Treatment of posterior and anterior urethral trauma

OBJECTIVE: To assess the occurrence and treatment of posterior urethral (most often caused by traffic accidents and comprising half of all cases of urinary tract traumas) and anterior urethral injury (usually iatrogenic during catheterization or cystoscopy, or caused by blunt trauma, e.g. straddle injury or penetrating trauma). PATIENTS AND METHODS: The records and details of patients with posterior and anterior urethral trauma were analysed from 61 urological departments in Poland between 1995 and 1999. RESULTS: During the 5-year period there were 268 cases of posterior and 255 of anterior urethral injury; for the former, most occurred during traffic accidents, and of the latter 206 were iatrogenic (during catheterization or cystoscopy), of which 48 were accompanied by perineal injury. The posterior injuries were isolated or involved many organs, mainly pelvic bones. Both types of injuries were diagnosed using ascending urethrography, voiding cysto-urethrography and urethroscopy/endoscopy. Treatment for posterior injuries included cystostomy alone or cystostomy with abdominal drainage or perineal drainage; some patients also had their urethra reconstructed. The treatment for anterior injuries was conservative in 193 patients and surgical in 62. CONCLUSION: The early detection and appropriate surgical treatment of posterior and anterior urethral injury is crucial for the recovery of urethral function, and avoids many complications.     

Management of traumatic urethral disruption in children: Oman experience, 1988-2000

Background: Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options. Methods: This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation. Results: In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations. Conclusions: Primary repairs required less hopitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions. J Pediatr Surg 37:1451-1455.     

The diagnosis of acute urethral trauma

Background

During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury.

Methods

A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted.

Results

There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma.

Discussion

Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.     

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.     

Dorsal on-lay preputial graft urethroplasty for anterior urethra strictures repair

Objectives To report the long-term results and evaluate the effectiveness of the dorsal on-lay preputial graft urethroplasty in patients suffering from anterior urethra strictures. Methods A total of 21 male patients, mean age 46.3 years (range 17–67), with anterior urethral strictures, underwent the dorsal on-lay preputial graft urethroplasty during the last 8 years, from October 1997 to September 2005. Strictures were located in bulbar urethra in 16 patients and in penile urethra in the remaining 5. The aetiology the stricture was traumatic injury of the anterior urethra in 12 patients and iatrogenic in 9 patients.␣A direct vision dorsal urethrotomy and the insertion of an urethral Foley catheter right before the procedure, facilitated the corpus spongiosum dissection and the preparation for urethroplasty. A voiding cystogram was performed on the day of urethral catheter removal to exclude extravasation and estimate the postoperative result. Results Mean follow-up time has been 49.9 months (range 6–95) and the outcome was favourable in 15 patients (71.43%). There were 3 recurrences in penile urethra strictures managed conservatively and three in bulbar urethroplasties, treated with internal urethrotomy followed by urethral dilatations. Conclusion Our results indicate that dorsal on-lay urethroplasty using preputial graft is an easy to learn and perform procedure, and offers the patient durable␣results with rather minimal complications.     

Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma

PURPOSE: Precise definition of pelvic fracture location may enable prediction of which subjects are at risk for urethral injury and understanding of the pathophysiological mechanism of injury. We determined the specific anterior pelvic injury locations associated with urethral injury. MATERIALS AND METHODS: We completed a retrospective, nested case-control study of 119 male patients evaluated at a single large level 1 trauma center between January 1, 1997 and July 15, 2003. We performed detailed measurements of the location, displacement and direction of force of each anterior pelvic fracture from computerized tomography and pelvic radiographs. Multiple logistic regression was used to determine associations between specific fracture locations and urethral injury after controlling for age, injury mechanism, injury severity and direction of force. RESULTS: Urethral injury was present in 25 patients and all had anterior pelvic fracture (inclusive of pubic symphysis diastasis). There were no urethral injuries in patients with fractures isolated to the acetabulum. Pelvic fractures that were independently associated with urethral injury from multiple regression analysis included displaced fractures of the inferomedial pubic bone, OR 6.4 (95% CI 1.6 to 24.9), and symphysis pubis diastasis, OR 11.8 (95% CI 4.0 to 34.5). Each millimeter of symphysis pubis diastasis or inferomedial pubic bone fracture displacement was associated with an approximately 10% increased risk of urethral injury. CONCLUSIONS: The location and displacement of anterior pelvic fractures in males predict risk of urethral injury and may be valuable in determining when evaluation of the urethra is appropriate.     

