Complex posterior urethral injury

Abstract

ObjectiveTo assess treatment strategies for seven different scenarios for treating complex pelvic fracture urethral injury (PFUI), categorised as repeat surgery for PFUI, ischaemic bulbar urethral necrosis (BUN), repair in boys and girls aged ⩽12 years, in patients with a recto-urethral fistula, or bladder neck incontinence, or with a double block at the bulbomembranous urethra and bladder neck/prostate region.Patients and methodsWe retrospectively reviewed the success rates and surgical procedures of these seven complex scenarios in the repair of PFUI at our institution from 2000 to 2013.ResultsIn all, >550 PFUI procedures were performed at our centre, and 308 of these patients were classified as having a complex PFUI, with 225 patients available for follow-up. The overall success rates were 81% and 77% for primary and repeat procedures respectively. The overall success rate of those with BUN was 76%, using various methods of novel surgical techniques. Boys aged ⩽12 years with PFUI required a transpubic/abdominal approach 31% of the time, compared to 9% in adults. Young girls with PFUI also required a transpubic/abdominal urethroplasty, with a success rate of 66%. In patients with a recto-urethral fistula the success rate was 90% with attention to proper surgical principles, including a three-stage procedure and appropriate interposition. The treatment of bladder neck incontinence associated with the tear-drop deformity gave a continence rate of 66%. Children with a double block at the bulbomembranous urethra and at the bladder neck-prostate junction were all continent after a one-stage transpubic/abdominal procedure.ConclusionAn understanding of complex pelvic fractures and their appropriate management can provide successful outcomes.

Management of male pelvic fracture urethral injuries: Review and current topics

“…The technical inexperience of the surgeon has been reported to be the most common cause of failed urethroplasty, and Mundy has recommended that urologists who are not routinely carrying out >15 urethroplasties a year should be referring patients to high‐volume centers where the caseload is enough to maintain surgical expertise . The patient's best chance of a cure is during the first attempt, and his QOL for the rest of his life depends on the decisions his surgeon makes . No matter what method of initial treatment is chosen, patients with subsequent urethral stenosis after PFUI should be referred to experts as soon as possible without being subjected to futile dilations or urethrotomies.…”

“…Currently, most urethral stenosis can be repaired by a single‐stage perineal anastomotic urethroplasty, called delayed anastomotic urethroplasty, that consists of the complete excision of scar, approximation of normal urethral mucosa from the two sections of the disrupted urethra and establishment of a tension‐free anastomosis, which was originally pioneered by Turner‐Warwick in the 1970s and subsequently further developed by Webster and Ramon using four distinct ancillary techniques to establish a tension‐free anastomosis . Substitution urethroplasty using skin flaps or ileal grafts is rarely necessary, except for patients with a long gap and/or limited residual bulbar length in re‐do cases . In brief, the patient is in a standard or exaggerated lithotomy position and the bulbar urethra is exposed by a midline or curved perineal incision depending on the surgeon's preference .…”

“…Although delayed urethroplasty carried out by an expert surgeon has a high success rate (nearly 90%) and low complication rate, recurrent stenosis can be encountered either shortly after removal of the urethral catheter (usually <48 h after surgery) or several months or years after surgery . Early recurrent stenosis is more common, and patients present with an inability to void that is caused by ischemia due either to severe vascular damage at the initial injury, to tension at the anastomosis because of inadequate bulbar urethral mobilization or to inadequate excision of scar tissue, which usually require salvage urethroplasty . In contrast, late recurrent cases present with a weak urinary stream due to narrowing of the anastomosis and are usually corrected by a single urethrotomy …”

“…20 In contrast to what is seen in adult patients, in children the site of injury tends to be more proximal, including the prostate and the bladder neck, and severe urethral disruption is more likely as a result of anatomical characteristics in children, including the fragile tissues of an immature pelvic structure, the relative intra-abdominal position of the bladder and an immature prostate. 5,[21][22][23] Furthermore, unstable pelvic fractures, such as Malgaigne fractures and straddle fractures, are much more common in children, and the incidence of PFUI after these severe pelvic injuries is higher in children than in adults. 16…”

Female urethral injuries associated with pelvic fracture: a systematic review of the literature

“…After delayed urethral repair, urinary incontinence in some form was reported in 23/75 patients (31%), with the majority having SUI. Of the 23 patients with incontinence after delayed urethral repair, four patients (17%) had nocturnal incontinence alone [33,35]. In two of 23 cases (9%), SUI resolved spontaneously at 4 weeks and 6 months, respectively [36,38].…”