Rupture Of Posterior Urethra Research Articles

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.

The Effect of Multiple Surgeries on Psychosocial Outcomes in Pediatric Patients: A Scoping Review.

Birth defects affect 3% of all babies born in the United States each year. Unlike reconstruction for many acquired deformities, one hallmark of reconstruction for complex congenital conditions is the requirement of multiple surgeries, procedures, and therapies from birth to maturity. These interventions often result in significant medical burden on children during development with potential long-term psychosocial consequences. The aim of this study was therefore to better define the psychosocial impact of repetitive operations on the pediatric patient. A scoping review was performed under the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Review guidelines. We searched the PubMed, Cochrane Library, Science Direct, and Web of Science databases using key words "number of surgeries," "psychosocial," "pediatric," and related terms. Primary articles published in English describing psychosocial outcomes in pediatric patients who underwent more than one procedure or surgery were included (n = 25). The Newcastle-Ottawa Scale was used to assess the quality of each study. We included 25 articles published between 1995 and 2019, which included 6520 patients. The most common diagnosis across all studies was congenital heart disease (CHD) (n = 4169, 63.9%), followed by cleft lip and palate (n = 1196, 18.3%). The average number of operations and procedures was 3.4 (range = 1-18) and 32.1 (range = 6-89), respectively. The association between repetitive surgeries and poorer psychosocial outcomes was demonstrated in children with early-onset scoliosis, CHD, hydrocephalus, bladder exstrophy, posterior urethral rupture, anorectal anomalies, and conditions requiring numerous nonsurgical procedures. There were also a few CHD, cleft lip and/or palate, and hydrocephalus studies that did not find a significant correlation. The studies here suggest that certain pediatric patient populations are at risk for impaired psychosocial functioning as a result of repetitive procedures. However, it is important to differentiate whether the association with poorer psychosocial outcomes is from the number of surgical procedures or whether the number if just a surrogate for increased disease complexity. Standardized psychosocial outcomes measures and future prospective, long-term, randomized clinical trials are also warranted.

Ureterscopic urethral realignment for the treatment of male posterior urethral rupture

目的 探讨输尿管镜下尿道会师术治疗男性后尿道断裂的疗效及安全性。 方法 回顾性分析本院自2011年3月至2015年5月收治的13例后尿道断裂的男性患者，行输尿管镜下尿道会师术的临床资料。 结果 有9例患者单纯经尿道输尿管镜下尿道会师术成功，4例患者联合耻骨上膀胱造瘘通道下行尿道会师术成功。手术时间15～55 min。术后随访1～4年，有9例患者排尿困难，其中6例患者定期尿道扩张后治愈，另3例患者接受尿道内切开术，其中2例患者经尿道内切开并按时扩张后治愈，1例患者最终在上级医院完成尿道狭窄段切除及尿道端端吻合术后治愈。有8例患者发生不同程度的性功能障碍。无患者发生尿失禁。 结论 输尿管镜下尿道会师术治疗男性后尿道断裂能够早期恢复尿道连续性，且损伤小、出血少、恢复快，值得临床推广。

Traumatic Posterior Urethral Strictures in Children and Adolescents.