小儿闭合性尿道损伤的早期诊断和治疗

目的：总结小儿闭合性尿道损伤的早期诊治试验。方法：回顾性分析２６例本病患儿的临床资料。结果：前尿道损伤１６例，球部损伤占９例，后尿道损伤１０例。尿道挫伤１３例，作保留导尿管＋抗炎治疗；部分断裂４例，作膀销单纯造瘘；完全断裂９例，作尿道会师＋牵引。术后效果满意，并发症少。结论：对小少闭合性尿道损伤，早期明确诊断，根据损伤程度和部位选择合理治疗方法，可取得较好效果。     

胆囊切除术中医源性损伤11例分析

目的探讨胆囊切除术中医源性损伤的原因、预防措施及其处理。方法回顾性分析我们1987年~2002年行胆囊切除术中医源性损伤11例的临床资料。结果痊愈9例,死亡2例。结论加强术者的责任心,解剖清楚,规范手术操作是预防医源性损伤的关键。     

Management of penile gunshot wounds

The management of 10 cases of penile gunshot wounds treated at Henry Ford Hospital from 1982 to 1986 is reviewed. All patients were assaulted by low velocity weapons (handguns). Eight patients had associated injuries, predominantly to the genital region (thigh, pubis, and scrotum). There were 5 urethral injuries; 4 were treated with primary repair, the remaining patient underwent delayed repair, complicated by severe urethral strictures requiring reoperation. Blood at the urethral meatus was suggestive of urethral injury but microscopic hematuria was not. Five penile injuries did not involve the urethra and were treated by debridement and primary wound closure with no immediate or delayed complications. In dealing with these injuries we recommend a high index of suspicion for urethral and regional organ injury and primary urethral closure if at all possible.     

Blunt Urethral Trauma: A Unified, Anatomical Mechanical Classification

Purpose

We propose a simple, anatomically based classification of blunt urethral injury as a replacement for currently used classifications, which are not comprehensive, anatomically inconsistent or based on a mixed anatomical/mechanistic formula. The latter are difficult to learn and use, and have not been universally adopted.

Materials and Methods

We reviewed most of the currently used general uroradiological, emergency radiological and urological textbooks to define the classification of urethral injuries that is most widely accepted. Most authors use the Colapinto and McCallum classification, modifications thereof or the older surgical classification of urethral injuries, which simply divides such injuries anatomically into anterior and posterior. However, there is little consensus about the best classification and none includes all of the blunt injuries of the urethra. To correct these difficulties we devised a comprehensive and anatomically consistent classification.

Results

The proposed classification categorizes blunt urethral trauma as I-posterior urethra intact but stretched (Colapinto and McCallum type I), II-partial or complete pure posterior injury with tear of membranous urethra above the urogenital diaphragm (Colapinto and McCallum type II), III-partial or complete combined anterior/posterior urethral injury with disruption of the urogenital diaphragm (Colapinto and McCallum type III), IV-bladder neck injury with extension into the urethra, IVA-injury of the base of the bladder with periurethral extravasation simulating a true type IV urethral injury and V-partial or complete pure anterior urethral injury.

Conclusions

The proposed classification is anatomically valid and includes all of the common types of blunt urethral injuries. Universal adoption of this system should permit comparison of various management/treatment modalities at various institutions.     

