Early endoscopic realignment as primary therapy for complete posterior urethral disruptions

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

The Immediate Management of Pelvic Fracture Urethral Injury-Endoscopic Realignment or Cystostomy?

PURPOSE

We determined whether endoscopic realignment or cystostomy would provide the best immediate management of pelvic fracture urethral injury.

MATERIALS AND METHODS

We retrospectively reviewed the records of 590 patients with pelvic fracture urethral injury. Of the patients 522 were included in analysis due to strict criteria, including 129 in the endoscopic realignment group and 393 in the cystostomy group. Data on stricture formation and length, intervention technique and long-term functional outcomes were analyzed.

RESULTS

In the endoscopic realignment group stricture developed in 111 patients (83%) at a mean of 23.5 months, which is longer than the 7.6 months reported in the cystostomy group (p <0.05). Mean stricture length was 3.2 cm in the realignment group and 3.7 cm in the cystostomy group (p <0.05). Internal urethrotomy was performed in 21 patients (19%) treated with realignment vs 18 (5%) treated with cystostomy (p <0.05). Further repair was accomplished via simple perineal anastomosis in 57 patients (51%) with realignment and 138 (35%) with cystostomy (p <0.05). Ancillary procedures such as corporeal splitting, inferior pubectomy and crural rerouting were necessary in 14 (13%), 14 (13%) and 5 patients (4%) in the endoscopic realignment group, and in 94 (24%), 100 (25%) and 43 (11%), respectively, in the cystostomy group (all p <0.05). The rates of impotence and incontinence did not statistically differ between the endoscopy and cystostomy groups (14.3% vs 16.2% and 1.6% vs 2.1%, respectively, p >0.05).

CONCLUSIONS

Endoscopic realignment may reduce stricture formation and length, and facilitate urethroplasty. However, endoscopic realignment is also associated with a prolonged clinical course for recurrence.

Pro: endoscopic realignment for pelvic fracture urethral injuries

Patients with pelvic fracture urethral distraction injuries may benefit from early endoscopic realignment. Realignment is associated with a low risk of immediate complications and has a high success rate for achieving catheter placement. Review of over thirty studies assessing for subsequent urethral stenosis, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Furthermore, realignment may result in easier subsequent urethroplasty and possibly shorter stenoses.

The management of the acute setting of pelvic fracture urethral injury (realignment vs. suprapubic cystostomy alone)

Background

In patients with pelvic fracture urethral injury there are two options for management: First, to realign as an early primary realignment over a catheter; and second, to place a suprapubic tube with delayed urethroplasty of the inevitable stricture.

Methods

We reviewed previous reports from 1990 to the present, comparing early endoscopic realignment, early open realignment and suprapubic tube placement, to determine the rates of incontinence, erectile dysfunction and stricture formation.

Results

Twenty-nine articles were identified. The rates of erectile dysfunction, incontinence, and stricture formation, respectively, were: for early endoscopic realignment, 20.5%, 5.8% and 43.8%; for open realignment over a catheter, 16.7%, 4.7% and 48.9%; and for a suprapubic tube and delayed urethroplasty 13.7%, 5.0%, and 89.0%. A one-way anova showed no difference in the mean rate of erectile dysfunction (P = 0.53) or incontinence (P = 0.73), and only stricture formation was significantly different (P < 0.1).

Conclusion

The rates of incontinence and erectile dysfunction are similar between the groups. Only the rate of stricture formation was higher in the suprapubic tube and delayed urethroplasty group.

Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis

OBJECTIVE

To compare primary urethral realignment (PR) with suprapubic cystostomy (SPC) for the management of pelvic fracture-associated posterior urethral injuries with regards to rates of stricture, erectile dysfunction, and urinary incontinence.

METHODS

Two electronic databases (MEDLINE and EMBASE) were searched with the assistance of a librarian. Title, abstract, and full text screening was carried out by 2 independent reviewers, with discrepancies resolved by consensus. Narrative reviews, surveys, and historical articles were excluded. Only studies reporting a direct comparison of PR vs SPC for the management of posterior urethral injuries associated with blunt trauma in adults were included. Quality assessment of the included articles was performed in duplicate. Stricture incidence was evaluated for all included studies, as were erectile dysfunction and incontinence rates when reported. All outcomes were treated as dichotomous data with calculation of odds ratio and were pooled using a random effects model with Review Manager 5.1.

RESULTS

Our comprehensive search yielded 161 unique articles. Nine articles were included in the final meta-analysis. Stricture rate was significantly lower in the PR group (odds ratio [OR] = 0.12, 95% confidence interval [CI] 0.04-0.41, P <.001). There was no significant difference between the 2 interventions with regards to erectile dysfunction (OR = 1.19, 95% CI 0.73-1.92, P = .49) or incontinence (OR = 0.75, 95% CI 0.38-1.48, P = .41).

CONCLUSION

PR appears to reduce the incidence of stricture formation after pelvic fracture-associated posterior urethral injuries as compared with SPC.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries

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.

Delayed repair is the ideal management for posterior urethral injuries- FOR the motion

Posterior urethral injuries are seen in trauma cases with pelvic fracture. The time-tested and honored method of management is immediate supra-pubic diversion followed by delayed repair. Immediate alignment as a management option is not new. It was abandoned 30 years ago due to high incidence of incontinence and impotence. However, of late there is a tendency towards immediate management of these injuries with various endoscopic maneuvers. Unfortunately, there is little evidence supporting this. Even these evidences are of limited in number and of limited duration of follow-up.

