Posterior Urethral Disruption Research Articles

Male urethral stricture disease: why management guidelines are challenging in low-income countries.

Urethral stricture disease (USD) is one of the commonest urological pathologies in adult men in low- or low-middle-income countries, providing a significant work burden for the small number of specialist surgeons who are able to provide appropriate treatment. The underlying causes of anterior urethral stricture relate to urethral fibrosis from sexually transmitted infection, with posterior urethral disruption secondary to pelvic trauma being an equally common cause of USD in many countries in sub-Saharan Africa. Anterior urethral strictures are often long, and multifocal, and bulbo-prostatic disruptions are usually due to relatively low-velocity pelvic trauma. The management options available in resource-poor settings are often severely limited by the individual's ability to pay for care, the availability of a specialist surgeon and, importantly, a shortage of functioning endoscopic equipment for less-invasive treatments. Consequently, reconstructive surgery is often regarded by the patient, and surgeon, as the most cost-effective and, therefore, primary means of treating a urethral stricture once urethral dilatation has failed. Regional anaesthetic techniques have limited the adoption of free-graft augmentation as an alternative to pedicled flaps of locally available skin for reconstruction, whilst an inability to provide tension-free bulbo-prostatic anastomoses has negatively impacted the outcome from the treatment of pelvic fracture disruption injuries in much of sub-Saharan Africa. However, Urolink has found that local surgeons can be taught sustainable skills required for successful complex urethroplasty when supported by longitudinal mentorship in the management of difficult clinical issues. Evidence-based practice is known to improve the standard of care in specific conditions in high-income countries, including the management of male USD. However, guidelines developed in high-income countries are not necessarily appropriate for stricture management in less well-resourced healthcare environments but could be adapted to help improve the delivery of stricture care for men in low- or low-middle income countries.

MP20-19 EARLY ENDOSCOPIC REALIGNMENT OF POST TRAUMATIC URETHRAL DISRUPTION

You have accessJournal of UrologyCME1 May 2022MP20-19 EARLY ENDOSCOPIC REALIGNMENT OF POST TRAUMATIC URETHRAL DISRUPTION Camille Haudebert, Juliette Hascoet, Vivien Graffeille, Karim Bensalah, Gregory Verhoest, Zine Eddine Khene, Romain Mathieu, Andrea Manunta, Benoit Peyronnet, and Lucas Freton Camille HaudebertCamille Haudebert More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Vivien GraffeilleVivien Graffeille More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , Zine Eddine KheneZine Eddine Khene More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Andrea ManuntaAndrea Manunta More articles by this author , Benoit PeyronnetBenoit Peyronnet More articles by this author , and Lucas FretonLucas Freton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic Fracture Urethral Injury (PFUI) is a rare but challenging to treat. The initial optimal management is not defined. The objective of the present study was to access short and long term results of early endoscopic realignment (EER) performed for male urethral disruption in a French university hospital. METHODS: All men who underwent an early endoscopic realignment for a PFUI between decembre 2004 and may 2019 in our center were included. Preoperative and perioperative outcome data were collected. The rate of complications for the surgical procedure was analyzed, as well as the rate of post-operative stenosis, erectile dysfunction and incontinence. The primary endpoint was success, defined as satisfying micturition with no urethral stricture at the time of last follow up. RESULTS: Twenty-four patients were included : 17 posterior urethral disruption and 7 anterior. The median time to realignment was 9 days (4-19). There were 3 realignment failure. The median operative time was 30 minutes (10-150). 18 of 21 patients resumed micturition after the surgery, one patient had an early post-operative urethral stricture, and two patients had perineal abscesses and were referred to an outside center for urethroplasty. Initial success rate of the procedure was 29.2% (7/24). Mean follow up time was 36 months (4-190).Eleven of 18 patients developed a urethral stricture during follow up. Seven patients were treated by one or two direct visual internal urethrotomy. Finally, only 8/24 patients (33,33%) required urethroplasty. There were no urethroplasty failure after previous EER. One patient reported stress urinary incontinence after two urethroplasty. There were insufficient data to conclude about erectile dysfunction. CONCLUSIONS: Early endoscopic realignment for PFUI has a low initial success rate but a majority of patients can benefit from endoscopic treatment afterwards and it did not compromise later urethroplasty. Thus, it seems licit to propose EER as first treatment for PFUI. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e325 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Camille Haudebert More articles by this author Juliette Hascoet More articles by this author Vivien Graffeille More articles by this author Karim Bensalah More articles by this author Gregory Verhoest More articles by this author Zine Eddine Khene More articles by this author Romain Mathieu More articles by this author Andrea Manunta More articles by this author Benoit Peyronnet More articles by this author Lucas Freton More articles by this author Expand All Advertisement PDF DownloadLoading ...

