UROGENITAL TRAUMA

doi: 10.1590/S1677-553820100001000021

Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone
Husmann DA, Boone TB, Wilson WT
Department of Surgery, University of Texas Southwestern Medical Center, Dallas
J Urol. 1993; 150: 70-2

• The management of partial transection of the anterior urethra following penetrating penile injuries is controversial. Optional therapeutic techniques range from a primary sutured reapproximation to urinary diversion alone. We recently managed 17 low velocity gunshot wounds to the external genitalia in which the missile traversed the penile corpus cavernosum, and was associated with less than 40% transection of the corpus spongiosum and anterior urethra. Nine patients were managed with suprapubic diversion, skin débridement and corporeal closure along with placement of a urethral catheter. Eight patients were managed by suprapubic diversion, débridement, closure of the corporeal bodies and a primary sutured reapproximation of the anterior urethra. Urethral strictures developed in 7 patients (78%) managed by a suprapubic tube and urethral stenting during an average followup of 20 months (range 18 to 24). In contrast, 1 patient (12%) managed by a sutured urethral approximation had a urethral stricture during an average followup of 20 months (range 18 to 30, p < 0.01). Our data support a significantly better prognosis for partial transection of the anterior urethra secondary to low velocity gunshot wounds if managed by aggressive wound débridement, corporeal repair, placement of a suprapubic catheter and primary repair of the urethra.

• 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