Straddle Injury Research Articles

外傷性尿道狭窄症に対する初回尿道形成不成功例の検討と救済手術

Salvage urethroplasty after failed repair of traumatic urethral injury is a urological challenge, and we herein describe our experience with it. From October 2010 to January 2012, five patients underwent salvage repair of failed urethroplasties for traumatic urethral injuries: three bulbar straddle injuries and two pelvic fracture urethral injuries. One of the three failed urethroplasties for bulbar straddle injuries was a stricture excision and primary anastomosis, and its failure was due to periurethral abscess formation. Another was an augmented anastomotic urethroplasty using buccal mucosa, and its failure was due to periurethral abscess formation. The third was a tube graft urethroplasty using buccal mucosa, and its failure was due to a stricture at the anastomotic site. Two failed urethroplasties for pelvic fracture urethral injuries were perineal anastomotic repairs combined with corporal separation and inferior pubectomy, and the failures of both were due to ischemic bulbar necrosis. The urethral gap lengths estimated from urethrograms ranged from 12 to 45 mm (mean = 26 mm). Urethroplasties in all patients with bulbar straddle injuries were salvaged by stricture excision and primary anastomosis with corporal separation, and urethroplasties in both patients with pelvic fracture urethral injuries were salvaged by abdominal transpubic perineal urethroplasty. Although the patients who underwent transpubic urethroplasty had transient pelvic girdle pain, no severe complications were observed. All patients were for 10 to 25 months postoperatively (mean = 16 months) able to void satisfactorily without additional treatment. Failed urethroplasties for traumatic urethral injuries can be salvaged with a second reconstruction surgery. The procedure of choice for this salvage is anastomotic urethroplasty with techniques for tension-free anastomosis.

S166 INTERNAL URETHROTOMY COMBINED WITH ANTEGRADE FLEXIBLE CYSTOSCOPY FOR MANAGEMENT OF OBLITERATIVE URETHRAL STRICTURE

We studied the safety and efficacy of flexible cystoscopy-guided internal urethrotomy in the management of obliterative urethral strictures.Forty-three flexible cystoscopy-guided internal urethrotomies were performed between 1999 and 2005. The indication for the procedure was nearly blinded bulbar or membranous urethral strictures not longer than 1 cm that would not allow passage of guide wire. Candidates were those who refused or were unable to undergo urtheroplasty. By monitoring any impression of the urethrotome on the monitor through the flexible cystoscope, we were able to do under-vision urethrotomy. All of the patients were started clean intermittent catheterization afterwards which was tapered over the following 6 months. Follow-up continued for 24 months after the last internal urethrotomy.Seventeen patients were younger than 65 years with a history of failed posterior urethroplasty, and 26 were older than 65 with poor cardiopulmonary conditions who had bulbar urethral stricture following straddle or iatrogenic injuries. Urethral stricture stabilized in 16 patients (37.2%) with a single session of urethrotomy and in 17 (39.5%) with 2 urethrotomies. Overall, urethral stricture stabilized in 76.7% of patients with 1 or 2 internal urethrotomies within 24 months of follow-up. No severe complication was reported.Flexible cystoscopy-guided internal urethrotomy is a simple, safe, and under-vision procedure in obliterative urethral strictures shorter than 1 cm. It can be an ideal option for patients who do not accept posterior urethroplasty or are in a poor cardiopulmonary condition that precludes general anesthesia.

