Patterns of urethral injury and immediate management:

Clinical observation of male bulbar urethral strictures resulting from straddle injuries associated with falling from heights and riding activities

OBJECTIVES

To retrospectively investigate and analyze the characteristics of male bulbar urethral strictures or occlusions resulting from straddle injuries caused by falling from heights and riding activities.

METHODS

The study included 56 patients with a history of straddle injury, who were divided into two groups: the falling group (n = 29) and the riding group (n = 27). All patients underwent urethroscopy and X-ray urethrography, followed by urethrotomy and anastomotic procedure. Both urethral and suprapubic catheters were retained for one month postoperatively. Subsequent follow-up assessments were conducted within one month to one year after surgery.

RESULTS

The clinical data of two groups were analyzed. The average ages were 40.1 ± 11.2 (falling group, aged 18-59) and 26.8 ± 4.4 (riding group, aged 19-35), P < 0.05. In the falling group, 21 cases (72.4%) had offspring, while in the riding group, only 3 cases (11.1%) had offspring, P < 0.05. The stricture segments in the falling group were predominantly located in the proximal part of the bulbar region (89.7%), whereas in the riding group they mainly found in the distal part (96.3%), P < 0.05. In terms of urethrography results, the average lengths of stricture segments were measured as 17.6 ± 2.8 mm and 15.5 ± 4.6 mm respectively, P < 0.05. During surgery, the average lengths of stricture segments were recorded as 19.0 ± 2.5 mm and 17.4 ± 6.1 mm, P > 0.05. In the falling group, 20 cases (69.0%) involved bulbocavernosus muscle injury, P < 0.05. In the riding group, 5 cases (18.5%) involved corpus cavernosum injury, P < 0.05. After one month of the operation, all cases were able to pass through the 16Fr urethroscope without any apparent urethral strictures or complications observed in urethrography results. The maximum urinary flow rate for all cases exceeded 15 ml/s. Two months and one year after the operation, all cases experienced smooth urinary flow and ejaculation without any disorders reported. 3 cases (10.3%) in the falling group and 7 cases (25.9%) in the riding group complained of urethral stretching pain during erection, P > 0.05.

CONCLUSIONS

Male bulbar urethral strictures or occlusions resulting from straddle injuries associated with falling from heights and riding activities exhibit distinct characteristics, necessitating the development of a comprehensive surgical plan tailored to the specific features of each condition and the diverse age groups affected.

Effect of Oltipraz on urethral healing: An experimental study

BACKGROUND

We aimed to examine the oral and topical effect of Oltipraz (OPZ) on fibrosis and healing after urethra injury in a rat model.

METHODS

In all, 33 adult Sprague-Dawley rats were divided randomly into 5 different groups: sham, urethral injury group (UI), oral Oltipraz treatment group for 14 days after urethral injury (UI+oOPZ), intraurethral Oltipraz treatment group for 14 days after urethral injury (UI+iOPZ) and only intraurethral Oltipraz treatment for 14 days without urethral injury (sham+iOPZ). Pediatric urethrotome blade was used to create the urethral injury model for the injury groups (UI, UI+oOPZ and UI+iOPZ). After 14 days of treatment, all rats were sacrificed after penectomy under general anesthesia. Urethral tissue was evaluated histopathologically for congestion, inflammatory cell infiltration and spongiofibrosis, and immunohistochemically for transforming growth factor Beta-1 (TBF) and vascular endothelial growth factor receptor2 (VEGFR2).

RESULTS

The congestion score was not statistically significantly different between the groups. Spongiofibrosis was distinctive in UI group and OPZ given groups. Inflammation and spongiofibrosis score were statistically significantly higher in the sham+iOPZ group compared to the sham group (P<0.05). VEGFR2 and TGF Beta-1 scores were statistically significantly higher in the sham+iOPZ group compared to the sham group (P<0.05). We did not find beneficial effect of OPZ on urethral healing. We found the harmful effect of intraurethral administration of OPZ in the group without urethral injury in compared to sham.