Patterns of urethral injury and immediate management

PURPOSE OF REVIEW: The management of urethral trauma remains controversial. The purpose of this review is to provide a concise account of the patterns of urethral injury and the current trends of its immediate management. RECENT FINDINGS: Recent studies have identified types of pelvic fractures associated with a higher risk of urethral injury. Recognition of these fractures coupled with timely radiographic imaging has facilitated the earlier diagnosis of urethral injury and ensured that serious long-term sequelae are minimized. In highly selected cases of complete anterior and posterior urethral disruption primary realignment by a combined antegrade and retrograde endoscopic approach is increasingly being considered as a management option to restore early urethral continuity. Urethral trauma secondary to penetrating gunshot wounds and penile fracture requires immediate surgical exploration and repair. SUMMARY: The urologist involved in the management of genitourinary tract trauma needs to recognize the patterns of urethral injury, especially those associated with certain pelvic fractures. A judicious and systematic approach coupled with a conscious effort to minimize short and long-term sequelae of all urethral injuries will ensure optimal results. There is a need for a consensus on the optimal management of each of the vast arrays of urethral injuries.     

Disrupting injuries of the membranous urethra--the case for early surgery and catheter splinting

We reviewed the outcome following primary definitive repair by catheter splinting in 16 patients presenting with total posterior urethral disruption following pelvic injury. There were two deaths in the early post-operative period due to pulmonary embolism associated with other serious injuries. Five patients were judged to have a significant stricture at the site of injury, but all proved amenable to management with endoscopic treatment or periodic dilatation. None required a urethroplasty. The two cases with stress incontinence were related to concomitant injury of the bladder neck. Impotence persisted in 2 or 5 patients followed for longer than 12 months. Complications from catheter traction were not seen using the system of light interrupted traction described. A case is made for primary management by catheter splinting of such urethral injuries.     

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.     

Urethral injuries in the Civil War

PURPOSE: We compiled all cases of urethral injury received in battle during the Civil War to detail their management and determine the outcome of treatment. MATERIALS AND METHODS: Surgeon medical reports of individual cases of urethral injury listed in the Medical and Surgical History of the Civil War, and pension records available in the National Archives and Records Administration were reviewed. RESULTS: A total of 105 cases of urethral injury from gunshot wounds, comprising 7% of all urogenital casualties, were reported during the Civil War between 1861 and 1865. Of them 22 (21%) were fatal and 83 patients (79%) cases survived. Debridement and catheter drainage of urinary extravasation or perineal urethrotomy was initial treatment. The majority of urethral injuries were complicated by troublesome strictures, fistulas, urinary incontinence and erectile impotence. Only 19 patients (23%) recovered fully. CONCLUSIONS: Civil War urethral injuries had devastating long-term consequences.     

尿道镜在急性闭合性尿道损伤治疗中的应用价值（附22例报告）

目的：探讨尿道镜在急性闭合性尿道损伤治疗中的应用价值。方法：对因骑跨伤致闭合性尿道球部损伤患者13例和骨盆骨折致后尿道损伤患者9例，采用电视尿道镜下留置导尿管行尿道会师术。结果：球部损伤患者12例会师成功，1例进镜失败；后尿道损伤患者5例会师成功，4例失败。随访0．5～5年，15例治愈，1例复发狭窄，1例失访。结论：采用尿道镜下尿道会师术治疗前尿道损伤安全合理，创伤小，疗效好，应成为首选方法；治疗后尿道损伤则需慎重，应根据伤情试行腔镜治疗。     

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.     

插入式胆肠吻合术治疗医源性胆道损伤27例

目的 评价插入式胆肠吻合术在医源性胆道损伤一期胆道重建中的临床应用效果.方法 对1995年1月-2006年12月施行的27例插入式且胆肠吻合术的病例资料进行回顾性分析.结果 27例中,开腹胆囊切除致胆管损伤21例,腹腔镜胆囊切除致胆管损伤6例.损伤的胆管直径均小于1.0 cm(0.3～0.8 cm).行胆管全插入式胆肠吻合10例,胆管前壁插入式胆肠吻合17例.术后无1例发生胆瘘和胆管狭窄.结论 插入式胆肠吻合术简单、安全、有效.在胆管较细且需要做胆肠吻合术的病例,应选择此术式.     

