Management Of Posterior Urethral Injuries Research Articles

Management of Pelvic Fracture Urethral Injury in Pediatric Patients

Purpose: Pediatric urethral surgery represents a significant surgical challenge due to smaller pelvis, decreased caliber and increased tissue fragility. This study aims to find the outcome and complications of perineal end to end anastomotic urethroplasty in the management of posterior urethral injury resulting from pelvic fracture. Methods: We performed 47 perineal bulbo-prostatic anastomotic urethroplasty for PFUIs from January, 2013 to January 2020. Mean age was 13 years with majority between 10 to 18 years (>85%). All were male patients. Two patients had history of failed anastomotic urethroplasty. Patients were selected as per selection criteria and were prepared for operation after adequate counseling. After surgical intervention patients were discharged with a supra-pubic catheter (SPC) and per urethral catheter in situ. On 22nd POD urethral catheter was removed and SPC on the next day if patient can void normally. 1st and 2nd follow up done on of 3rd and 6th month respectively following surgery. If patient voided well and Qmax>15ml/ sec; repair was defined as successful. Results: Success rate of anastomotic urethroplasty for PFUI was 91.47%. Total 4 procedures were failed including 1 urethro-cutaneous fistula and needed re-do anastomosis. We could not evaluate erectile dysfunction (ED) as many patients were unable to give appropriate information. Two patient developed incontinence which improved in subsequent follow-up. Conclusions: Anastomotic urethroplasty remains the gold standard in the management of PFUI. Operative series of pediatric urethral reconstruction usually involve small numbers. Experiences of anastomotic urethoplasty in large volume adult series reflects the higher outcome in pediatic patients. Bangladesh J. Urol. 2021; 24(1): 77-81

Comparative Study Between Outcomes of Early Primary Endoscopic Realignment Versus Suprapubic Cystostomy With Delayed Reconstruction in the Management of Posterior Urethral Injury

Objectives: To compare the outcomes of early primary endoscopic realignment and suprapubic cystostomy with the outcomes of delayed reconstruction in the management of posterior urethral injury. Methods: This is a quasi-experimental prospective study Conducted in the Urology department Dhaka medical college and hospital from January 2009 to December 2010. Atotal of 60 consecutive patients were selected for this study and inclusion criteria, male patients and age 18years and above. Posterior urethral injury resulting in distraction defect and urethral injury with pelvic fracture. Group-A, 28 patients underwent early primary endoscopic realignment after initial suprapubic urinary diversion and Group-B, 32 patients underwent primary suprapubic urinary diversion and delayed urethral reconstruction after 3 months of injury. Results: After procedure 21(75%) out of 28 patients in Group-A developed stricture 12(42.9%) had simple and short segment stricture and 7(32.1%) had simple and long segment stricture, while in Group-B 12(37.5%) patients developed simple and short segment stricture. All of the patients in Group-A had minimum blood loss during operation. While, majority (81.3%) of patients in Group-B had a history of maximum blood loss. None of the patients in Group-A developed incontinence throughout the observations period (from removal of catheter to 9 months), while 15.6% of the patients in Group-B had incontinence at removal of catheter after anastomotic urethroplasty and at 3 month. The incontinence further increased to 18.8% at 6 and 9 months. Complaints of impotence were significantly less in Group-A than that in Group-B throughout the period of observation (14.3% vs. 37.5%, p = 0.042; 14.3% vs. 37.5%, p = 0.042 and 14.3% vs. 37.5%, p = 0.042). At removal of urethral catheter, stricture formation was observed and statistically there was no difference in Group-A and Group-B (14.3% vs. 21.9% in Group-B, p = 0.448). At month 3, stricture formation was significantly higher in Group-A than that in Group-B (42.9% vs. 15.6%, p = 0.020). At month 6, about 18% of patients in Group-A had stricture, but none of patients in Group-B was found so (p = 0.018). Conclusions: Early primary endoscopic realignment of traumatic posterior urethral disruption is a simple, less traumatic, safe, and rapid technique. It provides a low morbidity and less postoperative complications. Though recurrent stricture formation is higher but the strictures are simple and short and amenable to be corrected endoscopically. It may be considered as initial therapy in the management of posterior urethral distraction defect over suprapubic cystostomy with delayed reconstruction. Bangladesh Journal of Urology, Vol. 17, No. 1, Jan 2014 p.29-35

