Pelvic Fracture Urethral Injury Research Articles

Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula.

To evaluate the effect of a new strategy of transperineal anastomotic urethroplasty (TAU) with proximal transection in treating pelvic fracture urethral injury (PFUI) associated with urethrorectal fistula (URF). A retrospective review of all patients treated by TAU with proximal transection and fistula repair for PFUI associated with URF was performed between August 2013 and July 2022. Information on demographics, peri-operative variables, and postoperative follow-up outcomes was collected. Successful surgery was defined as restoration of a uniform urethral calibre using flexible cystoscopy (third postoperative month) without strictures or leakage, with no further interventions required. Functional outcomes, including erectile function (assessed using the five-item International Index of Erectile Function) and urinary continence, were assessed. Forty patients diagnosed with PFUI associated with URF and treated by TAU with proximal transection and rectal fistula repair were enrolled. Six patients (15.0%) had a history of failed urethral reconstruction. The mean stenosis length and fistula diameter were 2.9 cm and 1.2 cm, respectively. All patients underwent faecal diversion before urethroplasty. After a median (range) follow-up of 45 (3-115) months, the final success rate was 90.0% (36/40). Postoperative complications included haematoma in three patients, epididymo-orchitis in three, wound infection in one, wound bleeding in one, delayed wound healing in three, and wound numbness in three. The overall incidence of postoperative erectile dysfunction reached 75.0%, with a median (range) score of 9 (0-19). Normal continence was achieved in 31 patients (77.5%). Occasional incontinence without the need for urinal pads occurred in eight patients, whereas one patient required urinal pads. Transperineal anastomotic urethroplasty with proximal transection is a precise and effective surgical strategy for treating PFUI associated with URF. This strategy ensures a high success rate and improves surgical efficiency.

Incidence of urethral stricture in patients with urethral trauma: a 10-year experience in an Indonesian tertiary hospital

BACKGROUND Urethral injuries are rarely life-threatening but can cause significant morbidity if left untreated. Until now, data on urethral trauma incidence are still limited in Indonesia. This study aimed to report the incidence of traumatic urethral stricture within 10 years of experience in treating urethral trauma. METHODS This retrospective study used a total sampling method for all patients with urethral trauma who came to the emergency department and agreed to undergo radiological evaluation. Patient data were collected from January 2012 to December 2021. All patients were followed up for 3 months after trauma, and the incidence of urethral stricture was analyzed using the chi-square or Fisher's exact tests as an alternative. RESULTS The overall incidence of urethral stricture was 48.4%. Of 122 patients, 82.0% had anterior urethral trauma. Grade III American Association for the Surgery of Trauma (43.4%) was the most common urethral trauma. The cause of urethral trauma was iatrogenic, pelvic fracture urethral injury (PFUI), straddle injury, and penile fracture, contributing in 64.8%, 18.0%, 16.4%, and 0.8% of the cases, respectively. Most patients (70.5%) underwent a cystostomy catheterization procedure as initial treatment. Straddle injury, PFUI, and a higher degree of urethral trauma were significantly associated with urethral stricture formation (p<0.05). CONCLUSIONS Straddle injury, PFUI, and a higher degree of urethral trauma were significantly related to a higher incidence of urethral stricture. Most low-grade and anterior urethral traumas can resolve spontaneously.

Pelvic fracture urethral injury in adolescents – Predictors of outcomes and surgical complexity

