Treatment of obliterated membranous and bulbous urethras by direct vision internal urethrotomy

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.

Rehabilitation of erectile function following radical prostatectomy

The concept of muscle rehabilitation after nerve injury is not a novel idea and is practiced in many branches of medicine, including urology. Bladder rehabilitation after spinal cord injury is universally practiced. The erectile dysfunction (ED) experienced after radical prostatectomy (RP) is increasingly recognized as being primarily neurogenic followed by secondary penile smooth muscle (SM) changes. There is unfortunately no standard approach to penile rehabilitation after RP because controlled prospective human studies are not available. This article reviews the epidemiology, experimental pathophysiological models, rationale for penile rehabilitation, and currently published rehabilitation strategies.

Reconstruction and Management of Posterior Urethral and Straddle Injuries of the Urethra

Urethral stricture disease, once associated mainly with gonococcal urethritis, is now most frequently a consequence of trauma, such as a fall-astride injury or a pelvic fracture. This article discusses issues and approaches related to the treatment of strictures associated with perineal straddle trauma and pelvic fracture urethral distraction defects. The authors emphasize that endoscopic procedures seldom cure these strictures and in-dwelling stents are seldom useful in treatment. Primary anastomotic techniques are associated with success rates in the high 90% range and appear to be remarkably durable in most cases. In contrast, tubed reconstruction of the urethra is inevitably associated with diminished success rates and with problems of durability.

CADAVERIC ANATOMY OF PELVIC FRACTURE URETHRAL DISTRACTION INJURY: MOST INJURIES ARE DISTAL TO THE EXTERNAL URINARY SPHINCTER

PURPOSE

The anatomy of posterior urethral distraction injuries is controversial. We present a cadaver study of posterior urethral distraction injuries. To our knowledge this is the first study that establishes that the most common location is distal to the external urinary sphincter.

MATERIALS AND METHODS

We performed an autopsy review of 10 male patients with posterior urethral distraction injuries.

RESULTS

Urethral disruption occurred distal to the external urinary sphincter in 7 of 10 patients. It appeared to occur when the anterior pelvic ring and urogenital diaphragm complex were displaced caudal and rostrally, tearing the urogenital diaphragm off of the urethra. The average inner mucosal defect +/- SD was 3.5 +/- 0.5 cm, while the defect between the outer urethral layer (tunica of the spongiosum) was 2.0 +/- 0.2 cm due to mucosal retraction. Simple and complex injuries could be observed, according to the clinical classification proposed by Turner-Warwick in 1989. Simple injuries had less significant dislocation of the symphysis, general maintenance of urethral continuity and slightly shorter mucosal distraction (3.3 cm). Complex disruptions had significant symphyseal dislocation, complete disassociation of the urethral ends (often with interposition of other tissues) and a slightly longer mucosal distraction (3.8 cm).

CONCLUSIONS

Posterior urethral distraction injuries appear to most commonly occur distal to the urogenital diaphragm, contrary to classic teaching. These injuries are on average between 3 and 4 cm, and they are more significant dorsal than ventral. They appear to occur as simple or complex injuries, mirroring the clinical findings seen in clinically simple and complex urethral strictures.

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.

Alternative endoscopic management in the treatment of urethral strictures

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.

Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation

Five patients with complete posterior urethral obliteration (less than 3 cm.) underwent endoscopic reconstitution of the urethra followed by planned direct vision internal urethrotomy and temporary self-dilation. Of these patients 3 complied with the treatment regimen and are currently free of voiding complaints (average followup 31 months), while 2 failed to perform self-dilation and required repeat internal urethrotomy. Of the latter 2 patients 1 then performed self-dilation and has a stable urethra (followup 2 years). The youngest patient refused to perform self-dilation and underwent successful perineal urethroplasty. Major complications did not occur. The treatment regimen as described is a suitable alternative to surgical urethroplasty in select patients with short urethral defects (less than 3 cm.) who are willing to perform temporary urethral self-dilation.

