ICUD on Urethral StricturesSIU/ICUD Consultation on Urethral Strictures: Pelvic Fracture Urethral Injuries
Section snippets
Mechanism of PFUI
The posterior urethra is susceptible to PFUI because of its intimate relationship with the bones of the pubic arch, to which it is tethered by the attachments to the puboprostatic ligaments and perineal membrane. Between the 2, the membranous urethra runs from the apex of the prostate to the perineal membrane, beyond which it becomes the bulbar urethra. Between these 2 fixed points, the urethral sphincter mechanism is vulnerable to injury.
PFUIs were typically described as prostatomembranous
Classification
Accurate classification of trauma can be an important guide for clinical management and the evaluation of outcomes. Several classifications have been proposed for PFUI (level 38, 18, 19, 20; level 421), but none has achieved widespread acceptance, in part, because they have not been comprehensive or not clinically useful (or both), but mainly, because no certain method exists for distinguishing between partial and complete injuries.
All classifications have been based on the radiologic
Clinical Presentation, Diagnosis, and Imaging
PFUIs should be suspected in all patients with a pelvic fracture, in particular when disruption of the pelvic ring causing rotational or vertical instability has occurred. These injuries are commonly associated with other internal injuries (level 3).31, 32 Although the incidence of PFUIs in pelvic fractures has ranged from 2%-25% in published studies (level 3),1, 2, 3, 5 these data came from single-institution cohort studies. Also, in a study by Bjurlin et al32 using data from the National
Acute Management
The uncontroversial immediate management of PFUIs is to place a suprapubic catheter to provide urinary drainage and reduce the risk of urinary extravasation. Thereafter, 2 alternative management approaches are available, and the choice between them has been extremely controversial. The first is simply to leave the suprapubic catheter (SPC) in place and perform an interval urethroplasty some months later. The alternative is to realign the urethra.
The rationale for SPC and interval urethroplasty
Reconstruction of Urethral Stenosis or Obliteration After PFUI
The standard approach to the treatment of PFUI stenosis or obliteration has been single-stage excision of the stenosis or obliteration and any associated fibrosis and an overlapping spatulated end-to-end anastomosis of the 2 ends. At a time when the injury was thought to occur at the prostatomembranous junction, the procedure came to be known as bulboprostatic anastomotic urethroplasty. Now that we know it occurs at the bulbomembranous junction, the procedure should be termed “a bulbomembranous
BN Injury
According to Mundy and Andrich,124 “typical” BN injuries (80% of all cases) will be found in lateral compression or open-book pelvic ring disruptions when the puboprostatic ligaments have been pulled apart, resulting in a longitudinal anterior rupture of the prostatic urethra secondarily involving the BN. “Atypical” injuries, such as transverse trauma to the BN or a “blow-out,” will account for the remainder.124 Children are more prone to transverse injuries.100 The diagnosis will be made by
Urorectal Fistula
Urorectal fistula occurs when a PFUI and anorectal trauma coexist, with or without an associated perineal degloving injury. The incidence has been 1.5%-1.8%,126 and the effects of trauma can be complicated by infection, ischemia, and/or iatrogenic manipulation.127, 128
Patients can present with local sepsis, with the passage of urine rectally, or with hematuria and fecaluria.127 The exact location and size can be demonstrated by contrast radiology or cystourethroscopy and rectal examination with
Recommendations
The following recommendations were made from a review of the available published data and expert opinion.
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Cited by (75)
Outcomes of early endoscopic realignment of post-traumatic posterior urethral ruptures
2023, Progres en UrologieSummary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma
2023, European Urology FocusThe effects of primary realignment or suprapubic cystostomy on prostatic displacement in patients with pelvic fracture urethral injury: a clinical study based on MR urethrography
2022, InjuryCitation Excerpt :PR and SPC has been discussed and compared in the past long period. Both of them were recommended for the pelvic fracture urethral injury by major urology association [9–11]. PR was done for shortening the distraction length and reducing the need of DAU.
Postoperative Infection of Male Posterior Urethral Stenosis with Pelvic Fracture: A Retrospective Study from a Chinese Tertiary Teferral Center
2021, UrologyCitation Excerpt :An epidemiological study found that pelvic fracture-associated urethral stenosis accounted for 37.87% of all cases of urethral stenosis.1 According to the recommended guidelines,14,15 end-to-end anastomosis was used as the first choice of treatment for patients with pelvic fracture-associated urethral stenosis at our urethral reconstruction center. With increasing number of end-to-end anastomosis procedures being performed, we have been aware of the importance of management of complications, especially infections.
The Japanese Urological Association's clinical practice guidelines for urotrauma 2023
2024, International Journal of Urology
Financial Disclosure: The authors declare that they have no relevant financial interests.