Pelvic fracture urethral injury (PFUI) is more severe in younger individuals. The adolescent group is prone to protracted morbidity due to severity of the injury and its impact on lifestyle. Hence, treatment options and data on outcomes are crucial in planning management. The adolescents are a subgroup in several series of PFUI, but literature exclusively studying this group is sparse. A retrospective review of all adolescents (aged between 10 and 19 years as defined by WHO) who underwent surgical repair for PFUI between January 2005 and December 2019 was conducted. Success was defined as a bell-shaped urine flow curve and Qmax of >15ml/s, no evidence of re-stricture (on cystoscopy/MCU), and no re-intervention. Measurements of the length of the urethral defect and bulbar urethra were done using a digital scale by the radiologist from micturating cystourethrogram (MCU). The Gapometry/Urethrometry (GU) index was calculated as the ratio of the length of the urethral defect to that of the bulbar urethra. Data was analysed using SPSS software version 20.0 and Stata Version 16. The primary outcome was the success of anastomotic urethroplasty. Secondary outcomes were evaluating factors predicting operative complexity (simple perineal versus elaborate perineal approach). We studied 22 patients, out of which 8 were referred following prior failed intervention elsewhere. The mean age was 16.5+2.7 years. All the patients were treated using a perineal approach with an overall success rate of 90.9%. Two patients had a failure and were managed with Endoscopic Internal Urethrotomy (EIU), and urethral dilatation. The median follow-up was 24 months. All 8 patients with prior failed interventions had a successful outcome. Twelve patients required inferior pubectomy (elaborate perineal approach). The median length of the urethral defect (2.3cm IQR- 1.45,3.30 vs. 1cm, IQR-0.65, 1.6) and the mean GU index (0.45±0.18cm vs. 0.25cm±0.12cm) were significantly higher in those who required an elaborate perineal approach. The perineal approach for surgical repair (anastomotic urethroplasty) of pelvic fracture urethral injury has a favourable success rate of 90.9% in adolescents. Re-do anastomotic urethroplasty for prior failed repairs also had a high success rate of 100%. Cases requiring an elaborate perineal approach were associated with a significantly higher Gapometry/Urethrometry Index (>0.45) and length of the urethral defect (>2.3cm). This information may assist in patient counselling and preparation for additional steps during repair.

Predictors of elaborated perineal or a combined abdominoperineal approach during repair for pelvic fracture urethral injury.

A step-based anastomotic urethroplasty is a standard technique for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). We aim to identify pre-operative factors, including results of conventional radiological imaging, for prediction of elaborated perineal or a combined abdominoperineal procedure. Retrospective observational study on 114 consecutive patients undergoing urethroplasty for PFUI between January 2020 and December 2022 was conducted. Surgical procedures were categorized according to the Webster classification into two groups: steps 1-2 (group 1) and steps 3-4 or a combined abdominoperineal repair (group 2). Pre-operative pattern results of RGU/VCUG were categorized regarding the relation between the proximal urethral stump with the pubic symphysis: posterior urethral stump below (pattern 1) or above (pattern 2) the lower margin of the pubic symphysis. Patient demographics were assessed. Univariate and multivariate logistic regression analyses were utilized. Overall, 102 patients were enrolled in the study for data analysis. On the multivariate logistic regression analysis, the presence of erectile dysfunction (OR 4.5; p = 0.014), prior combined treatment (endoscopic and urethroplasty) (OR 6.4; p = 0.018) and RGU/VCUG pattern 2 (OR 66; p < 0.001) significantly increased the likelihood of the need of step 3 or higher. The need of step 3 or higher during urethroplasty for PFUI can be predicted pre-operatively with conventional imaging (RGU/VCUG). Patients with proximal urethral stump above the lower margin of pubic symphysis were about 66 times more likely to need step 3 or higher during urethroplasty.

Ventral corporal plication: An additional maneuver for achieving tension-Free anastomosis in repair of failed pelvic fracture urethral injury

Ventral corporal plication: An additional maneuver for achieving tension-Free anastomosis in repair of failed pelvic fracture urethral injury

Redo inferior pubectomy for failed anastomotic urethroplasty in pelvic fracture urethral injury.

To assess the effect of redo inferior pubectomy on the management of complicated pelvic fracture urethral injury (PFUI) in patients with a history of failed anastomotic urethroplasty. We retrospectively reviewed all patients receiving redo anastomotic urethroplasty with redo inferior pubectomy for failed PFUI between January 2010 and December 2021. Patients with incomplete data and those who were lost to follow-up were excluded. Successful urethroplasty was defined as the restoration of a uniform urethral caliber without stenosis or leakage and further intervention. Functional results, including erectile function and urinary continence, were evaluated. Descriptive statistical analyses were then performed. Thirty-one patients were included in this study. Among them, concomitant urethrorectal fistula occurred in 2 patients, and concomitant enlarged bladder neck occurred in 1. The stenosis site was the bulbomembranous urethra in 2 patients and the prostatomembranous urethra in 29. The mean length of urethral stenosis in all patients was 3.1 cm (range, 2.0-5.0 cm). After a mean follow-up of 34.6 months, the final success rate was 96.8%. The incidence of erectile dysfunction reached 77.4% (24/31). Normal continence was achieved in 27 (87.1%) patients. One patient developed urinary incontinence of grade II requiring urinary pads because of an enlarged bladder neck. According to the Clavien-Dindo classification, postoperative complications of grade I occurred in 7 patients and grade II in 4. Repeat anastomotic urethroplasty with repeat inferior pubectomy provides reliable success rates for failed PFUI. In complicated cases, it should be known and mastered.

