Pelvic Fracture Urethral Distraction Defects Research Articles

Editorial Comment

In 1950, Badenoch 1 Badenoch A.W. A pull-through operation for impassable traumatic stricture of the urethra. Br J Urol. 1950; 22: 404-409 Crossref PubMed Scopus (77) Google Scholar described his pull-through operation for “impassable traumatic stricture of the urethra.” The Badenoch operation is not an operation that I have any experience with, nor have I ever felt the need to become facile with that technique. However, with that said, I am constantly amazed at the number of places that I have been, where surgeons do practice the Badenoch procedure and find it to be most useful for the reconstruction of pelvic fracture urethral distraction defects. The authors describe a series of 76 patients. They discuss excellent results and have good follow-up criteria. Using the operation for patients with complex conditions, as well as those with failed urethroplasty and those with failed urethrotomy, they report an overall success rate of 89%. Although this is slightly less than that from contemporary series using primary anastomotic techniques, it is not far below those success rates. They have a very acceptable rate of erectile dysfunction after urethral reconstruction, and they do not report any patients who complained of penile shortening or new onset of curvature. Although I have not seen the need to learn how to do this operation, it certainly would appear that it could represent an alternative method of dealing with pelvic fracture urethral injury. Urethral Pull-through Operation for the Management of Pelvic Fracture Urethral Distraction DefectsUrologyVol. 78Issue 4PreviewTo present our institutional experience in the management of pelvic fracture urethral distraction defects with urethral pull-through operation. Full-Text PDF ReplyUrologyVol. 78Issue 4PreviewThe management of pelvic fracture urethral distraction defect (PFUDD) is a difficult problem in urology. At present, it is widely accepted that the optimal procedure for the management of PFUDD is urethral anastomosis after excision of the intervening scarred segment through the perineum.1 A tension-free anastomosis is essential for a successful repair; however, in some cases, it is difficult to distinctly expose the proximal urethral stump because of its deep location after the excision of the stricture segment. Full-Text PDF

Transpubic posterior urethroplasty via perineal approach in children: A new technique

ObjectiveTo evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children. MethodsOf 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median = 8.5 years). The median distraction defect length was 4.8 cm (range 3.7–6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter. ResultsPatients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9–3.2 h) with a mean blood loss of 200 ml (range 50–640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis. ConclusionsTranspubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes.

Urethral Pull-through Operation for the Management of Pelvic Fracture Urethral Distraction Defects

To present our institutional experience in the management of pelvic fracture urethral distraction defects with urethral pull-through operation. Seventy-six patients (average age 34.5 years) with posterior urethral strictures caused by pelvic fracture urethral distraction defects underwent urethral pull-through operation at our department from July 1995 to September 2009. The estimated urethral stricture length was 2.0-3.5 cm (mean 2.5). Of these patients, 31 (41%) had undergone failed urethroplasty or urethrotomy after the initial management, and 5 (7%) had urethrorectal fistula. Urethral pull-through operation was performed 4-7 months (mean 4.9) after initial treatment or failed urethral reconstruction. The clinical outcome was considered a failure when any postoperative intervention was needed. Follow-up was 14-74 months (mean 42.5). The overall success rate was 89% (68/76). All treatment failures occurred within the first 6 months postoperatively. Failed repairs were successfully managed with internal urethrotomy in 1 patient, by urethral dilation in 6, and by another urethroplasty in 1. All patients were urinary-continent postoperatively. Of the potent patients, 2 (5%) became impotent after urethroplasty. There was no chordee, penile shortening, or urethral fistula recurrence. Urethral pull-through operation might be a less demanding and less time-consuming procedure. It does not increase the rate of impotence or incontinence and, with a high success rate, might serve as an alternative method for the management of pelvic fracture urethral distraction defects.