Long-Term Outcome of Primary Endoscopic Realignment for Bulbous Urethral Injuries: Risk Factors of Urethral Stricture

PurposeAlthough endoscopic realignment has been accepted as a standard treatment for urethral injuries, the long-term follow-up data on this procedure are not sufficient. We report the long-term outcome of primary endoscopic realignment in bulbous urethral injuries.MethodsPatients with bulbous urethral injuries were treated by primary endoscopic realignment between 1991 and 2005. The operative procedure included suprapubic cystostomy and transurethral catheterization using a guide wire, within 72 hours of injury. The study population included 51 patients with a minimum follow-up duration of 5 years.ResultsThe most common causes of the injuries were straddle injury from falling down (74.5%), and pelvic bone fracture (7.8%). Gross hematuria was the most common complaint (92.2%). Twenty-three patients (45.1%) had complete urethral injuries. The mean time to operation after the injury was 38.8±43.2 hours. The mean operation time and mean indwelling time of a urethral Foley catheter were 55.5±37.6 minutes and 22.0±11.9 days, respectively. Twenty out of 51 patients (39.2%) were diagnosed with urethral stricture in 89.1±36.6 months after surgery. A multivariate analysis revealed that young age and operation time were independent risk factors for strictures as a complication of urethral realignment (hazard ratio [HR], 6.554, P=0.032; HR, 6.206, P=0.035).ConclusionsUrethral stricture commonly developed as a postoperative complication of primary endoscopic urethral realignment for bulbous urethral injury, especially in young age and long operation time.

尿道狭窄症に対する経尿道的内尿道切開術の有効性の検討

Direct vision internal urethrotomy (DVIU) has been considered to be a low invasive and widely used therapeutic modality for male urethral stricture. However, its efficacy is still controversial. We herein evaluated the efficacy of DVIU for male urethral stricture. Nineteen patients 27 to 78 years old (median age = 59) underwent DVIU for urethral strictures at our hospital were included in this study. Strictures were at bulbar urethra in 17 patients, membranous urethra in 1 patient, and pendulous urethra in 1 patient. The stricture lengths estimated on retrograde urethrography were less than 1 cm in 13 patients, 1-2 cm in 2 patients, and more than 2 cm in 4 patients. The etiology of stricture was straddle injury in 7 patients, post transurethral surgery in 7 patients, pelvic fracture in 1 patient, and unknown in 4 patients. The operation was done by cold knife incision using guidewire. The duration of postoperative urethral catheterization was 5 to 35 days (mean 12.8 days). Follow up duration ranged from 1 month to 139 months (mean 48.2 months). The definition of postoperative re-stricture was the confirmation of re-stricture on retrograde urethrography or deterioration of symptom. While no severe complication was observed, postoperative re-stricture was seen in 13 patients. Stricture-free rates at 3 months, 6 months, and 5 years after the first DVIU were 44.4%, 38.1%, 20.3% respectively. Although second DVIU was done for 7 patients with re-stricture, six patients resulted in failure. Stricture-free rates at 3 months, 6 months, and 5 years after the second DVIU were 42.2%, 28.6%, 14.3% respectively. Though the third DVIU was done for two of them, they were unable to void just immediately after the removal of urethral catheters. Stricture-free rate in stricture less than 1 cm was higher than that in 1 cm or longer, though it did not reach significant difference (p = 0.1813). The efficacy of DVIU is lesser than we expected. DVIU seems to be excessively applied to male urethral strictures and should not be performed for long and recurrent urethral stricture.

Comparison of Immediate Primary Repair and Delayed Urethroplasty in Men with Bulbous Urethral Disruption after Blunt Straddle Injury

PurposeThe aim of this study was to analyze the outcomes of immediate primary repair (IPR) compared with delayed repair (DR) after initial suprapubic cystostomy.Materials and MethodsWe reviewed the records of 60 patients with bulbous urethral disruption after blunt trauma from February 2001 to March 2011. Seventeen patients who presented in an acute injury state underwent IPR; 43 patients underwent DR after the initial suprapubic cystostomy. None of the patients had undergone previous urethral manipulation. We compared the outcomes, including stricture, impotence, and incontinence, between the two management approaches. We also measured the time to spontaneous voiding, the duration of suprapubic diversion, and the number of days spent in the hospital.ResultsThe median follow-up was 20.5 months (range, 13 to 59 months; mean, 23.3 months). Among 17 patients in the IPR group, strictures developed in 2 patients (11.7%), and among 53 patients in the DR group, strictures developed in 8 patients (18.6%, p=0.709). The incidences of impotence and incontinence were similar in both groups (17.6% and 0% in the IPR group vs. 27.9% and 4.6% in the DR group, p=0.520 and 1.000, respectively). The time to spontaneous voiding and the duration of suprapubic diversion were significantly shorter in the IPR group (average 27.3 and 33.4 days, respectively) than in the DR group (average 191.6 and 198.1 days, respectively; p<0.001 and <0.001).ConclusionsIPR may provide comparable outcomes to DR and allow for shorter times to spontaneous voiding and reduce the duration of suprapubic diversion.

Traumatic Bilateral Testicular Dislocation Associated With an Anterior Posterior Compression Fracture of the Pelvis: A Case Report

Traumatic dislocation of a single testicle is an exceedingly rare event and bilateral dislocation is even less common. Traumatic testicular dislocation occurs by the mechanism of direct pressure exerted on the scrotum. Motorcycle collisions are the most frequent causative mechanism, usually related to deceleration straddle injuries. Since traumatic testicular dislocation is associated with other severe injuries, it is usually a late finding, leading to delayed diagnosis and treatment. This report describes a rare case of a patient involved in a motorcycle crash who sustained bilateral testicular dislocation associated with an anterior posterior compression pelvic fracture. To date, there are no reported cases involving management of bilateral testicular dislocation discovered during open reduction and internal fixation of the pelvis. Because the orthopaedic traumatologist may be the first to assess patients with pelvic fracture requiring surgery, the authors feel it is important to raise awareness of this injury.

The therapy of high-flow priapism by superselective internal pudendal artery embolisation

ObjectiveRetrospective summaries of the diagnosis, therapy and effectiveness of six high-flow priapism (HFP) cases caused by trauma.MethodsSix painless priapism male patients with an average age of 29 (18–45) years old,...

Efficacy of urethral catheterisation with a hydrophilic guidewire in patients with urethral trauma for treating acute urinary bladder retention after failed attempt at blind catheterisation

To evaluate the efficacy of urethral catheterisation using a hydrophilic guidewire under fluoroscopic guidance in patients with urethral trauma after a failed attempt at blind catheterisation. A diagnosis of urethral trauma was made in 39 cases in 38 men. Patients ranged in age from 41 to 85 years (mean age, 60 years). Causes of the urethral injuries were iatrogenic urethral injury during catheter placement (n = 18), traumatic self-removal of a catheter (n = 12), straddle injuries (n = 6) and motor vehicle accidents (n = 3). All patients underwent failed blind urethral catheterisation. After urethrography, we attempted to insert a hydrophilic guidewire through the urethra into the urinary bladder, and then to place a 3-way balloon retention urethral catheter into the bladder guided by prior passage of the guidewire under fluoroscopy. Of 39 attempts of inserting the urethral catheter into the urinary bladder, 34 (87.2%) were successful. Of 5 failures (12.8%), 2 were American Association for the Surgery of Trauma (AAST) urethral injury type 3 and 3 were type 4/5. Among these, there were 3 cases of pseudolumen formation. Hydrophilic guidewire-assisted urethral catheterisation in patients with urethral trauma is a safe, simple technique for relieving acute bladder retention after a failed attempt at blind catheterisation. Hydrophilic guidewire-assisted urethral catheterisation is useful following failed blind catheterisation. Immediate management of urethral injury is important to reduce morbidity. Hydrophilic guidewire-assisted urethral catheterisation can be applied immediately after diagnostic urethrography.

Case Records of the Children's Mercy Hospital

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.

