Childhood urethral injuries: perspectives on outcome and treatment

Specific characteristics of urethral strictures in a developing country (Brazil)

PURPOSE

Evaluate the main etiologies and clinical characteristics of male urethral stricture disease (USD) in Brazil.

METHODS

This multicentric study was performed using retrospective data collected from six Brazilian referral centers of urethral reconstruction. The database comprised data from 899 patients with USD who had undergone surgical treatment from 2008 to 2018. Age, stricture site and primary stricture etiology were identified for each patient.

RESULTS

The mean age was 52.13 ± 16.9 years. The most common etiology was iatrogenic (43.4%), followed by idiopathic (21.7%), trauma (21.5%) and inflammatory (13.7%). Of the iatrogenic causes, 59% were secondary to urethral instrumentation (60% by urethral catheterization and 40% by transurethral procedures), 24.8% by other procedures (prostatectomy, radiotherapy, postectomy) and 16.2% by failed hypospadia repairs. Pelvic fracture urethral distraction injuries were responsible for most of the trauma-related strictures (62.7%). When stratified by age, the most common stricture etiology was trauma in the 0-39 years old group (42.8%), idiopathic in the 40-59 years old group (32.4%) and iatrogenic in patients over 60 years old (68%). In regard to the stricture site, 80% presented with an anterior urethral stricture and 20% with a posterior stenosis. In the anterior stenosis group, the most common stricture site was bulbar (39.5%).

CONCLUSION

In Brazil, as in many developed countries, the most common cause of urethral stricture diseases is iatrogenic, especially urethral catheterization. These findings emphasize the need of a careful urethral manipulation and a better training of healthcare professionals. Trauma is still responsible for a great proportion of strictures and inflammatory etiologies are now less frequently observed.

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.

Characteristics of Idiopathic Urethral Strictures: A Link to Remote Perineal Trauma?

OBJECTIVE

To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common yet poorly understood entity.

PATIENTS AND METHODS

We retrospectively reviewed our urethroplasty database to identify men undergoing initial urethral reconstruction from 2007 to 2014 at 1 of 3 hospitals (N = 514). Patients were stratified by stricture etiology, including IUS, acute trauma, iatrogenic, hypospadias, balanitis xerotica obliterans, and radiation. IUS that had a known history of subacute or repetitive blunt force to the perineum (horseback riding, avid cycling, motocross, etc.) were subclassified as subacute or repetitive perineal trauma (SRPT).

RESULTS

Among 466 men undergoing initial reconstruction with available data, 215 (46%) were IUS cases. The median delay between IUS diagnosis and urethroplasty was 5.2 years, during which time men underwent a median of 2 endoscopic treatments. A total of 51 (24%) IUS cases recalled a distinct history of SRPT. Men with SRPT were slightly younger (median 43 vs 48 years, P = .01) but were remarkably similar in terms of urethral stricture length (2 vs 2 cm, P = .15), location (bulbar 96% vs 89%, P = .41), and treatment success (92% vs 88%; P = .61). Bulbar (-)SRPT and (+)SRPT IUS had similar clinical and morphometric features as those with known acute bulbar trauma with excellent 24-month stricture recurrence-free survival rates (93% vs 92% vs 97%, P = .19).

CONCLUSION

IUS have clinical features suggesting that many may be related to unrecognized or repetitive perineal trauma. Although treatment tends to be delayed, IUS have excellent urethroplasty success because most are short bulbar strictures amenable to anastomotic urethroplasty.

Contemporary urethral stricture characteristics in the developed world

OBJECTIVE

To assess the current etiology, features, and natural history of urethral stricture disease in the developed world.

MATERIALS AND METHODS

We analyzed the data from 1439 male patients with urethral stricture, who had undergone surgical treatment in our referral urethral center from 2000 to 2010. The preoperative evaluation included a detailed clinical history of stricture, uroflowmetry, retrograde and voiding cystourethrography, and urethroscopy. Statistical analysis was done for the stricture site, length, and etiology, patient age, and previous treatments.

RESULTS

Strictures were posterior in 112 (7.8%) and anterior in 1327 (92.2%). In the anterior group, 439 were penile (30.5%), 675 bulbar (46.9%), 71 penile plus bulbar (9.9%), and 142 panurethral (4.9%). The main causes were iatrogenic in 556 (38.6%), unknown in 515 (35.8%), lichen sclerosus in 193 (13.4%), and trauma in 156 (10.8%). The main iatrogenic strictures were from catheterization in 234 (16.3%), hypospadias repair in 176 (12.2%), and transurethral surgery in 131 (9.1%). The stricture distribution increased until about 45 years and then decreased. Strictures were uncommon in those<20 and >70 years old. The mean length was 4.15 cm; longer strictures were found in those with lichen sclerosus (7.45 cm) or after hypospadias repair (4.42 cm) and catheterization (4.40 cm). The mean length was also greater in the pretreated (4.34 cm) than in the untreated (3.64 cm) strictures.

CONCLUSION

Urethral stricture in developed countries mainly involves the anterior urethra, in particular the bulbar tract. The most common cause was iatrogenic. Hypospadias repair and lichen sclerosus represent emerging important causes. Finally, urethral stricture is not a disease of the elderly but involves all ages.

Etiology of urethral stricture disease in the 21st century

PURPOSE

We determined the current etiology of urethral stricture disease in the developed world and whether there are any differences in etiology by patient age and stricture site.

