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.     

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.     

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: 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.     

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).     

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.     

Result of suprapubic cystostomy only as primary management of posterior urethral rupture following pelvic fracture

Forty-five patients with posterior urethral injury following pelvic fractures were managed by suprapubic cystostomy alone as primary management. Simultaneous voiding cystourethrogram with retrograde urethrogram six weeks later revealed non-obliterative stricture in eight and total block in 36. Impotence was seen in 20 patients. Eight patients with non-obliterative stricture responded to optical internal urethrotomy. Out of 36 total block, 30 had long strictures in the posterior urethra and required transpubic urethroplasty. Impotence was not affected by transpubic urethroplasty.     

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.     

小儿尿道损伤的诊断与治疗

目的：探讨小儿尿道外伤及外伤后尿道狭窄的诊治经验。方法：在8例新鲜完全性后尿道断裂患儿中,3例行经耻骨上与会阴入路的尿道修复术,2例行尿道会师术,2例行膀胱造瘘术,1例女童行经耻骨后尿道吻合术。在18例陈旧性后尿道外伤患儿中,10例行经尿道内切开（TUR）术,4例行经耻骨、会阴联合入路修复术,4例行经会阴修复术。结果：8例新鲜后尿道断裂患儿中,术后出现尿道狭窄5例,不完全尿失禁1例。18例陈旧性尿道蛱雅患儿中,行TUR的成功率为60．0％,经会阴及经耻骨、会阴联合入路行尿道修复术的成功率为91．7％,有不完全尿失禁5例,会阴尿道造瘘尚未修复1例。结论：后尿道外伤的急症处理非常重要,如患儿情况允许,应尽量行经耻骨、会阴联合入路尿道修复术。经尿道内切开适用于绝大多数单纯性后尿道狭窄,经耻骨、会阴联合入路或经会阴修复尿道适用于复杂性后尿道狭窄或TUR失败者。     

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.     

Blunt urethral injury: results of initial management

Fourteen men with blunt urethral disruption were treated between 1979-1985. Injuries most commonly resulted from motor-vehicle accidents, as pedestrians or passengers. All patients had additional injuries, including pelvic fracture (13), extremity fractures (10), central nervous system (5), bladder (5) and rectal injury (3); the average injury severity score was 30. Pelvic fracture patterns included ten patients with a crushed pelvis, two with single anterior pelvic ring fractures and one with a double vertical fracture. Blood at the urethral meatus was noted in only five patients, gross hematuria without metal blood in another three, and a displaced prostate on rectal exam was found in 10 cases. All patients had a suprapubic cystostomy for management of the urethral injury. Thirteen of 14 patients survived (93%). The major complication was perineal sepsis. Based on this experience, it is concluded that: 1) the classical findings of urethral injury are not found consistently, 2) certain pelvic fracture patterns, particularly disruption of the anterior pelvic ring, are frequently associated with urethral injury and 3) aggressive and appropriate management of hemorrhage, pelvic fracture and concomitant injuries is important to minimize mortality.     

Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management

Controversy surrounds the management of prostatomembranous urethral injuries. We herein present 38 patients and review the findings of 538 in 19 reported series. Results indicate a high risk of stricture, impotence and incontinence if conventional early urethral realignment techniques are used. Therefore, it is suggested that this approach be reserved for cases demanding immediate intervention (high riding bladder, associated rectal tear, concomitant bladder neck injury or continued bleeding), and that all others be managed by initial suprapubic cystostomy alone and delayed urethroplasty. Urethroplasty selection is discussed.     

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.     