Pelvic fracture urethral distraction defects in children managed by anterior sagittal trans anorectal approach: A facilitating and safe acess

Purpose Trauma injuries of the posterior urethra resulting from pelvic fracture in children tend to be complete ruptures, with upper dislocation of the prostate. This paper aims to show our experience in using an anterior sagittal transanorectal approach (ASTRA) in the treatment of such injuries. Materials and methods The medical records of 11 patients with pelvic fracture urethral distraction defects who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Ages ranged from 1 year and 6 months to 23 years (mean age 11 years). Of the 11 patients, 8 had previously undergone failed urethroplasties. Results In 10 patients it was possible to perform tension free urethroplasty. One patient required inferior pubectomy and separation of the corpora cavernosa. Patients’ follow-up time varied from 10 months to 10 years and 9 months (mean 41 months). One patient had a urethral fistula and evolved with a urethral diverticulum successfully managed by diverticulectomy. One patient presented a urethral stenosis managed by urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent. Two patients had no urethral flow. One is undergoing bladder catheterization through the Mitrofanoff principle and the other one through the urethra. No patient presented fecal incontinence or rectourethral fistula. Conclusion This access, which is increasingly being used to approach posterior urethral diseases, has proved to be safe and effective in the treatment of pelvic fracture urethral distraction defects.

Current concepts in the management of pelvic fracture urethral distraction defects

Objectives:Pelvic fracture urethral distraction defect (PFUDD) may be associated with disabling complications, such as recurrent stricture, urinary incontinence, and erectile dysfunction. In this article we review the current concepts in the evaluation and surgical management of PFUDD, including redo urethroplasty.Materials and Methods:A PubMed™ search was performed using the keywords “pelvic fracture urethral distraction defect, anastomotic urethroplasty, pelvic fracture urethral stricture, pelvic fracture urethral injuries, and redo-urethroplasty.” The search was limited to papers published from 1980 to March 2010 with special focus on those published in the last 15 years. The relevant articles were reviewed with regard to etiology, role of imaging, and the techniques of urethroplasty.Results:Pelvic fracture due to accidents was the most common etiology of PFUDD that usually involved the membranous urethra. Modern cross-sectional imaging, such as sonourethrography and magnetic resonance imaging help assess stricture pathology better, but their precise role in PFUDD management remains undefined. Surgical treatment with perineal anastomotic urethroplasty yields a success rate of more than 90% in most studies. The most important complication of surgical reconstruction is restenosis, occurring in less than 10% cases, most of which can be corrected by a redo anastomotic urethroplasty. The most common complication associated with this condition is erectile dysfunction. Urinary incontinence is a much rarer complication of this surgery in the present day.Conclusions:Anastomotic urethroplasty remains the cornerstone in the management of PFUDD, even in previously failed repairs. Newer innovations are needed to address the problem of erectile dysfunction associated with this condition.

Management of the stricture of fossa navicularis and pendulous urethral strictures

Objective:Management of distal anterior urethral stricture is a common problem faced by practicing urologists. Literature on urethral stricture mainly pertains to bulbar urethral stricture and pelvic fracture urethral distraction defect. The present article aims to review the management of the strictures of fossa navicularis and pendulous urethra.Materials and Methods:The literature in English language was searched from the National Library of Medicine database, using the appropriate key words for the period 1985-2010. Out of 475 articles, 115 were selected for the review based on their relevance to the topic.Results:Etiology of stricture is shifting from infective to inflammatory and iatrogenic causes. Stricture of fossa navicularis is most often caused by lichen sclerosus et atrophicus and instrumentation. Direct visual internal urethrotomy is limited to selected cases in the management of pendulous urethral stricture. With experience and identification of various prognostic factors, conservative management by dilatation and internal urethrotomy is being replaced by various reconstructive procedures, using skin flaps and grafts with high success rates. Single-stage urethroplasty is preferred over the 2-stage procedure as the latter disfigures the penis and poses sexual problems temporarily.Conclusions:Flaps or grafts are useful for single-stage reconstruction of fossa navicularis and pendulous urethral strictures. The buccal and lingual mucosa serves as a preferred resource material for providing the inner lining of the urethra. Off-the-shelf materials, such as acellular collagen matrix, are promising.