Complete Posterior Urethral Disruption Accompanied by Complex Pelvic Fractures: Clinical Outcomes of Fluoroscopic Primary Posterior Urethral Realignment

PurposeTo evaluate the clinical outcomes of fluoroscopic primary posterior urethral realignment (PPUR) for complete posterior urethral disruption (PUD) accompanied by complex pelvic fractures. Materials and MethodsData from 15 male patients (median age, 58 years; range, 32–76 years) with traumatic PUD treated with fluoroscopic PPUR between 2016 and 2019 at a regional trauma center were retrospectively analyzed. The technical success (continuity of the ruptured urethra in PUD by Foley catheter placement) rate of fluoroscopic PPUR, trauma mechanism, concurrent embolization for pelvic arterial hemorrhage, time from the hospital visit to the start of the procedure, procedure time, Foley catheterization duration, and delayed complications were investigated. ResultsFluoroscopic PPUR was technically successful for 13 of 15 (87%) patients. Concurrent embolization for pelvic arterial hemorrhage was performed in 11 of 15 (73%) patients. The mean time between the hospital visit and procedure initiation was 181.6 minutes ± 83.2. The mean procedure time was 66.3 minutes ± 26.6. The mean Foley catheterization duration for 13 patients (technical success group) was 52.3 days ± 39.8 (median, 40 days; range, 21–177 days). Symptomatic urethral stricture developed in 9 of 13 (69.2%) patients after the procedure; 7 underwent visual internal urethrotomy, 4 required regular urethral dilatation, and 2 needed urethral stent insertion. Three of 13 (23%) patients did not have delayed complications during the 1-year follow-up. ConclusionsPPUR with fluoroscopic guidance appears safe and effective for achieving the continuity of the ruptured urethra in PUD. It enables PPUR without general anesthesia and the lithotomy position in patients with complex pelvic fractures.

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. 16, No. 1, Jan 2014 p.29-35

Tissue expander capsule as an induced vascular bed to prefabricate an axial vascularized buccal mucosa-lined flap for tubularized posterior urethral reconstruction: preliminary results in an animal model

Surgical repair of complex posterior urethral disruptions remains one of the most challenging problems in urology. The efficacy of using a tissue expander capsule as an induced vascular bed to prefabricate axial vascularized buccal mucosa-lined flaps for tubularized posterior urethral reconstruction in a rabbit model was tested. The experiments were performed in three stages. First, silicone tissue expanders were inserted into the groin to induce vascularized capsule pouch formation. Next, buccal mucosa grafts were transplanted into the newly formed capsular tissue supplied by axial vessels for buccal mucosa-lined flap prefabrication. Then, circumferential posterior urethral defects were created and repaired with the buccal mucosa graft (Group 1), the capsule flap (Group 2), and the prefabricated capsule buccal mucosa composite flap (Group 3). After surgery, notable contracture of the tubularized buccal mucosa graft was observed in the neourethra, and none of the rabbits in Group 1 maintained a wide urethral caliber. In Group 2, the retrieved neourethra showed little evidence of epithelial lining during the study period, and the lumen caliber was narrowed at the 3-month evaluation. In Group 3, the buccal mucosa formed the lining in the neourethra and maintained a wide urethral caliber for 3 months. The capsule may serve as an induced vascular bed for buccal mucosa-lined flap prefabrication. The prefabricated buccal mucosa-lined flap may serve as a neourethra flap for posterior urethral replacement.

