This article reviews the history, indications, technique, complications, and outcomes of primary urethral realignment of pelvic fracture urethral injuries. In clinically stable patients, an attempt at endoscopic urethral realignment is appropriate and may result in long-term urethral patency. However, long term follow up is necessary due to elevated rates of delayed stricture formation requiring endoscopic or surgical repair.
Key points
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Open primary repair of pelvic fracture urethral injuries (PFUIs) should not be performed due to unacceptably high blood loss and high rates of postoperative erectile dysfunction.
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Primary endoscopic realignment of PFUI is indicated for stable patients with PFUI, especially those with concomitant rectal and/or bladder injury.
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For unstable patients with PFUI, a suprapubic tube should be immediately placed. Endoscopic realignment can then be attempted during the first week after injury provided the patient has been appropriately stabilized.
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Even when primary realignment is successful, the majority of patients will develop a urethral stricture during the first year after the injury.
Introduction
Pelvic fracture urethral injury (PFUI) is an uncommon yet debilitating consequence of blunt pelvic trauma. The mechanism of these injuries involves major shearing forces at the bulbomembranous junction, resulting in avulsion of the urethra from the fixed urogenital diaphragm. PFUI rates vary from 5% to 25% in small series ; however, a recent review of the National Trauma Data Bank (NTDB) reported a lower prevalence of 1.54%. The initial management of these devastating injuries involves either primary urethral realignment or suprapubic cystostomy diversion followed by delayed urethroplasty. The potential advantages of primary urethral realignment include an earlier return to voiding, the possibility of avoiding future operative interventions, and better alignment of the proximal/distal urethral segments if an open urethroplasty is necessary in the future.
Introduction
Pelvic fracture urethral injury (PFUI) is an uncommon yet debilitating consequence of blunt pelvic trauma. The mechanism of these injuries involves major shearing forces at the bulbomembranous junction, resulting in avulsion of the urethra from the fixed urogenital diaphragm. PFUI rates vary from 5% to 25% in small series ; however, a recent review of the National Trauma Data Bank (NTDB) reported a lower prevalence of 1.54%. The initial management of these devastating injuries involves either primary urethral realignment or suprapubic cystostomy diversion followed by delayed urethroplasty. The potential advantages of primary urethral realignment include an earlier return to voiding, the possibility of avoiding future operative interventions, and better alignment of the proximal/distal urethral segments if an open urethroplasty is necessary in the future.
Historical perspective
PFUI management has changed significantly over the last 80 years. The earliest reported method of operative urethral repair was described by Young in 1929 and involved immediate, primary suturing of the disrupted urethral ends via a perineal approach. This method was abandoned in favor of the retroperitoneal approach because of concerns about placing the injured patient in a dorsal lithotomy position with a concomitant pelvic fracture. Immediate retroperitoneal exploration and primary urethral repair also passed out of favor because of unacceptably high blood loss and high rates of postoperative erectile dysfunction.
Ormond and Cothran first described primary urethral realignment in 1934, by reapproximating the torn urethral ends with a catheter and encouraging re-epithelialization via catheter traction. This technique, referred to as railroading, involved advancing a catheter across the urethral defect in an antegrade or retrograde fashion to realign the urethra. The catheter remained in place for 4 to 8 weeks. Initially, the patient’s catheter was maintained on 500 grams of traction at a 45° angle for the first 5 to 7 days after injury in an effort to realign the proximal and distal urethral ends. The theory supporting use of traction was to provide a scaffold for mucosal regeneration. Increased rates of incontinence were noted following the use of prolonged traction attributed to ischemic damage of the internal sphincter. Canine studies performed in the 1960s also demonstrated that the transected canine posterior urethra did not undergo mucosal re-epithelialization. Instead fibrous tissue filled the intervening gap.
Early techniques for urethral realignment were performed using either Davis interlocking sounds or magnetic sounds. These instruments are of historic interest used in the era before flexible cystoscopy. One sound was placed through the suprapubic tube tract, while the other was passed through the urethra. The sounds were advanced toward each other until the tips either linked together or were brought together via magnetic attraction. The tip of the SP tract sound then followed the penile sound until it exited the urethra, allowing a catheter to be advanced in a retrograde manner into the bladder. An SP tube could be placed for maximal drainage during healing. Primary urethral realignment was the standard of care for treatment of posterior urethral injuries from the 1930s until the 1960s. The technique later fell out of favor because of fear that primary urethral realignment caused further damage to the periprostatic tissue and neurovascular bundles, leading to impaired potency and continence.
In the mid-1950s, Endtner advocated for initial suprapubic cystostomy and no attempt at initial urethral manipulation. This would be followed by delayed, elective repair of the inevitable urethral stricture after 3 to 6 months of suprapubic catheter drainage. Although it generated a nearly 100% stricture rate, this delayed approach was the standard of care for the next 30 years.