Prognosis of urethral strictures following pelvic fracture urethral distraction defects–A single centre study

Introduction Urethral strictures remain a reconstructive dilemma due to high incidence of recurrence and unsatisfactory outcomes. Pelvic trauma remains the foremost etiology leading to morbidity. We evaluated this “ cause-effect” relationship of pelvic trauma to stricture outcome, to replenish our understanding of contemporary urethral strictures and highlight significance of type, degree and influence of primary management of pelvic trauma on the overall prognosis of urethral strictures. Materials and method 163 male patients with urethral strictures, primary etiology being pelvic trauma, were assessed preoperatively followed by retrograde urethrogram, urethrosonogram, uroflowmetry, and then subjected to pelvic radiographs to identify presence and type of pelvic fracture, and further sub-categorize them into grades A, B and C, of TILE classification. Thereafter, 6 weeks later, these patients underwent urethroplasty. Results Of 163 patients having pelvic trauma, 80 fell under category A of TILE grading, whereas 55 were under TILE B and 28 under TILE C. Most common stricture location was membranous urethra. Success rates were 96–98% till 1 year follow up, but after two years, they declined to 93%. TILE A and B had a better post operative course as compared to TILE C. Overall complication rate was 20.25%. Conclusion The magnitude of the impact of the type of pelvic fracture and its management has remained unexplored. Our representative study enunciates that these parameters play a vital role in the overall prognosis of urethral strictures and command due importance, to bridge the rift in this “ cause-effect” relationship.

Monti’s procedure as an alternative technique in complex urethral distraction defect

Pelvic fracture urethral distraction defect is usually managed by the end to end anastomotic urethroplasty. Surgical repair of those patients with post-traumatic complex posterior urethral defects, who have undergone failed previous surgical treatments, remains one of the most challenging problems in urology. Appendix urinary diversion could be used in such cases. However, the appendix tissue is not always usable. We report our experience on management of patients with long urethral defect with history of one or more failed urethroplasties by Monti channel urinary diversion. From 2001 to 2007, we evaluated data from 8 male patients aged 28 to 76 years (mean age 42.5) in whom the Monti technique was performed. All cases had history of posterior urethral defect with one or more failed procedures for urethral reconstruction including urethroplasty. A 2 to 2.5 cm segment of ileum, which had a suitable blood supply, was cut. After the re-anastomosis of the ileum, we closed the opened ileum transversely surrounding a 14-16 Fr urethral catheter using running Vicryl sutures. The newly built tube was used as an appendix during diversion. All patients performed catheterization through the conduit without difficulty and stomal stenosis. Mild stomal incontinence occurred in one patient in the supine position who became continent after adjustment of the catheterization intervals. There was no dehiscence, necrosis or perforation of the tube. Based on our data, Monti's procedure seems to be a valuable technique in patients with very long complicated urethral defect who cannot be managed with routine urethroplastic techniques.

1227 REDO POSTERIOR URETHROPLASTY IN CHILDREN: A RETROSPECTIVE STUDY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery IV1 Apr 20101227 REDO POSTERIOR URETHROPLASTY IN CHILDREN: A RETROSPECTIVE STUDY Samir Orabi Samir OrabiSamir Orabi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.750AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Management of children with failed posterior urethroplasty is a challenge for both surgeon and parents. Objective: A retrospective evaluation of different line of management of redo posterior urethroplasty in children METHODS 19 out of 96 (19.79 %) children that subjective to posterior urethroplasty surgery for pelvic fracture urethral distraction defect(PFUDD) were suffered from failed posterior urethroplasty and were admitted to our department between January 1998 to March 2008. Age ranged between 4 -16 y with a mean of 10.7y. The surgery was done as a second in 10 out 19 (52.6 %), as third in 6 (31, 6 %) and in 3 (15.8 %) as a fourth surgery. All patients were subjective to a thorough history taken, urine culture and sensitivity, ascending urethrogram, combined cysto-urethrogram and endoscopy. To achieve a tension free anastomosis, partial pubectomy was done in 11 out of 19 (57.9%) children, total perineal pubectomy in 6 (31.6 %) and tubed penile skin flap for a long distraction defect (> 5 cm) in 2 (10.5 %). Follow up ranged from 13 months to 7 y with a mean of 35 months in the form of subjective parameters as straining, recurrent UTI, stress or total urinary incontinence and objective parameters as urine culture and sensitivity, ascending urethrogram and endoscopy if needed. RESULTS 11 out of 19 children (57.9 %) had complications with a success rate of 36.8%. Stress urinary incontinence was encountered in 6 (31.6%), 4 children response to conservative treatment in the form anticholinergic drugs and other 2 children need microplastique injection. 3 (15.8 %) had anastomotic strictures and were treated by EVU. Urethral diverticulae with stones and strictures were encountered in two patients with penile skin flap. CONCLUSIONS The best chance of success of posterior urethroplasty in children is the first surgery and it must be done by expertise in a special center. In redo surgery, the surgeon must be aware of all kinds of urethroplasty and skin substitution must be avoided. Alexandria, Egypt© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e475 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samir Orabi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Redo-urethroplasty in pelvic fracture urethral distraction defect: an audit