Should primary realignment become the standard line of treatment for traumatic posterior and bulbar urethral disruption?

ObjectivesTo assess early urethral realignment and the correlation of severity of pelvic fracture, with impact of technique on continence and potency. MethodsProspective analysis on patients of post traumatic urethral disruption from 7/2013–5/2015 at Cairo University hospitals. Initial management entailed suprapubic tube insertion. Antegrade flexible cystoscopy or rigid ureteroscopy via the suprapubic access, together with retrograde rigid cystoscopy and real-time fluoroscopy. Follow up entailed history taking, uroflowmetry, urethrograms, cystoscopy, success rate, continence, erectile status after trauma and need for auxiliary procedures after catheter removal. ResultsA total of 18 men with a mean age of 27 ± 15 years. Endoscopic realignment (ER) was performed in 15 out of 18 patients. Open realignment was done in 3 cases. Mean OR time for ER was 30 ± 22 min. Estimated blood loss was minimal. Mean time from injury to primary realignment was 6.0 ± 3.8 days. We found a good correlation between presence of pelvic fracture and grade of urethral injury, but no correlation was found between Tile class and grade of urethral injury. A total of 9 (56.3%) out of 16 patients, who completed follow-up developed 2ry strictures. 6 had narrowing of the urethra and underwent DVIU; 2 of whom had recurrent stricture and needed urethroplasty. 3 had complete obliteration of the urethral lumen and definitive urethroplasty was done. Mean follow up duration 20.6 ± 5.3 months. No patient suffered from UI and only 1 out of 13 adult patients who completed follow up (7.7%) suffered ED. ConclusionsEarly urethral realignment is successful due to advances in endoscopic techniques.

Abstract No. 569 Interventional urethral realignment as a radical treatment in posterior urethral disruption accompanied by complex pelvic fracture

Unlike anterior urethral injury, posterior urethral rupture accompanied by complex pelvic fracture would have the distance between the ruptured urethra becoming wider due to pelvic hematoma, and thus, interventional urethral realignment would be expected to face similar difficulties as surgical urethral realignment. The purpose of this study was to evaluate the clinical efficacy of interventional urethral realignment as a radical treatment in patients with posterior urethral disruption. This retrospective study included 8 patients with traumatic posterior urethral disruptions who were treated with interventional urethral realignment between November 2016 and September 2017. All 8 patients were men with the mean age of 50.5 years. Reviewed results included patient demographics, technical success rate of interventional urethral realignment, fluoroscopic findings, manner of procedure, required procedure time, duration of urethral catheterization, and procedure-related complications. Interventional urethral realignment was technically successful in 6 of 8 patients (75.0%). The majority of patients were young male involved in motor vehicle crashes. In 5 patients, the catheter previously placed by retrograde urethrography was used as a landmark, and the antegrade guidewire was successfully navigated through the free space of urethra separated further by rupturing and exited through the outer urethral orifice by finding the true lumen of the distal urethra. In one patient, the rendezvous technique with a snare catheter in the free space was used. The mean procedure time was 51.2 minutes (range, 40–65 min). The mean duration of urethral catheterization after interventional urethral realignment was 63 days (range, 48–94 d). There were no immediate complications related to procedure, although all patients developed symptomatic urethral stenosis after urethral realignment. Interventional urethral realignment is a safe and minimally invasive procedure that can be performed in a patient with posterior urethral rupture accompanied by complex pelvic fracture. Thus, it can be viewed as a radical treatment that can reduce the frequency of invasive surgical procedures.

Endoscopic urethral realignment of traumatic urethral disruption: A monocentric experience.

