男性骨盆骨折后尿道损伤早期处理方式的历史演变

男性骨盆骨折后尿道损伤(PFUI)是泌尿外科修复重建领域棘手的问题之一,其早期处理目前尚有争议。本文将结合欧洲泌尿外科协会指南及相关文献对PFUI早期处理方式的历史演变进行梳理。     

男性骨盆骨折致后尿道损伤的治疗研究进展

泌尿生殖器损伤是骨盆骨折的严重并发症之一,患者常常合并严重多发伤,病情严重、复杂,临床医师在早期救治时往往顾此失彼。尿道损伤的长度、部位、严重程度与骨盆骨折的类型有关。目前关于骨盆骨折致后尿道损伤(PFUI)的早期处理、合并症的治疗方式尚无统一方案。近年来国内外学者对此进行了大量的研究,并且某些研究已取得良好的治疗效果。本文对男性PFUI的治疗作一综述。     

76例后尿道损伤诊治分析

目的 探讨骨盆骨折致后尿道损伤的早期诊治及处置.方法 总结76例后尿道损伤的处置过程及诊治经验.结果 采用单纯膀胱造瘘术10例,尿道会师术(气囊尿管牵引法)35例,早期尿道断端吻合术31例,都取得了较为满意的治疗效果.结论 在骨盆骨折所致后尿道损伤治疗中,在首保抢救生命的前提下,根据患者后尿道损伤的不同程度,患者合并伤的严重程度以及医院的诊疗条件和医师对尿道损伤手术的熟练程度,选用合适的术式,是保证患者生命,提高疗效,减少并发症的关键.     

骨盆骨折尿道损伤机理及其诊断进展

骨盆骨折后尿道损伤在发生机制上临床经常模糊不清,从而导致在诊断和治疗方面临床意见不一,为了总结骨盆骨折所致尿道损伤在发生机理和诊断方面的经验,本文回顾了有关骨盆骨折尿道损伤方面的资料。骨折的耻骨支数以及骶髂关节受累情况是造成尿道损伤的危险因素。根据创伤的程度,首先是尿道膜部被拉长,然后球膜交界处导致部分或完全性断裂。前列腺部尿道和膀胱颈部的损伤仅发生于儿童;而女性尿道损伤多是尿道前壁的撕裂,很少出现远端或近端尿道的完全断裂。对于高度怀疑的男性患者可用尿道造影进行诊断,女性可以通过尿道镜检查来完成。     

双窥镜尿道会师术早期治疗尿道损伤的疗效观察（附23例报告）

目的：探讨双内窥镜尿道会师术早期治疗尿道损伤的临床疗效.方法：回顾性分析23例尿道损伤患者采用输尿管软镜及尿道膀胱镜进行双内窥镜下尿道会师术的早期治疗经验.结果：23例损伤尿道在双内窥镜直视下会师均获得成功,全部患者无尿失禁,其中20例维持良好性功能.随访1～3年,18例无需进一步处理,尿流率正常;另5例出现短程排尿困难和继发性尿道狭窄,经短期定期尿道扩张或尿道内切开后,排尿正常.结论：双窥镜下尿道会师术早期治疗尿道损伤具有手术方式简单、手术时间短、微创、并发症少的优点,可有效用于男性闭合性尿道损伤的治疗,尤其是后尿道完全断裂及骨盆骨折患者.     

肠损伤合并骨盆骨折的诊治探讨

目的探讨肠损伤合并骨盆骨折的早期诊断和治疗。方法回顾性分析成功诊治肠损伤合并骨盆骨折13例,其中回肠损伤2例,乙状结肠损伤5例,直肠损伤6例,均合并骨盆损伤。结果本组无病死率,未发生严重术后并发症,远期疗效良好。结论及时、早期诊断和及早手术、选择正确术式是肠损伤合并骨盆骨折治疗的关键。     

骨盆骨折后尿道损伤及后尿道狭窄

骨盆骨折合并后尿道损伤的发病率近年来呈上升趋势 ,对后尿道损伤的诊断与处理日益重要 ,处理不当日后需再次手术 ,引起尿失禁、阳瘘则留下终身残废。作者就骨盆骨折后尿道损伤及后尿道狭窄的发病率、尿道损伤机制、后尿道损伤分类、诊断和处理作综述。     

