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Neuville P, Hagedorn JC, Skokan AJ, Morel-Journel N, Wessells H. Management of long-term functional sequelae of pelvic fracture urethral injury. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102711. [PMID: 39074537 DOI: 10.1016/j.fjurol.2024.102711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/25/2024] [Accepted: 07/25/2024] [Indexed: 07/31/2024]
Abstract
Pelvic fracture (PF) is a rare emergency, which led to pelvic fracture urethral injury (PFUI) in 1.6% to 25% of cases. Urethral injury assessment requires a thorough analysis of the initial injury history and imaging that combine cystourethrography acutely, repeat urethral imaging as well as adjunctive use of MRI in the follow-up period. A more complex surgical approach to the delayed reconstruction of PFUI may be predicted by the urethral gap length (cysto-urethrography) or a lower pubo-urethral angle (MRI). Delayed urethroplasty is the treatment of choice, performed once the patient has recovered from other acute injuries, typically at least 3months post-injury. It consists in men in a bulbo-prostatic anastomotic urethroplasty which may require several steps of increasing complexity to allow a tension-free anastomosis: corpora splitting, partial inferior pubectomy, and rarely total pubectomy or urethra rerouting. More complex cases of PFUI repair may be encountered (long gap between the two urethral segments, bulbar necrosis, false passage after failed endoscopic realignment, orthopedic hardware in pubic symphyseal region, pediatric PFUI, failed previous urethroplasty, associated anterior urethral stricture, or recto-urethral fistula) and should be managed in expert centers. Urethral patency is achieved by surgical reconstruction with an overall success rate of 86%. Evaluation of potential associated sequelae including erectile dysfunction and urinary incontinence must be anticipated and taken into consideration in the path of rehabilitation.
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Affiliation(s)
- Paul Neuville
- Department of Urology, University of Washington, Seattle, WA, United States; Service d'urologie, hospices civils de Lyon, Lyon, France.
| | - Judith C Hagedorn
- Department of Urology and Harborview Injury Prevention Center, University of Washington, Seattle, WA, United States.
| | - Alexander J Skokan
- Department of Urology, University of Washington, Seattle, WA, United States.
| | | | - Hunter Wessells
- Department of Urology, University of Washington, School of Medicine and Harborview Injury Prevention and Research Center, Seattle, WA, United States.
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Ojima K, Horiguchi A, Shinchi M, Tabei T, Hirano Y, Ito K, Azuma R. Transperineal bulbovesical anastomosis for extensive posterior urethral stenoses after treatment of prostatic disease. Int J Urol 2022; 29:1511-1516. [PMID: 36094662 DOI: 10.1111/iju.15029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We report our surgical experience of transperineal bulbovesical anastomosis (BVA) for extensive posterior urethral stenosis (PUS). METHODS Six male patients who had extensive PUS extending from the bulbomembranous urethra to the bladder neck due to prostatic disease treatment and underwent transperineal BVA between 2014 and 2020 were retrospectively reviewed. BVA was performed according to the elaborate perineal approach for pelvic fracture urethral repair with minor modifications. After confirming the absence of recurrent stenosis 6 months postoperatively, the patients were offered artificial urinary sphincter (AUS) placement for subsequent urinary incontinence (UI). RESULTS Median patient age was 68, and the etiology of PUS was radical prostatectomy for prostate cancer in four patients, brachytherapy for prostate cancer in one, and transurethral resection of the prostate for benign prostatic hyperplasia in one. All patients had been previously treated with multiple transurethral procedures such as urethrotomy and dilation. Median operative time and blood loss were 211 min and 154 ml, respectively. Five cases (83.3%) had no recurrent stenosis with a median follow-up of 45 months, but a single direct vision internal urethrotomy was performed in one (16.7%) due to restenosis. Four (66.7%) patients underwent AUS placement via transcorporal approach for subsequent UI, but two had it removed due to urethral erosion. CONCLUSION Transperineal BVA could effectively manage extensive PUS after prostatic disease treatment. Staged AUS placement could be a viable option for subsequent UI, but the risk of urethral erosion seemed high.
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Affiliation(s)
- Kenichiro Ojima
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Akio Horiguchi
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Masayuki Shinchi
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Tadashi Tabei
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Ryuichi Azuma
- Department of Plastic Surgery, National Defense Medical College, Saitama, Japan
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Horiguchi A, Shinchi M, Ojima K, Hirano Y, Ito K, Azuma R. Surgical and Patient-Reported Outcomes of Delayed Anastomotic Urethroplasty for Male Pelvic Fracture Urethral Injury at a Japanese Referral Center. J Clin Med 2022; 11:jcm11051225. [PMID: 35268315 PMCID: PMC8911321 DOI: 10.3390/jcm11051225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 12/28/2022] Open
Abstract
We aimed to assess the surgical and patient-reported outcomes of delayed anastomotic urethroplasty (DAU) for pelvic fracture urethral injury (PFUI). We included 211 male patients who underwent DAU for PFUI. DAU success was considered when the urethral lumen was sufficiently large for the passage of a flexible cystoscope, without additional treatment required. The patients completed the lower urinary tract symptoms (LUTS)-related quality of life (QOL) questionnaire (scores: 0, not at all; 1, a little; 2, somewhat; 3, a lot), EuroQol-5 dimensions (EQ-5D), and EQ-5D visual analog scale (EQ-VAS). Postoperative overall satisfaction was evaluated using the following responses: “very satisfied,” “satisfied,” “unsatisfied,” or “very unsatisfied.” DAU was successful in 95.3% cases, with a median postoperative follow-up duration of 48 months. Multivariate logistic regression analysis revealed that “greater blood loss” was an independent predictor of failed urethroplasty. Questionnaire responses were obtained from 80.1% patients. The mean LUTS-related QOL, EQ-5D score and EQ-VAS improved significantly from 2.8, 0.63 and 54.4 at baseline to 0.9, 0.81 and 76.6 postoperatively (p < 0.0001 for all parameters). Moreover, 35.5% and 59.2% of the patients responded being “satisfied” and “very satisfied,” respectively, with their DAU outcomes. DAU not only had a high surgical success rate, but also a significant beneficial effect on both LUTS-related QOL and overall health-related QOL.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
- Correspondence: ; Tel.: +81-4-2995-1676
| | - Masayuki Shinchi
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Kenichiro Ojima
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Ryuichi Azuma
- Department of Plastic Surgery, National Defense Medical College, Saitama 359-8513, Japan;
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Ma Y, Jian Z, Zhou L, Luo D, Jin X, Xiang L, Li H, Wang K. A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis. World J Urol 2021; 39:4227-4234. [PMID: 34146123 DOI: 10.1007/s00345-021-03764-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/11/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations. MATERIALS AND METHODS Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression. RESULTS Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%. CONCLUSIONS PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.
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Affiliation(s)
- Yucheng Ma
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Zhongyu Jian
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Liang Zhou
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Deyi Luo
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Xi Jin
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Liyuan Xiang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Hong Li
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Kunjie Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China.
