一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤5例报告

目的:探讨一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤的可行性.方法:自2001年6月～2007年6月,共收治骨盆骨折并发尿道断裂患者24例.对其中5例不稳定型骨盆骨折并发后尿道断裂伤的患者采取急诊尿道吻合或尿道会师术,同期行骨盆骨折复位内或外固定术.术后均随访 ,时间为3～12个月.结果:1例发生耻骨后感染,无死亡和尿道二期手术;术后随访,3例患者排尿满意,2例出现不同程度的排尿困难,经定期尿道扩张后排尿满意.结论:骨盆骨折的早期复位和有效固定是实现尿道修复的解剖基础,一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤是可行的.     

骨盆复位及固定在骨盆骨折后尿道断裂治疗中的作用

目的 探讨骨盆复位及固定在骨盆骨折后尿道断裂治疗中的作用。方法 将４１例男性骨盆骨折后尿道断裂患者分为尿道会师组（第１组）１５例，尿道会师＋骨盆复位及固定组（第２组）２６例，比较两组治疗结果。结果 第１组尿道瘢痕平均长度２．９ｃｍ，尿道有明显移位及弯曲。第２组尿道瘢痕平均长度０．５ｃｍ，尿道修复情况良好。结论 骨盆复位及固定可帮助断裂尿道的复位与固定，提高尿道会师术的效果。     

骨盆骨折伴后尿道断裂的早期治疗

骨盆骨折后尿道断裂是泌尿外科、骨科的常见急症，常合并多脏器损伤，病情危急，其预后很大程度上取决于早期处理。笔者自1996年4月～2006年3月共收治骨盆骨折伴后尿道断裂48例，均采用急诊尿道会师术，其中26例同时行骨盆复位内固定治疗，疗效满意。现报告如下。     

骨盆骨折合并后尿道损伤致阴茎勃起功能障碍48例临床分析

目的探讨男性骨盆骨折合并后尿道损伤致阴茎勃起功能障碍（ED）的诊治经验。方法回顾性分析48例男性骨盆骨折合并后尿道损伤患者的临床资料,其中28例急诊行尿道端端吻合术,13例患者Ⅰ期先行膀胱造瘘术,3～6个月后行尿道瘢痕切除＋Ⅱ期尿道吻合术或冷刀切开术,5例行尿道会师牵引固定术,2例行保守治疗后仅留置导尿管。其中15例不稳定型骨盆骨折并发后尿道断裂伤的患者同期行骨盆复位内固定术。结果 48例患者中39例出现不同程度勃起功能障碍,术后通过病史、查体、实验室检查,国际勃起功能指数、夜间阴茎勃起（NPT）监测,罂粟碱试验、彩色多普勒血流显像（CDU）、动态阴茎海绵体造影、球海绵体肌反射（BCR）和尿动力学检查等方法。其中神经性勃起障碍28例,动脉性15例,静脉性4例,心理性2例。结论 ED是骨盆骨折合并后尿道损伤的常见并发症,严重骨盆骨折致后尿道的损伤发生ED的机率明显升高。     

尿道会师配合水平牵引治疗后尿道完全断裂36例

目的：探讨骨盆骨折、后尿道完全断裂行尿道会师术后水平牵引尿道的治疗效果。方法：对36例骨盆骨折、后尿道完全断裂患者行尿道会师,术后水平牵引尿道,并随访观察疗效。结果：在35例随访病例中29例排尿通畅,4例改行尿道吻合术,2例转院。结论：尿道会师配合水平尿道牵引术治疗骨盆骨折、后尿道完全断裂,具有操作简单、疗效确切、便于护理等优点。     

外伤性女性尿道断裂的处理(附八例报告)

报告８例女性骨盆骨折致尿道断裂，经耻骨后行尿道修补对端吻合者４例，经会阴行尿道修补者２例，均一期恢复正常排尿；会师牵引者２例，术后１例恢复正常，１例需二期手术。对完全性尿道断裂者，强调早期行尿道断端吻合术     

