Complex pelvic fracture urethral distraction defects revisited

Abstract

A PFUDD may be considered as complex if it is associated with a PBBF, urethrorectal or urethrocutaneous fistula, urinoma cavity, or bladder neck incompetence. Complete excision of a PBBF usually requires a perineoretropubic approach. The initial trauma-related urethrorectal fistula usually opens into the prostatic urethra and its repair requires an abdominal approach, whereas an iatrogenic rectal fistula usually opens into the proximal bulbar urethra and can be resolved by a relatively simple perineal operation. Excision of a urinoma cavity or urethrocutaneous fistula can usually be accomplished from the perineum, while repair of a bladder neck incompetence requires an abdominal approach.

Simple perineal and elaborated perineal posterior urethroplasty

“…Others have reported their approach for correcting the PFUDD. Koraitim [23,29,30] has been a prolific and observant reporter of his ongoing experience and of procedure selection and outcomes from a less developed nation.…”

“…Despite this ability to now address even the longest defects, an abdomino-perineal approach can still be necessary to address the intrapelvic complicating features, such as bladder base fistula, pelvic floor cavity and some patients with a urethrorectal fistula [23] .…”

Optimising the outcome after anastomotic posterior urethroplasty

“…However, it is not easy to discriminate the false tract from the true prostatic urethra on either imaging study [8] . In such cases a correct anastomotic repair can be made by using suprapubic cysto-urethroscopy to recognise the prostatic urethra by identifying the verumontanum [5,9] .…”

“…The scar tissue can be completely excised via the perineum in most cases. However, in the presence of a para-urethral false passage extending into the bladder base, a perineo-retropubic approach is required for complete excision of the scar tissue [9] .…”

“…Accordingly, urethral gaps shorter than a third of the bulbar urethral length can usually be corrected by a simple perineal operation. However, in cases with longer gaps the anterior urethra must circumvent the long gap and reach the prostate by a more direct and shorter route, using the elaborated perineal or transpubic procedure [9,13,17] . Thus, a tension-free anastomosis could be made in these cases using the same elastic lengthening that was inadequate for a simple perineal repair.…”