Symphysiotomy: a viable approach for delayed management of posterior urethral injuries in children

PURPOSE: The outcome of symphysiotomy for accessing pelvic fracture related, obliterative urethral strictures is described. MATERIALS AND METHOD: In 7 boys and 3 girls 4 to 13 years old (mean age 6) surgical correction of a pelvic fracture related, obliterative urethral stricture was achieved through symphysiotomy. The stricture involved a prostatomembranous location in boys and complete vesicourethral distraction in girls. Patients were followed an average of 2.5 years (range 6 months to 4 years) by physical examination, urethrography and endoscopy. RESULTS: The stricture was successfully corrected in all patients and all void with a normal flow. All boys are continent but 2 of the 3 girls had early incontinence, which resolved with time in 1. In 2 of the 10 cases a previous attempt at perineal repair had already failed. No patient required urethrotomy or dilation and none had significant hemorrhage, fistulization, bladder hernia, chronic pain or secondary gait disturbance. CONCLUSIONS: Symphysiotomy is hereby revisited as a simple and effective approach for repairing traumatic posterior urethral injuries in the pediatric population. It can be performed instead of transpubic urethroplasty to manage long or otherwise complicated strictures.     

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

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta‐analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms ‘female pelvic fracture urethroplasty’, ‘female urethral distraction’, ‘female pelvic fracture urethral injury’ and ‘female pelvic fracture urethra girls.’ Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty‐one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very‐low‐quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.     

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.     

Long-term results of treatment of urethral injuries in males caused by external trauma.

Of 134 males with traumatic rupture of the urethra seen between 1967 and 1989, 10 have been lost to follow-up and 124 have been followed up for 1 to 22 years (mean 8); 100 patients had a pelvic fracture (3 with associated rectal injury) and 24 had perineal injuries. Prior to referral 31 patients (25%) had undergone treatment in addition to suprapubic cystostomy. Wherever possible, strictures were managed by optical urethrotomy (33) or intermittent dilatation (4). In 2 patients only a suprapubic cystostomy was possible. Skin inlay urethroplasty in 1 or 2 stages was performed in 75 cases, an end-to-end anastomosis with or without resection of the symphysis pubis in 7 and a scrotal tube pull-through in 3. The immediate and long-term results depended on the severity of the original injury. With minimal displacement the management was simple and the long-term prognosis good, a single urethrotomy being sufficient in 22 patients. Where there was considerable displacement the initial management was more difficult and there was a high incidence of long-term complications: of 73 patients treated by urethroplasty or end-to-end anastomosis, significant post-operative infection occurred in 11 (15%) and restenosis in 15 (20%), of whom 7 required a revision urethroplasty. Data in respect of potency were recorded in 80 patients: 28 of these were impotent, 20 of the 28 having sustained an injury with considerable displacement.     

Experience with management of posterior urethral injury associated with pelvic fracture

Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography of voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries.     

闭合性尿道球部损伤不同手术治疗效果与术后狭窄处理分析

目的比较闭合性尿道球部损伤早期行耻骨上膀胱造瘘术与膀胱镜下留置尿管术的临床效果及术后狭窄处理。方法回顾性分析2012年6月至2017年6月就诊的57例闭合性尿道球部损伤患者,耻骨上膀胱造瘘患者24例(造瘘组),膀胱镜下留置尿管患者33例(置管组)。随访期间发生狭窄的患者,根据狭窄程度行微创手术(内镜下尿道内切开术或尿道扩张术)或开放修复手术。比较两组患者术后狭窄的发生率、狭窄段长度、勃起功能障碍(ED)发生率。比较早期行膀胱镜下留置尿管治疗后发生狭窄的患者与早期行耻骨上膀胱造瘘治疗后发生狭窄的患者经微创手术治愈的比例。结果造瘘组和置管组术后狭窄发生率分别为33.33%(8/24)和63.64%(21/33),差异有统计学意义(P<0.05);狭窄段长度分别是(1.17±0.42)cm和(1.38±0.44)cm,差异无统计学意义(P>0.05),造瘘组与置管组ED发生率分别是4.17%(1/24)和6.06%(2/33),差异无统计学意义(P>0.05)。早期行膀胱镜下留置尿管治疗后发生狭窄的患者与早期行耻骨上膀胱造瘘治疗后发生狭窄的患者通过微创手术治愈比例的差异无统计学意义(χ^2=2.032,P=0.154)。结论尿道球部损伤患者早期行耻骨上膀胱造瘘可能降低术后尿道狭窄的发生,但对狭窄段长度及ED的发生可能无影响。     

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.