A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury

Management of long-term functional sequelae of pelvic fracture urethral injury

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.

Timing of male urethral injury treatment in patients with polytrauma: A retrospective study

INTRODUCTION

Male urethral injuries are uncommon, and the ideal timing of the definitive treatment remains controversial. This study aimed to compare the outcomes of early and delayed interventions (1 month or more after the injury) for male urethral injuries.

PATIENT AND METHODS

We conducted a retrospective review of the medical records of 67 male patients with urethral injuries treated at our institution between 2011 and 2020. We examined patient age, injury severity score (ISS), abbreviated injury scale, mechanism, location and severity of injury, presence of pelvic fractures, surgical interventions, timing of treatment, and complications. We analysed factors associated with urinary complications based on the location of urethral injury. Additionally, we performed a subset analysis of patients with severe injuries (ISS≥16) to assess the impact of delayed surgery.

RESULTS

Overall, 47 %, 37 %, and 27 % of patients in the delayed treatment group (N = 30) had urethral stricture (US), erectile dysfunction (ED), and/or urinary incontinence (UI). These rates were greater than the 22 % US, 3 % ED, and 11 % UI rates in the early treatment group (N = 37). The subgroup analysis revealed that patients with anterior urethral injury (AUI) who underwent delayed treatment (N = 18) tended to be more severely injured (ISS, 19 vs 9, p = 0.003) and exhibited higher rates of US (44% vs 21 %, p = 0.193) and ED (39% vs 0 %, p = 0.002) than those who received early treatment (N = 24). In the case of posterior urethral injury (PUI), the delayed treatment group (N = 13) had higher rates of US (50% vs 23 %, p = 0.326), ED (33% vs 8 %, p = 0.272), and UI (42% vs 0 %, p = 0.030) than the early treatment group. Regarding study limitations, more than 45 % of the enrolled patients were severely injured (ISS≥16), which may have potentially influenced the timing of urethral injury repair.

CONCLUSIONS

The treatment of male urethral injuries may be delayed due to concurrent polytrauma and other associated injuries. However, delayed treatment is associated with higher rates of urinary complications. Early treatment of urethral injuries may be beneficial to male patients with urethral trauma, even in cases of severe injury.

[Evaluation and management of urethral strictures-guideline summary 2024 : Part 2-posterior urethra]

In light of recently published international guidelines concerning the diagnosis, treatment, and aftercare of urethral strictures and stenoses, the objective of this study was to synthesize an overview of guideline recommendations provided by the American Urological Association (AUA, 2023), the Société Internationale d'Urologie (SIU, 2010), and the European Association of Urology (EAU, 2023). The recommendations offered by these three associations, as well as the guidelines addressing urethral trauma from the EAU, AUA, and the Urological Society of India (USI), were assessed in terms of their guidance on posterior urethral stenosis. On the whole, the recommendations from the various guidelines exhibit considerable alignment. However, SIU and EAU place a stronger emphasis on the role of repeated endoscopic treatment compared to AUA. The preferred approach for managing radiation-induced bulbomembranous stenosis remains a subject of debate. Furthermore, endoscopic treatments enhanced with intralesional therapies may potentially serve as a significant treatment modality for addressing even fully obliterated stenoses.