UROGENITAL TRAUMA

Pelvic fracture urethral injuries in girls
Podestá ML, Jordan GH
Urology Unit, Department of Surgery, Hospital de Niños Ricardo Gutiérrez, Associated Hospital to the University of Buenos Aires, Argentina
J Urol. 2001; 165: 1660-5

• Purpose: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome.
• Materials and Methods: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall, postoperative followup was 6 months to 6.3 years (median 3 years).
• Results: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl, complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps.
• Conclusions: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.
  
  
• Editorial Comment
  The above two articles illustrate the difficulty in diagnosing and managing the complications of female urethral injury from pelvic fracture. Such injuries can occur in up to 6% of all female pelvic fractures. Obviously, life threatening pelvic fractures and associated injuries need to be stabilized and reduced first, as part of traumatic resuscitation.
  Female urethral injuries from pelvic fracture are due to severe mechanisms of injury, with many injuries being urethral disruption injuries. Female urethral injuries are mainly bladder neck injuries that extend into the urethra and/or avulsion injuries. Presenting signs of urethral injury are blood at the introitus or gross hematuria. Avulsion injuries are mostly diagnosed upon attempted catheterization. Associated vaginal injury in very common (up to 87%) and ranges from an anterior vaginal wall laceration to circumferential disruption. Despite the above, up to 40% of female urethral injuries are missed at the time of injury. A high index of suspicion is key to making the diagnosis reliably. In the acute setting we advocate immediate repair of the urethral and the vaginal injuries, since if only a supra-pubic tube is placed, the urethra typically obliterates, or urethrovaginal fistula and/or vaginal stenosis results. Bladder neck injuries should also be repaired in the early post injury period (up to 2 weeks after) in order to prevent subsequent incontinence. Extensive surgical reconstruction is otherwise needed for such patients. If the patient is unstable, repair can often wait a few days until she is stable.
  In prepubertal girls, where the pelvis is narrow and space limited, repair of urethral stenoses is very difficult. Often times, a combined vaginal and abdominal approach in needed for successful reconstruction – and often may require a partial or total pubectomy. In such cases, an interposition flap of omentum is important to prevent bladder and bowel herniation.
  If the patient is incontinent after injury or repair, the urethra is typically fixed and rigid. In such cases, we have placed a bladder neck artificial sphincter, with good dryness. Unfortunately, the bladder is often too scarred to mobilize the bladder enough to do a bladder neck reconstruction, such as a Kropp or Young Dees Leadbetter

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