骨盆骨折后尿道断裂的治疗：损伤后早期吻合与延迟尿道成形的比较

有关严重的机械创伤致尿道断裂的泌尿外科处理仍存在很大的争议,其焦点是创伤后应该早期还是延缓处理较合适。本文作者通过分析96例患者来明确两种方法的远期效果。作者回顾性分析了1984年~2001年间由于骨盆骨折引起的后尿道断裂的男性患者,共191例,其中96例至今生存。96例中有57例接受早期治疗,39例行延迟尿道成形术,所有病例平均随访8.8年。术后所有病例均进行尿失禁、性功能及尿道狭窄的评估。本组中78%有严重伴随器官损伤,严重骨盆骨折76%。总死亡率51%。尿道断裂的诊断根据当时临床表现及随后的尿道造影。结果早期修补的患者术后尿道狭…     

尿道损伤的诊断与处理——尿道损伤早期诊断与处理的现状

尿道损伤在泌尿系损伤中较常见，约占10％～20％，男性多见，常伴有骑跨伤或骨盆骨折，部分为医源性损伤。尿道损伤可分为挫伤、裂伤和完全性裂伤。在骨盆骨折中约有10％发生前列腺膜部尿道裂伤，90％的病例发生于车祸和工伤^[1]。前尿道损伤多由骑跨伤引起，后尿道损伤多由骨盆骨折所致，并可伴发膀胱和直肠等脏器损伤。正确的早期诊断和处理非常重要，否则将易产生尿道狭窄、闭锁、假道、尿瘘和性功能障碍以及尿失禁。     

骨盆骨折后尿道断裂：早期复位和延期尿道成形术的治疗经验比较

严重器质性损伤导致的尿道断裂是早期复位还是延期行开放尿道成形术，目前仍然存在争论。作者报告了96例患者采取2种不同方式治疗的经验和长期随访结果。回顾性研究1984—2001年96例因严重骨盆骨折导致后尿道断裂的男性患者，其中57例早期复位，39例先行耻骨上膀胱造瘘，再延期行尿道成形术。     

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。     

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury

BACKGROUND: There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. STUDY DESIGN: We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. RESULTS: Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). CONCLUSIONS: Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.     

骨盆骨折后尿道损伤的处理与预后(附84例报告)

目的探索骨盆骨折合并后尿道损伤的安全、有效治疗方法。方法对８４例骨盆骨折伴后尿道损伤患者采用食指引导下，直接放置带有铁芯的双腔导尿管行简化的尿道会师加牵引术，术后适时尿扩。结果全组随访８１例，其中６９例可正常排尿，治愈率为８５．２％；阳萎３例。结论在多脏器伤合并后尿道损伤中，正确应用尿道会师加牵引术，拔管后及时尿道扩张可作为首选方法。     

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.     

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.     

Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE: Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management. MATERIALS AND METHODS: We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed. RESULTS: Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy. CONCLUSIONS: Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.     

损伤严重程度评分在骨盆骨折并后尿道断裂治疗中的应用

目的：探讨损伤严重程序评分（ISS）在骨盆骨折并后尿道断裂治疗中应用的意义。方法以AIS－90版为基础,采用ISS评分对293例男性闭合性骨盆骨折并后尿道断裂病人进行评估分析。结果ISS值随损伤部位数增加而增高,ISS值高,死亡率亦高,Ⅰ期尿道吻合组ISS＜16分,尿道会师术组ISS16－39分,膀胱造瘘组ISS平均≥40分。结论骨盆骨折并后尿道断裂为多发损伤,尿道断裂急症处理方法的选择应根据病人伤情程度及局部情况等决定,ISS评分在骨盆骨折并后尿道断裂的治疗选择中有重要的指导意义。     

Primary Endoscopic Realignment in Female Urethral Injuries with Pelvic Fracture Can Reduce Avoidable Morbidity

Female urethral injuries associated with Pelvic fracture are not as uncommon as it was previously thought. Primary endoscopic realignment of proximal urethra and catheterisation on guide-wire is very good procedure in early presentation. Every female patient with urethral injury due to pelvic fracture should be referred for primary repair to decrease the avoidable morbidity of these patients.     

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.