CONCLUSIONS

According to our results, we cannot suggest OPZ in the treatment of urethral injury. Future studies in this area are needed.

Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

A presentation of iatrogenic hypospadias after traditional circumcision: A case report

Introduction and Importance

Traditional circumcisions may cause complications such as hemorrhage, infection, amputations of the penis, meatal stenosis, and urethro-cutaneous fistula. In addition to all these complications, iatrogenic hypospadias, as in our case, is a rare condition. In general, complications are mild and preventable, especially in children, but when the procedure is carried out by unskilled providers, in unsterile conditions, or with inadequate equipment and supplies, severe complications are more likely to occur. Several degrees of urethral erosion, including iatrogenic hypospadias, might result from further injury. Particularly in intensive care facilities, the ventral male urethra can undergo this kind of trauma.

Case presentation

A 4-year-old child was circumcised at the age of 3 years, and after that, he bled profusely. His parents brought him to the hospital after 4 months. On physical examination of the patient, the glans was normal but there was an opening near the glans in the distal urethra at the subcoronal level. After the pre-operative check-up, the patient was prepared for elective surgery. An incision and dissection were performed to reveal the fistula tract all around by placing marker sutures from the edges of the fistula. The fistula opening was repaired with 6/0 PDS (polydioxanone) and a second layer was created over the urethral fistula repair, and then the skin was closed with 4/0 Vicryl (polyglactin).

Clinical discussion

Around the world, circumcision continues to be the most common procedure done on children. Injuries to the penis may actually happen with a 1% complication incidence. A poorly placed suture at the frenulum in an effort to achieve hemostasis is the most frequent cause of the fistula. This causes strangulation and necrosis of a portion of the urethral wall, which leads to the creation of a sub glandular fistula. It is important to properly identify and treat any life-threatening injuries to the urethra as soon as possible.

Conclusion

Considered a medical procedure that necessitates great care, circumcision should only be carried out by qualified surgeons under sterile hospital circumstances. Most circumcision-related injuries result from clamp circumcisions (such as Mogen or Gomco), and they can range from minor loss of penile skin to more serious glans, distal urethral, and penile shaft injuries.

Outcomes of early endoscopic realignment for blunt straddle injuries to the bulbar urethra: a single-center retrospective study

Background

The optimal acute management of patients with blunt straddle injury to the bulbar urethra remains in question. Conventionally, suprapubic diversion with delayed urethroplasty can always be considered, if necessary, but the role of early endoscopic realignment (EER) in the acute management of blunt straddle injuries to bulbar urethra is controversial. We report our clinical experience and outcomes with EER for patients with straddle injury to the bulbar urethra in a level one trauma center.

Methods

We retrospectively reviewed 44 male patients who were transferred to our trauma center between January 2013 and January 2019 for acute management of blunt straddle injury to the perineum leading to bulbar urethra injuries. We reviewed the medical records of those patients to identify demographics, emergency management and clinical outcomes.

Results

The most common injury mechanism was falling onto the perineum (n = 27, 61.4%), followed by motorcycle accident (n = 11, 25.0%) and bicycle accident (n = 6, 13.6%). Of the 44 patients, 14 (31.8%) were partial bulbar urethral ruptures and 30 (68.2%) were complete bulbar urethral ruptures. 31 (70.5%) patients successfully underwent EER and 13 (29.5%) patients failed attempted EER. the difference between successful EER attempts and failed ones in term of injured urethral mucosa integrity was statistically significant (P = 0.035, OR 8.667,95% CI: 0.998–75.235). In patients who underwent successful EER, urethral stricture occurred after catheter removal at a median of 8 (1–28) months in 24 (77.4%) patients and the mean stricture length was 1.8 ± 0.8 (0.5–3.0), which was not statistically significant when compared with those who failed EER (P = 0.103). Overall, 21 out of 24 (87.5%) patients with strictures after EER were successfully managed by urethroplasty.