Outcomes of early endoscopic realignment of post-traumatic posterior urethral ruptures

Post-traumatic rupture of the posterior urethra is a serious injury that can compromise the micturition and erectile prognosis of the often-young patient. The management of this lesion is still controversial, leaving the choice between early endoscopic realignment or suprapubic catheterization with deferred urethroplasty. The objective of this study was to report our clinical experience and outcomes with early endoscopic realignment (EER) for patients with pelvic fracture urethral injury. We underwent a retrospective review of patients with pelvic fracture associated urethral injury who underwent EER from 2010 to 2020. Preoperative, perioperative, and postoperative outcome data were collected. Complications for the surgical procedure were analyzed, as well as postoperative stenosis, urinary incontinence and erectile dysfunction. The primary endpoint was success, defined as satisfying micturition with no urethral stricture at the time of last follow-up. Early endoscopic realignment was performed in 26 patients managed for complete post-traumatic posterior urethral rupture. The median age was 26 (16-39) years. The most common mechanism of urethral injury was road traffic accidents in 69.23% of cases. The most common urethral injury was grade 4 in 23patients (88.46%). The median time to endoscopic realignment was 8days (3-18). The median time to postoperative bladder catheterization was 22 (10-32) days. The median follow-up time was 34 (18-54) months. Ten patients developed urethral stricture during follow-up: 7 (26.92%) were treated with one or two internal cold blade urethrotomies, 3 required urethroplasty. There were no urethroplasty failures after a first endoscopic realignment. Two patients reported severe stress urinary incontinence. The median IIEF-5 score at the date of last news was 23 (17-25). Early endoscopic realignment allows some patients to avoid a heavier surgical treatment, and doesn't compromise the realization of a later urethroplasty.

Editorial Comment on the article titled "Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial".

Editorial Comment on the article titled "Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial".

Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial.

To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children. This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding thedevelopment of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding. Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002). Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

A survey of emergency blunt urethral injury management in China: Reality versus guidelines

AbstractBackgroundAlthough urethral trauma may lead to serious consequences if mismanaged, treatment concepts are inconsistent. We designed a survey to investigate the current diagnosis and management of emergency blunt urethral trauma to aid future dissemination of relevant concepts.MethodsA 15‐item anonymous questionnaire was distributed via an online platform. It addressed items such as the cognition of how to diagnose of urethral trauma, optimal emergency management of a urethral trauma patient, and attitude towards early realignment for pelvic fracture urethral injuries.ResultsOf 538 respondents, 94.2% and 84.9% had received patients with straddle trauma urethral injuries or pelvic fracture urethral injuries, respectively, within the past year. In the emergency room, attempted urethral catheterization was the most selected examination method by respondents for diagnosis of both straddle injury (500/538) and pelvic fracture urethral injury (469/538). For patients with straddle injury, 41.3% of respondents performed endoscopic realignment and 31.6% preferred suprapubic cystostomy. For hemodynamically stable patients with PFUI, 42.2% of respondents preferred suprapubic cystostomy and 34.9% preferred endoscopic realignment. Most respondents felt favorably toward early realignment for pelvic fracture urethral injuries. After realignment, 61.3%, 24.5%, and 13.8% of respondents performed catheterization for 4, 8, and 12 weeks, respectively. Further, 54.6% of respondents believed catheter traction should be applied after realignment.ConclusionAlthough the number of yearly emergency urethral trauma cases was small, the opinions and practices of most urologists were consistent with guidelines. However, the significance of retrograde urethrography was not fully understood, and some respondents had incorrect views on catheter traction after realignment.