Introduction:The optimal management strategy for urethral injuries remains controversial. Suprapubic cystostomy followed by delayed urethral reconstruction or immediate primary urethral injury repair is associated with high complication rate. Early endoscopic realignment for urethral injuries provides early definitive procedure with low complications and avoids the need for further urethral reconstruction.Materials and Methods:Between April 2007 and March 2016, 27 patients with traumatic posterior urethral disruptions were reviewed. All patients were managed by endoscopic urethral realignment. Patients were followed up every 3 months for 18–36 months regarding incontinence, potency, and urine flow.Results:Endoscopic urethral realignment was performed immediately in 21 patients and was delayed in 6 patients. It was successful in 24/27 (88.8%) patients. During the procedure, the proximal urethral end was identified directly in four patients, and by the guidance of methylene blue injection, guidewire or endoscopic light in three, nine, and eight patients, respectively. The Foley catheter was removed after 9 weeks in 17/24 (70.8%) patients and after 12 weeks in 7/24 (29.2%) patients. Six months after realignment, minimal urethral stricture was developed in 4/24 (16.7%) patients. All of them were treated successfully with single session of internal urethrotomy without recurrence after 1-year follow-up. After 18–36-month follow-up period, all patients were potent, continent, and with satisfactory voiding pattern.Conclusions:Endoscopic primary realignment of posterior urethral rupture is less invasive and a safer procedure, without pelvic hemorrhage or additional injuries. It has low incidence of severe urethral stricture and avoids the need for delayed open urethral reconstruction.

Outcomes of Early Endoscopic Realignment of Post-Traumatic Complete Posterior Urethral Rupture

Objective: To report the experience with patients treated by early endoscopic realignment of complete post-traumatic rupture urethra.Methods: The cross sectional study included 30 patients in Dhaka Medical College Hospital and different private hospitals in Dhaka, Bangladesh, between April 2010 and March 2014 with post traumatic complete posterior urethral disruption. Pre-operative retrograde urethrography (RGU), micturition cysto urethrography (MCU) and ultrasonography (USG) of abdomen were performed to identify and to evaluate the Urethral defect length, the bladder neck competence, the prostate position and extend of pelvic hematoma. In second week after trauma, antegrade and retro-grade urethroscopy were performed to identify both urethral ends and insert a catheter. Before removal of catheter, Patients were followed up by pericatheter urethrogram after 4 weeks completed postoperative period. If extravasation seen, catheter was again maintained for another 2 weeks. Follow up was done by abdominal ultrasound and uroflowmetry 3 monthly up to 6 months and 6 monthly thereafter. RGU and MCU were performed 8 weeks after removal of catheter. Urinary continence and post-operative erectile dysfunction were assessed by direct patient interview.Results: 30 patients in the age group 18-60 years (mean 36 years) were treated. Patients were followed up for 12 to 36 months. Complete healing of the urethra occurred in 10 patients. Passable urethral stricture developed in 12 patients. Complete urethral obstruction occurred in 8 patients.Conclusion: Early endoscopic realignment for complete posterior urethral rupture is a feasible technique with no or minimal intra-operative complications. The technique is successful as the definite line of therapy in reasonable number of patients and it is seems to be effective Intervention for the prevention of inevitable urethral stricture formation.J Dhaka Medical College, Vol. 24, No.2, October, 2015, Page 136-140

