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

Emergency treatment of pelvic ring injuries: state of the art

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

A diagnostic approach of various urethral diseases using multimodal imaging findings: comprehensive overview

In clinical practice, urethral diseases are not as frequent as conditions affecting other components of the urinary system. Radiological imaging tests, such as retrograde urethrography, CT, MRI, and PET/CT, along with patient history, are crucial for accurately assessing relatively rare urethral lesions. This article aimed to provide a comprehensive overview of urethral lesions, from traumatic changes to neoplasms, and discuss the multimodal imaging findings of various urethral lesions that radiologists should know. To this end, the normal imaging anatomy of the urethra and a step-by-step approach that can be used in clinical practice have been presented to help in the systematic understanding of urethral lesions.

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.

Transperineal anastomotic posterior urethroplasty with bulbocavernosus flap and fibrin sealant in the complicated posterior urethral stricture reconstruction: a retrospective cohort study

BACKGROUND

Management of complicated posterior urethral stricture is challenging. Modified transperineal anastomotic urethroplasty (TAU) with bulbocavernosus flap interposition and human fibrin sealant provides another treatment option. The authors aimed to evaluate whether this technique could improve the success rate in the complicated posterior urethral stricture reconstruction in this study.

MATERIALS AND METHODS

Between 2016 and 2019, 48 patients underwent either conventional or modified TAU. The criteria for success included both the absence of clinical symptoms and no need for further surgical intervention during follow-up.

RESULTS

Twelve patients underwent the modified TAU (group A) using bulbocavernosus flap interposition and human fibrin sealant. Thirty-six patients underwent the traditional end-to-end anastomotic urethroplasty (group B). Follow-up was 24.3-57.2 months. The patients in group A had a higher surgery success rate compared to the patients in group B (91.7 vs. 63.9%, P =0.067), with a quasi-significant result. Besides, no postoperative complications were observed in group A, while two individuals in group B had urinary incontinence, but the difference was not significant (0 vs. 5.6%, P =0.404).

CONCLUSION

Based on the preliminary results, modified TAU with bulbocavernosus flap interposition and human fibrin sealant is a safe and feasible technique for complicated posterior urethral stricture reconstruction.

[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.

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

CONTEXT

The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care.

OBJECTIVE

To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma.

EVIDENCE ACQUISITION

A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series.

EVIDENCE SYNTHESIS

Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of urological trauma.

PATIENT SUMMARY

Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

Complex pelvic fracture with massive hemorrhage in low resource settings: Case report

Pelvic fractures can range from simple, requiring almost no therapy, to complex, mandating the attention of the orthopedic surgeon, trauma surgeon, interventional radiologist, or other specialists because they are associated with multisystem injury and life-threatening hypotension. We present a 16-year-old male who presented with a complex pelvic fracture following a motor vehicle accidents that did not survive despite the efforts in resuscitation. In complex pelvic fracture with hemodynamic instability (hypotension persevered) and high index suspicion of bladder injury, there is an immediate need for operative intervention, regardless of negative/positive FAST (Focused Assessment with Sonography in Trauma).

Epidemiology of posterior urethral injury among adults with traumatic pelvic ring disruptions: a 10-year retrospective review from a trauma care centre in Southeast Nigeria

Introduction

posterior urethral injuries can occur in polytrauma settings, and may contribute to morbidity post-trauma. The aim of this study is to determine the occurrence of pelvic fracture urethral injury (PFUI) in adult polytrauma patients who were successfully stabilized and to appraise the nature of associated injuries.

Methods

the medical records of stabilized polytrauma patients≥ 18 years of age from January 2010 to December 2019 were retrospectively reviewed focusing on those presenting with bony pelvis disruptions. Injuries were categorized using the injury severity scale (ISS) while bony pelvis disruptions were classed according to the Young-Burgess classification. Data on the demography of the patient, mechanism of injury, nature, and severity of injuries, class of pelvic fracture-disruption, and urethral integrity were collected and analyzed accordingly.

Results

of 111 patients with bony pelvis disruptions, 95 of them had adequate information and were included in our analysis. The mean age of participants was 37.3 ± 11.8 years and most of them were males (87.4%). Blunt pelvic trauma occurred in 96.8%. Lateral compression pelvic injuries were prevalent at 39.0%. In 54.7% of the patients, the injury severity score (ISS) was ≥ 27. At 25.3% and 24.2% respectively, the abdomen and the lower extremities most frequently sustained a grade ≥ 3 injuries (abbreviated injury scale (AIS) ≥3). At a rate of 2.1%, spinal cord injury was the least observed. In the 10 years, there were 6 PFUI among 83 stabilized polytraumatized men with mean ISS of 35.5 ± 8.3. The incidence rate of PFUI was 0.6 per 8.3 pelvic disruptions in men per year. Symphysis pubis disruption or fracture of the pubis or both was consistently seen in all PFUI. Higher ISS significantly relates to PFUI (p <0.001). The mechanism of bony pelvis disruption and the class of bony pelvis injury are determined by the severity and trajectory of the impact apparently relates to PFUI only through fracture-disruption of the pubic symphysis or the pubis.

Conclusion

about 7.2% of men presenting with traumatic disruption of the bony pelvis in polytrauma setting sustain PFUI. In polytrauma settings, PFUI should be suspected in cases of fracture-disruption of the pubis or symphysis pubis from any mechanism.

