Reconstructive surgery after perforating trauma of the lower urinary tract

Abstract

Whereas perforating injuries of the lower urinary tract with low-velocity missiles usually heal without sequelae, high-velocity missiles always cause extensive tissue sloughing and subsequent scar formation, which require difficult reconstructive surgery. As associated injuries of neighboring organs are the rule, an individual multidisciplinary approach is required. In 26 patients treated, urorectal fistulae had to be closed in 43% and the urethra was reconstructed in 62%; 37% required major orthopedic interventions. Rectourethral fistulae are best managed by the Mason transrectal technique. Shorter strictures of the urethra can be bridged by scar excision and end-to-end anastomosis and this was successfully performed to the bladder neck in 3 patients. Mine explosions affecting the perineum result in extensive destruction of the bulbar urethra, anus and rectum. Reconstruction must be staged into separation of urethra and rectum, repair of the anal sphincter, and urethroplasty. By covering defects with split-thickness skin meshgrafts, a shortage of skin is avoided. Impotence is managed with penile prostheses. Incontinence is usually due to associated neurogenic lesions and can in general be treated conservatively. In this series, all patients were freed of urostomies or colostomies and full rehabilitation was achieved in all with the exception of a tetraplegic patient. As documented by a mean of 2.8 operations and 37 days of hospitalization per patient, patience and time are essential prerequisites for success.