Newer techniques pertaining to urethral realignment were introduced in the late 1980s. These techniques evolved into a combination of transurethral and transvesical endourologic procedures in conjunction with fluoroscopy. This technique is postulated to reduce damage to erectile function compared with earlier methods of realignment, because there is no manipulation of the periprostatic tissues and neurovascular bundles.
Indications
Posterior urethral injury should be considered in male trauma patients who have sustained either a pelvic fracture or perineal trauma. Blood at the meatus should increase the level of suspicion. Basta and colleagues reported that 92% of male subjects with PFUI had inferomedial pubic bone fractures or pubic symphysis diastasis, and in 88% of subjects, the displacement was greater than 1 cm.
In patients who have sustained blunt trauma to the pelvis or perineum and who are clinically stable, a retrograde urethrogram (RUG) should be performed to characterize a potential urethral injury. If a urethral disruption injury is noted, then primary urethral alignment may be indicated. In patients in whom the index of suspicion for urethral injury is high, yet who are clinically unstable, the urologist may attempt placement of a urethral catheter followed by suprapubic catheter if urethral catheterization is unsuccessful. Retrograde urethrogram for diagnosis and injury staging can be performed after clinical stabilization of the patient.
Table 1 describes the American Association for the Surgery of Trauma (AAST) classification for urethral injuries along with their associated findings on retrograde urethrogram. In grades 1 and 2, the urethral mucosa is intact, and contrast does not extravasate during retrograde urethrogram. In these less severe injury patterns, gentle Foley catheter placement can be performed. Grades 3 to 5 injuries range in severity from partial to complete urethral lacerations ( Fig. 1 ), and they are amenable to primary urethral realignment using the techniques outlined in the following section. Specific indications for primary realignment in hemodynamically stable patients with PFUI include concomitant bladder and bladder neck injury (which makes SP cystostomy difficult or impossible), rectal injury (in which optimized drainage is recommended), and extreme displacement of the bladder and prostate from the membranous urethra ( Fig. 2 ). Fig. 3 outlines the authors’ suggested algorithm for the management of PFUI.
| Grade | Definition | Findings on RUG |
|---|---|---|
| 1 | Contusion | Normal RUG, blood at meatus |
| 2 | Stretch injury | Normal RUG, elongation of the urethra |
| 3 | Partial disruption | Extravasation of contrast, contrast into bladder |
| 4 | Complete disruption | Extravasation of contrast, <2 cm separation, no contrast in bladder |
| 5 | Complete disruption | Complete transection, >2 cm urethral separation or injury into prostate or vagina |
Technique: retrograde and antegrade/retrograde
Primary urethral realignment for posterior urethral injuries can be performed using several techniques. The most commonly described techniques for primary urethral realignment include retrograde and antegrade/retrograde.
Retrograde Approach
A flexible cystoscope is advanced into the urethra to the injured area. In the setting of partial urethral injuries, the cystoscope may be able to navigate the injury and be advanced directly into the bladder. Otherwise, a glide wire is passed through the damaged portion of the urethra into the bladder. Confirmation that the wire has traversed the injury and is coiled in the bladder is obtained by advancing a 5 F catheter over the wire. The guide wire is then removed leaving the 5 F catheter in place. Urine is then aspirated through the catheter, or, if fluoroscopy is available, a cystogram is performed. After confirmation of the 5 F catheter’s position, the guide wire is replaced, and a Council tip catheter is advanced over the wire into the bladder.
Antegrade/Retrograde Approach
This method employs an existing suprapubic tube tract, through which a flexible cystoscope is advanced to the bladder neck. A second cystoscope is advanced retrograde into the urethra. The 2 cystoscopes are advanced toward each other through the damaged portion of the urethra until the light from 1 cystoscope is visible by the other. Fluoroscopic images via a movable C-arm are helpful during this step in severe urethral disruptions to assess the alignment of the 2 cystoscopes in the anterior/posterior and lateral planes. Once correctly aligned, a wire is advanced through 1 cystoscope into the working port of the other cystoscope, thus establishing access from the suprapubic tract through the injured urethra and out the urethral meatus. The cystoscopes are removed, and a Council tip urethral catheter is passed over the wire across the damaged urethra and into the bladder, where the balloon is inflated. A suprapubic catheter may be left for maximal urinary drainage during healing.
