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Experience With Management of Posterior Urethral Injury Associated With Pelvic Fracture
Vol. 117, June Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright© 1977 by The Williams & Wilkins Co.
EXPERIENCE WITH MANAGEMENT OF POSTERIOR URETHRAL INJURY ASSOCIATED WITH PELVIC FRACTURE K. S. COFFIELD
AND
W. L. WEEMS
From the Division of Urology, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
ABSTRACT
Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography or voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries. Management of patients with posterior urethral injuries sustained with pelvic fractures remains controversial. The various methods described to treat these injuries attest to the challenge of successful management. 1 The principles of management of posterior urethral injuries have been to re-establish continuity of the urethra, to drain hematoma and extravasated urine and to provide drainage of the urinary tract. These principles appear straightforward but their implementation is not. The problems encountered are numerous and frequently begin with the initial evaluation of a patient with multiple injuries, more than 1 of which may be potentially lethal. If the lethal injuries are controlled so that an approach to the urethral injury is feasible the anatomic orientation is difficult owing to the bleeding, fractures, tissue disruption and inaccessible location of the injury. The risk of converting an incomplete urethral injury to a complete one may be substantial, since the incidence of incomplete urethral injury has been reported as being as high as 60 per cent. 2 Furthermore, extensive surgical intervention in the pelvis soon after this type of injury converts a closed hematoma to an open and potentially infected one. Infection may hasten urethral necrosis and exacerbate fibrosis formation, manifested by an increased incidence and severity of urethral stricture. 3 Without the complication of infection accurate realignment of the urethral ends is difficult and stricture occurs with some regularity.4-1; Finally, mobilization of the prostate and distal urethral stump to permit approximation can increase the neurovascular trauma sustained and may increase the risk of impotence, which already is substantial with this injury. Gibson reported that 39 per cent of his 59 patients were impotent, which correlated well with the average in his review of the literature. 4 • 7 Urinary incontinence also follows this injury and may reach 30 per cent. The bladder neck has an integral role in the maintenance of continence when the urogenital diaphragm is incompetent. 8 Ischemia from traction on the Foley balloon at the bladder neck, extensive mobilization of the bladder neck and injury during an attempt at hemostasis or from the pelvic fracture may render the bladder neck incompetent to account for the incontinent patient. These problems are the basis for considering another approach to the posterior urethral injury with pelvic fracture. In Europe, Johanson and Mitchell advocate delayed urethroplasty after initial management, and Morehouse and associAccepted for publication October 1, 1976. Read at annual meeting of Southeastern Section, American Urological Association, Hollywood, Florida, April 4-8, 1976. 722
ates brought this concept to the North American literature. 4 Initial management consists of avoiding urethral catheterization and performing a retrograde urethrogram. A cystogram is done if no urethral injury is detected and then an excretory urogram (IVP) is obtained. If posterior urethral injury is suspected by extravasation on retrograde urethrography simple cystostomy is advocated as the only immediate surgical therapy (fig. 1). Diagnosis is the immediate objective in this injury since it is essential to initiate treatment properly. Yet, there is not always a correlation between the presence or extent of extravasation on urethrography and the degree of urethral injury. Therefore, repeat retrograde urethrography and voiding cystourethrography are obtained 4 to 6 weeks after injury. If there is no stricture and the patient voids without difficulty, the suprapubic catheter is removed and the patient is followed to detect delayed sequelae. However, if there is evidence of severe damage to the urethra and subsequent surgical therapy is anticipated the patient is maintained on suprapubic catheter drainage for 3 to 4 months. When the pelvic hematoma has resolved, the tissues are softened and the pelvic fractures are stabilized the patient is considered for scrotal-inlay urethroplasty. The rationale is that a significant number of these patients have an incomplete urethral injury that will heal without stricture and without further operative treatment. 3 · 4 In addition, those patients who require further surgical therapy can be approached electively with confidence of success when stricture caused by posterior urethral injury necessitates operative intervention. ' Herein we review our experience in the management of urethral injuries resulting from pelvic fractures. These injuries were managed by early repai1· with urethral catheterization and by simple cystostomy. Since 1960 we have seen 205 patients with pelvic fracture and have evaluated 129 patients with pelvic fracture and hematuria. The other patients were excluded from the study. One woman with pelvic fracture, and bladder and urethral injuries was excluded from comparison, although urethral stenosis occurred. Of the 129 patients with pelvic fractures, hematuria and urologic evaluation 121 were studied with retrograde urethrography and IVP. If there was no urethral injury or if the patient was catheterized before urologic consultation a cystogram was done. Eight patients were not studied radiographically since urethral catheterization prior to urologic consultation was considered the cause of the microscopic hematuria. Subsequent inspection of their records revealed
FIG. l. Retrograde urethrog-ram immediately after pelvic fracture shows extravasation of contrast medium from posterior urethra.
