A POSTERIOR SAGITTAL PARARECTAL APPROACH FOR REPAIR OF POSTERIOR URETHRAL DISTRACTION INJURIES

763 INJURY OF LOWER URINARY TRACT IN PELVIC RING FRACTURES Filis K.1, Lefakis G.1, Maniotis V.1, Simaioforidis V.1, Prevezas N.2, Koritsiadis S.1 1 General Hospital of Nikaia, Dept. of Urology, Piraeus, Greece, 2General Hospital of Nikaia, Dept. of Orthopaedics, Piraeus, Greece

764 THE FACTORS AFFECTING ON THE RESULTS OF THE PRIMARY ENDOSCOPIC URETHRAL REALIGNMENT IN MALE URETHRAL INJURY Yu J.H., Yang S.W., Sung L.H., Chung J.Y., Noh C.H. Sanggye Paik Hospital, Inje University, Dept. of Urology, Seoul, South Korea

Introduction & Objectives: 3HOYLFULQJIUDFWXUHVPD\EHUHVSRQVLEOHIRUGLᚎHUHQWJUDGH and type of injuries of lower urinary tract. On this study we try to correlate the grade and type of a concrete pelvic ring fracture with the grade and the type of a lower urinary tract injury. Material & Methods: From year 2006 ,128 patients were treated on the emergency department for pelvic ring and acetabulum fracture. 82 of patients presented with pelvic ring injury(61 men,21 women) and 46 of patients presented with injury of DFHWDEXOXP PHQZRPHQ  &ODVVLᚏFDWLRQ RI SHOYLF ULQJ LQMXULHV PDGH E\ WKH 7LOH System. A correlation between the lower urinary tract injuries and the grade and type of pelvic ring injuries was initiated. Results: Of 82 patients with pelvic ring injury, 20(24%) assessed with injury of lower XULQDU\WUDFWLPDJLQJRUVXUJLFDOᚏQGLQJV 2IPHQ DVVHVVHGZLWKORZHU urinary tract injury . 5(8%) of them presented with urinary bladder rupture,10(16%) with SDUWLDOXUHWKUDOUXSWXUHDQG ZLWKFRPSOHWHXUHWKUDOUXSWXUH2ISDWLHQWVZLWK XUHWKUDOLQMXU\SDWLHQWVKDGEODGGHULQMXU\DOVR2ILQMXUHGZRPHQ KDG DORZHUXULQDU\WUDFWLQMXU\XULQDU\EODGGHUUXSWXUH 2IPHQZLWKDFHWDEXOXPLQMXU\   SUHVHQWHG ZLWK FRPSOHWH XUHWKUDO UXSWXUH DQG   ZLWK SDUWLDO XUHWKUDO rupture. Of the 11 women with acetabulum injury, 1 (9%) presented with urinary bladder UXSWXUH 0HQ   ZLWK 7LOH $ SHOYLF ULQJ LQMXU\ GLG QRW SUHVHQW DQ\ LQMXU\ RI WKH ORZHU urinary tract. Of 21 men with Tile B1(open book) pelvic ring injury, 16(76%) had not any XULQDU\WUDFWLQMXU\DQG SUHVHQWHGZLWKORZHUXULQDU\WUDFWLQMXU\ZLWKSDUWLDO urethral rupture,2 with bladder rupture). Of 7 men with Tile B2(lateral compression) SHOYLFULQJLQMXU\ KDGQRWXULQDU\WUDFWLQMXU\DQG SUHVHQWHGZLWKORZHU XULQDU\ WUDFW LQMXU\ ZLWK SDUWLDO XUHWKUDO UXSWXUH ZLWK EODGGHU UXSWXUH  2I  PHQ ZLWK7LOH&YHUWLFDOVKHDU  KDGQRWORZHUXULQDU\WUDFWLQMXU\DQG  SUHVHQWHGZLWKORZHUXULQDU\WUDFWLQMXU\ZLWKSDUWLDOXUHWKUDOUXSWXUHZLWKFRPSOHWH urethral rupture and 2 with bladder rupture). Conclusions: Pelvic ring injury does not coincide lower urinary tract injury Grade of pelvic ring injury does not correlate with the grade of lower urinary tract injury Acetabulum injury does not coincide with urinary tract injury and does not correlate with the grade of lower urinary tract injury