Conclusions

Although achieving a successful EER attempt is relatively easy for most patients with straddle injury to the bulbar urethra, it does not improve urethral healing significantly. Most patients with stricture formation after EER have to be cured with urethroplasty.

Different Techniques for Management of Problematic Urethral Catheterization in Male Children

Background: Urethral catheterization is very common, considered a minor procedure done by physicians and well-trained nurses. However, in some traumatic or congenital cases, male catheterization is problematic. A multitude of techniques are available and still can utilize the natural urethral opening to manage this distressing situation. Among these techniques, cystoscopic-assisted retrograde catheterization and railroad techniques are reliable options. This article aimed to document application and to evaluate outcomes of both techniques for problematic male urethral catheterization. Patients and Methods: In our hospitals from February 2015 to March 2020, 167 boys with problematic urethral catheterization underwent cystoscopic-assisted catheterization technique over a guidewire and 6 cases underwent railroad technique due to failed cystoscopic-assisted technique. Both techniques were done under general anesthesia with the patient in supine position and their details will be presented later on. Results: Patients' mean age was 7.2 ± 2.9 years (range = 2-14). One hundred sixty-seven cases (96.5%) underwent cystoscopic-assisted catheterization, while only 6 cases (3.5%) were managed by railroad technique. For cystoscopic-assisted technique, mean operative time was 4 ± 1.5 minutes (range = 6-18). Mean follow-up period was 54 ± 1 months (range 6-60) with only 1 case developed urethral stricture. For the railroad technique, operative time was 7.5 ± 2.6 minutes (range = 10-34), mean follow-up was 45 ± 3 months with 3 cases developed vesicocutaneous fistula, and 4 cases developed residual urethral stricture. Conclusion: Cystoscopic-assisted retrograde catheterization is a minimally invasive, safe, and reliable technique to catheterize the exceptionally difficult male urethra.

Novel Treatment Strategy for Management of Traumatic Bulbar Urethral Rupture Using Temporary Urethral Stent after Primary Realignment; Retrospective Comparison between Thermo-Expandable Urethral Stent and Self-Expandable Polymer-Coated Urethral Stent

A variety of retrievable and other types of temporarily placed stents are currently being used. However, only a few studies have considered primary endoscopic realignment with temporary urethral stent insertion in the event of traumatic bulbar urethral injury. We aimed to compare the clinical effectiveness and complications between thermo-expandable urethral stents and polymer-coated bulbar urethral stents (BUSs) for the treatment of traumatic bulbar urethral strictures. Between September 2011 and March 2018, 30 patients who had been diagnosed with complete bulbar urethral rupture following blunt trauma underwent temporary urethral stent placement after primary realignment. Thermo-expandable nickel-titanium alloy urethral stents were placed for 15 patients (group M), and retrievable self-expandable polymer-coated BUSs were placed for another 15 patients (group A). All stents were removed within 6 months after placement. The complications and maintained patency rates were compared between the two groups. The mean stent indwelling period was 5.0 ± 2.5 months in group M and 4.9 ± 4.0 months in group A. Both groups maintained high patency rates (Group M 12/15 (80.0%) and group A 13/15 (86.7%)). Five patients who developed urethral stricture underwent direct visual internal urethrotomy (DVIU), and no patients required repeat DVIU or open surgical urethroplasty. Both groups maintained the mean maximal urinary flow rate (Qmax) at 12 months after stent removal. Discomfort (46.7% vs. 6.7%), granulation tissue formation (73.3% vs. 26.7%) and post-void dribbling (80.0% vs. 20.0%) were more frequent in group M than in group A (p = 0.013, p = 0.011 and p = 0.001, respectively). In conclusion, both stents were effective for managing traumatic complete bulbar urethral rupture after primary realignment. However, the thermo-expandable urethral stents had a higher complication rate while the stent was in situ than the BUSs.

Pelvic fracture urethral injuries associated with rectal injury: a review of acute and definitive urologic and bowel management with long term outcomes

Background

Pelvic fracture urethral injuries (PFUI) with simultaneous rectal lacerations are unique rarely reported injuries. This paper serves to define our management, outcomes and make recommendations to improve the care of these patients.