catheter the incidence of at about 50 per cent it can be s1~rni,tH:a11t pvs,~HuLOC< exists for conversion of the incomplete irjury. 2) Those patients with minimal injury may heal uneventfully and remain undetected. Three patients had urethral and bladder injury but no patient had urethral and renal injury. In our series the incidence of combined urethral and vesical injury is lower than in other reports. A higher incidence should be expected. 3 Eleven patients with posterior urethral injuries were treated initially with suprapubic cystostomy. No attempt was made to evacuate hematoma in these patients. The only drainage was the suprapubic cystostomy. Nine patients seen before the initiation of the method presently used were treated with immediate closure of the urethral injury. Three of these patients were referred to our hospital after this procedure and no uniform method can be described since all patients were not treated the same surgeon. It would be reasonable to assume that there was uniformity to a degree in these procedures, dictated by the injury itself. An element of bias is acknowledged in this patient group because those referred after immediate closure were seen for treatment of complications arising from initial surgical management. A comparison of the 2 groups of patients reveals similar age g-roups. There is no real racial difference between the 2 groups. The length of followup is longer in patients in the immediate closure group because these patients were seen before patients in the delayed closure group (table 1). Eleven patients had posterior urethral enough to warrant surgical therapy, urethroplasty 3 to 6 nwnths post-injury." revision of the first stage and 5 needed a second revision. Eventually, all had a closing second stage urethroplasty from 8 to 18 months after the first stage. Comparison of the results and complications appears to show significant di_fferences in the 2 groups, although the numbers are small. Seven patients treated with primary closure suffered urethral stricture, 5 of whom have been maintained on urethral dilatation, while 2 required scrotal-inlay urethroplasty. Two patients are incontinent and 3 are impotent. Four ,-,u.unarnov have difficulty with or absence of ejaculation. Urinary tract infection has been documented postoperatively in 6 of these ,-,-··-Hu~, probably as a consequence of instrumentation. After second stage there has been no urethral stricture in those patients treated initially vvith cystostomy alone followed by 2). There have been no lfftPCltence in this
Fm. 2. Postoperative retrograde urethrngram after second stage urethropiasty. TABLE
discovered at a later that none had evidence of in convalescence. Evidence of urethral injury, found in 20 patients, was documented by retrograde urethrography in 17 at initial evaluation and by voiding cystourethrography in 3 several weeks post-injury. Incidentally, 39 patients had evidence of bladder injury and 24 had evidence of renal injury. Seventeen patients had urethral injury alone. Several investigators have discussed the consequence of the extent and site of posterior urethral injury. 2__, Usually, the injury is classified as contusion, or incomplete or complete interruption of urethral continuity. Prognostically, however, there has been little correlation with other than complete urethral injury for 2 reasons. 1) It is generally unknown how often an incomplete injury is converted to a complete one. Thirty-seven per cent of
l. Posterior urethral injury in 20 patients Age
Length of Followup
Av.
(yrs.)
(yrs.)