A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty

BACKGROUND

We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data.

METHODS

Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event.

RESULTS

There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01).

CONCLUSIONS

Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.

Lower urinary tract injuries in patients with pelvic fractures at a level 1 trauma center - an 11-year experience

BACKGROUND

Urological injuries can occur in patients with pelvic fractures. Treatment recommendations lack solid evidence and is often pragmatical. There is a continuous need to describe short- and long-term morbidity following lower urinary tract trauma.

OBJECTIVE

To describe incidence, diagnosis, treatment, and morbidity following lower urinary tract injuries in pelvic fractures.

PATIENTS AND METHODS

Retrospective study including patients with pelvic, including acetabular, fractures admitted to a Level I Trauma Centre covering 2.8 million citizens between 2009 and 2020. Outcome measurements comprised primary management, treatment trajectory, short- and long-term complications and outcomes.

RESULTS

A total of 39 (5%) patients with pelvic fractures had concomitant urethral and/or bladder injuries, and one patient with an acetabular fracture had a bladder injury. The management of urethral injuries varied vastly, and complete urethral ruptures were associated with severe short- and long-term complications. Only one patient with bladder injury experienced severe long-term complications.

CONCLUSIONS

Management of lower urinary tract injuries in patients with major pelvic fractures remains a major challenge. Special attention should be focused on urethral injuries where we uncovered an unsystematic treatment and follow-up even in a highly experienced centre, although this is also attributed to complicated multidisciplinary patient trajectories. There is a continuous need to reduce long-term complications following urethral trauma which should be addressed in multicenter studies.

Fibrinogen/poly(l-lactide-co-caprolactone) copolymer scaffold: A potent adhesive material for urethral tissue regeneration in urethral injury treatment

Since a scarcity of sufficient grafting materials, several complications can arise after urothelial defect reconstruction surgery, including severe hypospadias. Accordingly, developing alternative therapies, such as urethral restoration via tissue engineering are needed. In the present study, we developed a potent adhesive and repairing material using fibrinogen-poly(l-lactide-co-caprolactone) copolymer (Fib-PLCL) nanofiber scaffold to achieve effective urethral tissue regeneration after seeding with epithelial cells on the surface. The in vitro result found the Fib-PLCL scaffold promoted the attachment and viability of epithelial cells on their surface. The increased expression levels of cytokeratin and actin filaments were observed in Fib-PLCL scaffold than PLCL scaffold. The in vivo urethral injury repairing potential of Fib-PLCL scaffold was evaluated using a rabbit urethral replacement model. In this study, a urethral defect was surgically excised and replaced with the Fib-PLCL and PLCL scaffolds or autograft. As expected, the animals healed well after surgery in the Fib-PLCL scaffold group, and no significant strictures were identified. As expected, the cellularized Fib/PLCL grafts have induced the luminal epithelialization, urethral smooth muscle cell remodelling, and capillary development all at the same time. Histological analysis revealed that the urothelial integrity in the Fib-PLCL group had progressed to that of a normal urothelium, with enhanced urethral tissue development. Based on the results, the present study suggests that the prepared fibrinogen-PLCL scaffold is more appropriate for urethral defect reconstruction.

Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

Objectives

To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI).

Methods

Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results.

Results

A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1-8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5-9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8-10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation.

Conclusions

The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Posterior urethral stenosis: a comparative review of the guidelines

PURPOSE

We aimed to provide a thorough comparative review of the available guidelines on the diagnosis, management, and follow-up for patients with posterior urethral stenosis by the American Urologic Association (2016), Société Internationale d'Urologie (2010), and European Urologic Association (2022).

METHODS

The AUA, SIU, and EAU guidelines were evaluated for recommendations on the diagnosis, evaluation, and treatment of posterior urethral stenosis. We also included the EAU and AUA urologic trauma guidelines for the trauma-related stenosis. The level or strength of recommendations is included in case of disparity between the guidelines.

RESULTS

The three guidelines align considerably in recommendations provided for the diagnosis, management, and follow-up of patients with posterior urethral stenosis. SIU and EAU emphasize the role of repeat endoscopic treatment in guidelines compared to AUA.

CONCLUSION

The preferred method to repair bulbo-membranous stricture/stenosis following radiation therapy remains an area of active interest, focusing on continence preservation. Additionally, there may be a role for advanced endoscopic treatments with or without adjunct therapies to manage even obliterated stenoses.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS)

OBJECTIVES

To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury.

METHODS

Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs. minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score.

RESULTS

There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (p< 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (p<0.001).

CONCLUSIONS

In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

The contribution of the immune system to genitourinary fibrosis

Fibrotic diseases of the genitourinary tract are devastating and incompletely understood pathologies. These diseases include urethral and ureteral strictures, retroperitoneal fibrosis, and Peyronie's disease. They can contribute to obstructive uropathy and sexual dysfunction. Poor understanding of the pathophysiology of these diseases severely limits our ability to prevent and treat them. Genitourinary fibrotic diseases likely represent related pathologies that share common underlying mechanisms involving wound healing in response to injury. These diseases share the common feature of extracellular matrix abnormalities-such as collagen deposition, transforming growth factor-β accumulation, and dysregulation of collagen maturation-leading to abnormal tissue stiffness. Given the association of many of these diseases with autoimmunity, a systemic pro-inflammatory state likely contributes to their associated fibrogenesis. Herein, we explore the immunologic contribution to fibrogenesis in several fibrotic diseases of the genitourinary system. Better understanding how the immune system contributes to fibrosis in these diseases may improve prevention and therapeutic strategies and elucidate the functions of immunologic contributors to fibrosis in general.

