Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE: Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management. MATERIALS AND METHODS: We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed. RESULTS: Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy. CONCLUSIONS: Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.     

Pelvic fracture urethral injuries: the unresolved controversy

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.     

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic Alternatives

Purpose

We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children.

Materials and Methods

From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3).

Results

In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries.

Conclusions

As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapubic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.     

Pelvic fracture-associated urethral injuries in girls: experience with primary repair

OBJECTIVE: To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. PATIENTS AND METHODS: There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. RESULTS: All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9-60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. CONCLUSION: Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis.     

The management of strictures of the membranous urethra

We present 40 cases of posterior urethral stricture resulting from pelvic fracture injury or prostatectomy. The strictures were managed according to various factors but most important were stricture length and the absence of pathological conditions in the anterior urethra. Post-traumatic obliterative strictures less than 2 cm. long can be managed with excellent success via a 1-stage perineal bulboprostatic anastomotic repair. Combined abdominoperineal procedures are equally successful but are reserved for patients in whom the stricture is more than 2 cm. long or who have an associated bladder neck pathological condition. When associated anterior urethral disease mitigates against mobilization and extension of the urethra to accomplish an anastomotic repair, the vascularized island flap or 2-stage scrotal inlay procedure appears to be the optimal choice. Of 3 failures with full thickness skin grafts 2 may have been owing to suboptimal graft beds in the scarred pelvic floor and perineum. Direct vision urethrotomy is advocated for nonobliterative posttraumatic strictures, and the rationale for dilation rather than urethroplasty management of postprostatectomy strictures is presented.     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

Use of the flexible fiberoptic nephroscope in the preoperative evaluation and delayed repair of traumatic urethral strictures

A flexible, fiberoptic nephroscope was used in the preoperative evaluation and subsequent repair of obliterative, post-traumatic urethral strictures in 2 men. Antegrade passage of the flexible nephroscope through a previously established suprapubic cystostomy tract afforded direct visualization of the bladder neck and uninvolved urethra proximal to the strictures. Thereby, precise definition of involvement of the membranous urethra and striated external sphincter was established. This facilitated selection between transperineal and transpubic operative approaches as well as intraoperative localization of the proximal margins of the strictures.     

The radiographic approach to injuries of the prostatomembranous urethra in children.

We favor initial non-operative treatment (suprapubic cystostomy drainage only) for prostatomenbranous urethral injuries in children and adolescents. Non-operative treatment usually results in uncomplicated strictures that can be corrected by a 1-stage transperineal or transpublic operation 4 to 6 months later. A hands-off diagnostic approach, which relies on excretory urography and retrograde injection urethrography to demonstrate partial and complete tears, eliminates the need for blind passage of catheters, an invasive procedure that may lead to complicated strictures unsuitable for a 1-stage repair. If a 1-stage repair is planned it is necessary to determine the length of the stricture, whether there are local complications and whether the anterior urethra can be widely mobilized. The radiographic techniques used to plan a corrective operation and to evaluate the results are described.     

Recent traumatic injuries of the urethra

Traumatic injuries of the urethra are uncommon. Most lesions of the anterior (bulbar urethra) are straddle injuries and are initially dealt with by a suprapubic catheter with delayed treatment when urethral stenosis does ensue. Traumatic disruption of the posterior urethra is in most cases related to a pelvic fracture and is often associated with multiple life-threatening injuries, which receive priority treatment. Management of posterior urethral disruption remains a highly controversial issue: alternative treatments include early endoscopic realignment, early open surgical repair and suprapubic catheter and delayed open surgical repair. Management of urethral injuries is described and the different operative techniques are detailed.     

Female urethral and bladder neck injury after rape: an appraisal of the surgical management

The aim of this study was to discuss the surgical management of urethral and bladder neck injury after urethral coitus during rape. A 21-year-old lady presented with total urinary incontinence of 1-year duration after being raped. On examination, she had urethral laceration and a patulous urethra and bladder neck suggesting urethral coitus during the rape. Her introitus and vagina were however normal. She had repair of her urethral laceration and plication of her urethra and bladder neck via a vaginal approach. She regained her continence and voids without any residual urine. Urethral coitus is rare. Urethral coitus in the presence of a normal introitus and vagina is very rare. The urethral and bladder neck injury resulting from this can be satisfactorily corrected by urethral and bladder neck plication via a vaginal approach with the vaginal incisions positioned to forestall suture line apposition, which may lead to wound failure.     