Background: Management of partial or complete traumatic urethral disruptions of the posterior urethra in children and adolescents, secondary to pelvic fracture poses a challenge. Controversy exists as to the correct acute treatment of posterior urethral injuries and delayed management of PFPUDDs. We reviewed the urological literature related to the treatment of traumatic posterior urethral injuries and delayed repair of these distraction defects in children and adolescents.Material and Methods: There are few long-term outcomes studies of patients who underwent PFPUDDs repairs in childhood; most reports included few cases with short follow up. We excluded studies in which the cohort of patients was heterogeneous in terms of stricture disease, etiology and location.Results: Primary cystostomy and delayed urethroplasty is the traditional management for PFPUIs. Immediate repair is rarely possible to perform. Realignment of posterior urethral rupture in children is indicated in special situations: (a) concomitant bladder neck tears, (b) associated rectal lacerations, (c) long disruptions of the urethral ends. Before delayed reconstruction ascending urethrography and micturating cystourethrogram along with retrograde and antegrade urethroscopy define site and length of the urethral gap. However, the most accurate evaluation of the characteristics of the distraction defect is made when surgical exposure reveals the complexity of the ruptured urethra. Partial ruptures may be managed with urethral stenting or suprapubic cystostomy, which may result in a patent urethra or a short stricture treated by optical urethrotomy. The gold standard treatment for PFPUDDs in children is deferred excision of pelvic fibrosis and bulbo-prostatic tension-free anastomosis, provided a healthy anterior urethra is present. Timing of delayed repair is at 3 to 4 months after trauma. Some urologists prefer either the perineal access or the transpubic approach to restore urethral continuity in children with PFPUDDs. Substitution urethroplasties are used in children with PFPUDDs, when anastomotic repair can't be achieved due to severe damage of the bulbar urethra.Conclusion: As evidenced in this review the progressive perineo-abdominal partial transpubic anastomotic repair has advantages over the isolated perineal anastomotic approach in patients with “complex” PFPUDD. This approach provides wider exposure and facilitates reconstruction of long or complicated posterior urethral distraction defects

Rupture of Posterior Urethra without Pelvic Fracture: A Rare Presentation

Rupture of the posterior urethra is a rather uncommon finding in patients with pelvic trauma. It is usually accompanied by pelvic fractures. Herein, we report the case of a 27-year-old man with isolated rupture of the posterior urethra –without pelvic fracture- after falling. The patient was successfully treated with primary suprapubic cystostomy and delayed urethral reconstruction surgery, after which he was discharged in good condition with no urologic complication. The consensus on these cases is either to perform an early realignment or to do late reconstructive surgery.

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

Evaluation of early endoscopic realignment of post-traumatic complete posterior urethral rupture

Introduction:to report our experience with 41 patients treated by early endoscopic realignment of complete post-traumatic rupture urethra.Materials and Methods:The study includes patients presented to our institute, between May 2004 and April 2009, with post-traumatic complete posterior urethral disruption. Preoperative retrograde urethrography, voiding cystourethrography and abdominopelvic CT were performed to evaluate the urethral defect length, the bladder neck competence, the prostate position, and the extent of the pelvic hematoma. Within the first week after trauma, antegrade and retrograde urethroscopy were performed to identify both urethral ends and insert urethral catheter. Patients were followed up by pericatheter retrograde urethrogram monthly postoperatively till catheter removal on disappearance of extravasation. Retrograde urethrography, voiding cystourethrography and urethroscopy were performed 1 month after the removal of the catheter. Follow-up abdominal ultrasound and uroflowmetry monthly till 6 months, bimonthly till 1 year, and every 3 months thereafter were encouraged. Urinary continence and postoperative erectile dysfunction were assessed by direct patient interview.Results:Forty one patients in the age group 17-61 years (mean 37.9) were treated. Patients were followed up forConclusions:Early endoscopic realignment for complete posterior urethral rupture is a feasible technique with no or minimal intraoperative complications. The technique is successful as the definitive line of therapy in reasonable number of patients and seems to render further future interventions for inevitable urethral stricture easier.

Experiencia en reconstrucción postraumática de uretra posterior en niños: Hospital Universitario San Vicente de Paúl. Medellín 1987-2007

In order to evaluate the efficacy of different surgical techniques for the correction of traumatic lesions of the urethra, we performed a retrospective study in those patients, and evaluated different complications such as postsurgical stenosis of the urethra, incontinence and impotence (erectile dysfunction). A retrospective study was conducted, reviewing the clinical charts of 43 patients admitted to the San Vicente of Paul Hospital, with diagnosis of traumatic rupture of the posterior urethra from 1987 to 2007. We analyzed different demographic data, type of surgical correction, early and late complications. The average age of the patients was 7.7 years, the average follow up was 30.6 months, and all the patients were male with a posterior urethral rupture. 27 Patients underwent a primary urethral repair (63%), 13 patients underwent a cistostomy with later urologic reconstruction (30%), in 3 patients (7%) other surgical procedures were made. Overall complication rate was 39.5%. These complications were: Urethral stenosis, 26 patients (60.5%), urinary retention secondary to obstruction, 10 patients (23.3%), incontinence 10 patients (23.3%) and impotence 7 patients (16.3%). Patients treated with a primary urethral repair presented a significantly less development of infection, obstruction and stenosis, (p<0.05). Patients with pelvis fracture associated to urethral trauma had a significant higher risk of developing stenosis and impotence. (p<0.05). Both different surgical techniques compared showed a similar complication and morbidity rates in middle follow up. Each procedure should be selected according to clinical condition of the patient, the extension of the urethral damage, the associated traumatic lesions and the surgeon's expertise. In our searched patients, treated with a primary urethral repair we found a significantly less development of infection, obstruction and stenosis.

