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Gelman Adapter for Retrograde Urethrography

The Gelman adapter (CS Surgical) is a cone-shaped meatal-occlusion device designed by Joel Gelman (UC Irvine Center for Reconstructive Urology) in 1997 to perform a high-quality retrograde urethrogram (RUG) without a Foley balloon in the urethra. The adapter forms a painless friction seal at the urethral meatus, allowing contrast instillation under penile stretch without dilating, traumatizing, or distorting the urethra — the principal failure modes of balloon-occlusion RUG technique. The instrument is illustrated in Campbell-Walsh Urology and has been the reference RUG technique at high-volume reconstructive centers for over two decades.[1][2]

Design​

  • Cone-shaped tip, sized to seat against the external meatus and fossa navicularis.
  • Original plastic version (1997) was the prototype; the current generation is surgical-grade stainless steel (CS Surgical), reusable and autoclavable.[1]
  • Luer-compatible proximal connection for syringe-driven contrast injection.
  • No intra-urethral component — nothing is inserted past the meatus.

Why It Exists — The Foley-Balloon RUG Problem​

The traditional RUG technique uses a small Foley catheter advanced into the fossa navicularis and the balloon inflated to ~ 2 mL to occlude the urethra for contrast injection. Documented problems with this approach:[1]

  • Massive over-dilation at the inflation site: a 2 mL balloon expands to ~ 50 Fr circumference in the fossa navicularis, where the normal urethral caliber is only 24 Fr.
  • Painful dilation and mucosal tearing at the balloon inflation site.
  • Obscures distal urethral pathology: the balloon sits on top of any distal stricture or pathology in the fossa / penile urethra, making it invisible on the resulting study.
  • Distorts the anatomy being imaged: any urethrogram is only as accurate as the un-traumatized state of the urethra it captures.

The Gelman adapter eliminates all of the above by stopping at the meatus — no intra-urethral component, no balloon, no dilation.

Reconstructive-Urology Uses​

The Gelman adapter is the default RUG instrument for reconstructive workup of any anterior urethral stricture, recurrent stricture surveillance, and post-urethroplasty imaging where accurate stricture length and location matter for surgical planning.

  • Anterior urethral stricture workup — bulbar, penile, fossa navicularis, panurethral. The non-dilating technique preserves accurate length / location data critical for planning BMG urethroplasty approach and stage selection.
  • Recurrent stricture evaluation post-urethroplasty.
  • Post-DVIU / dilation surveillance.
  • Pre-operative imaging for Optilume DCB candidacy — accurate length measurement determines balloon length selection.
  • Pelvic-fracture urethral-injury preoperative imaging with simultaneous antegrade cystogram through SPT (the up-and-down-o-gram).
  • Post-prostatectomy bulbomembranous stricture / VUAS workup — non-traumatic imaging is especially important in the irradiated post-prostatectomy urethra.

Technique​

  1. Position: oblique, tilted ~ 45° (right anterior oblique is standard).
  2. Penis on stretch toward the contralateral shoulder.
  3. Seat the Gelman adapter against the meatus, gentle pressure to form the friction seal.
  4. Inject contrast slowly under continuous fluoroscopy — typically 30–60 mL total volume, instilled gradually to capture both the urethral phase and (if the external sphincter is voluntarily relaxed) early bladder filling.
  5. Capture the proximal extent of the stricture at maximum distension; the distal extent is captured during catheter / contrast withdrawal.

Gelman Adapter vs Alternative RUG Techniques​

MethodMechanismStrengthsWeaknesses
Gelman adapterCone-shaped meatal occlusion, no intra-urethral component[1]No dilation; no distal-stricture obscuration; non-traumatic; durable / reusableSingle-vendor (CS Surgical); per-instrument cost
Foley catheter balloon2 mL balloon inflation in fossa navicularisUniversally availableMucosal tear, dilation, obscures distal pathology, painful[1]
Penile clampPadded ring at coronal sulcusSimple, low-costMisses 2–4 cm of distal urethra inside the glans; cannot evaluate fossa / meatal disease[3]
3M sponge-plug method (Li 2023)Compressed sterile sponge inserted ~ 1.5 cm into anterior urethraLow-cost, well-tolerated (72.5% pain-free in 40-pt series); 100% procedural successIntra-urethral component; theoretical particulate / retention risk[3]

Why the Gelman Technique Matters Reconstructively​

A urethroplasty is only as good as the stricture map it is planned from. Improper RUG technique systematically under- or over-estimates stricture length, leads to wrong-incision planning, and can prompt unnecessary staged repair when a single-stage approach was feasible (or vice versa).[1] The Gelman adapter is one of the small handful of "the right way to do this test" reconstructive-urology standards — alongside oblique positioning, voluntary external-sphincter relaxation, and pairing the RUG with a simultaneous antegrade cystogram in PFUI workup.

Historical Context — Joel Gelman​

Joel Gelman, MD is Director of the Center for Reconstructive Urology at UC Irvine and one of the most influential contemporary GURS-affiliated reconstructive surgeons in posterior urethroplasty, complex urethral stricture, and reconstructive instrumentation. The RUG adapter was developed in 1997 as a clinical-pain-driven response to the Foley-balloon technique's documented failure modes. Like his other named instruments (Gelman Visualizing Sound CS7001, Uromax direct-vision balloon dilator), Dr. Gelman has publicly declined royalties on the adapter and maintains no financial relationship with the manufacturer to avoid conflict of interest.[2]

See also: Gelman Visualizing Sound, Rigid Cystoscope, Flexible Cystoscope, Urethral Stricture.

References​

1. Center for Reconstructive Urology (Gelman J). "Urethral stricture diagnostic evaluation — retrograde urethrogram and the Gelman adapter." Reference clinical-practice description; Gelman adapter pictured in Campbell-Walsh Urology. centerforreconstructiveurology.org/urethral-stricture/urethral-stricture-diagnostic-evaluation

2. Gelman J, Wisenbaugh ES. "Posterior urethral strictures." Adv Urol. 2015;2015:628107. doi:10.1155/2015/628107

3. Li W, Man L, Huang G. "An innovative method for occluding the urethral meatus and accessing urethra strictures in retrograde urethrography in males." BMC Urol. 2023;23(1):163. doi:10.1186/s12894-023-01331-5