Management of Pelvic Fracture Urethral Injury- 147 Cases

Background: Dhaka Medical College Hospital is the highest referral center for PFUI. As anstomotic urethroplasty is a challenging surgery and most of the surgeons refer these type of injuries to our center, we performed this study to evaluate the outcome of our cases.
 Objective: This study aims to find the outcome and complications of perineal end to end anastomotic urethroplasty in the management of posterior urethral injury resulting from pelvic fracture.
 Materials and Methods: We performed 147 perineal bulbo-prostatic anastomotic urethroplasty for PFUIs from January, 2013 to May, 2019. Mean age was 37 years with majority between 21 to 50 years (>85%). Nine patients had history of failed anastomotic urethroplasty. After surgical intervention patients were discharged with a supra-pubic catheter (SPC) and per urethral catheter in situ. On 22nd POD urethral catheter was removed and SPC on the next day if patient can void normally. 1st and 2nd follow up done on of 3rd and 6th month respectively following surgery. If patient voided well and Qmax>15ml/ sec; repair was defined as successful.
 Results: Success rate of anastomotic urethroplasty for PFUI was 93.87%. Total 9 procedures were failed including 2 urethro-cutaneous fistula and needed re-do anastomosis. Erectile dysfunction (ED) was present in 18 patients before operation and after surgery 12 more patients developed ED and total number was 30 during first follow up, which reduced to 24 during second follow-up. Two patient developed incontinence which improved in subsequent follow-up.
 Conclusion: Anastomotic urethroplasty remains the gold standard in the management of PFUI. Erectile dysfunction is the main issue to be concerned and need special attention.
 KYAMC Journal Vol. 10, No.-4, January 2020, Page 179-183

Outcomes of Early Primary Endoscopic Realignment and Delayed Reconstruction in the Management of Posterior Urethral Injury in Male

Background: Posterior urethral injury usually occurs in male patients with pelvic fractures. Posterior urethral injuries are associated with considerable morbidity including urinary incontinence, erectile dysfunction and urethral stricture. Objective: To compare the outcomes between early primary endoscopic realignment and delayed reconstruction in the management of male patients of posterior urethral injury. Methodology: This prospective study was conducted in the department of urology and department of casualty, Dhaka Medical College Hospital, Dhaka, Bangladesh from July 2015 to June 2017 among 50 male patients with posterior urethral injury. Fifty patients were randomly allocated into two groups; the group A consisted of 24 patients underwent early primary endoscopic realignment within 10 days after posterior urethral injury and the group B consisted of 26 patients underwent delayed reconstruction in form of anastomotic urethroplasty after 3 months. All patients were followed up at 3rd, 6th and 9th month after the procedure. Outcome variables were post-operative urethral stricture, urinary incontinence and erectile dysfunction. Data were analyzed and compared by statistical tests. Results: The mean (±SD) age of the study patients was almost similar between the groups (28.8 ± 8.4 vs. 27.4 ± 7.2 years, p = 0.486). In group A, 83.33% patients developed postoperative urethral stricture, none of them developed urinary incontinence and 20.83% developed erectile dysfunction; On the other hand, in group B, these rates were 38.46%, 23.07% and 38.46% respectively. Postoperative urethral stricture formation was significantly higher in Group A (p = 0.0012) but urinary incontinence and erectile dysfunction rates were significantly higher in Group B (p = 0.018 and p = 0.042 respectively). Conclusion: Early primary endoscopic realignment is better than delayed reconstruction in the management of male patients with posterior urethral injury. It provides less postoperative complications like urinary incontinence and erectile dysfunction, though postoperative urethral stricture formation is higher but amenable to be corrected endoscopically.