Experiencia en reconstrucción postraumática de uretra posterior en niños. Hospital Universitario San Vicente de Paúl. Medellín 1987-2007

ObjectiveIn order to evaluate the efficacy of different surgical techniques for the correction of traumatic lesions of the urethra, we performed a retrospective study in those patients, and evaluated different complications such as postsurgical stenosis of the urethra, incontinence and impotence (erectile dysfunction). MethodsA retrospective study was conducted, reviewing the clinical charts of 43 patients admitted to the San Vicente of Paul Hospital, with diagnosis of traumatic rupture of the posterior urethra from 1987 to 2007. We analyzed different demographic data, type of surgical correction, early and late complications. ResultsThe average age of the patients was 7.7 years, the average follow up was 30.6 months, and all the patients were male with a posterior urethral rupture.27 Patients underwent a primary urethral repair (63%), 13 patients underwent a cistostomy with later urologic reconstruction (30%), in 3 patients (7%) other surgical procedures were made.Overall complication rate was 39.5%. These complications were: Urethral stenosis, 26 patients (60.5%), urinary retention secondary to obstruction, 10 patients (23.3%), incontinence 10 patients (23.3%) and impotence 7 patients (16.3%).Patients treated with a primary urethral repair presented a significantly less development of infection, obstruction and stenosis. (p<0.05). Patients with pelvis fracture associated to urethral trauma had a significant higher risk of developing stenosis and impotence. (p<0.05). ConclusionsBoth different surgical techniques compared showed a similar complication and morbidity rates in middle follow up. Each procedure should be selected according to clinical condition of the patient, the extension of the urethral damage, the associated traumatic lesions and the surgeon`s expertise. In our searched patients, treated with a primary urethral repair we found a significantly less development of infection, obstruction and stenosis.Keywords: Trauma of urethra posterior. Children. Primary urethral repair. Cistostomy with later urologic reconstruction.

Trauma to the pelvis: urethral injury

The possibility and the degree of posterior urethral rupture must be investigated in cases of pelvic fractures, with the aim of minimizing the very serious consequences of stricture, impotence, and incontinence. Because clinical signs may be misleading, diagnosis and treatment needs to be based on accurate visualization of the urethra, which can be accomplished in most medical situations via dynamic retrograde urethrography (DRU). This technique reveals whether there is an intact but perhaps damaged urethra, or a partial or complete rupture. Accurate assessment then allows the medical team to decide on presurgical treatment, catheter placement, and the timing of surgical repair.

Traumatic Obliterative Urethral Strictures in Pediatric Patients: Failure of the Cut to Light Technique at Long-Term Followup

The cut to light procedure or antegrade and retrograde urethroscopy with endoscopic incision of obliterative urethral strictures is an accepted method of treating posterior urethral distraction injuries. We report long-term followup on 22 pediatric patients treated with this technique. The records of all pediatric patients with a posterior urethral distraction injury treated from 1986 through 2006 were reviewed. The cut to light procedure was performed for obliterative strictures less than 1 cm via a cold knife or laser in 11 patients each. A urethral catheter was left in situ for 3 weeks. Patients were then followed a minimum of 2 years. A total of 22 patients at a median age of 11 years (range 3 to 16) were treated. Followup revealed stricture recurrence in all patients. Median time to recurrence was 3 months after catheter removal (range 5 days to 1 year). Although intermittent catheterization to maintain patency was attempted in all patients, the development of impassable urethral strictures in 16 (73%) and complaints of chronic pain with catheterization in 4 (18%) led to end-to-end urethroplasty. Successful reconstruction with open surgery was achieved in 19 of 20 patients (95%). Two patients (9%) maintained urethral patency with intermittent catheterization. In children with obliterative posterior urethral distraction injuries a cut to light procedure had a long-term success rate of 0%. All patients required daily intermittent catheterization (9%) or formal urethral reconstruction (91%) to maintain patency. We would strongly recommend against treating pediatric obliterative urethral strictures with a cut to light procedure.

Diagnostic et traitement des ruptures de l'urètre postérieur

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until Resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.

Endoscopic Primary Realignment under Open Cystostomy in the Patients with Posterior Urethral Rupture that were Impossible for Lithotomy Position, Accompanied by Pelvic Bone Fracture: Long-term Results

Purpose: The aim of this study was to evaluate the long-term results of endoscopic primary realignment of a posterior urethral rupture accompanied by a pelvic bone fracture. Materials and Methods: Our study population consists of 7 patients who were able to be followed up for at least 5 years, of an initial 8 that underwent endoscopic primary realignment of a posterior urethral rupture due to a pelvic bone fracture. Operations were carried out in the following order; the bladder was incised to allow a metal sound, with stitching fiber then tied at its end so it could be advanced into the injured proximal urethra through the bladder neck. The fiber was then traced using a cystoscope and connected to a urethral catheter, which could be indwelled in the bladder by pulling the sound back. Results: The mean follow-up period was 8.1 (5.2-9.7) years. The mean operation time was 48.3 (28-71) minutes. There were no severe disruptions of the pelvic hematoma, transfusions or other additive injuries during the operations. Post-operation complications were observed in 4 patients; 3 cases of mild urethral stricture, which were treated with an endoscopic intra-urethrotomy followed by clean intermittent catheterization, 3 cases of erectile dysfunction and 1 case each of urinary incontinence and a urethral stone. Conclusions: This study clearly implies that endoscopic primary realignment of a severe posterior urethral rupture accompanied by a pelvic bone fracture is less invasive and a safer method, without pelvic hemorrhage or additional injuries. Early endoscopic intervention also improves the quality of life by reducing the possibility of an invasive procedure, and also prevents severe urethral stricture and the resultant complications by maintaining the continuity of the urethra. (Korean J Urol 2006;47:1361-1366)

Long-term urologic, orthopedic, and psychological outcome of posterior urethral rupture in children

Objectives To evaluate the long-term urologic, orthopedic, and psychological outcome of children after posterior urethral rupture (PUR) due to pelvic trauma. Methods We retrospectively reviewed the records of 49 children with PUR from 1986 to 2000. The long-term urologic results were determined by voiding function, continence, and erectile function. The orthopedic results were determined by pelvic radiography and a questionnaire. Psychiatric diagnoses were made using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria and the Structured Clinical Interview for DSM-IV Axis I Disorders. Results The mean follow-up was 12 years (range 4 to 17). The average age was 8 years at the time of the trauma and 20 years at the last follow-up. Urethral continuity was achieved in 97.9% of the children. Of the 49 patients, 19 had at least one urologic complication, 18 had orthopedic pathologic findings, and 21 had psychiatric diagnoses. The number of urologic procedures required (more than three), presence of long-term complications, and total number of hospitalizations (more than three) secondary to the injury significantly affected the development of a psychological disorder. Conclusions The results of our study have shown that posttraumatic PUR in children is associated with a significant rate of long-term complications. Nonoperative treatment of pediatric pelvic fractures associated with PUR has been quite successful. Repeated operations, the presence of long-term urologic complications, and frequent and long hospital stays result in serious attendant psychological problems. Therefore, careful and prolonged follow-up of posttraumatic urethral injury with a multidisciplinary approach is necessary to provide better outcomes and a better quality of physical and social life for these children.