Technique: additional considerations
Timing of Primary Urethral Realignment
Following diagnosis of a partial urethral injury (AAST grade 3), the authors’ practice is to make 1 attempt at retrograde urethral catheter placement. If unsuccessful, they proceed with endoscopic realignment via the retrograde approach outlined previously. Primary urethral realignment of a complete injury is often delayed 24 to 72 hours following injury, while the patient is stabilized in the trauma intensive care unit. The bladder is drained with a suprapubic catheter during this time. Delayed primary realignment can take place up to several days after the initial injury in a patient with a suprapubic catheter. The mean and median time to primary realignment in the authors’ published series of primary urethral realignment patients was 2 days, with a range of 0 to 7 days.
Placement of a Suprapubic Catheter
In the setting of delayed primary urethral realignment, the patient’s bladder is decompressed with a suprapubic catheter. The suprapubic catheter is placed either by the urologist at bedside or under ultrasound guidance in interventional radiology. In pelvic trauma patients, the bladder may be displaced cephalad by significant pelvic hematoma, making ultrasound-guided suprapubic catheter placement a safer option (see Fig. 2 ).
Intraoperative Considerations: Setting, Positioning, Fluoroscopy, Antibiotics
The setting of the primary urethral realignment, at the bedside versus the operating room, is dictated by the stability of the patient and the need for other surgical procedures. To minimize trips to the operating room, the authors’ preference is to perform primary urethral realignment in conjunction with other operative procedures, most commonly orthopedic. This provides several benefits, including close hemodynamic monitoring by anesthesia, a sterile environment, timely access to equipment and fluoroscopy, and the ability to perform an open repair of a possible concomitant bladder injury or bladder neck laceration.
The use of flexible cystoscopy allows for the patient to be positioned supine or in dorsal lithotomy position for both the retrograde or antegrade/retrograde approaches. When performed at bedside, the primary realignment is generally performed with the patient supine. Decisions regarding intraoperative positioning can be made with the input of the other surgical services involved in the planned procedures.
Intraoperative fluoroscopy is a helpful adjunct to both retrograde and antegrade/retrograde primary realignment. In the retrograde approach, fluoroscopy can confirm the proximal location of the wire in the bladder. In both approaches, a cystogram can be performed to evaluate for concomitant bladder or bladder neck injury. An intraperitoneal bladder injury or a bladder neck laceration are both indications for open operative repair. During the antegrade/retrograde approach, fluoroscopy can confirm that the 2 cystoscopes are in the appropriate anterior/posterior and lateral plane.
Peri-procedural antibiotic prophylaxis is recommended with either a first-generation cephalosporin or a fluoroquinolone. Practice patterns differ depending on the duration of antibiotic prophylaxis.
Frequency of Technical Success
The reported urethral catheter placement rate via primary realignment is high, ranging from 70 to 93%. Other series indicate that if initial primary realignment is unsuccessful, delayed primary realignment in 2 to 3 days may be achievable, as tissue edema may have resolved, enhancing visibility.
Duration of Urethral Catheterizaton
The published duration of urethral catheterization varies from 3 to 6 weeks. The authors’ practice is to maintain urethral catheterization for a minimum of 3 weeks for AAST grade 3 injuries and for 6 weeks for complete disruptions (AAST grade 4 and grade 5 injuries). Urethral catheters can be maintained longer if medically necessary as part of the patient’s poly-trauma recovery. A pericatheter retrograde urethrogram or voiding cystourethrogram (VCUG) is performed at the time of catheter removal to confirm absence of urethral extravasation. Bladder drainage should be maintained via urethral catheter or suprapubic catheter until urethral extravasation has fully resolved to reduce the risk of scrotal abscess. If present, the suprapubic catheter can be capped after radiologic confirmation of urethral healing. After confirmation of successful voiding, the suprapubic catheter can be removed.
Surgeon preference dictates whether to leave a suprapubic catheter in addition to the urethral catheter. Orthopedists often prefer removal of a suprapubic catheter after urethral realignment if open reduction and internal fixation are performed for the associated pelvic fracture. If retrograde realignment is achieved, delayed replacement of the SP under controlled conditions may be considered in high-risk patients. If the suprapubic catheter is still present, the authors will cap the SP tube after confirmation of urethral healing and allow voiding per urethra. The SP tube can be removed once the patient is able to successfully void.
Follow-up Protocol
Among patients who failed primary urethral realignment, the mean time to failure was 79 days, with a range of 0 to 288 days. The authors’ series indicates that although most patients fail within 6 months of urethral catheter removal, remote failures also occur. Given the high 79% stricture rate noted in their series, the authors’ follow-up protocol includes uroflowmetry, postvoid residual and/or cystoscopic evaluation at 1, 2, 3, 12, and 24 months. Patients undergo immediate RUG and/or cystoscopy if symptoms of obstructive voiding manifest. The authors strongly recommend scheduled follow-up after all catheters are removed and do not have patients follow-up on an as-needed basis.
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