[Contemporary management of pelvic fracture urethral injuries]

Posterior urethral injuries in men usually result from polytrauma with pelvic fractures and severe associated injuries. If left untreated, posterior urethral injury can lead to severe complications and even death, so precise diagnosis should be made when urethral injury is suspected. The cardinal symptom of urethral injury is blood leakage from the meatus. Retrograde urethrography is the diagnostic tool of choice. In the case of complete urethral avulsion, the formation of a urethral stricture due to pronounced scarring fibrosis is inevitable. In principle, various therapeutic approaches are available. Often, urinary diversion by means of a transurethral or suprapubic catheter is performed first. However, there is also the possibility of direct endoscopic or open urethral realignment with subsequent temporary catheterization. Immediate surgical reconstruction is useful only in exceptional cases of simultaneous bladder neck or rectal injury. In cases of complete urethral avulsion, secondary transperineal bulboprostatic reanastomosis at the interval after three months of suprapubic continuous drainage with excellent success rate is the gold standard and can be supplemented with ancillary maneuvers if necessary to ensure a tension-free anastomosis.

Primary Repair of Pediatric Posttraumatic Complete Bladder Neck Horizontal Transection: Our Experience

Complete transverse transection just below the bladder neck is extremely rare. We present two such cases with associated pelvic fracture following trauma. Both underwent early primary vesicourethral anastomosis with no postoperative complications and are continent in the follow-up.

Erectile Dysfunction after Conservative Treatment of Sacral Fractures in Males without Injury to the Urinary System

BACKGROUND

This study aimed to determine the incidence of erectile dysfunction (ED) reported by patients, and to define the prognostic relationship between ED and conservatively treated sacral fracture without urethral injury.

METHODS

Patients aged between 20 - 50 years who were sexually active and had no known sexual dysfunction prior to the trauma were included in the study. Seventy-seven patients (47 married, 30 single) treated conservatively for sacral fracture between April 2012 and February 2017 were retrospectively screened. Patients were compared in terms of age, marital status, body mass index (BMI), trauma mechanism, additional system injury, functional outcomes, and complications. Functional outcomes were assessed using the International Index of Erectile Function (IIEF-5) and the Majeed pelvic fracture functional assessment scale (MPS).

RESULTS

No statistically significant difference was observed between fracture types with respect to age, BMI, follow-up, marital status, trauma mechanism, and accompanying injury. The incidence of ED was 27.3% for those that received conservative treatment after sacrum fracture. The mean score of IIEF-5 was 18.6 ± 6.6 and MPS was 77.2 ± 13.2. There was no significant relationship between the injury type of the patients and the IIEF-5 and MPS scores (p = 0.593 and p = 0.907, respectively). The lowest IIEF-5 score was found in Denis type 2 fractures (p = 0.020).

CONCLUSION

The frequency of ED was higher in Denis type 2 sacrum fractures. Sexual function should be questioned in the follow-up, especially in those fracture types.

Transperineal anastomotic urethroplasty for the treatment of pelvic fracture urethral distraction defects: a progressive surgical strategy

PURPOSE

The aim was to reduce the difficulty of transperineal anastomotic urethroplasty for pelvic fracture urethral distraction defect (PFUDD) and make it easy to master through an effective strategy.

PATIENTS AND METHODS

Between January 2010 and December 2019, 1637 patients with PFUDDs were treated by transperineal anastomotic urethroplasty. The surgical strategy we used was the progressive transperineal anastomotic urethroplasty. First, after full mobilization of the distal bulbomembranous urethra, the stenotic urethra was transected directly at the proximal margin of the stenotic urethra to expose the proximal disrupted urethral end. Second, if the urethral stenosis location of some complicated cases was too deep to fully mobilize, the position of urethral transection was selected at the distal margin of the stenotic urethra. Then, the distal and proximal disrupted urethras were then trimmed and anastomosed without tension. A successful urethroplasty was defined as reestablishment of a uniform urethral caliber and no further interventions were needed.

RESULTS

Follow-up was obtained in 1475 patients. The success rate was 92.4% (1363/1475). Among the 112 failed patients, 10 patients received endoscopic urethrotomy, 99 underwent a secondary or third anastomotic urethroplasty and 3 successfully treated with perineal skin flap urethroplasty. After final successful urethroplasty, 125 patients (8.5%) had different degrees of urinary incontinence and 15 (1.6%) developed de novo erectile dysfunction (1.6%).

CONCLUSION

The progressive transperineal anastomotic urethroplasty strategy was effective for treating PFUDD cases, improving surgical efficacy and reducing complications. It may contribute to standardizing the transperineal anastomotic urethroplasty and making it easy to master.

Team Approach: Evaluation and Management of Pelvic Ring Injuries

A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.

A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis

PURPOSE

Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations.

MATERIALS AND METHODS

Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression.

RESULTS

Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%.

CONCLUSIONS

PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Erectile dysfunction and penile rehabilitation after pelvic fracture: a systematic review and meta-analysis

OBJECTIVE

To investigate the rate of erectile dysfunction (ED) after pelvic ring fracture (PRF).

