尿道会师术后导尿管留置时间的探讨

目的明确早期尿道会师术后支架导尿管留置时间与尿道愈合的关系。方法对３９例骨盆骨折合并后尿道断裂的患者采用导管周围尿道造影,对会师术后尿道愈合进行连续观察。结果３０例（７６％）导尿管留置时间在８周以上尿道始愈合;９例（２４％）在６周以内愈合;愈合时间最短者４周,最长者１８周。经１～１４年随访,排尿正常者２４例（６９％）,每年尿道扩张不超过２次;排尿基本正常者７例（２０％）。结论导尿管留置时间与尿道愈合、治疗效果呈正相关关系,而导管周围尿道造影可为支架导尿管的拔除提供可靠依据     

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。     

尿道损伤手术治疗及尿管留置时间的临床观察

1 临床资料 我们自1990年3月以来,共收治骨盆骨折伴后尿道损伤52例,采用简化的尿道会师术加牵引术,依据尿道造影情况决定尿道内置管时间。本组52例,均为男性。年龄16～69(平均42.5)岁。致伤原因:交通事故46例(88.5％),工伤4例(7.7％),斗殴2例(3.8％)。全组均伴有骨盆骨折,其中休克32例(61.5％),合并腹腔脏器损伤21例,并肾挫伤1例并双股骨干骨折1例。表现为不能自行排尿,尿道出血及其它脏器损伤的相关临床表现。均经试插导尿管失败。伤后均在24小时内急诊行尿道会师加膀胱造瘘术,同时处理合并伤。     

尿道会师术后尿道造影检查分析

在临床实践中 ,我们发现尿道会师术后尿道狭窄并发症的发生与气囊尿管拔除时间过早有关[1] 。 1983～ 1997年 ,我们采用尿道造影检查 ,对尿道会师术后尿道断裂的愈合情况与导尿管留置时间进行相关分析。1.资料与方法 :本组 2 6例均为男性 ,年龄 19～ 5 5岁 ,平均 30岁。 2 6例均为后尿道断裂伤 ,其中膜部尿道损伤 2 2例 (85 % ) ,前列腺尖部尿道损伤 4例(15 % )。所有病例均因交通或建筑等事故损伤所致 ,均伴有不同程度的骨盆骨折或耻骨联合分离。 2 6例均为新鲜后尿道损伤。在入院后除其他综合治疗外 ,立即行尿道会师术。气囊尿管选用2 0～…     

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。     

外牵引术在尿道会师术中的应用

本文报告骨盆骨折合并后尿道断裂32例,均得到随访,并做了尿道造影检查。给果单纯尿道会师者13例,其中10例尿道狭窄,占76.9％,尿道狭窄段平均符长度2.5cm。会师加牵引术治疗19例,尿道狭窄8例,占42.1％,尿道狭窄段平均长度1cm。我们认为尿道会师加牵引术在治疗后尿道损伤中具有方法简单,创伤小的特点,是后尿道损伤早期治疗的较好方法。     

自制尿道会师器的临床应用

作为骨盆骨折的合并伤,男性后尿道断裂比较常见,由于损伤性休克的原因,患者一般情况较差,不能耐受复杂的手术.尿道会师术仍是目前后尿道断裂早期处理的较好方法[1],但尿道会师术[2]操作繁琐,实际操作中引用了1条过渡性的导尿管,反复在尿道内通过,加重损伤尿道粘膜,易引起术后尿道狭窄、感染等并发症.鉴于此,我们试制了尿道会师器,自1998年起应用于临床共治疗20例后尿道断裂患者,与同期未用会师器的20例患者(随机分组)进行观察对比分析,效果显著,现报告如下.     

膀胱镜下尿道会师术治疗尿道损伤的临床分析

目的探讨膀胱镜下尿道会师术治疗尿道损伤的临床疗效。方法回顾性分析自2006年以来行膀胱镜下尿道会师术的12例尿道损伤患者的临床资料。结果 9例前尿道断裂行膀胱镜下尿道会师术成功,3例后尿道断裂会师失败后改开放手术治疗,术后均留置导尿管2～6周。随访6～30个月,均出现尿道狭窄,经尿道扩张后治愈。3例出现勃起功能障碍,其中2例经膀胱镜手术者半年后好转。结论膀胱镜下尿道会师术是急诊治疗尿道损伤的有效手段,创伤小、恢复快、效果满意。     

骨盆骨折合并后尿道断裂一期手术体会（附45例报告）

目的探讨骨盆骨折合并后尿道断裂一期手术方法，提高手术成功率。方法将45例患者根据不同的外伤情况分别给予不同术中及术后处理，骨盆骨折较重者给予尿道会师 尿道断端部分吻合或周围组织缝合 术后牵引，骨盆骨折较轻者给予尿道会师 尿道断端部分吻合或周围组织缝合。结果前者愈合后尿道损伤瘢痕平均长度为0．8cm，后者后尿道损伤瘢痕平均长度0．6cm，所有患者瘢痕无明显错位、变形、狭窄及弯曲。45例患者，39例不需长期扩张尿道，占总数87％。结论根据后尿道损伤情况不同，采用不同的处理方法，可明显提高尿道会师术的成功率。     

