UROGENITAL TRAUMA

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
  Acute, blunt posterior urethral injuries, I believe, have ample data in the literature to support early endoscopic realignment over a catheter instead of suprapubic tube placement. I was surprised to see that in this series, acute realignment of significant acute blunt anterior urethral injuries was certain no better and potentially worse than suprapubic urinary diversion.
  Seventy-eight patients are reported here, of which roughly half present acutely and half present long after the injury (all of these late cases had urethral stricture). Nine percent of those treated with urinary diversion required urethroplasty and 17% of those treated with primary catheter realignment needed surgery (p = not significant). More importantly, the length of the stricture seemed to be much longer on those managed with a urethral catheter (p < 0.5). The reason for this is unclear, and explanations involving “damage to the corpora spongiosum” are usually invoked in the literature. No matter what the reason, the data appears reasonably robust to suggest that acute catheter realignment of these injuries is not a good idea.
  Of note, this article, which deals with blunt injury, should not be confused with previously printed works concerning penetrating anterior urethral trauma. This, too, is controversial with some advocating immediate repair and others advocating suprapubic diversion alone.
  Although it will be psychologically difficult for me to avoid early urethral realignment of anterior strictures over a catheter (as I so strongly believe that it helps greatly in posterior urethral stricture) this and other series seem to indicate that suprapubic diversion may be the better option.

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA