Trauma to the anterior urethra: diagnosis and management

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).     

Die Verletzung der hinteren Harnröhre

Injuries of the posterior urethra are a result of a blunt trauma of the pelvic ring, lacerations of the perineum and iatrogenic perforation due to transurethral manipulations. Traumatic lesions of the posterior urethra in about 10% of these patients suffer also a bladder lace ration. The diagnosis of a urethral injury is ascertained by an i. v. urogramm and urethrogram. If a urethral trauma is suspected the insertion of a catheter should be avoided in any case. The treatment is divided in emergency treatment, which means evacuation and drainage of the haematoma and extravasation and suprapubic urinary derivation made by the surgeon and the primary realignment of delayed urethral reconstruction, both interventions being reserved for well trained urologists. Minimal lesions characterized by preserved continuity in small extravasations in the urethrogram are sufficiently treated by a suprapubic urinary diversion. Severe injuries are treated by realignment of the urethra over a splint, drainage of the perivesical space and urinary diversion. 63 % of the patient treated by this modality had perfect results and there was no need for further therapy. The proper replacement of the fractured pelvi bones are an integrated part of our plan of treatment. About 12% of patients with pelvic fracture and injury of the posterior urethra experience loose their potency. These can be explained by neurovascular injury. Impotence does not seem to be caused by surgical treatment, since the rate of impotence is similar in patients treated by primary realignment and suprapubic urinary diversion only.     

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.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Primary endourologic re-establishment of urethral continuity after disruption of prostatomembranous urethra.

A new technique for the early management of traumatic disruption of the prostatomembranous urethra has been used in 4 consecutive young patients. Urethral realignment by stenting the injured urethra with a catheter was achieved by combined urethroscopy and suprapubic instrumentation one to three days after the injury. We describe herein our experience with this technique and we suggest that it could be a valuable alternative in posterior urethral repair.     

Recent traumatic lesions of the male anterior urethra. Apropos of 17 cases

Seventeen cases of anterior urethral injuries are presented. The authors define the management of these lesions: emergency IVP and suprapubic catheter drainage; after three to five days, retrograde and voiding urethrography and surgical repair: end to end anastomosis when the rupture is complete (8 cases with 7 good results, 1 fair result), in case of partial rupture, surgical repair should be preferred (2 cases with 2 good results); the other alternatives, urethral catheter (2 cases), or suprapubic catheter drainage with delayed treatment of stricture (3 cases), appeared to be less comfortable, contusions must be treated conservatively.     

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.     

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.     

The effectiveness of early primary realignment in children with posterior urethral injury

AIM: The aim of this retrospective study was to compare the results of delayed repair and early primary realignments in patients with posterior urethral injury. METHODS: From 1990 to 2003, 20 children were admitted to the Medical Faculty of Uluday University, Bursa, Turkey, for posterior urethral injuries. Traffic accidents were the most common cause of injury (n = 17). Twelve patients (60%) who were referred early (1-10 days) underwent early realignment over a urethral tube. A total of eight patients (40%) underwent delayed repair using transpubic route. In these patients, surgical repair of the urethra was performed 5-6 months later. RESULTS: Of the 12 patients who underwent early urethral realignment, six required at least one visual internal urethrotomy following the removal of the urethral catheter. Urethral stricture developed in two of 12 patients (16.6%) who underwent early urethral realignment. Of the eight patients who underwent delayed repair, six required at least one visual internal urethrotomy following removal of the urethral catheter. Urethral stricture developed in three of eight patients (37.5%) who underwent delayed repair. This difference was statistically significant (P < 0.05). CONCLUSION: The urethral stricture in patients who underwent early primary realignment was less developed than the stricture that developed in those who underwent delayed management. According to these results we recommend early primary realignment in children with posterior urethral injury.     

Diagnosis and management of posterior urethra disruptions

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.     

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.     

Reconstruction of posterior urethral disruption: tips for success from our experience and from a literature review

Repair of a posterior urethral disruption associated with a pelvic fracture is a challenge for urologic surgeons. Here, we provide surgical and strategic tips to facilitate the delayed surgical repair of urethral distraction defects. Nine patients each with a traumatic posterior urethral distraction defect underwent delayed transperineal or transperineoabdominal bulboprostatic anastomosis. Four patients had previously undergone multiple procedures. Seven patients regained satisfactory urination without incontinence, although one other patient is suffering from incontinence. In one patient, urethral disruption occurred again after removal of the urethral catheter, and he is being managed by suprapubic catheter. In our experience, the key to success is to perform a true bulboprostatic mucosa-to-mucosa anastomosis without tension. For this purpose, a transperineoabdominal approach is of particular importance when the healthy mucosa of the prostatic apex cannot be revealed through a perineal approach due to dense fibrous scar or fractured bone. A partial pubectomy may be necessary according to the situation. By the transperineoabdominal approach, the scar tissue can be bypassed through a broad sub-pubic-arch tunnel, and a reliable anastomosis achieved.     

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.     

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy

BACKGROUND: We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement. METHODS: We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra. RESULTS: Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients. CONCLUSION: Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.     

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.     

Complications associated with surgical repair of urethrovaginal fistula

We present 4 patients seen in the last five years with urethrovaginal fistulas involving the mid or proximal urethra. Our experience in the transvaginal repair of these fistulas has been disappointing. The best chance for the development of a functioning continent urethra is by suprapubic bladder flap technique or bladder tube replacement with suprapubic urinary diversion. We suggest that no urethral catheter be placed. Complications following surgical repair have been fistula recurrence, urethral shortening and retraction, persistent reflux, bladder calculi, and bladder cancer.     

前尿道损伤早期处理的治疗体会

目的 探讨前尿道损伤早期处理方式的选择.方法 回顾性总结2001年9月至2011年6月我科47例尿道损伤患者的临床资料,分析术后并发症及排尿情况.结果 47例患者随访41例,随访时间1～84个月,术后2～6周拔除尿管;采用膀胱穿刺造瘘术3例,留置导尿8例,输尿管镜尿道置管术18例,腔镜下尿道会师术4例,尿道修补术或断端吻合术14例(术后会阴伤口感染2例,尿漏2例),术后31例排尿良好,尿道狭窄10例,失访6例.结论 前尿道不全断裂首选输尿管镜尿道置管术,不成功时行腔镜下尿道会师术,而对于前尿道断裂仍宜行尿道断端吻合术.     

Management of genitourinary injuries in patients with pelvic fractures.

Associated injuries frequently occur in patients who sustain fractures of the pelvis. Hemorrhage from intrapelvic vessels, rupture of the urinary bladder and avulsion of the membranous urethra in males are among the integral risks in this trauma. Non-operative methods of managing hemorrhage have gained favor in recent experience. The case records of 282 male patients with pelvic fractures were reviewed to evaluate experience with lower genitourinary injuries. Early recognition is important in bladder injuries, and surgical repair is advised, except in selected patients who may be managed by catheter drainage alone. Delayed complications of bladder injury are rare. Membranous urethral injuries entail a high risk of chronic stricture disease and sexual impotence. The rationale of early repair versus delayed repair of these injuries is discussed. The results in this series show advantage for delayed repair.     

Verletzungen des unteren Harntrakts und des Urogenitalsystems

Injuries of the lower urinary tract occur in patients with multiple injuries and trauma to the lower abdominal and pelvic region. Injuries of the male urethra including complete ruptures occur in 10% of pelvic fractures in males, while they are a rarity in females. Ruptures of the urinary bladder are either intra- or extraperitoneal. Ureteral injuries are relatively rare in blunt injuries and usually become manifest with infectious symptoms with a delay of days. Intraperitoneal ruptures of the urinary bladder always require urgent surgical repair while extraperitoneal ruptures can mostly be managed conservatively with catheter drainage of the bladder. In male patients with pelvic fractures any attempt of urethral catheterization which can otherwise make an urethral injury worse should be withheld until adequate urological examinations have led to the diagnosis or exclusion of urethral injury. The definitive surgical repair of a disruption of the male urethra should be undertaken with an interval of weeks to months. Long term sequelae of male urethral injury can be impotence and chronic stricture disease.     

The treatment of posterior urethral disruption associated with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty

PURPOSE: Urological treatment of the patient with severe mechanical trauma and urethral disruption remains controversial. Debate continues regarding the advisability of early realignment vs delayed open urethroplasty. We analyzed our experience with 96 patients to determine the long-term results of the 2 approaches. MATERIALS AND METHODS: We retrospectively reviewed the records of 191 men with posterior urethral disruption after severe blunt pelvic injury between 1984 and 2001, of whom 96 survived. Data on 57 patients who underwent early realignment were compared to those on 39 treated with delayed urethroplasty with an average 8.8-year followup (range 1 to 22). All patients were evaluated postoperatively for incontinence, impotence and urethral strictures. RESULTS: The majority of patients had severe concomitant organ injuries (78%) and severe pelvic fractures (76%). The overall mortality rate was 51%. Diagnosis of urethral rupture was based on clinical findings and retrograde urethrography. Strictures developed in 49% of the early realignment group and in 100% of the suprapubic tube group. Impotence (33.6%) and incontinence (17.7%) were less frequent in the early realignment group than in the delayed reconstruction group (42.1% and 24.9%, respectively). Patients with delayed reconstruction underwent an average of 3.1 procedures compared with an average of 1.6 in the early realignment group. CONCLUSIONS: Early realignment may provide better outcomes than delayed open urethroplasty after posterior urethral disruption. Increased complications are not seen and, although it can be inconvenient in the massively injured patient, it appears to be a worthwhile maneuver.