(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No

MP78-12 OUR EXPERIENCE IN PENILE IMPLANT AFTER ANASTOMOTIC URETHROPLASTY FOR PELVIC FRACTURE URETHRAL INJURY

You have accessJournal of UrologyCME1 Apr 2023MP78-12 OUR EXPERIENCE IN PENILE IMPLANT AFTER ANASTOMOTIC URETHROPLASTY FOR PELVIC FRACTURE URETHRAL INJURY Cora Fogaing, Pankaj Joshi, Daniel Esteban Gomez Zapata, Apurva Anand, Rathish Rajenderan, Shreyas Bhadranavar, Amey Talpallikar, Aryan Gune, and Sanjay Balwant Kulkarni Cora FogaingCora Fogaing More articles by this author , Pankaj JoshiPankaj Joshi More articles by this author , Daniel Esteban Gomez ZapataDaniel Esteban Gomez Zapata More articles by this author , Apurva AnandApurva Anand More articles by this author , Rathish RajenderanRathish Rajenderan More articles by this author , Shreyas BhadranavarShreyas Bhadranavar More articles by this author , Amey TalpallikarAmey Talpallikar More articles by this author , Aryan GuneAryan Gune More articles by this author , and Sanjay Balwant KulkarniSanjay Balwant Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic fracture urethral injury (PFUI) results from traumatic disruption of the urethra and is treated with anastomotic urethroplasty. Up to 60% of those patients have erectile dysfunction. Majority are treated with medical management. For those who fail, we perform penile implant. We present outcomes for a series of 41 patients who underwent penile implant insertion post anastomotic urethroplasty for PFUI. METHODS: Our centre is a tertiary referral centre and published the world’s largest series of PFUI experience. We analyzed a prospectively maintained database of 41 patients who underwent penile implant insertion post PFUI. Choice of implant was based on patient’s preference and insurance coverage. Functional outcomes using the IIEF-5 questionnaire and complications were analyzed. RESULTS: Mean delay between anastomotic urethroplasty and penile implant was 47 months. Semirigid penile implant was used in 92.7% of patients while three-piece inflatable penile implant was used in 7.3% of patients. Patients reported significant improvement in sexual function post implant with mean IIEF-5 score of 21.88 points compared to 3.27 points before the implant. Intraoperative complications included two septal perforations and one proximal crural perforation. Postoperative complications included two hematomas, two glans extrusion that were salvaged and one proximal urethral erosion that lead to implant removal CONCLUSIONS: Erectile dysfunction is a common occurrence in PFUI patients. Penile implant insertion in those patients is challenging due to ischemia of the corpora. If performed by experts, it is safe and leads to significant sexual function improvement. To date, this is the largest series of penile prosthesis insertion in PFUI patients post anastomotic urethroplasty. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1136 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cora Fogaing More articles by this author Pankaj Joshi More articles by this author Daniel Esteban Gomez Zapata More articles by this author Apurva Anand More articles by this author Rathish Rajenderan More articles by this author Shreyas Bhadranavar More articles by this author Amey Talpallikar More articles by this author Aryan Gune More articles by this author Sanjay Balwant Kulkarni More articles by this author Expand All Advertisement PDF downloadLoading ...

PD12-06 MICRO-SURGICAL PENILE REVASCULARIZATION AFTER PELVIC FRACTURE URETHRAL INJURIES

You have accessJournal of UrologyCME1 Apr 2023PD12-06 MICRO-SURGICAL PENILE REVASCULARIZATION AFTER PELVIC FRACTURE URETHRAL INJURIES Reynaldo Gomez, Jessica Pfeifer, Laura Velarde, and Rodrigo Campos Reynaldo GomezReynaldo Gomez More articles by this author , Jessica PfeiferJessica Pfeifer More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Rodrigo CamposRodrigo Campos More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Micro-surgical revascularization of the penis after a pelvic fracture urethral injury (PFUI) has been proposed to recover erections and / or to improve the irrigation of the spongiosum prior to urethroplasty, aiming to prevent ischemic failure of the reconstruction. METHODS: Patients who lost their erection after a PFUI were studied with color Doppler ultrasound of the cavernous arteries after intracavernous injection of prostaglandin. Those diagnosed with arteriogenic erectile dysfunction were confirmed with a selective pudendal pharmaco-arteriography (with intracavernous prostaglandin) and were offered a micro-surgical penile revascularization by means of a bypass of the inferior epigastric artery to the dorsal artery of the penis. RESULTS: Between April 1990 and July 2022, 16 patients were revascularized before urethroplasty. All were acutely managed by suprapubic cystostomy without realigment. The median age was 32 years (range 20-57), the median time between the accident and revascularization was 9 months (range 2-30) and the median time between revascularization and urethroplasty was 2 months (range 1-7). The mean surgical time was 280 min (220-290), with no intraoperative complications. There were 2 Clavien I postoperative complications and one Clavien II.With a median follow-up of 102 months (range 3-367), no patient presented urethroplasty stricture failure and no patient recovered erections despite bypass patency (verified by postoperative Doppler ultrasound in 11). CONCLUSIONS: Micro-surgical revascularization of the penis is feasible and safe, requires expertise in micro surgery and does not seem to have a role in recovering erections after PFUI. On the other hand, long-segment ischemic stricture failure is an infrequent but catastrophic complication of urethral reconstruction linked to post traumatic penile arterial insufficiency. In this setting, penile revascularization may contribute to increase urethral blood flow and may be valuable to prevent ischemic failure of the urethral reconstruction. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e402 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Reynaldo Gomez More articles by this author Jessica Pfeifer More articles by this author Laura Velarde More articles by this author Rodrigo Campos More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of Pelvic Fracture Urethral Injury: Is Supracrural Urethral Rerouting (Step 4) Becoming Anecdotical or Does It Remain in Force?

Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. We evaluated the outcomes of anastomotic urethroplasty (especially Step 4 or higher) or substitution urethroplasty in patients with PFUI at our center. Between 2013 to 2021, we retrospectively collected data on patients with PFUI. Surgical procedures were categorized according to the Webster classification and rates of each step were reported. The success rate was defined as Qmax above 10 mL/s and no need for further treatment. In this period, 737 male patients with PFUI were surgically treated. Notably, 18.8%, 17.6%, 46%, 1.8%, and 5.6% of included patients received steps 1, 2, 3, and 4 and the abdominoperineal approach, respectively. In 68 (9.2%) patients, the substitution of urethroplasty with a pedicled preputial tube (PPT) was needed. The success rate was 69.2% in Step 4, 74.4% in the abdominoperineal approach, and 86.4% in PPT; however, recurrence-free survival was not significantly different between groups (p = 0.22). Step 4 perineal anastomotic urethroplasty represents a surgical option in the armamentarium of PFUI treatment. Indications should be carefully reviewed to improve patient selection and avoid surgical failure, stopping at the step which first gives a tension-free anastomosis.

Outcomes of early endoscopic realignment for pelvic fracture urethral injury

Outcomes of early endoscopic realignment for pelvic fracture urethral injury

Application of 3D printed pelvic fracture related urethra and surrounding tissue as preoperative planning model

ObjectiveUrethral stenosis caused by pelvic fracture urethral injury (PFUI) is a complex urological disease, especially for the redo cased. However, to find the proximal end of the posterior urethra, and to avoid injury to the rectum and to forecast to remove the inferior pubic margin are two key points for a successful surgery. These steps can be challenging for even the most experienced urologists. This study is to describe a new technique for understanding the three-dimensional (3D) anatomy of the urethra, which will also aid in surgical planning and simplify urethroplasty.Materials and methodsThree patients underwent routine urethroscopy, X ray urethrography and contrast CT urethrography. The 3D images were then reconstructed, and the data were transmitted to a 3D printer. 3D models were printed with polyacrylic acid to simulate the anatomical structure and relationship of urethral stenosis with pubic symphysis and rectum. Various diagnosis methods were compared with the condition in surgery. The patients and trainee questionnaires were performed.ResultsThree models of urethral CT were obtained. These models were presented to patients and trainee doctors along with routine urethroscopy, urethrography, and urethral CT. The scores of patients and trainee question forms demonstrated that the 3D printed urethral stenosis model of pelvic fracture has obvious advantages in urethral adjacency and ease of understanding. The 3D printed urethras were easy to show the pubic symphysis and simulate its excision and exposure of urethra. The model could show the precise distance from urethra to rectum to prevent the rectum injury in surgery.Conclusions3D printing technology can be applied to the preoperative evaluation of urethral stenosis caused by PFUI. It can be auxiliary to understand the anatomical structure of the posterior urethra, the direction of urethral displacement, protecting the rectum and the forecasting for pubectomy. It is especially helpful for the accurate preoperative planning of some complex urethral stenosis and redo cases.

Epidemiology of posterior urethral injury among adults with traumatic pelvic ring disruptions: a 10-year retrospective review from a trauma care centre in Southeast Nigeria.

