UROGENITAL TRAUMA

Treatment of pelvic fracture-related urethral trauma: a survey of current practice in the UK
Andrich DE, Greenwell TJ, Mundy AR
Institute of Urology, London, UK
BJU Int. 2005; 96: 127-30

• Objective: To quantify experience of pelvic fracture-related urethral trauma (PFUT), a condition not often encountered and managed by urologists.
• Methods: The consultant urologists of the UK and Ireland were contacted informally to establish their experience with PFUT and its management, both immediate and delayed. In addition, particular individuals thought to have a specific interest in PFUT were targeted for more data.
• Results: The overall response rate was 49% (235 responders), representing 78% of urological departments, including all the targeted individuals. Of the responders, 129 (55%) had never seen PFUT in 1-25 years of consultant practice. Only four urologists (2% of responders) saw three or more cases a year. Another four (2%) saw one or two cases per year and the remaining 98 (41%) saw PFUT less frequently. Acutely, 69% of urologists who treated PFUT did so by placing a urethral catheter. Subsequent strictures were treated endoscopically for as long as this was possible. The other 31% inserted a suprapubic catheter and referred the patient for reconstructive surgery if needed. Those who used urethroplasty for strictures after PFUT were identified and targeted; half used urethral mobilization and spatulated anastomosis alone. Only three surgeons performed more than five procedures a year.
• Conclusion: Whatever a specialist reconstructive unit might do, practice in the wider urological community is different. Even within specialized units, PFUT is rare and the surgical management is often significantly different from published ‘expert’ opinion.
  
  
• Editorial Comment
  This British paper eloquently states what those of us who specialize in trauma and urethral reconstructive surgery have experienced in practice for years. Despite a wealth of literature supporting that managing urethral distractions by a “reconstructive ladder” is antiquated and prone to failure, this is the most common method practiced by contemporary British and Irish urologists. Furthermore, most UK urologists manage only a handful of urethral distraction injuries their entire career, and even fewer have performed a posterior urethroplasty. It is this general lack of experience and knowledge of the literature that makes minimally invasive methods of management disproportionably popular. Posterior urethral injury from pelvic fracture is a distraction injury where the space between the separated ends of the urethra fills with scar. Thus, posterior urethral distraction injuries are not really urethral strictures, and thus minimally invasive methods and “cut to the light” procedures do not have any durable success.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA