UROGENITAL TRAUMA

doi: 10.1590/S1677-553820100001000020

Straddle injuries to the bulbar urethra: management and outcomes in 78 patients
Park S, McAninch JW
Department of Urology, University of California School of Medicine and Urology Service, San Francisco General Hospital, USA
J Urol. 2004; 171(2 Pt 1): 722-5

• Purpose: We describe our experience with blunt straddle injuries to the anterior urethra and identify factors that may affect patient outcome.
  Materials and Methods: We reviewed the San Francisco General Hospital Urologic Trauma data base to identify men with blunt straddle injury. We analyzed presentation and initial management, location and length of urethral stricture, surgical options, and long-term outcome after reconstruction.
  Results: Of 78 patients, 40% presented to the emergency department acutely and 60% presented 6 months to 10 years after injury complaining of obstructive symptoms, of whom 30% reported at least 1 episode of urinary retention. Initial acute management was suprapubic cystostomy in 81% of cases and primary realignment in 19%. Urethral strictures were predominantly located in the proximal bulb. Mean stricture length was significantly longer in men with delayed presentation (2.7 vs 1.8 cm, p <0.05). No relationship was found between stricture length and the mechanism of injury or initial management technique. However, patients who had undergone primary realignment required complex flap or graft urethroplasty at a greater rate compared with men who had undergone suprapubic diversion (p = 0.054). Transperineal urethroplasty was required in 92% of patients with the majority undergoing end-to-end anastomosis. The success rate was 95% at a mean followup of 25 months (range 10 to 180). Recurrent stricture occurred in 4 men with prior urethral manipulation and it was managed successfully by direct vision internal urethrotomy alone.
  Conclusions: After blunt straddle injury to the perineum the primary morbidity is anterior urethral stricture, for which suprapubic cystostomy is appropriate initial management. The majority of patients require surgery but with careful preoperative planning and adequate resection of fibrotic tissue the long-term success rate can approach 95%. If it arises, recurrent stricture responds well to direct vision internal urethrotomy alone.

• Editorial Comment
  While a few of the above articles are old, they illustrate important teaching points about how urethral injury etiology dictates outcome and the best choice for management.
  Blunt crush injuries to the urethra typically results in a short segment of spongiofibrosis that occurs in the mid bulbar urethra. Stricture etiology, location and length typically dictate the type of repair selected and the success of the long term outcome. With a blunt injury, the stricture is typically less than 2 cm and the natural elasticity of the mobilized urethra can bridge the gap. The spongiofibrosis from a straddle injury is isolated to a short segment, while the rest of the urethra and the rest of the corpus spongiosum are normal. Inflammatory strictures typically cause a more diffuse spongiofibrosis, and thus are often best managed by an onlay skin flap or buccal mucosal graft.
  Straddle injuries are not to be confused with the stenoses that occur from pelvic fracture. With pelvic fracture, the injury is a distraction injury where there is disruption of the urethra and corpus spongiosum at the level of the membranous - bulbar junction or the membranous and the prostate. Here there is no real spongiosum fibrosis and “urethral stricture” – but scar tissue that fills the gap. Primary realignment is the preferred management of such injuries because it a distraction injury and not a stricture. Historically, the outcomes of primary realignment are a reduction in urethral stricture by 50%, while the rates of erectile dysfunction and incontinence are the same as a suprapubic tube. Furthermore, the eventual stricture that does occur is often shorter and more amenable to urethrotomy.
  From the above abstracts, I think the conclusion that straddle injuries should be managed by suprapubic tube alone, as the best management that should be followed. Intuitively, we would assume that the Denis Browne principle would apply here and stenting would promote epithelialization. However, until a randomized prospective trial takes pace – and I doubt that any such study will be done soon – we should resist the temptation to primarily realign the urethra. As to urethral penetrating urethral injuries from low velocity gunshot wounds (no delayed ischemia or blast effect) the site of injury is typically short. A short area of injury can be bridged by adequate mobilization and natural elasticity of the urethra, particularly in the bulbar urethra. In the penile urethra, over mobilization and an anastomosis on tension may result in chordee or stricture failure. Primary realignment of a short penile urethral injury is not the first treatment of choice – but rather surgical exploration and primary repair. When the defect is too long (more than 1 cm or so), urethral marsupialization and a two stage repair (in the method of Johansson) is probable best.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu