Elsevier

Urology

Volume 83, Issue 3, Supplement, March 2014, Pages S48-S58
Urology

ICUD on Urethral Strictures
SIU/ICUD Consultation on Urethral Strictures: Pelvic Fracture Urethral Injuries

https://doi.org/10.1016/j.urology.2013.09.023Get rights and content

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run—mainly strictures, erectile dysfunction, and urinary incontinence—which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

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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    Financial Disclosure: The authors declare that they have no relevant financial interests.

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