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus and Web of Science Library databases was conducted in January 2020. Included were original studies performed on humans assessing ED after PRF according to the 5-item International Index of Erectile Function (IIEF-5) questionnaire and fracture classification following Young and Burgess, Tile or Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association. Furthermore, interventional cohort studies assessing the effect of penile rehabilitation therapy with phosphodiesterase-5-inhibitors (PDE-5-I) on IIEF-5 scores compared before and after treatment were included. Results were presented as forest plots of proportions of patients with ED after PRF or mean changes on IIEF-5 questionnaires before and after penile rehabilitation. Studies not included in the quantitative analysis were narratively summarised. Risk of bias assessment was conducted using the revised tool for the Quality Assessment on Diagnostic Accuracy Studies.

RESULTS

The systematic literature search retrieved 617 articles. Seven articles were included in the qualitative analysis and the meta-analysis. Pooled proportions revealed 37% of patients with ED after suffering any form of PRF (result on probability scale pr=0.37, 95% CI: 0.26 to 0.50). Patients after 3 months of penile rehabilitation therapy reported a higher IIEF-5 score than before (change score=6.5 points, 95% CI: 2.54 to 10.46, p value=0.0013).

CONCLUSION

Despite some heterogeneity and limited high-quality research, this study concludes that patients suffering from any type of PRF have an increased risk of developing ED. Oral intake of PDE-5-I for the purpose of penile rehabilitation therapy increases IIEF-5 scores and may relevantly influence quality-of-life in these patients.

PROSPERO REGISTRATION NUMBER

CRD42020169699.

Deep learning to segment pelvic bones: large-scale CT datasets and baseline models

PURPOSE

Pelvic bone segmentation in CT has always been an essential step in clinical diagnosis and surgery planning of pelvic bone diseases. Existing methods for pelvic bone segmentation are either hand-crafted or semi-automatic and achieve limited accuracy when dealing with image appearance variations due to the multi-site domain shift, the presence of contrasted vessels, coprolith and chyme, bone fractures, low dose, metal artifacts, etc. Due to the lack of a large-scale pelvic CT dataset with annotations, deep learning methods are not fully explored.

METHODS

In this paper, we aim to bridge the data gap by curating a large pelvic CT dataset pooled from multiple sources, including 1184 CT volumes with a variety of appearance variations. Then, we propose for the first time, to the best of our knowledge, to learn a deep multi-class network for segmenting lumbar spine, sacrum, left hip, and right hip, from multiple-domain images simultaneously to obtain more effective and robust feature representations. Finally, we introduce a post-processor based on the signed distance function (SDF).

RESULTS

Extensive experiments on our dataset demonstrate the effectiveness of our automatic method, achieving an average Dice of 0.987 for a metal-free volume. SDF post-processor yields a decrease of 15.1% in Hausdorff distance compared with traditional post-processor.

CONCLUSION

We believe this large-scale dataset will promote the development of the whole community and open source the images, annotations, codes, and trained baseline models at https://github.com/ICT-MIRACLE-lab/CTPelvic1K .

A Modified Endoscopic Primary Realignment of Severe Bulbar Urethral Injury

Purpose: Male urethral injury is a common urologic emergency in developing countries. Whether early or late treatment of urethral injuries is often multifactorial and controversial. The goal of this study is to determine whether early realignment can reduce postsurgical complications and evaluate the clinical feasibility of emergency endoscopic urethroplasty using single rigid ureteroscopy in the treatment of bulbar urethral severe injury. Patients and Methods: Between September 2013 and March 2019, 15 male adult patients (mean age 35 years; from 21 to 62 years) with severe bulbar urethral injury were enrolled into the current study. The patients mainly presented with dysuria or painful urination (15/15, 100%), urethral bleeding (13/15, 86.7%), and urinary retention (11/15, 73.3%). Six of them had swelling of perineal or scrotal soft tissue, while four had testicular contusion. No pelvic fracture was found in all cases with CT scanning of the pelvic cavity. The bulbar urethral at grade IV was confirmed to be completely ruptured in all cases by endoscopy during operation. The modified endoscopic primary realignment was performed. Results: This new urethral repair technique was effectively performed in all patients and none converted to open operation. Mean operation time was 42.3 ± 11.5 minutes (28-52 minutes) and the mean Foley catheter indwelling time was 34.5 ± 6.9 days (28-42 days). During a follow-up of 41.3 ± 22.8 months (12-64 months), mild urethral strictures (grade I) (19.7 ± 9.5 weeks, 10-27 weeks postsurgery) developed in 8 patients (53.3%) and then were all improved 2.1 ± 0.8 months (1.3-2.9 months) after periodic dilatations of the urethra (4-10 times). Erectile dysfunction (ED) occurred in three patients (20%) after surgery, who recovered from mild ED to normal by administration with oral sildenafil (100 mg, three times a week) for 12 weeks. The International Index of Erectile Function-5 (IIEF-5) score was significantly improved after surgery (M ± SD, 25 ± 3) compared with before (16.4 ± 3.5) (p < 0.05). No incontinence and other complications occurred in all cases. Conclusions: Early endoscopic realignment via suprapubic puncture cystostomy by single rigid ureteroscopy provides an effective, feasible, and safe procedure for severe bulbar urethral injury.

A singular case of massive urethrorrhagia solved by transarterial embolization

Background

Urethrorrhagia is frequent in pelvic trauma, rarely due to traumatic injuries of internal pudendal artery branches.

Case presentation

Our aim is to underline the role of transarterial embolization in selected patients, as in this case in which a young man manifested urethral hemorrhage after high-energy motorcycle crash not associated with injuries of the inferior urinary tract. Multi-detector computed tomography (MDCT) showed pubic symphysis diastasis and perineal hematoma with pseudoaneurysm into the penis bulb. The first approach was conservative with perineal external compression and intravenous injection of tranexamic acid. Afterward, due to the decline of clinical conditions, we decided to perform a selective angiography, confirming the vascular injury of distal branches of both internal pudendal arteries with contrast agent extravasation into urethral bulb; endovascular embolization was performed with detachable micro-coils. The principal results were seen quickly, indeed urethrorrhagia arrested and hemoglobin values normalized. Erectile function was preserved at 6-months follow-up.

Conclusions

Endovascular embolization proved to be a minimally invasive therapeutic approach, clinically effective, with a low rate of complications and high probability to preserve erectile function.

[Radiological diagnosis of pelvic ring fractures]

EPIDEMIOLOGY

Traumatic fractures of the pelvic ring are relatively rare, but are associated with increased risk of mortality. Depending on injury mechanism and main vector of energy impact, a distinction is made between anteroposterior compression, lateral compression, and vertical shear (Young and Burgess classification), while the stability-related classification according to Tile distinguishes between type A (stable), type B (rotationally unstable) and type C (completely unstable). A comprehensive modern classification is given by the AO/OTA.

RADIOLOGICAL FRACTURE DIAGNOSIS

Plain pelvis x‑rays lack sufficient sensitivity but are still used to detect highly unstable pelvic fractures. CT has superior sensitivity and specificity. In addition to fracture classification, CT allows reliable assessment of associated vascular and bladder/urethral injuries and large soft tissue hemorrhage. MRI is unparalleled in showing bone marrow edema, cauda and plexus complications, and peripelvic soft tissue damage. MRI may also prove to be a valuable diagnostic tool for pelvic ring injuries in children, adolescents and young women, provided they are hemodynamically stable. Angiography, ultrasonography and bone scintigraphy are additional important diagnostic and therapeutic options.

PRACTICAL RECOMMENDATIONS

Knowledge of basic pelvic trauma mechanisms is important to understand the potential severity of traumatic pelvic fractures and to classify them correctly in terms of stability. Being familiar with typical concomitant injuries in pelvic ring fractures allows reliable diagnosis and their communication with the clinician. CT remains the "diagnostic workhorse". In fragile pelvic fractures, the often prolonged course with fracture progression must be taken into account, which is why MRI is of particular importance herein.

An overview of the key principles and guidelines in the management of pelvic fractures

Pelvic fractures are complex injuries with a range of different presentations depending on the mechanism of trauma. Due to the morbidity and mortality of pelvic fractures, patients require thorough investigation and timely management with multidisciplinary input. Various surgical and non-surgical techniques can be used to treat pelvic fractures, as well as any associated visceral injuries. Following repair, it is important to remain vigilant for postoperative complications such as infection, sexual and urinary dysfunction, chronic pain and adverse psychological health. This article summarises the relevant UK guidance and literature and presents them in a format that follows the patient’s journey. In doing so, it highlights the key perioperative factors that need to be considered in cases of pelvic fracture.

Urethral injury in children: Experience in a teaching hospital in Enugu, Nigeria

Background:

Urethral injury in children is uncommon, and its treatment is challenging. This study evaluated our experience in the management of urethral injuries in children who presented at the paediatric surgical unit of a teaching hospital in Enugu, Nigeria.

Methods:

The medical records of patients younger than 15 years old admitted to our centre with urethral injury from January 2008 and December 2017 were reviewed retrospectively.

Results:

During the period of the study, 11 cases (all male) were managed. The mean age of the patients at presentation was 11 years. Road traffic accident was the most common mechanism of injury, and the bulbar urethra was the most injured part of the urethra. All the patients had urethroplasty through the perineal approach. There was 90% success at first instance. One patient required redo urethroplasty.

Conclusion:

Urethral trauma is associated with considerable morbidity. Road traffic accident was the most common mechanism of injury, and the bulbar urethra was the part of the urethra most affected. Transperineal urethroplasty was an effective modality of treatment.

[Combined transperineal and transpubic urethroplasty for patients with complex male pelvic fracture urethral distraction defect]

OBJECTIVE

To evaluate the clinical effects and characteristics of combined transperineal and transpubic urethroplasty for patients with complex pelvic fracture urethral distraction defect (PFUDD).

METHODS

We retrospectively reviewed the clinical data of 17 male patients with complex posterior PFUDD from January 2010 to December 2019. The complications included urethrorectal fistulas in 2 patients (11.8%), urethroperineal fistula in 1 patient (5.9%). Ten patients had undergone previous treatments: dilatation in 3 patients (17.6%), internal urethrotomy in 1 patient, failed urethroplasty in 6 patients (35.3%), of whom 2 patients had two times of failed urethroplasties. All the patients were performed with urethroplasty by combined transperineal and transpubic approach with removing the entire pubic bone followed by the anastomosis.