Primary endoscopic realignment following posterior urethral disruption

We describe 5 cases in which complete posterior urethral disruption associated with pelvic fracture was managed by primary endoscopic realignment 7 to 19 days after injury. Realignment was accomplished using a flexible endoscope through the suprapubic tract and a rigid or flexible cystoscope in the distal urethra. A guide wire was passed from the suprapubic tract through the disrupted membranous urethra and out the distal urethra. A Councill catheter was left indwelling for 5 to 10 weeks. After removal a program of intermittent self-catheterization was continued for 3 months. Excellent results were obtained in 4 patients who are continent, including 2 who are potent. This technique allows considerable reduction of patient morbidity without compromising formal urethroplasty should it later be required.

Endoscopic re-establishment of membranous urethral disruption

A total of 17 patients with traumatic membranous urethral disruption underwent urethral reconstruction via a core-through technique. Followup was 1 to 8 years (mean 3.7 years) postoperatively, and included 6 weeks with an indwelling catheter, periodic dilation for 6 months and occasional sounding. Within 1 year postoperatively, 6 patients required additional scar incision, including 3 who underwent scar resection. At 1 to 8 years postoperatively 6 patients had complications: 3 had stricture requiring periodic dilation (including 2 who underwent scar incision), while 2 had mild stress incontinence and 1 had nocturnal enuresis. Traumatic impotence was noted in 7 patients but the operation was not the cause in any. This method of endoscopic management was found to be an acceptable alternative to urethroplasty in cases of membranous urethral disruption.

Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases

A total of 74 patients with posterior urethral distraction defects (1.5 to 7 cm. long) that followed pelvic fracture was managed by a 1-stage perineal repair. End-to-end anastomosis was performed in all cases but in 66 a variety of surgical maneuvers were necessary to accomplish a tension-free anastomosis. These techniques, which included distal urethral mobilization, corporeal body separation, inferior pubectomy and supracrural urethral rerouting, were resorted to in a sequential manner as needed. Excellent results were achieved in 96% of the cases. These surgical techniques are described and discussed.

Vascular complications of transurethral incision of post-traumatic urethral strictures

Retrograde or antegrade transurethral incision of urethral strictures that have formed after complete rupture of the membranous urethra has been advocated to restore urethral continuity. With this technique we encountered vascular complications in 2 patients, which consisted of opening of a patent vessel entrapped in the fibrous tissue of the stricture. The opened vein in 1 patient healed without bleeding. The opened artery in the other patient did not heal with catheter drainage and pressure dressings, resulting in recurrent severe hemorrhage that necessitated stage 1 urethroplasty with ligation of the artery. The entrapment of a patent vessel in fibrous scar tissue resulting from complete urethral rupture is believed to be responsible for these complications.

Blunt pelvic trauma

Blunt pelvic trauma results in significant morbidity and mortality from associated genitourinary, neurological, vascular, and visceral damage. Diagnosis begins in the ED with the initial trauma evaluation. Proper treatment using a multidisciplinary approach and cooperation between orthopedist, urologist, trauma surgeon, and emergency physician should minimize complications.

Pelvic fracture and injury to the lower urinary tract

The presence of a urologic injury must be considered in all patients with pelvic fracture. Uroradiographic evaluation starting with retrograde urethrography is indicated in all male patients with concomitant gross hematuria, bloody urethral discharge, scrotal or perineal ecchymosis, a nonpalpable prostate on rectal examination, or an inability to urinate. If the urethra is normal, a catheter may be passed, and in the presence of gross hematuria, a cystogram must be performed. Female patients rarely suffer urethral lacerations. The urethra is examined, and a Foley catheter may be passed without a urethrogram. The immediate management of associated urologic injuries continues to evolve and evoke controversy. Selected cases of extraperitoneal bladder perforation may be safely managed solely by catheter drainage. Intraperitoneal perforations require surgical exploration and repair. Urethral disruption (partial or complete) may be safely managed by primary cystostomy drainage with management of potential complications (stricture, impotence, incontinence) in 4 to 6 months.