Unusual Cause of Failure of End-to-end Anastomotic Urethroplasty for Traumatic Obliterative Bulbar Urethral Stricture

End-to-end anastomotic urethroplasty (EEA) for traumatic bulbar urethral stricture has excellent long-term success rate. We encountered a patient with obliterative bulbar stricture and persistent phlegmon in perineum resulting from straddle injury. Phlegmon-excision and EEA was performed, which ended up in recurrence. Thorough excision of recurrent nodules & scar with stage-I urethroplasty was performed using 'scrotal shutter flap'. Histopathology of phlegmon of first surgery and nodules & urethral margins of second revealed amyloidosis. Stage-II urethroplasty was performed 3-months later after which he is well at 24 months follow-up. This is the first case of perineal-urethral amyloid associated with trauma. Etiology is elusive.

Combining Free Buccal Mucosal Graft and Local Tissue from Urethral Diverticulectomy to Repair Complex Urethral Stricture: Report of a Case

The repair of a complex urethral stricture is a great challenge to all surgeons. Most patients with such a condition underwent repeated endoscopic procedures before having the definitive open repair. We describe a 38-year-old male who sustained straddle injury and subsequently developed stricture at the bulbar urethra. The affected urethral segment was 1-2 cm long in the beginning, but became 6 cm in length after more than 10 endoscopic procedures. Prior to definitive repair, we noted multiple false passages and diverticula in the urethra. In this particular case, the trauma-related urethral diverticulum was used as part of the ventral floor and the rest of the urethral lumen was reconstructed with a free buccal mucosal graft. Following the urethroplasty, a short web-like stricture (＜0.5 cm in length) developed three months after the operation. The short stricture was further managed by endoscopic internal urethrotomy only once. No recurrence was noted up to 18 months thereafter.

Genito-urinary system injuries in Lagos: pattern and general treatment outcome

Genitourinary injuries (GUI) are relatively uncommon. Even though mortality from isolated injuries is rare, they are commonly associated with significant and life long morbidity. This study is to assess the pattern of the injuries and the overall short term treatment outcome in our environment. Fifty consecutive patients diagnosed with genitourinary injuries seen by the Urology Unit through the Accident and Emergency, emergency referrals (or consultations) from the ward or theatre between June 2004 to February 2006 were included in the study. Information collected included demographic data, pattern of presentation, aetiology of injury, type of injury the type of treatment and the immediate outcome. There was a total of 61 injuries in 50 patients. Road traffic accidents was the commonest cause of GUI (58%) followed by straddle injuries (18%) and iatrogenic causes (12%) and miscellaneous (12%). The male- female ratio was 6:1. The urethral was also the most commonly injured organ (60.6%), followed by the kidney (11.5%). The testes were the least injured organs (1.6%). The blunt renal injuries and extraperitoneal bladder injuries were managed by non operative means while most other injuries were managed by surgical intervention. Immediate treatment outcome was satisfactory in most patients. There was one mortality. Most cases of GUI are preventable. Improved safety on the roads,'proper training of surgeons and attention to clinical and surgical details will go a long way in preventing GUI. Early intervention significantly reduces the morbidity and mortality.

Patterns of accidental genital trauma in young girls and indications for operative management

Background/purpose The aim of this study was to define the injury patterns of accidental genital trauma (AGT) in female patients and examine the indications and outcomes of operative intervention. Methods Review of patients younger than 16 years with AGT from 1980 to 2007 excluding sexual- and obstetric-related injuries. Results One hundred sixty-seven patients met the criteria. Mean (±SEM) age was 6.9 (0.2) years. There were 70.5% straddle injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). Injuries to the labia were most frequent (64.0%). Injuries to the posterior fourchette (7.8%) and hymenal disruption (8.4%) were less frequent. There was 87.9% of AGT that was managed expectantly without further sequelae. Twenty patients (12.1%) were managed operatively. Penetrating injuries were more likely to require operative management ( P ≤ .03). The operative group was also more likely to have multiple genital injuries (60% versus 25%, P < .01). Proctoscopy, vaginoscopy, and/or cystoscopy were performed in 55% of patients in the operative group. Conclusions Accidental genital trauma is most commonly caused by straddle-type injuries and is usually amenable to nonoperative management. Hymenal disruption and injuries to the posterior fourchette are uncommon with these types of injuries.

