PELVIC FRACTURE URETHRAL INJURIES: THE UNRESOLVED CONTROVERSY

0022-5347/99/1616143310 THEJOURNAL OF UROLOGY Copyright 0 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 161, 1433-1441, May 1999 Printed in U.S.A.

Review Article PELVIC FRACTURE URETHRAL INJURIES: THE UNRESOLVED CONTROVERSY MAMDOUH M. KORAITIM From the Department of Urology, College of Medicine, University of Alexandria, Alexandria, Egypt

ABSTRACT

Purpose: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. Materials and Methods:All data on pelvic fracture urethralinjuries in the English literature for the last 50 years were critically analyzed.Studies were eligible only if data were complete and conclusive. Results: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured a t the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). Conclusions: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury. KEY WORDS:pelvis, fractures, urethra, wounds and injuries

Of all injuries to the urinary tract the most debilitating and controversial is that which affects the posterior urethra. If not managed properly it may lead to a lifelong condition with deleterious consequences comprising not only the ability to void and maintain urinary continence, but also the ability to reproduce.' The unresolved controversy about initial treatment of pelvic fracture urethral injuries has continued throughout this century.' The debate revolves around the vulnerability to late complications which may occur as a direct consequence of injury or because of initial treatment. Recent evolution of innovative endourological and radiological techniques to achieve urethral continuity as well as reports of magnetic resonance imaging and duplex ultrasound in impotent patients after pelvic fracture urethral injuries have added new dimensions to the debate."-I0 We attempt to resolve the long-standing debate and reach definite conclusions regarding development of a treatment plan for pelvic fracture urethral injuries.

2,419 cases from 1901 to 1968 indicated that the posterior urethra was injured in 1.6 to 2 5 9 (mean 9.9%)of these A similar range of incidence has been reported in more recent studies. This disparity is substantially influenced by differences in age groups and types of pelvic fracture in different series.1:l Also, the disparity occurs partly because some series are prospective and others are retrospective. While the former includes all cases, the latter may only include those referred for evaluation and care, thereby missing many less severe cases.I4 According to the majority of authors patients in the first 3 decades of life with a reported age range of 3 to 83 years (mean 33) are the most liable to sustain pelvic fracture urethral injury.l.14-'7 As late as 1965 female urethral injuries associated with pelvic fracture for all practical purposes were believed to be nonexistent and since then only sporadic cases have been reported.'" However, a review of the more recent literature revealed a 4.6 to 6 9 overall incidence of these injuries.1s.

INCIDENCE

ETIOLOGY

Reported incidences of urethral injury in men with pelvic fracture diverge broadly. Data from 2 extensive reviews of

It is not generally recognized that half of all pelvic fractures occur as a result of minimal to moderate trauma, such

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as a fall from a standing height, and 95%are minor."O On the other hand, more severe pelvic fractures associated with urethral injuries are usually caused by vehicular accidents (68 to 844)or falls from heights (6 to 25%),13.14.21.22 with the former more than 4 times as likely as the latter to produce serious urological injuries.23 In vehicular accidents the majority of patients are pedestrians struck by a motor vehicle rather than occupants of a vehicle involved in a n acciLess common causes are falls under a collapsed building, slipping, machinery accidents and being thrown or kicked by an animal, such as a horse.25 Before the motor vehicle age industrial and mining accidents were the most common causes of pelvic fractures and associated urinary tract injuries. Therefore, these lesions were most common in men who by occupation and general activity were more prone to this type of trauma. Later motor vehicle accidents replaced industrial accidents as the most common cause.26 Automation, improvement in industrial safety and increased motor vehicle accidents have combined to effect this reversal. PATHOGENESIS

Types of pelvic fracture. The true anatomical pelvis represents a formidable protective structure that must be disrupted before the posterior urethra can be injured by external trauma. The pubic arch and symphysis pubis are anterior, the iliac bones are lateral, and the sacrum and sacroiliac joints are posterior. Pelvic fractures may be classified as clinically stable or unstable. Stable fractures involve up to 3 of the 4 ischiopubic rami only, isolated fractures of iliac bones, avulsion fractures at the insertion of muscles and sacral fractures. With these fractures the pelvis can safely bear weight at an early stage. Unstable fractures involve the 4 ischiopubic rami or the posterior as well as anterior arch of the pelvic ring.20 Pelvic fractures may also be classified according to the direction of the force of injury. The major forces are anteroposterior compression, lateral compression with or without rotation and vertical shear. This classification should allow the surgeon to define precisely the injury and its mechanism and, therefore, apply counterforces to maintain stable reduction. Anteroposterior compression and lateral compression fractures may be associated with a stable or unstable hemipelvis but vertical shear fractures are grossly unstable.". 27 Special consideration must be given to straddle and Malgaigne fractures. A straddle or 4 rami fracture is usually caused by lateral compressive force and rarely by anterior compression injury (fig. 1,A). Many violent lateral compression forces may cause a straddle fracture with posterior disruption through the sacrum, sacroiliac joint or ilium. The largest number of injuries and complications in pelvic trauma displays this pattern.27 A Malgaigne fracture is anterior through the ipsilateral ischiopubic rami or symphysis pubis and associated with massive posterior disruption through the sacrum, sacroiliac joint or ilium (fig. 1, B ) . The force in a Malgaigne fracture is in the vertical plane and shearing by nature. Since the inclination of the pelvis to the