MATERIAL AND METHODS

Between January 2001 and August 2007 we prospectively collected a database on 268 male patients with urethral stricture disease who underwent urethroplasty at a referral center. The database was analyzed for possible cause of stricture and for previous interventions. Subanalysis was done for stricture etiology by patient age and stricture site.

RESULTS

The most important causes were idiopathy, transurethral resection, urethral catheterization, pelvic fracture and hypospadias surgery. Overall iatrogenic causes (transurethral resection, urethral catheterization, cystoscopy, prostatectomy, brachytherapy and hypospadias surgery) were the etiology in 45.5% of stricture cases. In patients younger than 45 years the main causes were idiopathy, hypospadias surgery and pelvic fracture. In patients older than 45 years the main causes were transurethral resection and idiopathy. In cases of penile urethra hypospadias surgery idiopathic stricture, urethral catheterization and lichen sclerosus were the main causes, while in the bulbar urethra idiopathic strictures were most prevalent, followed by strictures due to transurethral resection. The main cause of multifocal/panurethral anterior stricture disease was urethral catheterization, while pelvic fracture was the main cause of posterior urethral strictures.

CONCLUSIONS

Of strictures treated with urethroplasty today iatrogenic causes account for about half of the urethral stricture cases in the developed world. In about 1 of 3 cases no obvious cause could be identified. The etiology is significantly different in younger vs older patients and among stricture sites.

Traumatisme de l'urètre antérieur : diagnostic et traitement

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).

Anterior urethral strictures: etiology and characteristics

OBJECTIVES

To evaluate the etiology and characteristics of symptomatic anterior urethral strictures in a large series of men presenting for urologic treatment in an effort to determine the common themes that may influence possible prevention or treatment strategies. Many questions about the origin and features of contemporary anterior urethral stricture disease remain unanswered.

METHODS

The records of 175 men with symptomatic anterior urethral strictures were reviewed. Data were entered both prospectively by careful patient questioning and retrospectively from detailed chart review. The stricture length, location, and cause were recorded from urologic presentation, before definitive treatment. Posterior strictures from pelvic fracture urethral disruption defects were excluded from this review.

RESULTS

A total of 194 strictures were identified in 175 men. Most strictures were idiopathic (65 of 194, 34%) or iatrogenic (63 of 194, 32%); fewer were inflammatory (38 of 194, 20%) or traumatic (28 of 194, 14%). Most involved the bulbar urethra (n = 100, 52%). Pendulous strictures (mean 6.1 cm) were longer on average than those in the fossa navicularis (mean 2.6 cm) or bulb (mean 3.1 cm). Prolonged catheterization (n = 26) and transurethral surgery (n = 25) were common causes of iatrogenic strictures.

CONCLUSIONS

Our results showed that idiopathic and iatrogenic strictures are surprisingly common. External trauma was a relatively uncommon cause of anterior urethral stricture disease overall. Unnecessary urethral catheterization and repeated urethral instrumentation should be avoided to prevent stricture formation or exacerbation. More study is necessary to determine the origin of anterior urethral stricture disease.

Management of traumatic urethral disruption in children: Oman experience, 1988-2000

BACKGROUND

Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options.

METHODS

This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation.

RESULTS

In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations.

CONCLUSIONS

Primary repairs required less hospitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions.

Early endoscopic realignment as primary therapy for complete posterior urethral disruptions

We assessed the outcome of early endoscopic realignment of posterior urethral disruptions. We evaluated six patients who underwent early or delayed endoscopic realignment for the disrupted posterior urethra over a 3-year period. C-Arm fluoroscopy guidance and orientation in two planes were used as necessary. Potency, restructure rates, and continence were assessed in addition to hospital length of stay, intraoperative blood loss, and uroflow. The collective results of ten publications were also reviewed. In the present study, all of the six patients were continent. One had diminished erectile capability, and four required subsequent internal urethrotomies. Evaluation of the cumulative data (including the present study) showed an overall 9% incontinence rate, 60% potency rate, and 54% restricture rate. Endoscopic realignment of the disrupted posterior urethra is a minimally invasive procedure with results comparable to those of open delayed urethroplasty. Early and delayed repairs have been applied with similar results, the former being advocated in patients who are medically and orthopedically stable. Hospital stay, loss of work, morbidity, and related complications are also markedly decreased with early endoscopic realignment.

Delayed management of posterior urethral disruption in children

OBJECTIVE

To review the results of delayed operative treatment of total disruption of the posterior urethra in children.

PATIENTS AND METHODS

Twelve boys (3-12 years, mean 7.5) with a suprapubic catheter were referred after primary management in other hospitals. All but one had been involved in road traffic accidents. In addition to their urethral injury, they all had pelvic fractures and the majority also had other major associated injuries. Six to 14 months after injury, abdominoperineal transpubic urethroplasty was performed in 11 patients according to Turner-Warwick. In one case a perineal anastomotic urethroplasty was performed.

RESULTS

After the operation, voiding cysto-urethrography showed a wide anastomosis in all cases. After 3 to 45 months follow-up, there were no strictures. Eight boys were continent, two were totally incontinent, two had stress incontinence and one nocturnal enuresis. All patients with confirmed erections after injury also had erections after their operation.

CONCLUSION

Primary suprapubic cystostomy and delayed repair can be used successfully for the treatment of posterior urethral disruption in children.