Urethral gap in complete disruption of membranous urethra

In patients with complete disruption of the membranous urethra treated initially with placement of a suprapubic cystostomy, delayed synchronous retrograde and voiding cystourethrograms failed to demonstrate accurately the distance between the two urethral ends. Radiographic exposure obtained during synchronous instrumentation of the anterior and posterior urethra in the anesthetized patient was the most precise method of defining the extent of the urethral gap. Any surgical decision should be based on this type of investigation. In most cases of pelvic crush injuries, the severed membranous urethra probably remains attached in close proximity to the distal segment, thus directing the redescent of the prostate and bladder base in the presence of a contracting pelvic hematoma.     

Traumatic rupture of female urethra

Complete avulsion of the female urethra secondary to blunt trauma is uncommon. It is associated with pelvic fractures, and because of the close association of the urethra and vagina a vaginal laceration also occurs. The paucity of lesions associated with pelvic fracture may be explained by the relative mobility and shortness of the urethra in the female. The treatment of urethral trauma in females has not been established. Vaginal, transpubic, or retropubic approaches have been used successfully. We report on 3 cases of urethral trauma with anterior vaginal lacerations treated by retropubic approach with good results.     

Voiding and sexual dysfunctions after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment.

OBJECTIVE: The aim of this study is to evaluate the effects of the different immediate treatment modalities on the sexual and voiding functions in pelvic fracture urethral injuries. METHODS: The records of 38 male patients with traumatic posterior urethral injuries were reviewed, 18 of whom were treated by initial suprapubic cystostomy and delayed repair (Group 1), and 20 by primary urethral realignment (Group 2). Types of pelvic fractures and urethral injuries were classified according to surgical and radiological findings. Long-term voiding functions were determined by the patient questionnaire, residual urine and uroflow. Sexual functions were also determined by the patient questionnaire and a penile duplex ultrasound study. RESULTS: Mean follow-ups of Groups 1 and 2 were 37 and 39 months, respectively. Membranous urethral disruption extending to the urogenital diaphragm was the most frequent urethral injury (type 3), with incidences of 66.7% and 77.7%, respectively. There were no statistically significant differences in mean age, incidence of pelvic fracture types and urethral injury types between groups (p > 0.05). After the immediate treatments, 16.7% and 55% of the patients regained normal urination, and stricture developed in 83.3% and 45% of the patients, respectively. In 44.4% of the patients in Group 1 and 10% in Group 2, urethral strictures required open urethroplasty (p < 0.05). Erectile impotence before urethroplasty in 17.6% and 20%, anejaculation after urethroplasty in 17.6% and 15% and incontinence in 5.6% and 10% of the patients were found in Groups 1 and 2, respectively (p > 0.05). However, 88.8% and 90% of patients eventually achieved normal urination with complete continence. CONCLUSION: Sexual and voiding dysfunction after pelvic fracture posterior urethral injury seem to be the result of the injury itself, not of the immediate treatment modalities. In urethral disruption injuries, primary urethral realignment seems more favourable than suprapubic cystostomy and delayed repair.     

Partial tears of prostatomembranous urethra in children.

Five boys having sustained a pelvic fracture were found to have incomplete tears of the prostatomembranous urethra. Three patients were treated with suprapubic cystostomy drainage alone and fared better than 2 who were treated with urethral catheter stenting and drainage. A recommendation is made for the "hands-off" approach to the evaluation and management of membranous urethral injuries.     

Pelvic Fracture and Associated Urologic Injuries

Successful management of patients with major pelvic injuries requires a team approach including orthopedic, urologic, and trauma surgeons. Each unstable pelvic disruption must be treated aggressively to minimize complications and maximize long-term functional outcome. Commonly associated urologic injuries include injuries of the urethra, corpora cavernosa (penis), bladder, and bladder neck. Bladder injuries are usually extraperitoneal and result from shearing forces or direct laceration by a bone spicule. Posterior urethral injuries occur more commonly with vertically applied forces, which typically create Malgaigne-type fractures. Common complications of urethral disruption are urethral stricture, incontinence, and impotence. Acute urethral injury management is controversial, although it appears that early primary realignment has promise for minimizing the complications. Impotence after pelvic fracture is predominantly vascular in origin, not neurologic as once thought.     