FRII-15 ‘EVOLUTION OF INNOVATION’: HISTORICAL PERSPECTIVES ON THE MANAGEMENT OF URETHRAL STRICTURE DISEASE

You have accessJournal of UrologyHistory of Urology: History Forum1 Apr 2017FRII-15 ‘EVOLUTION OF INNOVATION’: HISTORICAL PERSPECTIVES ON THE MANAGEMENT OF URETHRAL STRICTURE DISEASE Devang Desai, Pankaj Joshi, Hazem Orabi, Sandesh Surana, and Sanjay Kulkarni Devang DesaiDevang Desai More articles by this author , Pankaj JoshiPankaj Joshi More articles by this author , Hazem OrabiHazem Orabi More articles by this author , Sandesh SuranaSandesh Surana More articles by this author , and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2464AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral stricture is a prevalent and challenging urological condition. Management has evolved over the last century, specifically with the advent of oral mucosal grafts for urethroplasty. We review the history of urethral stricture treatment. METHODS A literature search of medical texts, journal articles and historical texts was performed pertaining to history of urethral strictures. RESULTS Urethra originates from the Greek word ourein ‘urinate'. Urethral stricture was first depicted in Hindoo scriptures (6th century BC). Susruta described in Ayurveda the treatment by means of graduated dilators of metal or wood. Ambrose Pare in his depictions of urethrotomy mentions ‘A silver weir, sharp at the upper end, is to be passed in as far as the obstruction, then by oft thrusting it in and out, it may wear and make plain the resisting caruncles'. In 1894, Sapezho first used oral mucosa in urethroplasty. Humby revived the use in 1941. This landmark discovery revolutionized urethral surgery. Several modern innovations have since been described: staged repair (Johanson 1953), dorsal onlay (Barbagli 1996), ventral onlay (Morey, McAnnich 1996), dorsal inlay penile (Hayes and Malone1999), dorsal inlay bulbar (Asopa 2001), panurethral stricture management (Kulkarni 2000), nerve sparing and bulbospongiosus sparing bulbar reconstruction (Barbagli 2008), Enterourethroplasty (Mundy 2010), Non-transecting anastomotic urethroplasty (Mundy 2015). Over this period the perineal incision has evolved from a lamda to a midline incision. Current advances include liquid mucosal grafts; tissue engineering and stem cells, which would halt the process of fibrosis and prevent stricture formation. Posterior urethral injuries have traditionally been managed by anastomotic urethroplasty. Pierce 1962 performed total abdominal pubectomy. Paine & Coombs 1968 performed anastomotic urethroplasty after excision of scar by abdominal approach. 1973 Waterhouse developed abdominoperineal approach. 1976 Turner-Warwick used omental wrap for transpubic primary anastomosis. Webster & Goldwasser 1986 performed perineal anastomotic urethroplasty using inferior pubectomy. Kulkarni 2010 described etiology and management of posterior urethral injuries. Currently a progressive stepwise approach has been used for managing posterior urethral injuries. CONCLUSIONS Management of urethral stricture patients has evolved over the last century. The use of oral mucosal grafts is still one the greatest advancements. As we continue to better understand urethral strictures, we hope to make even greater strides over the next decade. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1072 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Devang Desai More articles by this author Pankaj Joshi More articles by this author Hazem Orabi More articles by this author Sandesh Surana More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A modified open surgical technique for the management of posterior urethral injuries

A modified open surgical technique for the management of posterior urethral injuries

Primary Realignment vs Suprapubic Cystostomy for the Management of Pelvic Fracture–associated Urethral Injuries: A Systematic Review and Meta-analysis

To compare primary urethral realignment (PR) with suprapubic cystostomy (SPC) for the management of pelvic fracture-associated posterior urethral injuries with regards to rates of stricture, erectile dysfunction, and urinary incontinence. Two electronic databases (MEDLINE and EMBASE) were searched with the assistance of a librarian. Title, abstract, and full text screening was carried out by 2 independent reviewers, with discrepancies resolved by consensus. Narrative reviews, surveys, and historical articles were excluded. Only studies reporting a direct comparison of PR vs SPC for the management of posterior urethral injuries associated with blunt trauma in adults were included. Quality assessment of the included articles was performed in duplicate. Stricture incidence was evaluated for all included studies, as were erectile dysfunction and incontinence rates when reported. All outcomes were treated as dichotomous data with calculation of odds ratio and were pooled using a random effects model with Review Manager 5.1. Our comprehensive search yielded 161 unique articles. Nine articles were included in the final meta-analysis. Stricture rate was significantly lower in the PR group (odds ratio [OR] = 0.12, 95% confidence interval [CI] 0.04-0.41, P <.001). There was no significant difference between the 2 interventions with regards to erectile dysfunction (OR = 1.19, 95% CI 0.73-1.92, P = .49) or incontinence (OR = 0.75, 95% CI 0.38-1.48, P = .41). PR appears to reduce the incidence of stricture formation after pelvic fracture-associated posterior urethral injuries as compared with SPC.

Primary urethral realignment should be the preferred option for the initial management of posterior urethral injuries

The initial management of posterior urethral injuries is controversial. Options of management include immediate surgical realignment, early realignment using minimally invasive techniques or simple suprapubic catheter (SPC) placement followed by delayed urethroplasty. The latter method has been preferred by most urologists but the last couple of decades have seen increasing reports of early urethral realignment which have provided better if not similar results as SPC placement. In this article a detailed analysis of studies involving primary realignment has been presented to reinforce the argument in favor of this approach.