Immediate closure (9 pts.) Delayed closure (11 pts.) TABLE
26
5-50
33
15-54
2. Complications
Immediate Closure 9 Pts.
Stricture Incontinence Impotence Abnormal ejaculation Urinary infection
4-13 l½-6
Delayed Closure 11 Pts.
Incidence
(%)
Incidence
7 2 3
(77) (22)
(33)
0 0 0
4
(44) (66)
1 2
6
(%)
(0) (0) (0) (9) (18)
724
COFFIELD AND WEEMS
legal decisions. Two patients had urinary tract infection after second stage urethroplasty. One required hospitalization with parenteral antimicrobials to eradicate a resistant organism. Both patients are now free of recurrent infection (table 2). It appears that simple cystostomy after appropriate and careful diagnostic evaluation can be used as the initial therapeutic step in the injured posterior urethra. The data presented complement evidence found by Morehouse and associates that a rarely seen, complicated injury may be treated with confidence by the simple early expedient of cystostomy drainage. If the urethra is injured severely, its reconstruction can be undertaken in a setting conducive to good results. REFERENCES
1. Pierce, J. M., Jr.: Management of dismemberment of the pros-
tatic-membranous urethra and ensuing stricture disease. J.
Urol., 107: 259, 1972. 2. Petkovic, S. D.: A clinical study of urethral injuries. J. Urol., 75: 81, 1956. 3. Mitchell, J. P.: Injuries to the urethra. Brit. J. Urol., 40: 649, 1968. 4. Morehouse, D. D., Belitsky, P. and MacKinnon, K.: Rupture of the posterior urethra. J. Urol., 107: 255, 1972. 5. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 6. Myers, R. P. and DeWeerd, J. H.: Incidence of stricture following primary realignment of the disrupted proximal urethra. J. Urol., 107: 265, 1972. 7. Gibson, G. R.: Impotence following fractured pelvis and ruptured urethra. Brit. J. Urol., 42: 86, 1970. 8. Turner-Warwick, R. T.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968.
THE JOURNAL OF UROLOGY Copyright© 1977 by The Williams & Wilkins Co.
EXPERIENCE WITH MANAGEMENT OF POSTERIOR URETHRAL INJURY ASSOCIATED WITH PELVIC FRACTURE K. S. COFFIELD
AND
W. L. WEEMS
From the Division of Urology, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
ABSTRACT
Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography or voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries. Management of patients with posterior urethral injuries sustained with pelvic fractures remains controversial. The various methods described to treat these injuries attest to the challenge of successful management. 1 The principles of management of posterior urethral injuries have been to re-establish continuity of the urethra, to drain hematoma and extravasated urine and to provide drainage of the urinary tract. These principles appear straightforward but their implementation is not. The problems encountered are numerous and frequently begin with the initial evaluation of a patient with multiple injuries, more than 1 of which may be potentially lethal. If the lethal injuries are controlled so that an approach to the urethral injury is feasible the anatomic orientation is difficult owing to the bleeding, fractures, tissue disruption and inaccessible location of the injury. The risk of converting an incomplete urethral injury to a complete one may be substantial, since the incidence of incomplete urethral injury has been reported as being as high as 60 per cent. 2 Furthermore, extensive surgical intervention in the pelvis soon after this type of injury converts a closed hematoma to an open and potentially infected one. Infection may hasten urethral necrosis and exacerbate fibrosis formation, manifested by an increased incidence and severity of urethral stricture. 