Spectrum of management options for pediatric pelvic fracture urethral injury and outcome analysis: 12-year tertiary center experience

Abstract

IntroductionPediatric pelvic fracture–associated urethral injuries (PFUIs) are relatively rare injuries that occur in secondary to high impact pelvic trauma. There is no consensus yet on the optimal management approach. ObjectivesIn this study, the authors reviewed their experience of pediatric PFUIs and discussed the current spectrum of potential management options. Study designThe authors retrospectively evaluated a cohort of 33 children (≤14 years) treated for PFUI between January 2005 and December 2017. ResultsThe mean age of presentation was 11.2 ± 2.1 years (range 6–14). All the subjects were male. Average stricture length was 2.5 + 1.4 cm. Transperineal anastomotic repair (TPAR) was done in 27 patients; Mitrofanoff procedure was done in three patients; Badenoch's procedure, preputial flap, and transpubic urethroplasty (TPU) was done in 1 patient each. Overall success rate for TPAR was 85%. Minor complications (Clavien grade I and II) were seen in eight cases (24.2%). Average hospital stay was 11.3 days (range 6–15). The mean follow-up duration was 13.8 months (range 9–18). DiscussionAs not many large overview studies were known, this retrospective study is small step for developing a protocol for patients with a pediatric PFUI that needs treatment. The goal of surgery in pediatric PFUI–associated posterior urethral strictures is to achieve a tension-free bulboprostatic anastomosis after excision of the distraction segment. Transperineal anastomotic repair is the best and most commonly performed surgery for pediatric PFUI with 85–98% success rates. The success rates for TPAR may be lower in children because of smaller pelvic cavity, small caliber urethra, and poorly formed elastic spongiosa. Hence, a TPAR should be attempted in every case of posterior urethral stricture post-PFUI. If a tension-free anastomosis is not possible, then procedures depending on local stricture characteristics such as TPU may be required. ConclusionMost pediatric posterior urethral strictures post-PFUI (≤2 cm) can be managed by delayed TPAR with reasonable success rates. Few selected patients may require procedures such as TPU based on local stricture characteristics.TableFactors affecting choice of surgery and outcomeTableSurgery groupNo.Previous interventionDefect siteMean defect length (cm)SuccessFailureTPAR274BMU-25BU-022234Badenoch procedure11BMU-01410Mitrofanoff30BMU extending upto BN-03630Preputial flap urethroplasty11BMU-01401TPU11BMU + Long BU segment-01510TPAR, transperineal anastomotic repair; TPU, transpubic urethroplasty; BMU, bulbomembranous; BU, bulbar urethra; BN, bladder neck.