
  • Manage irrigation pressure. Adequate irrigation is required to clear hematoma but excessive pressure extravasates into the pelvic hematoma cavity.
  • Do not pursue blind "cut to the light." Explicitly discouraged by the AUA 2023 amendment; rarely successful and may extend the injury.[7]
  • Concomitant procedures. PER pairs well with same-anesthetic orthopedic fixation or laparotomy at Level 1 centers — reducing OR trips and allowing simultaneous pelvic embolization in the IR-guided variant.[10][16]
  • Track failure early. Mean time to failure after catheter removal is ~80 days; structured surveillance (uroflow, PVR, cystoscopy) is essential to catch recurrence.[18]

Bottom Line​

PER is best understood as an injury-specific rather than universal early-management strategy. For complete PFUI, contemporary prospective data and the most recent meta-analysis show no advantage over SPT alone in obstruction or urethroplasty rates, and current AUA guidelines favor SPT as initial management.[19][4] For partial posterior or partial anterior bulbar injuries, PER offers a meaningful benefit in reducing stricture rates and potentially avoiding open reconstruction.[6][1] When PER fails, urethroplasty is still feasible — though prior manipulation may alter the stricture pattern and modestly reduce subsequent anastomotic success in some series.[24][25]

References​

1. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

2. Johnsen NV, Dmochowski RR, Mock S, et al. Primary endoscopic realignment of urethral disruption injuries — a double-edged sword? J Urol. 2015;194(4):1022-6. doi:10.1016/j.juro.2015.03.112.

3. Zhang Z, Fang L, Chen D, et al. A modified endoscopic primary realignment of severe bulbar urethral injury. J Endourol. 2021;35(3):335-341. doi:10.1089/end.2020.0567.

4. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma guideline 2020: AUA guideline. J Urol. 2021;205(1):30-35. doi:10.1097/JU.0000000000001408.

5. Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x.

6. Peng X, Guo H, Zhang X, Wang J. Straddle injuries to the bulbar urethra: what is the best choice for immediate management? J Trauma Acute Care Surg. 2019;87(4):892-897. doi:10.1097/TA.0000000000002388.

7. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

8. Gheiler EL, Frontera JR. Immediate primary realignment of prostatomembranous urethral disruptions using endourologic techniques. Urology. 1997;49(4):596-9. doi:10.1016/s0090-4295(97)80002-7.

9. Melekos MD, Pantazakos A, Daouaher H, Papatsoris G. Primary endourologic re-establishment of urethral continuity after disruption of prostatomembranous urethra. Urology. 1992;39(2):135-8. doi:10.1016/0090-4295(92)90269-3.

10. Jeon CH, Kwon H, Kim JH, et al. Complete posterior urethral disruption accompanied by complex pelvic fractures: clinical outcomes of fluoroscopic primary posterior urethral realignment. J Vasc Interv Radiol. 2021;32(3):343-349. doi:10.1016/j.jvir.2020.10.029.

11. Porter JR, Takayama TK, Defalco AJ. Traumatic posterior urethral injury and early realignment using magnetic urethral catheters. J Urol. 1997;158(2):425-30.

12. Cohen JK, Berg G, Carl GH, Diamond DD. Primary endoscopic realignment following posterior urethral disruption. J Urol. 1991;146(6):1548-50. doi:10.1016/s0022-5347(17)38162-4.

13. Lee MS, Kim SH, Kim BS, Choi GM, Huh JS. The efficacy of primary interventional urethral realignment for the treatment of traumatic urethral injuries. J Vasc Interv Radiol. 2016;27(2):226-31. doi:10.1016/j.jvir.2015.08.006.

14. White JL, Hirsch IH, Bagley DH. Endoscopic urethroplasty of posterior urethral avulsion. Urology. 1994;44(1):100-5. doi:10.1016/s0090-4295(94)80017-0.

15. Köhrmann KU, Henkel TO, Schmidt P, Rassweiler J. Antegrade-retrograde urethrotomy for treatment of severe strictures of the urethra: experience and literature review. J Endourol. 1994;8(6):433-7; discussion 437-8. doi:10.1089/end.1994.8.433.

16. Chung PH, Wessells H, Voelzke BB. Updated outcomes of early endoscopic realignment for pelvic fracture urethral injuries at a Level 1 trauma center. Urology. 2018;112:191-197. doi:10.1016/j.urology.2017.09.032.

17. Kim FJ, Pompeo A, Sehrt D, et al. Early effectiveness of endoscopic posterior urethra primary alignment. J Trauma Acute Care Surg. 2013;75(2):189-94. doi:10.1097/TA.0b013e31829bb7c8.

18. Leddy LS, Vanni AJ, Wessells H, Voelzke BB. Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a Level 1 trauma center. J Urol. 2012;188(1):174-8. doi:10.1016/j.juro.2012.02.2567.

19. McCormick BJ, Keihani S, Hagedorn J, et al. A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury. J Trauma Acute Care Surg. 2023;94(2):344-349. doi:10.1097/TA.0000000000003774.

20. Owen K, Joe W, Palgunadi IN, Soebhali B. A systematic review and meta-analysis of surgical approaches in pelvic fracture-associated urethral injury: primary endoscopic realignment versus delayed urethroplasty. World J Urol. 2025;43(1):603. doi:10.1007/s00345-025-05994-7.

21. Zou Q, Zhou S, Zhang K, Yang R, Fu Q. The immediate management of pelvic fracture urethral injury — endoscopic realignment or cystostomy? J Urol. 2017;198(4):869-874. doi:10.1016/j.juro.2017.04.081.

22. Barrett K, Braga LH, Farrokhyar F, Davies TO. Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis. Urology. 2014;83(4):924-9. doi:10.1016/j.urology.2013.12.031.

23. Elliott DS, Barrett DM. Long-term followup and evaluation of primary realignment of posterior urethral disruptions. J Urol. 1997;157(3):814-6.

24. Singh BP, Andankar MG, Swain SK, et al. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology. 2010;75(1):179-82. doi:10.1016/j.urology.2009.06.081.

25. Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol. 2007;177(4):1374-7. doi:10.1016/j.juro.2006.11.092.

26. Neu S, Remondini T, Hird A, et al. A retrospective look at long-term outcomes after definitive surgical repair for traumatic pelvic fracture urethral injuries — does initial management make a difference? Urology. 2022;160:203-209. doi:10.1016/j.urology.2021.10.036.