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.     

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.     

The surgical repair of posterior urethral strictures by the transpubic urethroplasty or pull-through technique

The management of strictures of the posterior urethra is reviewed in 75 adults and 19 children. Of the patients 66 were treated by a perineal pull-through technique and 28 underwent a transpubic approach. The transpubic approach provided excellent exposure to the damaged urethra with minimal morbidity, and good results were obtained in 89 per cent of the children and 69 per cent of the adults. Three patients had partial incontinence postoperatively but 2 recovered completely after 6 months. With the perineal pull-through technique, good results were achieved in 80 per cent of the children and 66 per cent of the adults. Worsening of sexual function was not seen in either treatment group as a consequence of the operation. As a result of this experience the transpubic approach is preferred in cases of complex urethral strictures, cases in which the length of the damaged urethra exceeds 3 cm. or in small children, reserving the pull-through technique for low-lying urethral strictures less than 3 cm. long.     

Diagnosis and classification of urethral injuries

Urethral injuries are uncommon and rarely life-threatening in isolation. They are, how-ever, among the most devastating urinary system injuries because of significant long-term sequelae, including strictures, incontinence, erectile dysfunction, and infertility.Urethral trauma may be categorized by mechanism of injury (ie, blunt versus penetrating injury) and by location (ie, posterior versus anterior urethra). Injuries to the posterior urethra are classically associated with pelvic fractures, while anterior urethral trauma usually arises secondary to injudicious instrumentation or perineal straddle injury. This article reviews the major etiologies and mechanisms of urethral trauma, describes how these injuries are diagnosed, and explains classifications of urethral trauma. Timely and accurate diagnosis and classification of urethral injuries leads to appropriate acute management and reduced long-term morbidity.     

Cadaveric anatomy of pelvic fracture urethral distraction injury: most injuries are distal to the external urinary sphincter

PURPOSE: The anatomy of posterior urethral distraction injuries is controversial. We present a cadaver study of posterior urethral distraction injuries. To our knowledge this is the first study that establishes that the most common location is distal to the external urinary sphincter. MATERIALS AND METHODS: We performed an autopsy review of 10 male patients with posterior urethral distraction injuries. RESULTS: Urethral disruption occurred distal to the external urinary sphincter in 7 of 10 patients. It appeared to occur when the anterior pelvic ring and urogenital diaphragm complex were displaced caudal and rostrally, tearing the urogenital diaphragm off of the urethra. The average inner mucosal defect +/- SD was 3.5 +/- 0.5 cm, while the defect between the outer urethral layer (tunica of the spongiosum) was 2.0 +/- 0.2 cm due to mucosal retraction. Simple and complex injuries could be observed, according to the clinical classification proposed by Turner-Warwick in 1989. Simple injuries had less significant dislocation of the symphysis, general maintenance of urethral continuity and slightly shorter mucosal distraction (3.3 cm). Complex disruptions had significant symphyseal dislocation, complete disassociation of the urethral ends (often with interposition of other tissues) and a slightly longer mucosal distraction (3.8 cm). CONCLUSIONS: Posterior urethral distraction injuries appear to most commonly occur distal to the urogenital diaphragm, contrary to classic teaching. These injuries are on average between 3 and 4 cm, and they are more significant dorsal than ventral. They appear to occur as simple or complex injuries, mirroring the clinical findings seen in clinically simple and complex urethral strictures.     

Posterior urethral reconstruction

Summary The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation – an injury that is often complicted by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100 % versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that “urethra is the best substitute for urethra”.      