Modified Primary Urethral Realignment Under Flexible Urethroscope

ABSTRACTObjective: To assess the clinical significance of flexible endoscopic realignment in the treatment of posterior urethral disruption in comparison to the traditional open realignment method. Methods: A total of 58 patients suffering posterior urethral disruption were enrolled into the current study from January 2003 to May 2009. Of them, 23 patients (Group A) were treated with modified technique of urethral realignment under flexible urethroscopy and 35 patients (Group B) received conventional open realignment. Results: Either procedure was successfully performed in both groups. However, the operation time was significantly shorter in Group A (29.1 ± 9.5 min) than that in Group B (58.1 ± 11.2 min, p < 0.001). Also, patients in Group A had a significantly decreased incidence of stricture (4 of 23 cases in Group A versus 15 of 35 cases in Group B, p = 0.043) and formation of false urethra (0 of 23 cases in Group A versus 7 of 35 cases in Group B, p = 0.035). Prevalence of secondary urethroplasty was less in Group A (1/23) compared to Group B (8/35), but there was no statistical difference (p = 0.057). In addition, there was no significant difference in morbidity of urinary infection, incidence of incontinence, and impotence between the two groups (p > 0.05). Conclusion: Compared to the traditional open realignment, the new technique of urethral realignment under flexible endoscope has the advantage of short operation time, minimally invasive and less complications.

Re: Simplified Reconstruction of Posterior Urethral Disruption Defects: Limited Role of Supracrural Rerouting

Re: Simplified Reconstruction of Posterior Urethral Disruption Defects: Limited Role of Supracrural Rerouting

Deferred endoscopic urethral realignment: Role in management of traumatic posterior urethral disruption

ObjectivesThe aim of our study is to assess the value of deferred endoscopic urethral realignment after traumatic posterior urethral disruption. Patients and methodsBetween June 2001 and August 2011, we evaluated 28 patients who presented 3–6 weeks (mean 27±6 days) after experiencing traumatic posterior urethral disruptions and pelvic fractures; immediate and early realignment were overdue in these cases. Patient variables included mode of presentation, mechanism of trauma, type of pelvic fracture, and Abbreviated Injury Scale (AIS). Under fluoroscopic guidance, a guidewire was passed into the injured urethral segment from the distal to proximal injured ends using a long Chiba needle, and realignment was performed using endoscopic urethrotomy. The follow-up period ranged from 18 to 98 months (mean 43±22.5 months). ResultsAfter the procedure, 46% of patients were stricture free. After one visual internal urethrotomy (VIU) and two VIU's, 60% and 64% of patients were stricture free. No cases of post-procedural incontinence occurred, and impotence was reported in only 14% of patients. Type of pelvic fracture was the only variable that significantly affected the success rate, where the success rate decreased from 100% in stable pelvic fracture to 25% in bilateral rotationally and vertically unstable pelvic fracture. ConclusionWhen early realignment is postponed for any reason, deferred endoscopic realignment is considered an adequate substitute because urethral continuity can be achieved in a group of patients without increase incidence of impotence and incontinence.

1135 Posterior urethral realignment in management of posterior urethral disruption: Feasibility and outcome

1135 Posterior urethral realignment in management of posterior urethral disruption: Feasibility and outcome

Complications of primary realignment of posterior urethral disruption after pelvic trauma.

Background:There are two fundamental selections for the management of traumatic posterior urethral injury, delayed repair or early primary realignment.Objectives:The aim of this study was to assess the complications of primary realignment of posterior urethral disruption.Patients and Methods:This retrospective descriptive cross-sectional study was done at the Shohada-ye Ashayer University Hospital in Khorramabad. All male patients admitted to the hospital with posterior urethral disruption and had undergone primary realignment of the urinary tract between 2003 and 2010 were included. Primary realignment of the urinary tract was done up to 24 hours after injury. The patients underwent open cystostomy and then a nelaton catheter was inserted from the bladder neck to the distal urethra anterogradely. Upon voiding from the catheter, another nelaton catheter was fixed to it and was pulled into the bladder. The catheter was removed if the urethra was intact in the retrograde urethrography after three weeks. The patients were followed for six months. The data were presented as mean and percentage.Results:A total of 24 patients were evaluated while seven, eleven, four, and two patients were aged under 20, 20 to 39, 40 to 59, and over 60 years old, respectively. Thirteen patients (54.16%) had urinary tract stenosis after the primary realignment. Erectile dysfunction was reported in three of them. Urinary incontinence did not occur in patients without stenosis.Conclusions:Early primary realignment of posterior urethral disruption had significant complications. In this study we did not have a control group, thus we could not compare the complications of delayed repair and early primary realignment of the posterior urethra. We recommend further case-control studies with larger sample size.

