Pelvic Fracture-associated Urethral Injuries Research Articles

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

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.

MP55-11 TEMPORAL TRENDS IN THE INCIDENCE OF PELVIC FRACTURE ASSOCIATED URETHRAL INJURIES IN UNITED STATES

INTRODUCTION AND OBJECTIVES:Pelvic fracture associated urethral injuries (PFUIs) can cause significant patient morbidity. The management of these patients is complex and can result in lifelong cons...

Outcome of patients with failed pelvic fracture-associated urethral injury repair: A single centre 10-year experience.

The management of recurrent posterior urethral strictures developing after pelvic fracture urethral injury (PFUI) is a challenging task. Despite availability of many surgical approaches, there is no consensus regarding the optimal approach. The objective of this study was to present our 10-year experience in the management of recurrent urethral strictures due to PFUI. We did a retrospective single-institution review of patients who underwent surgical management for recurrent posterior urethral strictures from January 2006 to December 2016 using descriptive statistics. We included only those patients with PFUI who underwent some definitive surgical procedure for their previous failed repair(s). The final analysis included data of 50 male patients (10 adolescents and 40 adults). Mean age of the patients was 29.92±10.62 years. The average length of stricture was 3.02±1.47 cm. Progressive perineal urethroplasty (PPU) was done in 40 cases. Two patients with concomitant rectourethral fistula/false passage underwent transpubic urethroplasty (TPU). Three patients with complete bulbar necrosis were managed with single stage/staged preputial tube reconstruction. One patient underwent microsurgical urethroplasty using radial free forearm flap while in two patients each Mitrofanoff appendicovesicostomy and perineal urethrostomy was done. Majority of complications were minor (Clavien Grade 1 and 2). Overall success rate of PPU was 75%. Mean follow-up period was 29.46±10.68 months (range: 13-60 months). Most cases of recurrent posterior urethral strictures of <3 cm in length can be operated by PPU with reasonable success rates. Complex and long-segment (higher than 3 cm) strictures require use of ancillary procedures like TPU, substitution urethroplasty and Mitrofanoff appendicovescostomy.

Controversies in the management of pelvic fracture urethral distraction defects.

Pelvic fracture associated urethral injury (PFUI) is a sequel of blunt pelvic trauma. The published rate of urethral injury varies from 5-25% in different series. Management includes options from primary realignment to delayed anastomotic urethroplasty. Anastomotic urethroplasty include an elaborated progressive perineal approach and combined transpubic approach. Though the treatment and approach is well accepted across the globe, controversies do exist. Through this section we would debate the literature regarding some controversial issues in management of PFUI. The aim of this article was to evaluate and elucidate upon the controversies that surround the PFUI repair in this era.The following controversial and pertinent issues with respect to the repair of such injuries were reviewed: Primary realignment versus delayed repair of PFUI, Necessity of inferior pubectomy, Predictability of inferior wedge pubectomy, Spatulation of distal bulbar and proximal urethral ends, Nomenclature of bulbar urethra. This study and evaluation comes from a tertiary high-volume center of reconstructive urology. Apart from our own center's experience the literature was reviewed for evidence synthesis and framing an opinion. Each of the above principles and surgical steps regarding management of pelvic fracture urethral injury was dealt with sequentially and evidence based literature reviewed. Only data from high volume urethroplasty centers and peer reviewed articles which made significant contribution were considered. The data was analyzed and conclusion drawn. On evidence collection there was sparse and scattered evidence in favour of early realignment even after technical advancement. Delayed anastomotic urethroplasty with progressive perineal approach is recommended. Inferior wedge pubectomy cannot be predicted based upon current conventional imaging.The injury and urethral distraction has a wide spectrum and with the fallibility of imaging, inferior pubectomy is a necessary steps under relevant settings to gain access to the posterior urethra. There are multitude of ways to spatulate urethra at either end although literature does not provide a superior way. Spatulation of distal urethra dorsally and leaving the proximal sphincter active urethra unspatulated is be the best scientifically. There is a need to reclassify the bulbar urethra to the penoscrotal junction to avoid under mobilization of bulbar urethra during the repair. There is no conclusive article addressing the controversial issues highlighted in this article. Adequate mobilization of bulbar urethra should be done till penoscrotal junction. Inferior pubectomy as a technique cannot be predicted and its utility cannot be underestimated. The spatulation of urethra can be done in multiple ways. Current anatomical definition of bulbar urethra is erroneous to imply urethra only in the bulb but with respect to surgery it should be extended till the penoscrotal junction.

Management of childhood pelvic fracture-associated urethral injury

Surgical treatment of pelvic fracture-associated urethral injury(PFUI) continues to be a difficult problem to be solved in urology.Children with an immature prostate and puboprostatic ligament may suffer from posterior urethral disruptions in a manner different from adults.Considering these distinctions, the management of pediatric PFUI presents a challenge for urologist as no consensus or algorithm has been proposed or accepted.Now, through analyzing the pathogenesis, presentation, diagnosis and treatment of PFUI, give the principle of the management.The choice of immediate repair or delayed repair should be decided according to the particular situation.Immediate Ⅰ stage anastomosis of urethra for PFUI is recommended when the patient′s condition is stable, serious complications are treated, and the surgeon is experienced.If the patient′s condition is unstable or no experienced urologist is available, a suprapubic catheter should be placed for bladder decompression and try to get a good condition for delayed urethroplasty. Key words: Child; Urethra; Injury; Treatment

Management of pelvic fracture-associated urethral injuries: A survey of Canadian urologists.

The management of pelvic fracture-associated urethral injuries (PFUI) is not standardized and optimal management is controversial. We surveyed Canadian urologists about their experiences and opinions regarding optimal management of PFUI. Canadian urologists were surveyed via an anonymous, bilingual, web-based, 12-item questionnaire. A total of 735 Canadian urologists were invited to participate via email distributed by the Canadian Urological Association. Of the 146 urologists who participated (19.9% response rate), the majority practice at a trauma centre (53.2%), but manage only 1-5 PFUI/year (71.5%). Most participants (82.6%) favour primary realignment compared to suprapubic (SP) tube with delayed repair (15.3%) and immediate reconstruction (2.1%). Compared to SP diversion and delayed repair, the majority of participants believe primary realignment is associated with equivocal incontinence (61.2%) and erectile dysfunction rates (75.8%), but has lower stricture rates (73.0%). Among respondents who perform primary realignment, 45.4% concurrently place a SP tube, while 54.6% do not. While 91% believe SP tubes do not increase the risk of pelvic hardware infections, 31.6% report that orthopedic surgeons alter their management of pelvic fractures in the presence of a SP tube. Most Canadian urologist respondents - even those practicing at trauma centres - manage very few PFUIs/year. There is reasonable consensus among respondents that primary realignment is favourable to delayed or immediate reconstruction, but discordance on whether or not to place concurrent SP tubes. The urological and orthopedic consequences of SP tubes in the management of traumatic urological injuries warrant further investigation.

Surgical repair of the iatrogenic falsepassage in the treatment of trauma-induced posterior urethral injuries

Pelvic fracture associated urethral injury (PFAUI) is a rare and challenging sequel of blunt pelvic trauma. Treatment of iatrogenic false urethral passage (FUP) remains as a challenge for urologists. In this case report we reviewed the iatrogenic FUP caused by wrong procedures performed in the treatment of a patient with PFAUI and the treatment of posterior urethral stricture with transperineal bulbo-prostatic anatomic urethroplasty in the management of FUP. A 37-year-old male patient with PFAUI had undergone a laparotomy procedure for pelvic bone fracture, complete urethral rupture, and bladder perforation 8 years ago. After stricture formation, patient had undergone procedures that caused FUP. Following operations, he had a low urinary flow rate, and incontinence and urgency even with small amounts of urine. FUP was diagnosed by voiding cystourethrography and retrograde urethrography. FUP was fixed with open urethroplasty with the guidance of flexible antegrade urethtoscopy. False passage should always be taken into account in the differential diagnosis of patients with persistent symptoms that underwent PFAUI therapy. In addition, we believe that in the evaluation of patients with PFAUI suspected for having a false passage, bladder neck and urethra should be assessed by combining routine voiding cystourethrography and retrograde urethrography with preoperative flexible cystoscopy via suprapubic route.

Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair

Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair

Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair

No AccessJournal of UrologyUrological Survey: Trauma, and Genital and Urethral Reconstruction1 Apr 2005Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair Allen F. MoreyM.D. Allen F. MoreyAllen F. Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)61051-8AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Pelvic Fracture-Associated Urethral Injuries in Girls: Experience With Primary Repair." The Journal of Urology, 173(4), pp. 1211–1212 References 1 : Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management. J Urol2000; 163: 282. Link, Google Scholar 2 : Pelvic fracture urethral injuries in girls. J Urol2001; 165: 1660. Abstract, Google Scholar © 2005 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 173Issue 4April 2005Page: 1211-1212 Advertisement Copyright & Permissions© 2005 by American Urological Association, Inc.MetricsAuthor Information Allen F. Morey More articles by this author Expand All Advertisement Loading ...