RESULTS

The mean age of the patients included in this study was 35.5 (range: 21-62) years. The mean length of stricture was 5.5 (range: 4.5-7.0) cm, the mean follow-up was 27 (range: 7-110) months, the mean time of operation was 190 (range: 150-260) min, the mean evaluated blood loss was 460 (range: 200-1 200) mL. There were 5 patients who needed blood transfusion intraoperatively or postoperatively. Wound infection was seen in 4 out of 17 patients and thrombosis of lower extremities in 1 out of 17 patients. The last follow-up showed that the mean postoperative maximum urinary flow rate was 22.7 (range: 15.5-40.7) mL/s. After removing the catheter, one patient presented with decreased urinary flow and symptoms of urinary infection. Cystoscopy showed the recurrent anastomotic stricture, which was cured by internal urethrotomy. In our series, the success rate of the combined transperineal and transpubic urethroplasty was 94.1% (16/17).

CONCLUSION

Combined transperineal and transpubic urtheroplasty can achieve a tension free anastomosis after removing the entire wedge of pubis in some patients with complex PFUDD. However, this procedure should be completed in a regional referral hospital due to the complexity of the operation and the high percentage of complications.

[Combined transperineal and transpubic urethroplasty for patients with complex male pelvic fracture urethral distraction defect]

OBJECTIVE

To evaluate the clinical effects and characteristics of combined transperineal and transpubic urethroplasty for patients with complex pelvic fracture urethral distraction defect (PFUDD).

METHODS

We retrospectively reviewed the clinical data of 17 male patients with complex posterior PFUDD from January 2010 to December 2019. The complications included urethrorectal fistulas in 2 patients (11.8%), urethroperineal fistula in 1 patient (5.9%). Ten patients had undergone previous treatments: dilatation in 3 patients (17.6%), internal urethrotomy in 1 patient, failed urethroplasty in 6 patients (35.3%), of whom 2 patients had two times of failed urethroplasties. All the patients were performed with urethroplasty by combined transperineal and transpubic approach with removing the entire pubic bone followed by the anastomosis.

RESULTS

The mean age of the patients included in this study was 35.5 (range: 21-62) years. The mean length of stricture was 5.5 (range: 4.5-7.0) cm, the mean follow-up was 27 (range: 7-110) months, the mean time of operation was 190 (range: 150-260) min, the mean evaluated blood loss was 460 (range: 200-1 200) mL. There were 5 patients who needed blood transfusion intraoperatively or postoperatively. Wound infection was seen in 4 out of 17 patients and thrombosis of lower extremities in 1 out of 17 patients. The last follow-up showed that the mean postoperative maximum urinary flow rate was 22.7 (range: 15.5-40.7) mL/s. After removing the catheter, one patient presented with decreased urinary flow and symptoms of urinary infection. Cystoscopy showed the recurrent anastomotic stricture, which was cured by internal urethrotomy. In our series, the success rate of the combined transperineal and transpubic urethroplasty was 94.1% (16/17).

CONCLUSION

Combined transperineal and transpubic urtheroplasty can achieve a tension free anastomosis after removing the entire wedge of pubis in some patients with complex PFUDD. However, this procedure should be completed in a regional referral hospital due to the complexity of the operation and the high percentage of complications.

Let-7i-5p Regulation of Cell Morphology and Migration Through Distinct Signaling Pathways in Normal and Pathogenic Urethral Fibroblasts

microRNAs regulate subcellular functions through distinct molecular mechanisms. In this study, we used normal and pathogenic fibroblasts in pelvic fracture urethral distraction defects (PFUDD) patients. PFUDD is a common disease that could severely affect patients’ life quality, yet little is known about the molecular mechanism associated with pathogenic fibrosis in PFUDD. Our data showed that let-7i-5p performs a multi-functional role in distinct signaling transduction pathways involved in cell morphology and cell migration in both normal and pathogenic fibroblasts. By analyzing the molecular mechanism associated with its functions, we found that let-7i-5p regulates through its direct target genes involved in collagen metabolism, cell proliferation and differentiation, TGF-beta signaling, DNA repair and ubiquitination, gene silencing and oxygen homeostasis. We conclude that let-7i-5p plays an essential role in regulating cell shape and tissue elasticity, cell migration, cell morphology and cytoskeleton, and could serve as a potential target for clinical treatment of urethral stricture patients.

Comparison of efficiency of vascular-preserving urethroplastic methods of the bulbo-membranous part of the urethra

Introduction

There are several options for vessel-sparing anastomotic procedures that allow one to avoid disturbances in the normal blood supply to the spongy body and successfully perform plastic surgery of distal urethral strictures.

Aim

To perform a comparative analysis of the effectiveness of reconstructive surgical treatment of strictures of the bulbo-membranous urethra with anastomotic surgery with and without vessel-sparing.

Material and methods

A prospective study was carried out on 28 patients with a diagnosis of stricture of the bulbo-membranous urethra who underwent treatment in the period 2012–2018 in the conditions of a urological hospital of Irkutsk City Clinical Hospital No. 1. Anastomotic urethroplasty was performed using one of two methods: with full mobilization of the spongy body bulb and a vessel-sparing method when the spongy body does not intersect.

Results

The effectiveness of the classical method of anastomosing EPA-TWW ((excision and primary anastomosis urethroplasty (Turner-Warwick) and excision and Jordan’s technique of vessel sparing excision and primary anastomosis)) was comparable with the method of anastomosing without crossing the (spongy body of EPA-J). Postoperative changes in the parameters of the functional status of patients based on the International Prostate Symptom Score (IPSS), International Index of Erectile Function, and Quality of Life were comparable in patients undergoing EPA-TWW and EPA-J. The final data indicate a statistically equivalent risk of developing complications such as urinary incontinence, shortening of the penis, and decreased erectile function.

Conclusions

The study did not demonstrate a statistically significant difference in the effectiveness of the treatment and the risks of complications during anastomotic surgery with or without vessel-sparing. However, an unformalized assessment demonstrates the best state of erectile function in patients after vascular-preserving surgery.

Clinical outcomes of blood transfusion to patients with pelvic fracture in the initial 6 h from injury

As part of the treatment of pelvic fracture, major hemorrhage poses a challenge for trauma surgeons. The aim of the present study was to evaluate the clinical outcomes of blood transfusion in the initial 6 h after pelvic fracture, and to define the blood transfusion volume required for each pelvic fracture type. A retrospective cohort study was performed on patients with pelvic fracture at a single Level I Trauma Centre over a 3-year period. A total of 1,297 patients were transported to our trauma centre within 2 h of injury and blood transfusion was administered in the initial 6 h after pelvic fracture. Review of the patients' medical records provided the initial pelvic radiographs and data from emergency department care. Clinical outcomes, including frequency of blood transfusion, blood transfusion volume, injury severity scores and mortality, were evaluated. All pelvic fractures were defined as closed fractures and patients were categorized according to the Arbeit fuer Osteosynthese (AO) classification system. Statistical methods were used to identify trends to provide guidance for clinical prediction. Complete data were available for 497 patients with pelvic fracture, 104 (20.9%) of which received blood transfusion. The blood transfusion volume in the initial 6 h ranged from 0 to 10,000 ml, with a mean of 1,213.94±1354.11 ml. The total mortality rate was 1.8%. Among the patients with C-type pelvic fractures, the frequency of blood transfusion was 59.0% and the mean volume was 2,191.30±1,740.93 ml. The mortality rate for C-type pelvic fractures was 11.43%. The B3 subtype of pelvic fractures had the highest transfusion frequency (53.6%), while the C3 subtype had the largest blood transfusion volume (5,700.00±4,666.90 ml). Patients with type A-C pelvic fractures had a progressively larger mean transfusion volume, transfusion frequency and mortality in the initial 6 h after pelvic fracture. The AO classification system was demonstrated to be a useful tool for the identification of pelvic fracture risk in the present study.

Risks and Strategies to Avoid Approach-Related Complications During Operative Treatment of Pelvic Ring or Acetabular Fractures

Injuries of the pelvic ring or the acetabulum are either to be found in young patients with high energy trauma mechanisms or in geriatric patients after simple falls with very low impact energy. The indication for surgical stabilization is given by the grade of instability. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of reachable anatomical structures and possible risks of the different approaches are important. In this review, we summarize the standard surgical approaches to the pelvic ring and to the acetabulum. We describe the reachable anatomical structures for each approach, approach-related pitfalls, and we focus on strategies to reduce approach-related complications.

Comparing complications of urethral stricture across various ages: a retrospective analysis of findings from retrograde urethrogram and voiding cysto-urethrogram over 10 years

Objective

To determine the rate and the distribution of the structural defects in the urinary bladder complicating urethral stricture in men, and to compare the complications observed in the younger patients to those observed in the older patients.

Methods

Retrospectively, case files of patients diagnosed of urethral stricture using retrograde urethrogram (RUG) and voiding cysto-urethrogram (VCUG) from February 2009 to August 2018 were analyzed. Stricture characteristics were outlined. In addition, complicating structural defects in the lower urinary tract proximal to the stricture site were documented. The complicating defects identified in the patients were segregated according to age for any observable associations. Logistic regression analysis was used to define the nature of the association of patient age, stricture site, number and length, with distribution of complicating structural defects. Analyses were done using SPSS® version 20.

Results

Within the 10-year review period, 257 of 421 suspected cases of urethral stricture were confirmed. Patients are between 1 and 104 years of age (mean: 50.1 ± 19.1 years; median: 51.0 years IQR 35.0–65.0). Bulbar (34.2%); short segment (62.6%); partial (73.9%) strictures are prevalent. Forty-seven (18.3%) of 257 patients presented with 1 or more complications. Bladder diverticulum (8.6%) and urethra-cutaneous fistula (6.6%) are prevalent complications. The distribution of complications does not vary with age, or with stricture characteristics.

Conclusion

Presentation with complications is not uncommon. The distribution of these complications does not vary with age or with stricture characteristics.

'Poles apart presentation': diagnosis and management of iatrogenic posterior urethral false tract in cases of pelvic fracture urethral injury

Iatrogenic creation of false tract in posterior urethra while managing a case of pelvic fracture urethral injury is a dreadful complication. The spectrum of presentation ranges from complete urinary incontinence to urinary retention. We describe three such cases created due to railroading or attempted repair. Case 1 presented with total urinary incontinence following open perineal urethroplasty for posterior urethral trauma while two cases presented with failure to void after endoscopic or open surgical management for the same. One patient was managed with endoscopic resection of the septum between the false passage and true posterior urethra; two cases required redo urethroplasty. All patients voided well postoperatively and were continent. Surgeon experience and meticulous endoscopic evaluation are the keys to success. Forceful attempt at per urethral catheter placement in the acute setting should be avoided. Blind railroading of the catheter and unnecessarily forceful passage of suprapubic metal bougie during urethroplasty should be condemned.