3 Without the complication of infection accurate realignment of the urethral ends is difficult and stricture occurs with some regularity.4-1; Finally, mobilization of the prostate and distal urethral stump to permit approximation can increase the neurovascular trauma sustained and may increase the risk of impotence, which already is substantial with this injury. Gibson reported that 39 per cent of his 59 patients were impotent, which correlated well with the average in his review of the literature. 4 • 7 Urinary incontinence also follows this injury and may reach 30 per cent. The bladder neck has an integral role in the maintenance of continence when the urogenital diaphragm is incompetent. 8 Ischemia from traction on the Foley balloon at the bladder neck, extensive mobilization of the bladder neck and injury during an attempt at hemostasis or from the pelvic fracture may render the bladder neck incompetent to account for the incontinent patient. These problems are the basis for considering another approach to the posterior urethral injury with pelvic fracture. In Europe, Johanson and Mitchell advocate delayed urethroplasty after initial management, and Morehouse and associAccepted for publication October 1, 1976. Read at annual meeting of Southeastern Section, American Urological Association, Hollywood, Florida, April 4-8, 1976. 722
ates brought this concept to the North American literature. 4 Initial management consists of avoiding urethral catheterization and performing a retrograde urethrogram. A cystogram is done if no urethral injury is detected and then an excretory urogram (IVP) is obtained. If posterior urethral injury is suspected by extravasation on retrograde urethrography simple cystostomy is advocated as the only immediate surgical therapy (fig. 1). Diagnosis is the immediate objective in this injury since it is essential to initiate treatment properly. Yet, there is not always a correlation between the presence or extent of extravasation on urethrography and the degree of urethral injury. Therefore, repeat retrograde urethrography and voiding cystourethrography are obtained 4 to 6 weeks after injury. If there is no stricture and the patient voids without difficulty, the suprapubic catheter is removed and the patient is followed to detect delayed sequelae. However, if there is evidence of severe damage to the urethra and subsequent surgical therapy is anticipated the patient is maintained on suprapubic catheter drainage for 3 to 4 months. When the pelvic hematoma has resolved, the tissues are softened and the pelvic fractures are stabilized the patient is considered for scrotal-inlay urethroplasty. The rationale is that a significant number of these patients have an incomplete urethral injury that will heal without stricture and without further operative treatment. 3 · 4 In addition, those patients who require further surgical therapy can be approached electively with confidence of success when stricture caused by posterior urethral injury necessitates operative intervention. ' Herein we review our experience in the management of urethral injuries resulting from pelvic fractures. These injuries were managed by early repai1· with urethral catheterization and by simple cystostomy. Since 1960 we have seen 205 patients with pelvic fracture and have evaluated 129 patients with pelvic fracture and hematuria. The other patients were excluded from the study. One woman with pelvic fracture, and bladder and urethral injuries was excluded from comparison, although urethral stenosis occurred. Of the 129 patients with pelvic fractures, hematuria and urologic evaluation 121 were studied with retrograde urethrography and IVP. If there was no urethral injury or if the patient was catheterized before urologic consultation a cystogram was done. Eight patients were not studied radiographically since urethral catheterization prior to urologic consultation was considered the cause of the microscopic hematuria. Subsequent inspection of their records revealed
FIG. l. Retrograde urethrog-ram immediately after pelvic fracture shows extravasation of contrast medium from posterior urethra.