Methods

We retrospectively reviewed all patients with a PFUI and concurrent rectal injury treated from 1990-2018, initial surgical treatments, along with definitive surgical repair were reviewed. Statistical analysis considered P values <0.05 as significant.

Results

Eighteen patients were identified; median follow-up post injury is 4 years, range 1-12 years. Injuries that impacted urologic care included concurrent bladder neck lacerations (BNL) in 50% (9/18) and concurrent neurologic injuries in 28% (5/18). In the nine patients with a simultaneous BNL, 44% (4/9) underwent a primary sutured anastomotic repair of the BNL and urethra, 33% (3/9) underwent primary closure of the bladder neck and SPT drainage and 23% (2/9) had primary repair of BNL with urethral realignment. Continued urinary extravasation through the BN despite the initial surgery resulted in life threating pelvic sepsis in 56% (5/9) versus 0% (0/9) in the patients without a bladder neck laceration, P=0.012. Long term follow up revealed, 22% (2/9) are currently voiding per urethra, neither are continent, one with chronic diaper dependent incontinence, one with stress incontinence. Urinary continence was eventually obtained in 44% (4/9) with either closure of the bladder neck and creation of a continent catheterizable stoma (3 pts) or with cystectomy and creation of an Indiana pouch (1 pt), 33% (3/9) were managed with eventual cystectomy and an enteric urinary conduit. In the nine patients with no concurrent bladder neck injury all were managed with a suprapubic tube placement and consideration for a delayed urethral reconstruction. Delayed end to end urethroplasties were performed in 67% (6/9). Eighty-three percent (5/6) are continent, 50% (3/6) are voiding per urethra without sequale, 33% (2/6) developed recurrent urethral strictures, one was treated with a single DVIU and has retrained urethral patency, at four years post treatment, one is on daily intermittent catheterization to maintain patency. Stress incontinence is noted in 17% (1/6). Due to concurrent neurologic injuries 33% (3/9) of these pts did not undergo further attempt at repair and have been managed with a long-term suprapubic tube.

Conclusions

PFUI with simultaneous rectal lacerations have significant comorbid injuries, especially, concurrent bladder neck lacerations and neurologic injuries that affect the urologic prognosis. In patients with a concurrent BNL we recommend initial intervention include primary lower urinary tract reconstruction with simultaneous proximal urinary diversion to help prevent the complication of persistent urinary extravasation with resultant pelvic sepsis.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Emergency treatment of male blunt urethral trauma in China: Outcome of different methods in comparison with other countries

Treatment of male urethral trauma is always a challenging problem. In China, as the incidence of urethral trauma keeps rising, more and more studies relating to this are being published. To compare the outcome of different emergency treatments in China and other countries, we searched Chinese and English literature about this topic in the past 16 years. A total of 167 studies involving 5314 patients were included, with 144 in Chinese and 23 in English. All studies were retrospective in nature. Based on the analyses, surgical methods include open realignment, endoscopic realignment and primary repair, and we summarized and compared the success rate and complications (mainly erectile dysfunction and incontinence) of each method. We found that realignment of posterior urethra has similar success rate in China and other countries, but the outcome of realignment of anterior urethra is variable. The reason remains unknown. While long abandoned in Western countries, primary repair of anterior urethra is still an option in China and has high success rate.

Gunshot wounds to the lower urinary tract: a single-institution experience

BACKGROUND

This study aimed to analyze characteristics and outcomes of gunshot wounds to the lower urinary tract at our Level I trauma center. Our hypothesis is that gunshot wounds to the lower urinary tract have characteristic bullet trajectories, injury patterns, and associated injuries.

METHODS

Our prospective trauma database was composed of reviewed gunshot wounds to the lower urinary tract including the pelvic ureter, bladder, or urethra from 1989 through 2011.