EAU Guidelines on Urethral Trauma

CONTEXT

These guidelines were prepared on behalf of the European Association of Urology (EAU) to assist urologists in the management of traumatic urethral injuries.

OBJECTIVE

To determine the optimal evaluation and management of urethral injuries by review of the world's literature on the subject.

EVIDENCE ACQUISITION

A working group of experts on Urological Trauma was convened to review and summarize the literature concerning the diagnosis and treatment of genitourinary trauma, including urethral trauma. The Urological Trauma guidelines have been based on a review of the literature identified using on-line searches of MEDLINE and other source documents published before 2009. A critical assessment of the findings was made, not involving a formal appraisal of the data. There were few high-powered, randomized, controlled trials in this area and considerable available data was provided by retrospective studies. The Working Group recognizes this limitation.

EVIDENCE SYNTHESIS

The full text of these guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article comprises the abridged version of a section of the Urological Trauma guidelines.

CONCLUSIONS

Updated and critically reviewed Guidelines on Urethral Trauma are presented. The aim of these guidelines is to provide support to the practicing urologist since urethral injuries carry substantial morbidity. The diversity of urethral injuries, associated injuries, the timing and availability of treatment options as well as their relative rarity contribute to the controversies in the management of urethral trauma.

Urethral cystoscopic realignment and early end-to-end anastomosis develop different influence on erectile function in patients with ruptured bulbous urethra

The objective of this study is to compare the influence on erectile function between urethral cystoscopic realignment and early end-to-end anastomosis treating ruptured bulbous urethra. 58 cases were selected, 32 had urethral cystoscopic realignment (group I) and 26 cases had urethral end-to-end anastomosis (group II). The parameters of P-CDU (Penile Color Duplex Ultrasound), NPT (Nocturnal Penile Tumescence), and IIEF-5 (International Index of Erectile Function) were compared between the two groups 6 months after operation. Group I was higher than group II in IIEF (21 vs 14) with significant differences. With P-CDU we observed an improvement in penile vascularization in group I as confirmed by the detection of an increase in peak systolic velocity (PSV) (26 cm/s vs 16 cm/s, p<0.01) and a decrease in end diastolic velocity (EDV) (3 cm/s vs 6 cm/s p<0.05), resulting in an increase in resistive index (RI) (0.85 vs 0.56, p<0.05). The parameters of NPT showed a significant increase compared to group II (p<0.01) in satisfactory erection number (5 vs 1.5), maximum rigidity (80% vs 42%), and total time that the increase in circumference was greater than 30% of baseline during sleep (100 sec vs 30 sec). Urethral cystoscopic realignment treating ruptured bulbous urethra can reduce the incidence of erectile dysfunction [ED]. A long term follow-up should be studied.

Simultaneous two-plane x-ray imaging for endoscopic recanalization of prostatomembranous urethral disruption

We describe a technique that uses simultaneous two-plane images to facilitate endoscopic recanalization of prostatomembranous urethral disruption. This technique is very useful for identifying the true passage and to perform endoscopic recanalization safely.

Reconstruction of posterior urethral disruption

Posterior urethral disruption may be a devastating complication of pelvic trauma. The acute management of these injuries is reviewed as well as the controversy surrounding early versus delayed repair. The various approaches to delayed repair of pelvic fracture urethral distraction defects are presented and the technique of perineal repair is discussed in detail.

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy

BACKGROUND

We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement.

METHODS

We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra.

RESULTS

Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients.

CONCLUSION

Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.

Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up

OBJECTIVES

The management of complete or partial posterior urethral disruption is controversial and much debate continues regarding immediate versus delayed definitive therapy. We further analyze our experience and long-term results using early endoscopic realignment.

METHODS

Between April 1991 and June 1995, 8 men with posterior urethral avulsion, either complete or partial and secondary to blunt trauma and pelvic fractures, presented to our institution. A variety of endourologic techniques were employed to achieve urethral continuity while attempting to minimize stricture formation, incontinence, and impotence.

RESULTS

After a mean of 50.4 months (range 35 to 85) of follow-up, 7 men (87.5%) are continent, with 2 of those requiring intermittent self-dilation ranging from once every 7 days to once a month. One patient required conversion to an open perineal urethroplasty. Of the 8 patients, 5 (62.5%) are potent, and 2 others achieve adequate erections for intercourse using intracorporeal injections. Four of the 8 have required subsequent internal urethrotomies with eventual voiding stabilization over the course of 1 2 months. Average time to realignment was 9.5 days (range 0 to 19).

CONCLUSIONS

Primary endoscopic realignment offers an effective method for treating traumatic urethral injuries. Our long-term follow-up provides further support for use of this technique by demonstrating that urethral continuity can be established without increased incidence of impotence, stricture formation, or incontinence. By achieving early and minimally invasive realignment, we seem to lessen the severity of stricture disease that almost uniformly afflicts those patients who undergo delayed repair. If a minimally invasive technique should fail, it does not seem to delay nor does it preclude further management using open techniques.