Introduction & Objectives: Recently, early primary endoscopic urethral realignment is considered as a promising primary treatment method for the male urethral injury. The HᚎHFWLYHQHVVRIWKHSULPDU\HQGRVFRSLFXUHWKUDOUHDOLJQPHQWFDQEHHYDOXDWHGE\FRPSOLFDWLRQ UDWHLHXUHWKUDOVWULFWXUH ZKLFKDUHDᚎHFWHGE\IDFWRUVVXFKDVVLWHDQGVHYHULW\RILQMXU\:H UHWURVSHFWLYHO\HYDOXDWHGYDULDEOHIDFWRUVDᚎHFWLQJWKHHᚎHFWLYHQHVVRIWKHSULPDU\HQGRVFRSLF XUHWKUDOUHDOLJQPHQWLQPDOHXUHWKUDOLQMXU\WRLGHQWLI\WKHVLJQLᚏFDQWULVNIDFWRUV Material & Methods: Male patients who were treated for the urethral injury between January 1995 and December 2006 were included in the study. Primary endoscopic urethral realignment was done in 48 patients(pts) out of 52 pts who were otherwise well in general condition. Four pts who were not feasible for lithotomy position were excluded. Foley catheter was removed when there was no urine leakage detected by retrograde urethrography(RGU). Evaluation of urinary incontinence and erectile dysfunction was done within 6 months after the procedure. Cystoscopy and RGU were done to rule out urethral stricture in pts presenting with newly developed voiding symptoms. Results: 7KHPHDQDJHRISWVZDVs \HDUVDQGWKHRSHUDWLRQVZHUHFDUULHG out within 5-72 hours after the injury. Forty four pts with anterior urethral injury underwent SULPDU\HQGRVFRSLFXUHWKUDOUHDOLJQPHQWFRPSOHWH SDUWLDO 3ULPDU\HQGRVFRSLFXUHWKUDO realignments were achieved in 4 pts with posterior urethral injury(complete(2), partial(2)). 'XULQJWKHIROORZXSSHULRGXUHWKUDOVWULFWXUHZDVUHFXUUHGLQSWVSWVXQGHUZHQWLQWHUQDO urethrotomy once or twice and 4 pts was treated with internal urethrotomy or open surgery more WKDQWKUHHWLPHV$QWHULRUXUHWKUDOLQMXU\ZDVIRXQGLQSWVDQGSRVWHULRUXUHWKUDOLQMXU\LQ SWV)LYHSWVVXᚎHUHGIURPFRPSOHWHXUHWKUDOLQMXU\DQGWKHUHPDLQLQJSDUWLDOXUHWKUDOLQMXU\ 7KHVWDWLVWLFDOO\VLJQLᚏFDQWIDFWRURIXUHWKUDOVWULFWXUHUHFXUUHQFHZDVWKHVHYHULW\RIWKHXUHWKUDO LQMXU\S  (UHFWLOHG\VIXQFWLRQZDVGHYHORSHGLQDWRWDORISWVDQWHULRU SRVWHULRU  FRPSOHWH  SDUWLDO  7KH VWDWLVWLFDOO\ VLJQLᚏFDQW IDFWRU RI HUHFWLOH G\VIXQFWLRQ FRPSOLFDWLRQ was the location of the urethral injury(p=0.046). Urinary incontinence was observed in 1 patient with posterior urethral injury, who was treated conservatively. Conclusions: 3DWLHQWVZLWKFRPSOHWHXUHWKUDOLQMXU\KDGDVLJQLᚏFDQWO\KLJKHUUDWHRIUHFXUUHQFH of urethral stricture after the primary endoscopic urethral realignment, Urethral stricture after the SULPDU\HQGRVFRSLFXUHWKUDOUHDOLJQPHQWFDQRFFXUZLWKDVLJQLᚏFDQWO\KLJKHUUDWHLQFRPSOHWH urethral injury, whereas the incidence rate of erectile dysfunction after the primary endoscopic XUHWKUDOUHDOLJQPHQWLVPDLQO\DᚎHFWHGE\SRVWHULRUORFDWLRQRIWKHXUHWKUDOLQMXU\

765

766

A POSTERIOR SAGITTAL PARARECTAL APPROACH FOR REPAIR OF POSTERIOR URETHRAL DISTRACTION INJURIES

URETHRAL TRAUMA IN PELVIC FRACTURES: A REVIEW OF 48 CASES WITH LONG-TERM FOLLOW-UP

Abdalla M.A.

Lumen N., Oosterlinck W., Hoebeke P.

Assiut University Hospitales, Dept. of Urology, Assiut, Egypt

Ghent University Hospital, Dept. of Urology, Ghent, Belgium

Introduction & Objectives: To report our initial experience with the posterior sagittal pararectal approach as an alternative in the treatment of complicated urethral distraction defect after pelvic trauma.