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.     

Pelvic Fracture Urethral Injuries: Evaluation of Various Methods of Management

Purpose

The results of various immediate treatments of urethral injuries complicating a fractured pelvis were evaluated.

Materials and Methods

The records of 100 male patients with pelvic fracture urethral injury were reviewed, 73 of whom were treated by suprapubic cystostomy and delayed repair, 23 by primary realignment and 4 by primary suturing. Also, the findings of 771 patients reported in the literature were reviewed.

Results

Urethral stricture was an almost inevitable consequence (97 percent of the cases) after suprapubic cystostomy. Primary realignment decreased the incidence of stricture to 53 percent but produced a 36 percent impotence rate. Primary suturing also decreased the incidence of stricture to 49 percent but produced the greatest complication rates for impotence (56 percent) and incontinence (21 percent).

Conclusions

Suprapubic cystostomy alone is indicated for incomplete urethral rupture, slight urethral distraction and critically unstable patients, and when there are inadequate facilities or inexperienced surgeons. Primary realignment is advised if there is wide separation of the urethral ends, or associated injury of the bladder neck or rectum. Primary suturing is not recommended for any condition.     

Injuries to the urethra and urinary bladder associated with fractures of the pelvis

The posterior urethra or urinary bladder may be injured in patients who sustain fractures of the bony pelvis. It is important to assess the urethra radiologically by retrograde urethrography before introducing a urethral catheter to avoid missing a urethral injury or causing further damage. The author's approach to the immediate management of urethral injury is suprapubic cystostomy. The urethra may be repaired later after other injuries have healed. With this approach the incidence of permanent impotence and incontinence will be low and the stricture cure rate high. If the urethra has not been injured, a catheter is introduced and cystography performed to rule out bladder injuries. If the bladder is ruptured, the area is explored, the perivesical space drained and urinary drainage is provided by either a suprapubic cystostomy or a urethral catheter.     

Female epispadias repair: a new 1-stage technique

PURPOSE: Female epispadias is a rare anomaly. According to the literature it is usually treated with staged procedures, including bladder neck reconstruction, to achieve continence. We developed a 1-stage surgical technique that offers the possibility of achieving continence and a cosmetically normal appearance of the vulva. MATERIALS AND METHODS: We treated 4 patients 4 months to 8 years old. The main point of the technique is to free completely the urethral plate and bladder neck from surrounding tissue. After tubularizing the urethral plate into a urethra modified needle suspension brings the bladder neck and proximal urethra into the intra-abdominal position. The pelvic floor is then reconstructed between the anterior vaginal wall and urethra. Thus, continence may be attained by intra-abdominal positioning of the bladder neck and proximal urethra as well as by pelvic floor reconstruction. RESULTS: Of our 4 consecutive cases of primary untreated epispadias the technique proved successful in 3, while followup is too short in 1. One patient is completely dry and voids without a further procedure. Postoperatively 2 patients with 5 years or more of followup required injection of a bulking agent at the bladder neck level to achieve continence, including 1 who is damp during the day without the need to change clothes and 1 on clean intermittent catheterization twice daily because post-void residual urine volume causes recurrent urinary tract infection. CONCLUSIONS: The described technique is promising for treating this disabling anomaly.     

Prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty

Management of prostatomembranous urethral disruptions associated with pelvic fractures remains a major controversy in urology. A group of 64 patients who suffered a prostatomembranous urethral disruption in association with a pelvic fracture and who were managed initially by suprapubic cystostomy with delayed urethroplasty was compared to 17 patients managed initially by primary realignment. No statistically significant difference in the incidence of impotence or urinary incontinence was found between the 2 groups (p greater than 0.5) Secondary reconstructions for impassable strictures developed in 95% of the patients treated by a suprapubic tube alone compared to 53% of those treated by primary realignment. Indeed, only 1 patient in the latter group achieved urethral continuity that did not require further intervention. We conclude that while primary realignment is associated with no increase in the instance of impotence and urinary incontinence, it subjects the patient to a major operation at a critical time and provides little in the way of long-term positive gains for the effort expended. In the final analysis the outcome is more dependent upon the nature of the injury and the quality of the repair than upon the order in which the repair is effected.