RESULTS

We identified 50 patients (median age, 25 years; range, 3-53 years) with lower urinary tract injury. There was a mean of 2.3 bullets per patient (range, 1-8), with 26 patients injured from a single bullet. Urologic injury involving only the bladder occurred in 72% (36 of 50) of the patients. Ureteral injury was diagnosed in 20% (10 of 50) of the patients. Bullet trajectory was known in the majority of multiple bullet injuries and all cases involving a single bullet.All patients but one were managed operatively. During exploration, 90% (34 of 38) with transmural bladder injury had recognized bladder entry and exit wounds. Overall, 80% (40 of 50) had concurrent gastrointestinal injury. In patients with a single gunshot wound to the lower urinary tract, 58% (15 of 26) sustained concomitant intestinal injury, and 23% (6 of 26) sustained rectal injury.Of 20 posteroanterior gunshot wounds, 80% had buttock entry. All 10 single-bullet buttock-entry gunshot wounds injured the bladder. Isolated ureteral injury was associated with lower abdominal entry and anteroposterior trajectory. Urethral injury occurred in 4, with 75% upper-thigh entry.

CONCLUSION

Penetrating injuries to the lower urinary tract most commonly involve the bladder. During exploration for gunshot wounds to the bladder, two injury sites should be expected because failure to close may lead to complications. Gunshot wounds to the lower urinary tract often occur with concomitant bowel injury, with buttock entry. A multidisciplinary approach involving general surgery is imperative.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

Long-term outcome of primary endoscopic realignment for bulbous urethral injuries: risk factors of urethral stricture

Purpose

Although endoscopic realignment has been accepted as a standard treatment for urethral injuries, the long-term follow-up data on this procedure are not sufficient. We report the long-term outcome of primary endoscopic realignment in bulbous urethral injuries.

Methods

Patients with bulbous urethral injuries were treated by primary endoscopic realignment between 1991 and 2005. The operative procedure included suprapubic cystostomy and transurethral catheterization using a guide wire, within 72 hours of injury. The study population included 51 patients with a minimum follow-up duration of 5 years.

Results

The most common causes of the injuries were straddle injury from falling down (74.5%), and pelvic bone fracture (7.8%). Gross hematuria was the most common complaint (92.2%). Twenty-three patients (45.1%) had complete urethral injuries. The mean time to operation after the injury was 38.8±43.2 hours. The mean operation time and mean indwelling time of a urethral Foley catheter were 55.5±37.6 minutes and 22.0±11.9 days, respectively. Twenty out of 51 patients (39.2%) were diagnosed with urethral stricture in 89.1±36.6 months after surgery. A multivariate analysis revealed that young age and operation time were independent risk factors for strictures as a complication of urethral realignment (hazard ratio [HR], 6.554, P=0.032; HR, 6.206, P=0.035).

Conclusions

Urethral stricture commonly developed as a postoperative complication of primary endoscopic urethral realignment for bulbous urethral injury, especially in young age and long operation time.

The diagnosis of acute urethral trauma

BACKGROUND

During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury.

METHODS

A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted.

RESULTS

There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma.

DISCUSSION

Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.

Urethral injuries after pelvic trauma: evaluation with urethrography

Urethral injury is a common complication of pelvic trauma that, if undiagnosed, may lead to significant long-term morbidity. Segments of the urethra that are near the pubic rami and the puboprostatic ligaments are particularly vulnerable. Although computed tomography is commonly used for the initial imaging evaluation of patients with polytrauma, urethral injury is better assessed and classified by using urethrography. Complete urethral imaging is especially important at presentation because the insertion of a transurethral bladder catheter may exacerbate an existing injury (eg, cause a partial urethral tear to become a complete transection). However, even for radiologists who are familiar with standard technique, urethrography after pelvic trauma may be particularly challenging because the patient is immobile or a surgical fixation device or indwelling urethral catheter is present. Various methods may used to overcome these difficulties and ensure that optimal images are obtained so that a correct diagnosis can be made without additional imaging evaluations.