输尿管镜下尿道会师术治疗急性尿道损伤（附36例报告）

目的探讨输尿管镜下尿道会师术治疗急性尿道损伤的效果。方法 36例急性尿道损伤患者均在输尿管镜直视下行尿道会师术。结果 36例均一次性成功完成尿道会师术,术后平均4周拔出导尿管并按时行尿道扩张。均获随访,时间6个月～2年。术后6个月行膀胱镜和尿道造影复查,见尿道断端愈合良好,34例无狭窄或轻度狭窄,排尿正常,尿流率均在19 ml/s以上,1例因尿道严重狭窄实施尿道狭窄段切除端端吻合术,1例因尿线变细尿道扩张无效后行离子电切镜内切开。1例并发性功能障碍。结论输尿管镜下尿道会师术治疗急性闭合性尿道损伤具有操作简单、疗效可靠、创伤小、并发症少、恢复快等优点,值得临床应用。     

Pericatheter urethrography and its use in post interlocking sound urethroplasty]

21 cases of posterior urethral rupture due to pelvic fracture were treated by acute interlocking sound urethroplasty since 1982. Postoperative pericatheter urethrography was carried out to observe the recover of urethral rupture. The results showed that the time for recover of ruptured urethra varied from 4 to 13 weeks. 71% of all cases required more than 8 weeks for recovery. The patients were followed up from 1 to 9 years, and 86% of them showed satisfactory results. It is believed that pericatheter urethrography not only provides an objective proof for the recovery of ruptured urethra but also can be used as a reliable basis for the removal of stenting catheter.     

Verletzungen des unteren Harntrakts und des Urogenitalsystems

Injuries of the lower urinary tract occur in patients with multiple injuries and trauma to the lower abdominal and pelvic region. Injuries of the male urethra including complete ruptures occur in 10% of pelvic fractures in males, while they are a rarity in females. Ruptures of the urinary bladder are either intra- or extraperitoneal. Ureteral injuries are relatively rare in blunt injuries and usually become manifest with infectious symptoms with a delay of days. Intraperitoneal ruptures of the urinary bladder always require urgent surgical repair while extraperitoneal ruptures can mostly be managed conservatively with catheter drainage of the bladder. In male patients with pelvic fractures any attempt of urethral catheterization which can otherwise make an urethral injury worse should be withheld until adequate urological examinations have led to the diagnosis or exclusion of urethral injury. The definitive surgical repair of a disruption of the male urethra should be undertaken with an interval of weeks to months. Long term sequelae of male urethral injury can be impotence and chronic stricture disease.     

First aid and general principles of treatment of urethral injuries accompanying pelvic fractures

Adequate first aid and operation done in due time with participation of an urologist enables the successful primary repair of urethral injuries accompanying pelvic fractures. Suprapubic cystostomy, drainage of the pre- and subvesical space towards the perineum, splinting of the urethra with an ureteral catheter and ureteral or at least paraureteral sutures done through a perineal incision are the principal requirements. Avoidance of catheterization, but eventually emptying of the bladder through a suprapubic puncture in the preoperative period and treating the urethra with greatest gentleness in time of repair should prevent additional injury to the urethra, in most cases only partially torn. Further development shall lead to giving up the theory of two-stage operations of urethral injuries.     

Pelvic fracture injuries of the female urethra

OBJECTIVE: To review pelvic fracture urethral injuries in women, generally regarded as rare and thus discussed infrequently. PATIENTS AND METHODS: Twelve patients (age range 7-51 years) with such injuries were reviewed; most had associated injuries, generally more severe than seen in males with urethral injuries. RESULTS: Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence. CONCLUSIONS: Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males.     

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.     

The nature of urethral injury in cases of pelvic fracture urethral trauma

PURPOSE: We examine the urethral injury associated with pelvic fracture that is said to be due to a shearing force through the membranous urethra which inevitably destroys the urethral sphincter mechanism. MATERIALS AND METHODS: A total of 20 asymptomatic cases were prospectively studied, including symptomatically, radiologically, endoscopically and urodynamically, 1 to 4 years after an apparently successful anastomotic repair of a pelvic fracture urethral distraction defect. RESULTS: There was evidence of urethral sphincter function, including urodynamically in 11 (55%), endoscopically in 13 (65%) and functionally in 17 (85%) patients. CONCLUSIONS: These findings, coupled with surgical observation, suggest that the urethral injury associated with pelvic fracture is avulsion of the membranous urethra from the bulbar urethra rather than a shearing through the membranous urethra, and that some degree of urethral sphincter function is preserved in a significant percentage of patients.     

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.     

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.     

Pelvic fractures and traumatic lesions of the posterior urethra

We report on the retrospective analysis of 61 traumatic lesions of the posterior urethra in a fractured pelvis. In collaboration with the orthopedic surgeons, 44 cases could be classified with regard to the nature and mechanism of the pelvic fracture. No direct relationship between the structural integrity of the dorsal ring segment and the urological pathology could be established. However, the mechanism of injury in 35/44 cases with pelvic girdle injuries and urethral pathology appears to be a predominantly lateral compression force. Ten of the 44 patients received a surgical stabilization of the fracture and open splinting of the urethra at the same time. An infection in the area of surgery developed in only one of these patients; however, this cleared up completely under antibiotic therapy and closed suction irrigation. The primarily conservative treatment of urethral lesions (27/61) is compared with primary open splinting or reanastomosis (34/61), which we prefer, with regard to the number of reoperations and late results. The joint conclusion of urologists and orthopedic surgeons concerns a primary simultaneous surgical treatment both of the urethral lesion and the pelvic fracture.