To predict the outcome of redo-urethroplasty after failed single or multiple open urethral procedures for pelvic fracture urethral distraction defects. From January 1997 to December 2006, 43 patients underwent redo-urethroplasty for pelvic fracture urethral distraction defect. Forty-one were referred from other centers. All had undergone open surgery along with an endoscopic procedure (one or more procedures in each patient) which included endoscopic internal urethrotomy, urethral stenting or urethral dilations. There were 43 men with mean age of 29 (range 11-52). Eleven had associated injuries: intraperitoneal bladder rupture (3), bladder neck (2), rectum (3), anal sphincter (2), combined bladder, rectum and anal sphincter (1). Trocar suprapubic cystostomy was performed in 22, rail-road procedures in 10 and open suprapubic cystostomy in 11 along with the management of associated injuries as immediate treatment. Of 43 patients, 28 had progressive perineal, and 12 had transpubic repair. Three patients had total bulbar necrosis, and they underwent prepuceal tube reconstruction (1) and staged substitution with BMG and standard scrotal inlay (2). Analysis of various factors like number of attempts at previous surgery and stricture length did not affect the outcome. A successful result was achieved in 36 (83.72%), improved and stable in five and failure in two. The overall result of redo-urethroplasty for pelvic fracture urethral distraction defect continues to be gratifying. Failures happen usually within the first 3months. Substitution urethroplasty can be reserved for those who have long distraction defect. Long-term follow-up is essential using stringent criteria to measure success.

Assessment and Management of an Open Bladder Neck at Posterior Urethroplasty

To determine the factors that may influence the risk of injury to the bladder neck in patients sustaining a pelvic fracture urethral injury and report our experience in the management of an open bladder neck at the time of delayed repair. We identified 21 patients with an open bladder neck on cystography before they underwent repair of a pelvic fracture urethral distraction defect. Of these patients, 12 were continent after urethroplasty and 9 received bladder neck reconstruction concomitant with or subsequent to urethroplasty. Bladder neck reconstruction was performed by Young-Dees-Leadbetter (5) or anterior bladder flap-tube (4) procedure. Patients with an incompetent bladder neck were usually (67%) children <or=15 years old, had been most commonly (75%) managed initially by primary realignment, and all (100%) had fracture of ipsilateral ischiopubic rami. The preoperative cystogram showed a bladder neck opening of a rectangular shape, and suprapubic cystoscopy revealed a fixedly open bladder neck. Of the 9 patients who received a bladder neck reconstruction, 7 (78%) had a successful outcome and 2 (22%) had a treatment failure. It seems that the risk of injury to the bladder neck increases in children, in ipsilateral ischiopubic rami fracture and in cases managed initially by primary realignment. At posterior urethroplasty, the presence of an incompetent bladder neck is suspected by the finding of an open bladder neck of a rectangular shape on cystography and a fixedly open bladder neck on suprapubic cystoscopy. Reconstruction of the bladder neck by Young-Dees-Leadbetter procedure probably offers the best successful results.

Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique

We compared posterior urethral strictures after pelvic fracture urethral distraction defects in India and Italy. We retrospectively analyzed the records of patients in India and Italy who underwent repair for posterior urethral stricture after pelvic fracture urethral distraction defect. We investigated etiology, emergency treatment type, the specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair, posterior urethroplasty techniques and results. Of 255 patients with a median age of 33 years 117 (45.8%) and 138 (54.2%) were evaluated in India and Italy, respectively. In India the most common causes of pelvic fracture urethral distraction defects were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents. The most common emergency treatment was suprapubic cystostomy (79.5% of cases). Of the patients 70.1% were treated in emergency fashion by a surgeon and 85.4% had complex posterior urethral strictures. The most common technique was anastomosis with inferior and total pubectomy in 56.4% and 15.3% of cases, respectively. In Italy the etiology was mainly automobile accidents (39.2%). The most common emergency treatment was endoscopic realignment (49.2% of cases). Of the patients 92.7% were treated in emergency fashion by a urologist and 68.1% had simple urethral strictures. Perineal anastomosis and laser urethrotomy were the most used techniques (38.4% and 21.1% of cases, respectively). In India 92 cases (78.6%) were successful and 25 (21.4%) failed while in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Median followup was 74 months (range 12 to 239). Differences in emergency treatment for pelvic fracture urethral distraction defects influence the choice of delayed posterior repair and results.

Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and role of ancillary maneuver: A retrospective study in 172 patients

Objective:We present our experience with transperineal bulboprostatic anastomosis procedure and compare the results with age of patients, length of urethral stricture, effect of previous treatment and need for ancillary procedures.Materials and Methods:We retrospectively reviewed the outcome of 172 patients who underwent perineal urethroplasty procedure for traumatic stricture in our institute. Simple perineal anastomosis was done in 92 patients. Perineal anastomosis and corporal separation were done in 52 patients. Perineal anastomosis with inferior pubectomy was done in 25 patients. Perineal anastomosis with rerouting was done in three patients. Age, prior treatment, length of stricture, and ancillary techniques required during reconstruction were compiled. The clinical outcome was considered as failure when any postoperative instrumentation was needed.Results:Out of 172 cases that underwent transperineal urethroplasty procedure, 157 (91.28%) were successful. Simple perineal urethroplasty procedure showed a success rate of 93.4%, perineal anastomosis with separation of corporal bodies had a success rate of 90.4%, perineal anastomosis with inferior pubectomy had a success rate of 88% and perineal anastomosis with rerouting of urethra around the corpora had a success rate of 66.7%.Conclusion:The success rate of delayed progressive perineal urethroplasty procedure for post-traumatic stricture urethra is excellent and majority of the failures occurs in prepubescent boys and in those undergoing secondary repair.

Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique

Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique

UP-3.098: Bulbar Artery Sparing During Reconstruction of Pelvic Fracture Urethral Distraction Defects (PFUDD)

Reconstruction of pelvic fracture urethral distraction defects (PFUDD) requires mobilization of the bulbar urethra to reach the prostatic apex. To achieve this, the spongiosum's bulb needs to be separated from the perineal body, with division of the bulbar arteries. The distal urethral stump then becomes a flap, with retrograde irrigation from the glans and some perforating arteries. However, in some cases, penile arterial supply is compromised by the pelvic fracture, resulting in penile arterial insufficiency. In such cases, ischemic necrotic failure of the urethral reconstruction has been reported. In this video we demonstrate a technique to preserve arterial blood supply to the bulb.

VID-05.10: Bulbar Artery Sparing During Reconstruction of Pelvic Fracture Urethral Distraction Defects (PFUDD)

Reconstruction of pelvic fracture urethral distraction defects (PFUDD) requires mobilization of the bulbar urethra to reach the prostatic apex. To achieve this, the bulb of the spongiosum needs to be separated from the perineal body, with division of the bulbar arteries. The distal urethral stump then becomes a flap, with retrograde irrigation from the glans and some perforating arteries. However in some cases, penile arterial supply is compromised by the pelvic fracture, resulting in penile arterial insufficiency.