超声刀腹腔镜胆囊切除术胆管损伤的特点和处理

目的 探讨超声刀无钛夹法腹腔镜胆囊切除术(UHS-LC)胆管损伤的特点、处理方法及预防措施.方法 回顾性分析近5年行UHS-LC1863例的临床资料,11例发生胆管损伤,全部经手术修复,随访1～5年.结果 11例胆管损伤分别为:右肝管损伤3例,肝总管损伤2例,胆总管横断3例,胆总管穿孔2例,胆总管横断合并左、右肝管同时损伤1例;损伤于手术中发现9例,手术后发现2例.11例患者共施行再手术13次,无胆管狭窄,无死亡病例.结论 手术时一定要弄清肝总管、胆总管与胆囊管三者的关系,采用顺逆相结合的方法,遵循"辨-切-辨"原则,腹腔镜下打结技术对术者要求较高,尤其是三孔法LC,过分牵拉Calot三角易造成出血和副损伤,在靠近胆总管的地方尽量使超声刀刀头的背面朝上,并且其背面绝对不能直接接触胆总管,术中及术后早期发现胆管损伤者,应即刻妥善处理.     

医源性桡神经损伤诊治的临床探讨

目的探讨医源性桡神经损伤的病因和手术时机。方法分析1998年5月-2003年1月间收治的16例医源性桡神经损伤病例。结果损伤病因有手术误伤12例，压迫伤2例，手法复位损伤2例。10俐显微手术治疗，疗效优者6例，良者2例，可1例，差1例，优良率达80％；6例保守治疗恢复功能。结论手术误伤是医源性桡神经损伤的主要原因，显微外科治疗是挽救医源性桡神经损伤的有效手段，手术时机的选择是影响疗效的重要因素。     

骨盆创伤知名血管损伤的紧急处理策略

目的 探讨骨盆创伤中骨盆知名血管损伤时的紧急处理策略。方法 回顾性分析2005年1月至2021年10月山东省立医院收治的58例骨盆知名血管损伤病人的临床资料，其中男36例，女22例，年龄为（47.9±14.8）岁（24~75岁）。其中“死亡冠”血管损伤15例（医源性损伤8例）；臀上动静脉损伤17例（医源性损伤7例）；臀下动静脉损伤6例（医源性损伤1例）；阴部内动脉损伤13例；髂外动静脉（股动静脉）损伤7例（医源性损伤3例）。所有病人根据不同的血管损伤机制，术中根据不同的情况分别选择直接血管结扎、纱布填塞、血管造影栓塞或联合腹主动脉阻断等方法急救止血。结果 58例骨盆知名血管损伤的病人，其中有55例病人得到成功的处理，术后存活。其中2例因“死亡冠”血管损伤所致的大出血死亡，1例因臀上动脉医源性损伤所致的大出血死亡。结论 临床医生在面对骨盆及臀部创伤时要充分了解并掌握骨盆知名血管损伤的预防和处理，同时也不能忽视骨盆知名血管的潜在损伤。了解骨盆骨折类型与血管损伤的潜在联系，对于“死亡冠”血管，可行预防性结扎避免损伤，一旦损伤在无法结扎的情况下应纱布填塞压迫止血结合介入栓塞；对于臀上和臀下血管，造影栓塞可作为第一选择，必要时可联合腹主动脉球囊阻断；对于阴部内动脉，纱布填塞及造影栓塞均有较好的效果；对于髂外血管的损伤，可在腹主动脉球囊阻断下行血管修补或置换。当骨盆知名血管损伤时，根据具体情况，掌握止血急救的措施，根据自已医院条件和自身的经验选择合适的方法，提高病人的预后和生存率。