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[Combined transperineal and transpubic urethroplasty for patients with complex male pelvic fracture urethral distraction defect]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020. [PMID: 32773794 PMCID: PMC7433633 DOI: 10.19723/j.issn.1671-167x.2020.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the clinical effects and characteristics of combined transperineal and transpubic urethroplasty for patients with complex pelvic fracture urethral distraction defect (PFUDD). METHODS We retrospectively reviewed the clinical data of 17 male patients with complex posterior PFUDD from January 2010 to December 2019. The complications included urethrorectal fistulas in 2 patients (11.8%), urethroperineal fistula in 1 patient (5.9%). Ten patients had undergone previous treatments: dilatation in 3 patients (17.6%), internal urethrotomy in 1 patient, failed urethroplasty in 6 patients (35.3%), of whom 2 patients had two times of failed urethroplasties. All the patients were performed with urethroplasty by combined transperineal and transpubic approach with removing the entire pubic bone followed by the anastomosis. RESULTS The mean age of the patients included in this study was 35.5 (range: 21-62) years. The mean length of stricture was 5.5 (range: 4.5-7.0) cm, the mean follow-up was 27 (range: 7-110) months, the mean time of operation was 190 (range: 150-260) min, the mean evaluated blood loss was 460 (range: 200-1 200) mL. There were 5 patients who needed blood transfusion intraoperatively or postoperatively. Wound infection was seen in 4 out of 17 patients and thrombosis of lower extremities in 1 out of 17 patients. The last follow-up showed that the mean postoperative maximum urinary flow rate was 22.7 (range: 15.5-40.7) mL/s. After removing the catheter, one patient presented with decreased urinary flow and symptoms of urinary infection. Cystoscopy showed the recurrent anastomotic stricture, which was cured by internal urethrotomy. In our series, the success rate of the combined transperineal and transpubic urethroplasty was 94.1% (16/17). CONCLUSION Combined transperineal and transpubic urtheroplasty can achieve a tension free anastomosis after removing the entire wedge of pubis in some patients with complex PFUDD. However, this procedure should be completed in a regional referral hospital due to the complexity of the operation and the high percentage of complications.
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Horiguchi A. Management of male pelvic fracture urethral injuries: Review and current topics. Int J Urol 2019; 26:596-607. [PMID: 30895658 DOI: 10.1111/iju.13947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/22/2019] [Indexed: 12/25/2022]
Abstract
Pelvic fractures from high-energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
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Single-surgeon series of delayed anastomotic urethroplasty for pelvic fracture urethral injury: an analysis of surgical and patient-reported outcomes of a 10-year experience in a Japanese referral center. World J Urol 2019; 37:655-660. [DOI: 10.1007/s00345-019-02630-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022] Open
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Gomez RG, Campos RA, Velarde LG. Reconstruction of Pelvic Fracture Urethral Injuries With Sparing of the Bulbar Arteries. Urology 2015; 88:207-12. [PMID: 26616094 DOI: 10.1016/j.urology.2015.09.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/14/2015] [Accepted: 09/17/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To present a novel reconstruction technique for patients with pelvic fracture urethral injuries (PFUI) with bulbar artery sparing. MATERIALS AND METHODS We modified the traditional technique for PFUI reconstruction to preserve the proximal arterial inflow to the bulb. Since 2008, 26 consecutive patients have undergone this technique at our institution. The bulbar arteries are located using a Doppler ultrasound stethoscope and then the bulb is mobilized from one side only, without detachment from the perineum. The artery from that side is sacrificed to preserve the contralateral one; sometimes both arteries can be spared. Removal of the scar and end-to-end anastomosis is performed as usual. Successful arterial preservation was verified by postanastomosis Doppler auscultation. RESULTS Mean age was 37 years (15 to 70). Median time from trauma to urethral reconstruction was 11 weeks and mean stenosis length was 2.3 cm (1 to 4.5 cm). The left bulbar artery was preserved in 14 cases, the right in 4, and both arteries were spared in seven; an accidental injury of the artery to be preserved occurred in the remaining case. At a mean follow-up of 20 months (2-69), all patients are voiding normally stricture free. CONCLUSION Preservation of proximal arterial blood supply to the bulb during PFUI reconstruction is feasible and safe. A well-perfused reconstruction should heal better and theoretically our technique may avoid ischemic failure of the urethroplasty. A larger series and replication of our results in other centers are necessary to validate our technique's potential benefits.
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Affiliation(s)
- Reynaldo G Gomez
- Urology Service Hospital del Trabajador, Santiago, Chile; Universidad Andres Bello School of Medicine, Santiago, Chile.
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Shau YH, Wu ST, Kao CC, Cha TL, Tsao CW, Meng E, Yu DS, Sun GH, Tang SH. Management of complex urethral stricture disease: Algorithm and experience from a single institute. UROLOGICAL SCIENCE 2015. [DOI: 10.1016/j.urols.2015.06.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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