Embolization with microcoils for urethral hemorrhage: A case report

RATIONALE

Microcoils are a permanent embolic material, and blood vessels that have been embolized by a microcoil remain occluded for a prolonged period of time. The pudendal artery is an important functional vessel for penile erection. Whether simultaneous embolization of the bilateral pudendal artery using microcoils can seriously affect penile erection has not been sufficiently studied.

PATIENT CONCERNS

A 47-year-old male patient, after undergoing brain surgery, accidentally pulled out the Foley catheter causing a urethral hemorrhage. The patient was immediately treated using a new larger Foley catheter inserted under urethroscopic guidance and medication. However, massive bleeding occurred on the tenth day after the procedure.

DIAGNOSIS

A right internal iliac angiography performed after the bleeding event demonstrated a rupture at the end of the right internal pudendal artery with the contrast agent flowing out directly from the urethra. A super selective internal pudendal angiogram showed a small amount of hemorrhage at the end of the left internal pudendal artery.

INTERVENTIONS

The patient underwent interventional treatment. After the bilateral internal iliac angiography was performed, super-selective internal pudendal artery embolization with microcoils was performed. A subsequent bilateral internal pudendal angiogram did not show any abnormality.

OUTCOMES

During the follow up period of 2 months, the patient had no complaints of difficulty in urination or sexual dysfunction.

LESSONS

Some doctors do not advocate the use of coils as embolic agents in bilateral pudendal artery lesions because of concerns over erectile dysfunction. There is rich vascular circulation in the perineum. Thus, in arterial embolization for the treatment of penile bleeding, regardless of the type of embolic material used, the key is to ensure accurate embolization to maintain good collateral circulation. This principle can help limit the occurrence of sexual dysfunction to the lowest possible levels after such procedures.

Urethroplasty for urethral injuries and trauma-related strictures in children and adolescents: a single-institution experience

INTRODUCTION

Urethral injuries and trauma-related strictures (UITSs) in children are rare. The treatment is challenging but crucial to avoid life-long urinary complications such as recurrent stricture formation, urinary incontinence, and impotence.

OBJECTIVE

The aim was to report on the surgical and functional outcome of urethroplasty for UITSs and to provide data on patient-reported outcome measures (PROMs).

MATERIAL AND METHODS

Between November 2001 and October 2017, 18 male children (≤18 years; median: 13 years) underwent urethroplasty for UITSs at a single tertiary referral center. Etiology was iatrogenic in five (27.8%), perineal straddle injury in six (33.3%) and pelvic fracture urethral injury (PFUI) in seven (38.8%) patients. PFUIs and short (≤3 cm) bulbar strictures were treated by transperineal anastomotic repair (n = 15; 83.3%), whereas a long bulbar stricture and a penile stricture were treated by, respectively, a preputial skin graft and flap urethroplasty. A penetrating penile urethral injury during circumcision underwent early exploration with primary repair of the laceration. Failure was defined as need for additional urethral instrumentation. PROMs were sent to patients ≥16 years at the latest evaluation.

RESULTS

Median follow-up was 57 (range: 8-198) months. No complications and grade 1, 2, and 3 were present in, respectively, 13 (72.2%), two (11.1%), one (5.6%), and two (11.1%) patients. The success rate in a tertiary referral center was 94.4%. An immediate failure was observed in a patient with a PFUI and concomitant bladder neck injury. PROMs were available in 12 patients. Four patients (33.3%) reported erectile dysfunction. Post-void dribbling (25%) and urgency (50%) were the most frequently reported complaints. All patients were satisfied after urethroplasty and stated that they would undergo the surgery again.

DISCUSSION

This series corroborates the recent trend in favor of transperineal anastomotic repair for PFUI, with combined abdominoperineal approach reserved for complex situations (e.g. bladder neck injury). For anterior UITSs, adaption of the technique to the characteristics of UITSs (etiology, location, length, and quality of graft bed) yielded excellent outcomes. Future systematic use of PROMs is also needed in children to elucidate the impact of urethroplasty on the urinary and sexual function.

CONCLUSION

External trauma is the most important etiology of UITSs, but iatrogenic causes should not be neglected. Urethroplasty, mainly by anastomotic repair (AR) but with the technique adapted to local stricture characteristics if necessary, has an excellent long-term success rate in experienced hands. Functional disturbances are frequent, but despite this, patient satisfaction is high after urethroplasty.

Management of male pelvic fracture urethral injuries: Review and current topics

Pelvic fractures from high-energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.

Multiple Injuries to the Lower Urinary Tract: Two Cases and Comparison with the EAU Guidelines

Blunt trauma to the lower urinary tract is usually associated with pelvic fractures. The European Association of Urology (EAU) provides guidelines to diagnose and treat these injuries. The guidelines summarise the available evidence and provide recommendations on diagnosis and treatment of these patients. Therefore, these guidelines are important adjuncts to the urologist and emergency physician in the clinical decision-making. However, strict adherence to the guidelines is not always easy or possible because of concomitant injuries obscuring the clinical picture. This is illustrated by two case reports of concomitant injuries of the lower urinary tract (bladder with urethral injury). The clinical decisions will be discussed point by point and should serve as a practical teaching moment for the reader.

Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

Objective

To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA.

Materials and Methods

Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis.

Results

Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not.

Conclusions

Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.