Our Changing Strategies on Bladder Neck Suspension Operations

With currently changing strategies, we retrospectively reviewed our operative results in female stress incontinence to find a suitable solution to correct both urethral hypermobility and intrinsic sphincter dysfunction with reasonable success rates.No Incision Bladder Neck Suspension (NIBNS), Modified Four Corner Bladder Neck Suspension (MFCBNS) and in situ vaginal wall sling operation with bone fixation were performed on 24, 26, 25 patients from 1992 to 1994, 1994 to 1996, 1996 to 1998, respectively, with pre- and postoperative evaluations and success rate determinations.Cure rates for NIBNS operations were 90.47, 72.2 and 50 per cent after 6 months, 2 years and 5 years, respectively. For MFCBNS operations cure rates were 96 and 75 per cent after 6 months and 2 years; for in situ vaginal wall sling by bone fixation the rates were 100 per cent in primary cases and 80 per cent in secondary cases after one year of follow-up. After two years the cure rate was 88.8 per cent in primary cases.By fixation and elevation of the urethrovesical junction and by external compression from under the urethra, in situ vaginal wall sling by bone fixation offers a better solution to urethral hypermobility and intrinsic sphincter dysfunction for urinary stress incontinence.     

Urethrectomy in men with transitional cell carcinoma of bladder

Data on a selected group of 90 male patients who had total cystectomy for diffuse transitional cell carcinoma in situ, multiple bladder neoplasms involving the trigone, or transitional cell carcinoma encroaching on the bladder neck and/or involving the prostatic urethra were studied in relation to the incidence of urethral involvement. Of the 59 patients who had only total cystectomy, 8 (13.5 per cent) required a subsequent therapeutic urethrectomy for clinical anterior urethral carcinoma. Of the remaining 31 patients who underwent simultaneous prophylactic urethrectomy at the time of cystectomy, 2 (6.4 per cent) had transitional cell carcinoma and 1 had moderate mucosal atypia of the anterior urethra. Although the remaining urethra constitutes a potential hazard for further tumor formation, only l of 10 patients with urethral carcinoma possibly died of urethral tumor recurrence. Therefore, the urologist has a choice either to follow the patient closely with cytologic urethral wash or to do a prophylactic urethrectomy, especially in patients who are difficult to follow-up closely.     

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.     

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。     

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.     

Risk factors for urethral injuries in men with traumatic pelvic fractures

Urethral injuries are commonly associated with pelvic fractures. The prompt recognition and appropriate management of these injuries may significantly impact subsequent morbidity, yet few studies have addressed the identification of the risk factors for urethral injury in men with pelvic fractures. We reviewed retrospectively the records of 405 men with pelvic fractures seen at our medical center, including 21 (5 per cent) with urethral injuries. Of the 21 men 14 (67 per cent) had fractures involving a pubic ramus and a sacroiliac joint, and 12 (57 per cent) had no physical signs (blood at the urethral meatus, perineal hematoma or a high-riding prostate) that would suggest a urethral injury. The likelihood for the presence of physical signs is directly related to the interval since injury. We believe that men with the combination of rami fractures and sacroiliac disruption should undergo retrograde urethrograms before urethral instrumentation, and that physical signs are unreliable indications for urethral injuries, especially soon after the injury.     

Initial management of acute urethral injuries

A study was made of 30 cases of acute urethral trauma treated over a 7-year period. There were 10 anterior and 20 posterior urethral injuries, the majority of these being partial ruptures. Posterior urethral injuries were caused by road traffic accidents in 75% of cases while 80% of the anterior urethral injuries were of the "straddle" type. There was only 1 case of iatrogenic injury to the anterior urethra. During follow-up, all patients required periodic dilatations for stricture except for the single case of iatrogenic injury. An average of 5 dilatations controlled all of the strictures except for 2 that required urethroplasties.     

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.     

