UROGENITAL TRAUMA

The treatment of posterior urethral disruption associated with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty
Mouraviev VB, Coburn M, Santucci RA
Prostate Centre, Vancouver General Hospital, Vancouver, British Columbia, Canada
J Urol. 2005;173: 873-6

• Purpose: Urological treatment of the patient with severe mechanical trauma and urethral disruption remains controversial. Debate continues regarding the advisability of early realignment vs delayed open urethroplasty. We analyzed our experience with 96 patients to determine the long-term results of the 2 approaches.
• Materials and Methods: We retrospectively reviewed the records of 191 men with posterior urethral disruption after severe blunt pelvic injury between 1984 and 2001, of whom 96 survived. Data on 57 patients who underwent early realignment were compared to those on 39 treated with delayed urethroplasty with an average 8.8-year followup (range 1 to 22). All patients were evaluated postoperatively for incontinence, impotence and urethral strictures.
• Results: The majority of patients had severe concomitant organ injuries (78%) and severe pelvic fractures (76%). The overall mortality rate was 51%. Diagnosis of urethral rupture was based on clinical findings and retrograde urethrography. Strictures developed in 49% of the early realignment group and in 100% of the suprapubic tube group. Impotence (33.6%) and incontinence (17.7%) were less frequent in the early realignment group than in the delayed reconstruction group (42.1% and 24.9%, respectively). Patients with delayed reconstruction underwent an average of 3.1 procedures compared with an average of 1.6 in the early realignment group.
• Conclusions: Early realignment may provide better outcomes than delayed open urethroplasty after posterior urethral disruption. Increased complications are not seen and, although it can be inconvenient in the massively injured patient, it appears to be a worthwhile maneuver.
  
  
• Editorial Comment
  Mouraviev et al, detail their extensive experience with a retrospective review of 191 urethral disruption injuries. The acute management of pelvic fracture and associated urethral injury is controversial. Classically, acute management is a “delayed approach” of placement of a suprapubic tube, percutaneously, if the bladder is full, or open, if the bladder is decompressed or has a concomitant bladder or bladder neck injury. After a minimum period of three months, the urethral injury is reconstructed. This method of delayed definitive management is particularly useful in rural or small hospitals where no Urologist is available. The main complication of this method is the near 100% stricture rate. Of historical interest is open primary repair of acute urethral disruption, which is absolutely contraindicated due to technical difficulty, risk of uncontrolled pelvic bleeding, and unacceptably high rates of impotence and incontinence.
  The other management option that has gained considerable recent support is delayed or immediate primary urethral realignment by endoscopic means. Here, two cystoscopes, one antegrade and one retrograde, are used to get a wire and catheter across the urethra. The immediate approach is reserved for the stable patient with a short urethral distraction distance. The delayed approach is a type of damage control, where the unstable patient is first resuscitated and then when stable, the urethra is later realigned (usually after 2 to 10 days, typically concomitantly when Orthopedics internally fixes the pelvic fracture).
  Contrary to prior reports, the authors here report higher impotence (42%) and incontinence (25%) with the delayed approach over early realignment. This is difficult to explain since such complications are thought to be from the mechanism of the original injury. Regardless, similar to the literature, primary realignment appears here to reduce the eventual stricture and impotence rates. When posterior strictures do occur, it appears that the eventual stricture may be shorter and easier to manage. This may be a selection bias, since patients with the most severe urethral distractions are typically the most severely injured and unstable, and thus often not primarily realigned. Another added benefit to realigning the urethra is that the suprapubic tube can be removed and not be in the way of any inguinal orthopedic incisions. Primary urethral realignment makes good common sense, appears to reduce complications; and is thus an integral management tool in the contemporary management of urethral distraction injuries.

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