Leaving No Stone Unturned

Leaving No Stone Unturned

Erectile function after posterior urethroplasty for pelvic fracture‐urethral distraction defect injuries

To determine the specific effect of pelvic fracture-urethral distraction defect (PFUDD) injuries on erectile function (EF) in men after pelvic fractures, and to compare EF to that found in other studies of men who sustained pelvic fractures, as currently the relationship between erectile dysfunction (ED) and PFUDD has not been elucidated using validated questionnaires. With approval from the institutional review board, patients who sustained a PFUDD injury and had a posterior urethroplasty from 1990 to 2004 were identified from a database. Patients were contacted by telephone, and those who were willing to participate were given the International Index of Erectile Function (IIEF) questionnaire. Using unpaired Student's t-tests, IIEF scores were compared to normal controls, and to results of other studies of men sustaining pelvic fractures. In all, 26 men completed the IIEF, among whom EF was compromised in 14 (54%), including eight with severe ED (31%). Orgasmic function and ejaculation was maintained. Men with a PFUDD had significantly worse EF than men in other series with pelvic fractures. Men who sustain a PFUDD are at significantly greater risk of ED than those with no urethral distraction injury. Men with PFUDD injuries represent a target population for early penile rehabilitation programmes.

Transperineal Bulboprostatic Anastomosis in Patients With Simple Traumatic Posterior Urethral Strictures: A Retrospective Study from a Referral Urethral Center

To evaluate the results of ancillary procedures for posterior urethroplasty and compare them with the severity of urethral stricture. A total of 301 patients (average age: 36 years) with posterior urethral strictures due to pelvic fracture urethral distraction defects were included in the study. Delayed transperineal bulboprostatic anastomosis was performed 6-24 months (mean 10 months) after pelvic fracture urethral distraction defects. Simple perineal anastomosis: 103 (34.2%) patients (group 1); perineal anastomosis with separation of the corporeal bodies: 89 (29.6%) patients (group 2); perineal anastomosis with inferior pubectomy: 95 (31.6%) patients (group 3); perineal anastomosis with rerouting of the urethra around the corpora cavernosum: 14 (4.7%) patients (group 4). The clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the total success rate of the procedures. The secondary outcome examined the success rate of the procedures according to the ancillary surgical steps. Of the 301 delayed transperineal bulboprostatic anastomosis procedures, 263 (87.4%) were successful and 38 (12.6%) were unsuccessful. Simple perineal anastomosis without ancillary procedures reflected an 89.3% success rate, perineal anastomosis with separation of the corporeal body had an 86.5% success rate, perineal anastomosis with inferior pubectomy had an 84.2% success rate, and perineal anastomosis with urethral rerouting had an 85.7% success rate. Corporal splitting, inferior pubectomy, and urethral rerouting are beneficial and useful ancillary procedures in transperineal posterior urethroplasty to achieve tension-free anastomosis.

Predictors of Surgical Approach to Repair Pelvic Fracture Urethral Distraction Defects

We identified preoperative factors predictive of the appropriate surgical approach to anastomotic repair of pelvic fracture urethral distraction defects. We reviewed the medical records and imaging studies of 121 patients who had undergone anastomotic repair of a pelvic fracture urethral distraction defect. The review was focused on 10 preoperative clinicoradiological variables that may influence or predict the surgical repair. The patients were categorized as having undergone a simple perineal operation (78 patients, group 1), or an elaborated perineal or a combined perineo-abdominal procedure (43 patients, group 2). Univariate and multivariate analyses were used to identify preoperative parameters predictive of the type of anastomotic repair. In addition, ROC analysis was used to assess prediction results of the multivariate analysis. On univariate analysis 5 parameters were significant predictors of the type of repair, while on multivariate analysis only 3 parameters remained strong and independent predictors including the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index was a proxy for all other parameters. At a cutoff index of 0.35 the appropriate surgical repair was predicted with 91% specificity and a 95% positive predictive value. When ROC analysis was performed the AUC was 0.979. The type of anastomotic repair of pelvic fracture urethral distraction defect can be predicted by 3 preoperative factors, namely the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index has the highest predictive accuracy and is a proxy for all other factors. An index less than 0.35 indicates a simple perineal operation and an index greater than 0.35 indicates an elaborated perineal or a transpubic procedure.