Long-term outcome of posterior urethral rupture in boys: A comparison of different surgical modalities

Objectives To evaluate the long-term outcome of posterior urethral rupture due to pelvic trauma. Methods We retrospectively reviewed the records of 49 children with posterior urethral rupture from 1986 to 2000. The urologic evaluation at the last follow-up visit was made by the same surgeon and included physical examination, ultrasonography, simultaneous retrograde urethrography, and voiding cystourethrography, as well as cystourethroscopy in some cases. The long-term urologic results were determined by voiding function, continence and erectile function, and semen analysis. Results The mean follow-up was 12 years (range 4 to 17). The average age was 8 years at the time of trauma and 20 years at the last follow-up visit. Primary realignment (22 patients), immediate repair (8), and delayed repair (16) were performed for posterior urethral rupture. Urethral continuity was achieved in 97.9% of patients, and 30 (61.2%) were free of symptoms. The overall rate of long-term complications was significantly greater in patients with a prostatic urethra location injury, and it was similar for the three surgical procedures. Conclusions The results of our study have shown that, apart from partial injury, all types of surgical treatment are equally problematic, with similar complication rates and long-term morbidity. The procedure of choice should be individualized, depending on the anatomy and the extent of the urethral injury, stability of the patient, and presence of additional injuries.

Primary realignment of posterior urethral rupture.

We report the results of treatment of posterior urethral rupture (PUR) by primary realignment with some modifications of the technique. In this prospective study, 25 patients (mean age, 33.5 years; range, 18 to 70 years) in whom PUR had been proved underwent primary urethral realignment. All patients were evaluated postoperatively for urinary incontinence, erectile dysfunction, and urethral stricture. They were followed for a mean of 20 months (range, 9 to 27 months). In 20 of 25 patients (80%), posterior urethral rupture was associated with pelvic fractures and in 2 (8%), bladder rupture was also present. None of the patients had urinary incontinence. Six patients (24%) had evidence of postoperative stricture that required urethral dilatation and/or direct vision internal urethrotomy in 2 or 3 procedures under local anesthesia. Erectile dysfunction was reported by 4 patients (16%) as a decreased quality of erection, all of whom responded to sildenafil. We believe that primary realignment of PUR is a simple procedure associated with low morbidity. It is recommended for patients who are stable and have no other significant intra-abdominal and pelvic organ injuries.

THE ROLE OF SILDENAFIL IN THE TREATMENT OF ERECTILE DYSFUNCTION IN PATIENTS WITH PELVIC FRACTURE URETHRAL DISRUPTION

Erectile dysfunction (ED) is a common sequel of pelvic fracture urethral disruption (PFUD). After repair of the urethral injury ED may be the most devastating long-term effect for the patient. Some patients with ED may regain normal erectile function. We prospectively studied the response to sildenafil and the erectile function of patients with ED due to PFUD. The erectile function of patients referred to us with PFUD for urethroplasty were prospectively evaluated before surgery. Patients underwent nocturnal penile tumescence testing and, if results were abnormal, penile duplex ultrasonography with intracavernous injection and arteriography were performed to diagnose the etiology of ED. Patients were questioned about erectile function every 3 months after surgery and if they complained of ED they were offered 100 mg sildenafil. Patients were followed for at least 18 months after surgery. A total of 29 consecutive patients were evaluated and 22 (76%) of them had ED before surgery. Sufficient followup was available for 15 of the patients. Overall 47% of these patients responded favorably to sildenafil. Of the patients 60% with neurogenic ED and 20% of those with arterial ED responded to this treatment. In 33% of the patients ED resolved within the followup period. All patients with spontaneous resolution of ED previously responded to sildenafil (71% of sildenafil responders). In patients with ED due to PFUD, those with neurogenic ED are more likely to respond to sildenafil than those with arterial damage. Favorable response to sildenafil may predict spontaneous resumption of normal erectile function over time.

Delayed primary realignment of posterior urethral rupture.

The treatment of acute posterior urethral rupture is controversial. Twelve patients who presented with acute posterior urethral rupture over a five-year period were treated by delayed primary realignment of the injury. The technique of this procedure and the outcome are the subject of this presentation. Eight patients had successful realignment without strictures. Two patients with strictures responded to simple dilatations with bougies and the other two had formal urethroplasty.