Straddle injuries to the bulbar urethra: management and outcomes in 78 patients

Straddle injuries to the bulbar urethra: management and outcomes in 78 patients

Straddle injuries to the bulbar urethra: management and outcome in 53 patients

Straddle injuries to the bulbar urethra: management and outcome in 53 patients

Traumatic urologic injuries in Ile-Ife, Nigeria

Background:In a developing country with limited healthcare resources, traumatic injuries and their management pose a significant challenge to healthcare delivery.Aim:To highlight the challenges in the management of traumatic urologic injuries in patients in our setting.Setting and Design:Patients presenting with traumatic injuries to the urinary tract, between January 1996 and December 2005, in a University Teaching Hospital in Southwestern Nigeria were the subjects of this study.Patients and Methods:Clinical records of patients who had such injuries were reviewed.Results:Ninety injuries occurred in 86 patients including 77 males and 9 females aged 14–68 years. Fourteen (15.5%) of the injuries involved the kidneys, urinary bladder was involved in 23 (25.6%) and the male urethra in 53 (58.9%) injuries. The mechanisms of injury were road traffic accidents in 52 (60.5%) patients, straddle injuries in 18 (20.9%), trauma to the back in 8 (9.3%), falls from a height in 6 (7.0%) and gunshot injuries in 2 (2.3%) patients. Associated injuries include pelvic fractures in 33 (38.4%) patients, limb bone fractures in 13 (14.1%), intestinal injuries in 12 (13.0%) and spinal injuries in 8 (8.7%) patients. In most patients, diagnosis was made based on clinical suspicion and minimal investigations such as abdominal ultrasound, urethrocystoscopy and/or urethrocystography. The outcome was good in most patients and mortality was recorded in only 2 (2.3%) patients who had concomitant spinal and burns injuries.Conclusion:Prompt management instituted on clinical suspicion of injuries presents a good outcome in patients in a limited resource setting.

Pediatric Vulvovaginal Disorders: A Diagnostic Approach and Review of the Literature

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

Straddle injuries to the bulbar urethra: management and outcome in 53 patients

To describe our experience with blunt injuries to the bulbar urethra and their late sequelae to identify factors that may affect patient outcome. A retrospective study was performed on 53 male patients who presented, between January 2001 and December 2005, with blunt traumatic injury to the bulbar urethra. The definitive diagnosis of urethral rupture was made by retrograde urethrography, where urethral rupture was classified into partial or complete. The minimum follow-up period was 3 years. The initial management was either suprapubic cystostomy or endoscopic urethral realignment over a urethral catheter using a cystoscope to pass a guide-wire over which the catheter was inserted. Stricture formation was managed by visual internal urethrotomy (VIU) for passable strictures and urethroplasty (stricture excision and re-anastomosis) for impassable strictures or recurrence after VIU. The follow-up period was three years. The results were analyzed by SPSS software (chi-square and Student's-t-test). Stricture formation occurred in 19 of 22 patients (86%) with complete urethral rupture and in 10 of 31 (32%) with partial rupture (p < 0.001). Strictures occurred in 11 of 31 (35%) patients treated initially with suprapubic cystostomy and in 18 of 22 (82%) treated with primary urethral realignment (p < 0.001). The success rate after VIU was 15% (4 of 26 patients) and after urethroplasty it was 96% (24 of 25 patients) (p < 0.001). Suprapubic cystostomy is better than urethral realignment and catheterization as primary management after straddle injury to the bulbar urethra. Stricture excision and re-anastomosis is better than VIU as delayed management for strictures that develop after straddle injury to the bulbar urethra.