Posterior urethral injuries and the Mitrofanoff principle in children

OBJECTIVE: To report our experience of children with trauma causing posterior urethral injury who at some stage underwent a Mitrofanoff intervention, as post-traumatic urethral injuries can demand long-term treatment which (regardless of the surgical intervention) requires a period of dilatation of the reconstructed urethra. PATIENTS AND METHODS: From 1992 to 2001, 14 patients with urethral injuries underwent a Mitrofanoff procedure. Thirteen had been run over by a motor vehicle and had severe hip injuries, and one had a direct non-penetrating perineal impact lesion (13 boys and one girl, aged 2-13 years at the time of the accident). In all cases the Mitrofanoff procedure involved interposing the appendix between the bladder and the umbilicus. Only one of the children (because of extremely high bladder filling pressures) also underwent an augmentation cystoplasty and closure of the bladder neck because there were bony fragments in the urethra. RESULTS: The Mitrofanoff technique was considered useful in most cases. All patients during a given period used the Mitrofanoff conduit to empty their bladder every 3 h; 10 of the 14 are currently voiding urethrally, with an adequate flow, and four are not, but emptying the bladder periodically via the appendicovesicostomy. The only girl in the group has a major hip deformity and is unlikely to undergo urethroplasty; two patients are expecting definitive treatment and the other, although having a patent urethra, has no urinary flow. He is currently 19 years old and has no erections. CONCLUSIONS: The treatment of posterior urethral injuries represents a challenge to surgical teams. Although primary suturing of the separated urethral ends is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases.     

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.     

Urethral stricture: single-stage urethroplasty by a free skin flap

A single-stage procedure involving the use of a free skin flap for the correction of urethral strictures was performed on eighteen patients. In this series, the strictures were mainly located in the region of the bulbar urethra. Good results were obtained in fourteen cases (80 per cent) out of the eighteen, with a two year followup, or less. The method is simple and effective. In the authors' experience, it has provided a higher success rate than any other procedure described to date. In view of this high success rate, and the equivalent successes reported in the literature, the authors consider that this technique, and urethrotomy, constitute the treatment of choice for urethral stenosis.     

电子膀胱软镜在后尿道狭窄（闭锁）患者中的临床应用与价值

目的：探讨电子膀胱尿道软镜在后尿道狭窄（闭锁）患者的临床应用与价值,为手术治疗提供客观依据。方法：总结2009年7月~2010年12月收治98例后尿道狭窄（闭锁）患者的电子膀胱尿道软镜检查资料。结果：98例患者后尿道狭窄（闭锁）长度为1．5～7．0cm,术中发现尿道假道6例,尿道直肠瘘6例,后尿道结石患者19例,狭窄段接近前列腺者26例,后尿道完全闭锁者22例。结论：电子膀胱尿道软镜具有可弯曲,创伤小,无视野盲区,可以方便的观察患者后尿道的情况,为选择手术方式及手术中的具体操作提供可靠的依据。     

The traumatic dural sinus injury — a clinical study

Summary In a period of 13 years 978 cases of severe head injuries were operated on in our clinic. An analysis of the medical reports includes injuries of the superficial dural sinus (39 cases=4%): among these injuries of the anterior and central part of the superior sagittal sinus (66 per cent), injuries of the transverse sinus (18 per cent), injuries of the posterior part of the superior sagittal sinus (8 per cent), and combined injuries of different dural sinuses (8 per cent).Clinical data, i.e. the causes of accident, radiological examination results, intracranial lesions, operation technqiues and outcome are analysed and discussed. The analysis of cases with dural sinus injuries shows a high mortality rate (total mortality rate: 16 patients=41%; intra-operative mortality rate: 8 patients=20%).     

Cystectomy for superficial bladder cancer

One hundred nine patients with Stage O or A bladder cancer unmanageable transurethrally underwent radical cystectomy and ileal conduit urinary diversion without lymphadenectomy. Fifty-six were also given planned preoperative radiation therapy. Five-year survival rate was 76 per cent for the entire group. Irradiation eradicated all of the tumor (P_o) in 36 per cent of patients, no patient P₀ after irradiation had recurrent disease, and local recurrence was noted in only 3.5 per cent of the irradiated patients compared with 9.4 per cent of those not irradiated. Urethral cancer was present in 9 per cent of our patients, a finding that does not support our previous impression that patients with multifocal bladder cancer or tumors involving the prostatic urethra had a higher than average incidence of urethral carcinoma.