骨盆骨折引起后尿道损伤的早期处理

目的：探讨骨盆骨折引起后尿道损伤早期合理的处理方法。方法：回顾性分析36例男性骨盆骨折并发后尿道损伤患者的临床资料，其中8例尿道黏膜裂伤或尿道部分断裂患者行留置导尿，另28例尿道完全断裂患者均在伤后24h内行手术治疗，其中18例行尿道会师加牵引，其余10例单纯膀胱造瘘。结果：随访6个月～5年，8例留置尿管患者，拔管后排尿通畅6例，尿线变细2例，经定期尿道扩张，排尿正常。18例尿道会师加牵引患者，拔管后适时扩张尿道，排尿通畅15例，尿线较细3例，经定期尿道扩张后，1例排尿通畅，2例失败。10例单纯膀胱造瘘患者，术后均不能排尿，分别于伤后6～12个月行开放手术及尿道内切开治疗。结论：尿道会师加牵引术是治疗骨盆骨折所致后尿道断裂的有效方法。     

骨盆骨折并后尿道损伤后阴茎勃起功能障碍的病因学研究

我们对1986～1998年间60例骨盆骨折后尿道损伤及外伤性尿道狭窄病人进行性功能随访,探讨骨盆骨折合并后尿道损伤后阴茎勃起功能障碍的发生原因。报告如下。临床资料　本组60例,受伤时年龄11～59岁,平均30岁。随访时间6个月～10年,平均3.5年。致伤原因:车祸伤34例,高处坠落伤9例,塌方9例,碾压伤8例。骨盆骨折类型:耻骨双骨折或伴坐骨骨折23例,单侧耻骨骨折或伴坐骨骨折18例,19例未记录骨折类型。尿道部分断裂11例,完全断裂49例。60例中8例新鲜尿道损伤者经早期处理(2例仅留置导尿管,2例急诊行尿道吻合术,4例行尿道会师术)后仅行尿道扩张,未再…     

前列腺固定术治疗后尿道损伤

我院于1985年1月～1996年1月共收治男性后尿道损伤27例，其中21例采用尿道会师牵引加前列腺固定术，并在手术方法上加以改进，疗效满意，现报告如下。1资料与方法1．1一般资料本组27例，年龄18～57岁，平均37岁。发生于坠跌伤3例，挤压伤7例，车祸17例，均并发骨盆骨折。其中4例为多发性严重骨盆骨折，2例并发胸腹部多脏器损伤。膜部尿道损伤2例，膜上尿道部分损伤1例，膜上尿道完全断裂、耻骨膀跳韧带完全折断、前列腺尖后移24例。1．2治疗方法单纯膀胱造疾4例，尿道会师气囊导尿管牵引加膀优造瘘1例，尿道会师气囊导尿管牵引加前列腺固定…     

膀胱粘膜移植尿道成形术治疗陈旧性尿道狭窄

陈旧性尿道狭窄是泌尿外科临床工作的难题之一,常因狭窄段长、位置高不易显露、炎症或其他局部病理情况,使尿道修复成功率低或术后并发症多而不够满意。我院自1983年元月以来采用膀胱粘膜移植尿道成形术,治疗陈旧性尿道狭窄10例,效果满意,现报告如下。临床资料:10例均为男性,年龄18～52岁,平均37.6岁。尿道狭窄长度为2.5～5cm.8例为骨盆骨折致后尿道断裂,2例骑跨伤致尿道球部断裂。10例中7例曾急诊行尿道会师术,1例耻骨上膀胱造瘘;2例尿道球部断裂曾行断端吻合术,术后经反复尿道扩张仍有排尿不畅。3例后尿道断裂者曾     

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.     

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 and Associated Urologic Injuries

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

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.     

尿道导引器在尿道会师术中的应用

目的:探索一种更安全、简便的治疗创伤性尿道断裂的手术方法。方法:对18例后尿道损伤和4例尿道球部断裂病例先作膀胱穿刺造瘘,后用尿道导引器以导引和会师的方法完成尿道会师术。结果:22例中21例完成会师手术,1例因合并膀胱破裂改为开放手术。18例硬膜外麻醉和3例局部麻醉下完成手术;平均手术时间18min,平均术中出血20ml,术后常规尿道扩张3月。21例获随访3月至2年,最大尿流率(MFR):15～22ml/s有13例,10～14ml/s有7例,1例因瘢痕狭窄术后3个月后行尿道吻合术。结论:穿刺导引法尿道会师术简便易行,减少了麻醉和术中损伤风险,可在局麻下施行,值得推广。     

Management of male pelvic fracture urethral injuries: Review and current topics

Pelvic fractures from high‐energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.     

Prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty

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

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.