Current management of pelvic fracture urethral injuries: to realign or not?

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

BACKGROUND

Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI.

METHODS

Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction.

RESULTS

There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784).

CONCLUSION

In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Role of magnetic resonance imaging in the management of male pelvic fracture urethral injury

The management of male pelvic fracture urethral injury remains a urological challenge. Pelvic fracture urethral injury can be associated with sequelae, such as urethral gap, erectile dysfunction and urinary incontinence. Delayed anastomotic urethroplasty, the gold standard treatment for urethral gaps caused by pelvic fracture urethral injuries, is technically demanding, and reconstructive urologists should preoperatively obtain as much detailed anatomical information as possible. A combination of antegrade and retrograde urethrography is the fundamental preoperative evaluation, but it cannot accurately assess the urethral gap length, the degree of lateral prostatic displacement, the anatomical relationship of the urethra with its surrounding structures (such as the rectum and dorsal venous complex) or periurethral problems (such as minor fistulae or cavitation). To make up for these limitations of urethrography, magnetic resonance imaging has emerged as a non-invasive, multiplanar and high-resolution modality for the evaluation of pelvic fracture urethral injury. Magnetic resonance imaging has excellent soft-tissue contrast, and can clearly show the urethra and periurethral tissues without the effects of radiation, thus enabling clinicians to anticipate the required ancillary techniques for delayed anastomotic urethroplasty and to predict functional outcomes, such as erectile function and urinary continence, after delayed anastomotic urethroplasty. This review discusses the role of magnetic resonance imaging in the evaluation of pelvic fracture urethral injury and its impact on patient management.

Temporal trends in the incidence of severe pelvic fracture urethral injuries in the United States from 1998 to 2014

OBJECT

To use a contemporary population-based cohort to investigate temporal trends in the national incidence of pelvic fracture urethral injuries (PFUIs) in the United States.

METHODS

Using the NIS (National Inpatient Sample), we identified patients with a severe PFUI by a combination of an ICD-9 diagnosis code for pelvic fracture (808.xx) and ICD-9 procedure code for suprapubic tube (57.17 or 57.18) from 1998 to 2014. We compared the annual rates of PFUIs and the annual rates of pelvic fractures alone.

RESULTS

An estimated total of 6052 ± 347 males with PFUIs were identified. The average age was 38.4 ± 0.5 years. 9.1% ± 0.8% of patients died while hospitalized. In the time frame studied, the rate of PFUI significantly decreased during from 532 patients in 1998 to 255 patients in 2014. Sensitivity analysis excluding patients with bladder repairs identified a similar trend. The annual rate of PFUI per 1000 pelvic fractures has also decreased from 14.6 ± 1.6 in 1998 to 6.5 ± 0.9 in 2014 (p = 0.001).

CONCLUSIONS

In this population level study, the number of severe PFUIs has decreased in the United States from 1998 to 2014, which coincides with the implementation and enforcement of seat belt and air bag regulations. Given the rarity of these cases, there is a strong need for collaborative efforts in research and teaching at tertiary care centers for reconstructive urology.

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.

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.