catheter the incidence of at about 50 per cent it can be s1~rni,tH:a11t pvs,~HuLOC< exists for conversion of the incomplete irjury. 2) Those patients with minimal injury may heal uneventfully and remain undetected. Three patients had urethral and bladder injury but no patient had urethral and renal injury. In our series the incidence of combined urethral and vesical injury is lower than in other reports. A higher incidence should be expected. 3 Eleven patients with posterior urethral injuries were treated initially with suprapubic cystostomy. No attempt was made to evacuate hematoma in these patients. The only drainage was the suprapubic cystostomy. Nine patients seen before the initiation of the method presently used were treated with immediate closure of the urethral injury. Three of these patients were referred to our hospital after this procedure and no uniform method can be described since all patients were not treated the same surgeon. It would be reasonable to assume that there was uniformity to a degree in these procedures, dictated by the injury itself. An element of bias is acknowledged in this patient group because those referred after immediate closure were seen for treatment of complications arising from initial surgical management. A comparison of the 2 groups of patients reveals similar age g-roups. There is no real racial difference between the 2 groups. The length of followup is longer in patients in the immediate closure group because these patients were seen before patients in the delayed closure group (table 1). Eleven patients had posterior urethral enough to warrant surgical therapy, urethroplasty 3 to 6 nwnths post-injury." revision of the first stage and 5 needed a second revision. Eventually, all had a closing second stage urethroplasty from 8 to 18 months after the first stage. Comparison of the results and complications appears to show significant di_fferences in the 2 groups, although the numbers are small. Seven patients treated with primary closure suffered urethral stricture, 5 of whom have been maintained on urethral dilatation, while 2 required scrotal-inlay urethroplasty. Two patients are incontinent and 3 are impotent. Four ,-,u.unarnov have difficulty with or absence of ejaculation. Urinary tract infection has been documented postoperatively in 6 of these ,-,-··-Hu~, probably as a consequence of instrumentation. After second stage there has been no urethral stricture in those patients treated initially vvith cystostomy alone followed by 2). There have been no lfftPCltence in this
Fm. 2. Postoperative retrograde urethrngram after second stage urethropiasty. TABLE
discovered at a later that none had evidence of in convalescence. Evidence of urethral injury, found in 20 patients, was documented by retrograde urethrography in 17 at initial evaluation and by voiding cystourethrography in 3 several weeks post-injury. Incidentally, 39 patients had evidence of bladder injury and 24 had evidence of renal injury. Seventeen patients had urethral injury alone. Several investigators have discussed the consequence of the extent and site of posterior urethral injury. 2__, Usually, the injury is classified as contusion, or incomplete or complete interruption of urethral continuity. Prognostically, however, there has been little correlation with other than complete urethral injury for 2 reasons. 1) It is generally unknown how often an incomplete injury is converted to a complete one. Thirty-seven per cent of
l. Posterior urethral injury in 20 patients Age
Length of Followup
Av.
(yrs.)
(yrs.)
Immediate closure (9 pts.) Delayed closure (11 pts.) TABLE
26
5-50
33
15-54
2. Complications
Immediate Closure 9 Pts.
Stricture Incontinence Impotence Abnormal ejaculation Urinary infection
4-13 l½-6
Delayed Closure 11 Pts.
Incidence
(%)
Incidence
7 2 3
(77) (22)
(33)
0 0 0
4
(44) (66)
1 2
6
(%)
(0) (0) (0) (9) (18)
724
COFFIELD AND WEEMS
legal decisions. Two patients had urinary tract infection after second stage urethroplasty. One required hospitalization with parenteral antimicrobials to eradicate a resistant organism. Both patients are now free of recurrent infection (table 2). It appears that simple cystostomy after appropriate and careful diagnostic evaluation can be used as the initial therapeutic step in the injured posterior urethra. The data presented complement evidence found by Morehouse and associates that a rarely seen, complicated injury may be treated with confidence by the simple early expedient of cystostomy drainage. If the urethra is injured severely, its reconstruction can be undertaken in a setting conducive to good results. REFERENCES
1. Pierce, J. M., Jr.: Management of dismemberment of the pros-
tatic-membranous urethra and ensuing stricture disease. J.
Urol., 107: 259, 1972. 2. Petkovic, S. D.: A clinical study of urethral injuries. J. Urol., 75: 81, 1956. 3. Mitchell, J. P.: Injuries to the urethra. Brit. J. Urol., 40: 649, 1968. 4. Morehouse, D. D., Belitsky, P. and MacKinnon, K.: Rupture of the posterior urethra. J. Urol., 107: 255, 1972. 5. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 6. Myers, R. P. and DeWeerd, J. H.: Incidence of stricture following primary realignment of the disrupted proximal urethra. J. Urol., 107: 265, 1972. 7. Gibson, G. R.: Impotence following fractured pelvis and ruptured urethra. Brit. J. Urol., 42: 86, 1970. 8. Turner-Warwick, R. T.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968.