Symphysiotomy: A Viable Approach for Delayed Management of Posterior Urethral Injuries in Children

The outcome of symphysiotomy for accessing pelvic fracture related, obliterative urethral strictures is described. In 7 boys and 3 girls 4 to 13 years old (mean age 6) surgical correction of a pelvic fracture related, obliterative urethral stricture was achieved through symphysiotomy. The stricture involved a prostatomembranous location in boys and complete vesicourethral distraction in girls. Patients were followed an average of 2.5 years (range 6 months to 4 years) by physical examination, urethrography and endoscopy. The stricture was successfully corrected in all patients and all void with a normal flow. All boys are continent but 2 of the 3 girls had early incontinence, which resolved with time in 1. In 2 of the 10 cases a previous attempt at perineal repair had already failed. No patient required urethrotomy or dilation and none had significant hemorrhage, fistulization, bladder hernia, chronic pain or secondary gait disturbance. Symphysiotomy is hereby revisited as a simple and effective approach for repairing traumatic posterior urethral injuries in the pediatric population. It can be performed instead of transpubic urethroplasty to manage long or otherwise complicated strictures.

Symphysiotomy: A Viable Approach for Delayed Management of Posterior Urethral Injuries in Children

Symphysiotomy: A Viable Approach for Delayed Management of Posterior Urethral Injuries in Children

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.

Experience With Management of Posterior Urethral Injury Associated With Pelvic Fracture

Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography or voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries.

Incidence of Stricture Following Primary Realignment of the Disrupted Proximal Urethra

No AccessJournal of Urology1 Feb 1972Incidence of Stricture Following Primary Realignment of the Disrupted Proximal Urethra Robert P. Myers and James H. Deweerd Robert P. MyersRobert P. Myers More articles by this author and James H. DeweerdJames H. Deweerd More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)60998-4AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1972 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byPodesta M, Medel R, Castera R and Ruarte A (2018) Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic AlternativesJournal of Urology, VOL. 157, NO. 4, (1444-1448), Online publication date: 1-Apr-1997.Zincke H and Furlow W (2018) Long-Term Results with Transpubic UrethroplastyJournal of Urology, VOL. 133, NO. 4, (605-606), Online publication date: 1-Apr-1985.Patterson D, Barrett D, Myers R, DeWeerd J, Hall B and Benson R (2018) Primary Realignment of Posterior Urethral InjuriesJournal of Urology, VOL. 129, NO. 3, (513-515), Online publication date: 1-Mar-1983.Pierce J (2018) Editorial CommentsJournal of Urology, VOL. 129, NO. 3, (515-515), Online publication date: 1-Mar-1983.Peters P (2018) Editorial CommentsJournal of Urology, VOL. 129, NO. 3, (515-516), Online publication date: 1-Mar-1983.Harshman M, Cromie W, Wein A and Duckett J (2018) Urethral Stricture Disease in ChildrenJournal of Urology, VOL. 126, NO. 5, (650-654), Online publication date: 1-Nov-1981.Kramer S, Furlow W, Barrett D and Kelalis P (2018) Transpubic Urethroplasty in ChildrenJournal of Urology, VOL. 126, NO. 6, (767-769), Online publication date: 1-Dec-1981.Colapinto V and McCallum R (2018) Injury to the Male Posterior Urethra in Fractured Pelvis: A New ClassificationJournal of Urology, VOL. 118, NO. 4, (575-580), Online publication date: 1-Oct-1977.Malek R, O’Dea M and Kelalis P (2018) Management of Ruptured Posterior Urethra in ChildhoodJournal of Urology, VOL. 117, NO. 1, (105-109), Online publication date: 1-Jan-1977.Coffield K and Weems W (2018) Experience With Management of Posterior Urethral Injury Associated With Pelvic FractureJournal of Urology, VOL. 117, NO. 6, (722-724), Online publication date: 1-Jun-1977.Waterhouse K, Abrahams J, Caponegro P, Hackett R, Patil U and Peng B (2018) The Transpubic Repair of Membranous Urethral StricturesJournal of Urology, VOL. 111, NO. 2, (188-190), Online publication date: 1-Feb-1974. Volume 107Issue 2February 1972Page: 265-268 Advertisement Copyright & Permissions© 1972 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Robert P. Myers More articles by this author James H. Deweerd More articles by this author Expand All Advertisement PDF downloadLoading ...