Improper Retrograde Urethrogram Technique Leads to Incorrect Diagnosis

Radiology Page Improper Retrograde Urethrogram Technique Leads to Incorrect Diagnosis A 32-year-old man sustained a straddle injury dur- ing a motorcycle accident. Physical examination re- vealed blood at the urethral meatus and a closed right humerus fracture. Before Foley catheter inser- tion a retrograde urethrogram was obtained (part A of figure). Contrast failed to fill the bladder indicat- ing a possible complete disruption at the penoscrotal junction. However, on closer inspection the study was not technically sound. The penis was folded over the scrotum, whereas it should be on full stretch and perpendicular to the body to straighten the bend in the urethra at the penoscrotal junction. In addition, there was venous intravasation of contrast material in the corpus spongiosum and surrounding veins, indicating ex- cessive pressure or speed of contrast injection. 1 Another retrograde urethrogram using the proper technique showed only partial urethral disruption and contrast flow to the bladder (part B of figure). A well lubricated Foley catheter was gently inserted through the urethra into the bladder. A month after the injury repeat retrograde urethrogram showed an area of stricture in the bulbar urethra which was subsequently balloon dilated. Blunt urethral injuries usually result from strad- dle type of trauma incurred after forceful contact of the perineum with a blunt object. 2 Any focused ex- ternal force as encountered in falls and vehicular accidents can crush the immobile bulbous urethra against the inferior pubis. Blood at the meatus is seen in at least 75% of patients after external ante- rior urethral trauma. 2 No instrumentation should be used until a proper retrograde urethrogram is obtained if meatal blood is present or suspicion of urethral injury exists. A retrograde urethrogram is taken by positioning the patient obliquely at 45 degrees with the bottom leg flexed 90 degrees at the knee and the top leg kept straight. A 12Fr Foley catheter is introduced into the fossa navicularis, the balloon is inflated with 2 ml saline to prevent dislodgement, the penis is placed on gentle traction and 20 to 30 ml undiluted water soluble contrast material are injected with the film exposed. 3 Occasionally a Foley catheter has been success- fully placed before evaluating the urethra. In this setting if no meatal blood is present and suspicion of injury is low, further imaging is not needed. If blood is present a pericatheter retrograde urethrogram should be performed. Some advocate the coaxial placement of a 3Fr catheter to the level of the pos- terior urethra followed by contrast injection. 4 In our experience this technique does not distend the ure- thra sufficiently to properly define the injury. Better anatomical detail is provided by injecting contrast material through a 3Fr catheter or angiocatheter A, on retrograde urethrogram performed using poor technique urethra appears disrupted. B, on properly performed retrograde urethrogram urethra is in continuity. THE JOURNAL OF UROLOGY ® Copyright © 2009 by A MERICAN U ROLOGICAL A SSOCIATION www.jurology.com Vol. 182, 716-717, August 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.04.060

Straddle Injury in Girls. A Pilot Study Testing Potential for an Injury Surveillance Registry

Objectives: Straddle injury represents a rare and complex injury to the female genito urinary tract (GUT). Overall prevention would be the ultimate goal, but due to persistent inhomogenity and inconsistency in definitions and guidelines, or suboptimal coding, the optimal study design for a prevention programme is still missing. Thus, medical records data were tested for their potential use for an injury surveillance registry and their impact on future prevention programmes. Design: Retrospective record analysis out of a 3 year period. Setting: All patients were treated exclusively by the first author. Patients: Six girls, median age 7 years, range 3.5 to 12 years with classical straddle injury. Interventions: Medical treatment and recording according to National and International Standards. Main Outcome Measures: All records were analyzed for accuracy in diagnosis and coding, surgical procedure, time and location of incident and examination findings. Results: All registration data sets were complete. A specific code for “straddle injury” in International Classification of Diseases (ICD) did not exist. Coding followed mainly reimbursement issues and specific information about the injury was usually expressed in an individual style. Conclusions: As demonstrated in this pilot, population based medical record data collection can play a substantial part in local injury surveillance registry and prevention initiatives planning.