posterior urethral injuries can occur in polytrauma settings, and may contribute to morbidity post-trauma. The aim of this study is to determine the occurrence of pelvic fracture urethral injury (PFUI) in adult polytrauma patients who were successfully stabilized and to appraise the nature of associated injuries. the medical records of stabilized polytrauma patients≥ 18 years of age from January 2010 to December 2019 were retrospectively reviewed focusing on those presenting with bony pelvis disruptions. Injuries were categorized using the injury severity scale (ISS) while bony pelvis disruptions were classed according to the Young-Burgess classification. Data on the demography of the patient, mechanism of injury, nature, and severity of injuries, class of pelvic fracture-disruption, and urethral integrity were collected and analyzed accordingly. of 111 patients with bony pelvis disruptions, 95 of them had adequate information and were included in our analysis. The mean age of participants was 37.3 ± 11.8 years and most of them were males (87.4%). Blunt pelvic trauma occurred in 96.8%. Lateral compression pelvic injuries were prevalent at 39.0%. In 54.7% of the patients, the injury severity score (ISS) was ≥ 27. At 25.3% and 24.2% respectively, the abdomen and the lower extremities most frequently sustained a grade ≥ 3 injuries (abbreviated injury scale (AIS) ≥3). At a rate of 2.1%, spinal cord injury was the least observed. In the 10 years, there were 6 PFUI among 83 stabilized polytraumatized men with mean ISS of 35.5 ± 8.3. The incidence rate of PFUI was 0.6 per 8.3 pelvic disruptions in men per year. Symphysis pubis disruption or fracture of the pubis or both was consistently seen in all PFUI. Higher ISS significantly relates to PFUI (p <0.001). The mechanism of bony pelvis disruption and the class of bony pelvis injury are determined by the severity and trajectory of the impact apparently relates to PFUI only through fracture-disruption of the pubic symphysis or the pubis. about 7.2% of men presenting with traumatic disruption of the bony pelvis in polytrauma setting sustain PFUI. In polytrauma settings, PFUI should be suspected in cases of fracture-disruption of the pubis or symphysis pubis from any mechanism.

Management of male stress urinary incontinence in high-risk patients: a narrative review.

The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

Voiding dysfunction: Postsuccessful anastomotic urethroplasty for pelvic fracture urethral injury

Introduction: Anastomotic urethroplasty (AU) is the standard of care for pelvic fracture urethral injuries (PFUIs). Few patients despite having successful AU have postoperative voiding dysfunction due to an unrecognized neurogenic bladder. This article outlines clinical signs which may predict these injuries. Materials and Methods: We retrospectively evaluated our database of more than 1000 cases. Patients who underwent successful AU with postoperative voiding dysfunction were included. The success of urethroplasty was determined by a retrograde urethrogram (RGU) and endoscopic evaluation. Voiding dysfunction was defined as patients with poor urine flow (Qmax <10 ml/s) postsurgery. Urodynamics (UDS) was performed postoperatively on all patients. Results: Six men were included with an average age of 27 years (all required step 3 AU). A RGU and endoscopy revealed a patent anastomosis. UDS showed neurogenic detrusor underactivity. There were variable occurrences of other lower motor neuron findings – muscle atrophy, fasciculations, sensory loss, areflexia, and fecal incontinence. The common factor was that all patients had a foot drop on preoperative assessment. Conclusions: Coexistent neurogenic bladder with PFUI is rare. The presence of foot drop and other lower motor neuron signs is a predictor for voiding dysfunction. We recommend these patients should have UDS before surgical repair and must be counseled accordingly.

An Audit of Management of Male Urethral Stricture and its Outcome: A Retrospective Review

Background: Urethral stricture leads to obstructive voiding dysfunction. We report an audit of surgical management of urethral stricture in adult males. Methods: The records of all patients diagnosed with urethral stricture from December 2017 to March 2019 at B. P. Koirala Institute of Health Sciences, Nepal were retrieved. Preoperative, surgical, and postoperative follows-up data were evaluated. The American Urological Association International Prostatic Symptom Score (AUA-IPSS) and Uroflowmetry (voided volume and peak urinary flow rate (Qmax)) were used to assess the outcome of the surgery. Results: Among 50 patients, the majority (46%) belonged to 40 - 59 years. Twenty-five patients (78.1%) with traumatic anterior urethral stricture underwent excision and primary end to end anastomotic (EPA) urethroplasty; seven patients (21.9%) with pelvic fracture urethral injury (PFUI) underwent progressive perineal urethroplasty (PPU) with EPA; eight patients with inflammatory urethral stricture underwent Kulkarni urethroplasty; four patients with iatrogenic urethral stricture underwent EPA; six patients with idiopathic urethral stricture underwent Barbagli dorsal onlay urethroplasty. All patients had preoperative voided volume &lt; 150ml, Qmax &lt; 15ml/s. Thirty patients had complete obliteration; the remaining patients had severe storage and voiding symptoms (AUA-IPSS ≥ 20) before surgery. Except for two patients who underwent redo surgery, outcome of urethroplasty was successful in terms of storage and voiding symptoms (AUA-IPSS &lt; 7) and uroflometry findings (voided volume &gt; 150ml and Qmax &gt;15ml/s). Conclusion: Urethreal stricture was most common in the age group of 40 - 59 years and traumatic stricture was the most common cause.