Introduction & Objectives: Pelvic fractures are complicated by urethral trauma in 5-10% of the cases. Disruption of the urethra is responsible for important morbidity and long-term invalidity if not correctly treated. Urethral continuity can be restored by urethroplasty. A review of 48 patients with long-term follow-up was done at our centre.

Material & Methods: Twenty-four patients with posttraumatic pelvic fracture urethral distraction defects (PFUDDs) underwent urethroplasty in our department IURP 0DUFK  WR -XQH  ,Q  RI WKRVH SDWLHQWV WKH SRVWHULRU VDJLWWDO pararectal approach was utilised. Of the 7 patients, 5 had failed previous transperineal repair, where as the other 2had long-distance urethral distraction GHIHFW )ROORZXS LQFOXGHG UHWURJUDGH XUHWKURJUDSK\ 58*  DQG XURᚐRZPHWU\ ZKLFKZHUHGRQHSRVWRSHUDWLYHO\DWZNDQGDQGPRDQGWKHUHDIWHU when needed. Clinical outcome was considered a success at the time that no postoperative procedure was needed Results: Of the 7 patients, 5 were in the paediatric group with ages ranging from 9 to 14 yr, whereas 2 patients were adults (21 and 50 yr). The aetiology of 3)8''VLQDOOSDWLHQWVZDVURDGWUDᚑFDFFLGHQW0HGLDQOHQJWKRIWKHVWULFWXUH was 5 cm. The median opera tive time was 240 min, whereas the median hospital stay was 10 d. postoperatively, 1 patient developed gluteal abscess that was VXFFHVVIXOO\PDQDJHGFRQVHUYDWLYHO\)ROORZXSSHULRGUDQJHGIURPWRPR PHGLDQPR $OOSDWLHQWVVKRZHGFULWHULDRIVXFFHVVLQFOXGLQJVDWLVIDFWRU\ XURᚐRZPHWU\PHGLDQ4PD[POV SDWHQW58*DQGVXEMHFWLYHLPSURYHPHQW LQ WKH YRLGLQJ SDWWHUQ 2QO\  SDWLHQW GHYHORSHG GLᚑFXOW\ PR SRVWRSHUDWLYHO\ and was successfully managed by urethral dilation. Conclusions: This technique is a good alternative approach for repair of complicated PFUDDs. It is safe and has the advantage of better visualization RIWKHDSH[RIWKHSURVWDWHDQGVXUJLFDOᚏHOGZLWKVXEVHTXHQWJRRGRXWFRPHV ZLWKRXWLPPHGLDWHRUUHPRWHHᚎHFWVRQWKHVSKLQFWHULFIXQFWLRQRIWKHUHFWXPRU bladder. Further studies with larger cohort of patients are needed to justify the VSHFLᚏFLQGLFDWLRQVRIWKLVDSSURDFK

Eur Urol Suppl 2008;7(3):262

Material & Methods: %HWZHHQ  DQG   SDWLHQWV ZHUH WUHDWHG E\ urethroplasty because of a urethral trauma after pelvic fracture. Mean follow-up LVPRQWKVUDQJHPRQWKV ,Q DSUHYLRXVXUHWKURSODVW\ was already performed (=secondary cases) but failed. In the majority of the SDWLHQWV DUHSDLURIWKHXUHWKUDOWUDXPDZDVGRQHDIWHUDWOHDVWPRQWKV waiting (“delayed repair”). All patients were treated by perineal approach and the FRQWLQXLW\ZDVUHSDLUHGE\HQGWRHQGDQDVWRPRVHDIWHUH[FLVLRQRIWKHᚏEURWLF tissue. Results: In 9 patients (19%) a recurrence was reported. The recurrence rate was markedly higher in the patients that underwent former treatment (secondary FDVHV     UHFXUUHQFH IRU WKH VHFRQGDU\ FDVHV YHUVXV    LQ patients that were not previously treated for their urethral lesion. Impotence was reported by 12 patients (25%) and one patients developed minor stress incontinence after treatment. In 2 cases, the rectum was injured during the procedure but could be repaired. These were both secondary cases with severe ᚏEURVLVDQGIHZUHOLDEOHDQDWRPLFODQGPDUNV Conclusions: Urethral lesions after pelvic fractures are responsible for important morbidity and invalidity. Adequate treatment is needed in these mostly young patients. In almost every patient, the lesion can be treated by perineal approach and with end-to-end anastomose. Recurrence rate and complications seem to be higher in patients that already underwent (failed) urethroplasty and for this reason, urethroplasty in pelvic fractures should not be done by every urologist but should be reserved for reference centres.