Transpubic urethroplasty: a single center experience.

Objective. To evaluate the long-term results of transpubic urethroplasty for pelvic fracture urethral distraction defects. Patients and Methods. Sixteen patients who had undergone transpubic urethroplasty for posttraumatic complex posterior urethral disruptions between 2007 and 2013 were analyzed retrospectively and prospectively. Patients were followed up for a mean (range) of 24 (6–60) months by history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Results. The mean age of the patients was 30.4 years. The estimated radiographic stricture length before surgery was 4.3 cm. Transpubic urethroplasty was successful in 14 out of 16 patients. Postoperative complications were recurrent stricture (12.5%), urethrocutaneous fistula (12.5%), incontinence (31.25%), impotence (25%), and wound infection (18.75%). Failed repairs were successfully managed endoscopically in one patient and by perineal anastomotic repair in the other, giving a final success rate of 100%. Five out of 16 patients were incontinent of which 3 of them resolved and 2 had permanent incontinence. Impotence was seen in 4 out of 16 patients. There were no reported complications of pubectomy in any of our patients. Conclusions. Though considered obsolete now, transpubic urethroplasty for complex posterior urethral disruptions is still a viable alternative with excellent results and minimal morbidity.

Outcomes after Urethroplasty for Radiotherapy Induced Bulbomembranous Urethral Stricture Disease

We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

Long-term outcomes following posterior urethroplasty for traumatic pelvic-fracture associated posterior urethral disruption in a contemporary cohort

Figler, Brad David MD; Dy, Geolani MD; Wessells, Hunter B. MD, FACS; Voelzke, Bryan B. MD Author Information

Early effectiveness of endoscopic posterior urethra primary alignment

Posterior urethra primary realignment (PUPR) after complete transection may decrease the gap between the ends of the transected urethra, tamponade the retropubic bleeding, and optimize urinary drainage without the need of suprapubic catheter facilitating concurrent pelvic orthopedic and trauma procedures. Historically, the distorted anatomy after pelvic trauma has been a major surgical challenge. The purpose of the study was to assess the relationship of the severity of the pelvic fracture to the success of endoscopic and immediate PUPR following complete posterior urethral disruption using the Young-Burgess classification system. A review of our Level I trauma center database for patients diagnosed with pelvic fracture and complete posterior urethral disruption from January 2005 to April 2012 was performed. Pelvic fracture severity was categorized according to the Young-Burgees classification system. Management consisted of suprapubic catheter insertion at diagnosis followed by early urethral realignment when the patient was clinically stable. Failure of realignment was defined as inability to achieve urethral continuity with Foley catheterization. Clinical follow-up consisted of radiologic, pressure studies and cystoscopic evaluation. A total of 481 patients with pelvic trauma from our trauma registry were screened initially, and 18 (3.7%) were diagnosed with a complete posterior urethral disruption. A total of 15 primary realignments (83.3%) were performed all within 5 days of trauma. The success rate of early realignment was 100%. There was no correlation between the type of pelvic ring fracture and the success of PUPR. Postoperatively, 8 patients (53.3%) developed urethral strictures, 3 patients (20.0%) developed incontinence, and 7 patients (46.7%) reported erectile dysfunction after the trauma. The mean follow-up of these patients was 31.8 months. Endoscopic PUPR may be an effective option for the treatment of complete posterior urethral disruption and enables urinary drainage to best suit the multispecialty surgical team. The success rate of achieving primary realignment did not appear to be related to the complexity and type of pelvic ring fracture.

Results of delayed repair of posterior urethral disruption injuries in Maiduguri

AimPosterior urethral disruption injuries (PUDI) are common and on the increase because of vehicular accidents and civil conflicts. The operative management of PUDI continues to pose a challenge to the urologist because of erectile dysfunction and incontinence from the injury or following repair. The aim of the present study was to review the outcome of delayed repair of PUDI.Patients and MethodsThe present study is a retrospective study of all male patients who underwent operation for PUDI at a urology unit between April 2008 and September 2010. The causes, presentation, diagnostic investigations, initial management, definitive operative management and complications were obtained from patients' clinical records.ResultsForty‐five male patients with PUDI were managed; their mean age was 37.38 ± 20.014 years (range 8–80 years). Most of the injuries were because of vehicular accidents (46.67 per cent) and missile injuries (15.56 per cent). The presenting features included inability to pass urine (100 per cent), bleeding from the urethra (60 per cent) and suprapubic swelling and pain (86.67 per cent). The initial management was a suprapubic cystostomy. Twenty‐nine (64.44 per cent) patients had associated pelvic fracture, 17 (37.78 per cent) long bone fractures and 13 (28.89 per cent) bladder injuries. Other associated injuries included the bowel, head, ribs and liver (31.12 per cent). The perineal approach in repair was effected in 37 (82.22 per cent) patients, and eight (17.78 per cent) had combined abdominal and perineal approaches. The urine flow rate was 15–20 mL/s in 36 (80 per cent) patients, and 10–15 mL/s in nine (20 per cent) patients. The main postoperative complications included wound infection, incontinence and erectile dysfunction.ConclusionPUDI are on the increase in north‐eastern Nigeria because of increases in road vehicular accidents and firearm injuries from civil strife. The main causes of PUDI in Maiduguri are road vehicular accidents, firearms and civil strife. The results of delayed repair are equally good, despite the absence of immediate endoscopic realignment.

11 SUCCESS RATE OF EARLY PRIMARY URETHRAL REALIGNMENT IS INDEPENDENT OF THE SEVERITY OF PELVIC TRAUMA AFTER TOTAL POSTERIOR URETHRAL DISRUPTION

INTRODUCTION AND OBJECTIVES: Recent studies have shown a role for early urethral primary realignment after complex pelvic trauma. Technical difficulties may be overcome with appropriate technique and technology. We examined the success rate of early urethral primary realignment of total posterior urethral disruption after complex pelvic trauma and the correlation of the severity of pelvic fracture. METHODS: An analysis of a prospective database was performed of patients with pelvic fracture associated with total urethral disruption underwent urethral realignment from 2005 to 2012 at Level I Trauma Center. Fractures were classified according to the orthopedic Young-Burgess classification. Initial urological management consisted of suprapubic tube insertion when the patient was unable to void. We utilized anterograde flexible cystoscopy via suprapubic tube, retrograde rigid cystoscopy and real-time fluoroscopy. Failure of realignment was defined as the inability of urethral catheterization using a retrograde/ anterograde approach. Follow up consisted of urethrograms, urofluxometry and cystoscopy evaluation. We also analyzed continence and erectile function after trauma. The necessity of other procedures such as dilatation, DVIU or urethroplasty was also evaluated after catheter removal. RESULTS: A total of 480 consecutive patients were screened and we found 18 patients with total posterior urethral disruption after complex pelvic trauma with the inability to void. The mean patient age was 40 years. The success rate of the procedure was 100%. Mean operating time was 47 11 minutes. Estimated blood loss was minimal. A total of patients 50.0% had associated organ related injuries. The realignment was accomplished within 3 days after admission. There was no correlation between the orthopedic type of classification and the success of urethral realignment. A total of 10 (56%) patients developed urethral strictures during follow up. Urinary incontinence occurred in 3 (17%) patients and 10 (56%) patients self-reported erectile dysfunction after the trauma. The mean follow up of these patients were 30.2 months. CONCLUSIONS: Early primary endoscopic realignment of total posterior urethral disruption after complex pelvic trauma had 100% success rate due to technology and surgical technique. Moreover, there was no correlation of the severity of pelvic fracture. Pelvic orthopedic classification did not show correlation with post procedure urinary incontinence or erectile function after the trauma.