FIG. 1. A, straddle fracture. B , Malgaigne fracture

vertical plane is 40 degrees, vertical shear must result in posterior as well as upward displacement of the affected hemipelvis.'7 Vertical shear fracture is associated with a relatively high rate of morbidity and mortality. About 21% of patients who sustain a fatal injury in a motor vehicle accident have a Malgaigne pelvic injury.2o Risk factors. The risk of urethral injury associated with a traumatic pelvic fracture is greatly influenced by patient sex and age as well as the type of fracture. Although the incidence of pelvic fracture is about the same in women and men, associated urethral injuries occur much less frequently in women. In a report on 200 patients with pelvic fracture 17 of the 121 men had urethral disruption, whereas none of the 79 women had urethral injuries.15 Also, in a review o f 234 patients with pelvic fracture 12 of the 109 men sustained urethral rupture, whereas none of the 125 women had urethral injuries.23This sex linked low risk of traumatic injury to the female urethra has been attributed to its short length and relative mobility as well as the absence of rigid attachments to the pubis which are peculiar to the male urethra.28.29 On the other hand, an age linked preponderance of urethral injury occurs in children 15 years old or younger, which may be explained by the difference in patterns of pelvic fracture between children and adults. While fractures with a high risk of urethral injury are more common in children (56 versus 24%),low risk fractures are more common in older patients (76 versus 44%)and these differences are statistically significant.13 Few studies have correlated the risk of urethral injury bilateral with the types of pelvic f r a c t ~ r e . ' 3 . 2 1 . In ~ ~1, ~series ~ pubic arch fractures were more often associated with serious urinary tract injury than unilateral fractures.30 In other series Malgaigne fracture was the predominant type associated with urethral injury.zz.30 These conclusions were reached by relating the number of cases with urethral injuries associated with each type of fracture to the total number of cases with urethral injuries in the same series. However, the type of fracture as a risk factor for urethral injury should instead be calculated by relating the number of cases with to the number without urethral injuries associated with each type of fracture. Also, the risk ratio of different types of pelvic fracture could be determined by calculating the odds ratio.:" For this method each type of pelvic fracture is tested against the remaining types in a series to determine its importance as a risk factor for urethral injury. Thus, in a prospective study of 203 consecutive men with pelvic fracture the highest risk of urethral injury was for straddle fracture combined with diastasis of the sacroiliac joint (odds ratio 24), which was 24 times more likely to be associated with urethral injury than other pelvic fractures, followed by straddle fracture alone (odds ratio 3.85) and Malgaigne fracture (odds ratio 3.40).13The risk of urethral injury was low for single ramus and ipsilateral rami fractures (odds ratio 0.64 and 0.76, respectively) and nonexistent for fractures not involving the ischiopubic rami, for example isolated fractures of acetabulum, ilium and sacrum. Thus, the type of fracture as a risk factor for urethral injury is influenced by the number of broken pubic rami and involvement of the posterior pelvic arch with fractures of the anterior arch. The risk increases considerably from odds ratio 0.64 for single ramus and 0.76 for ipsilateral rami to 3.85 for 4 rami fracture. Also, involvement of the posterior pelvic arch increases the risk of ipsilateral pubic rami fracture from odds ratio 0.76 to 3.40 as well as that of straddle fracture from odds ratio 3.85 to 24.13 Obviously pelvic fractures as they relate to urethral injury may be classified as no risk-isolated fractures of acetabulum, ilium and sacrum, low risk-single and ipsilateral rami fractures or high riskstraddle and Malgaigne fractures. Mechanism of urethral injury. It has long been accepted that urethral rupture in men occurs at the prostatomembranous junction by a shearing force which may avulse the apex

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of the prostate from the urogenital diaphragm.2.12.32.:~This phragm (supradiaphragmatic rupture) with extravasation into concept has been maintained because of the traditional belief the pelvis and type 111-the urogenital diaphragm is disrupted, that the prostate is perched on a firm layer of fascia separat- usually completely rupturing the membranous urethra within ing it from the urogenital diaphragm. Such an arrangement it with injury to the proximal bulbous urethra as well (subdiawould actually make the prostatomembranous junction at phragmatic rupture).41They, as well as others, believe that type the superior surface of the urogenital diaphragm a frail spot 111 constitutes most urethral ruptures in pelvic fractures (66 to readily susceptible to shearing stress. Unfortunately sub- 85%), and because the lesion is mainly subdiaphragmatic exstantial refuting evidence has not entirely eliminated this travasation occurs into the perineum as shown on retrograde common misconception. urethr0graphy.4~More recently Goldman et a1 added type IV to Recent cadaveric studies have demonstrated no distinct this classification for injuries of the bladder neck and prostatic superior membrane of the so-called urogenital diaphragm urethra.@ separating the sphincter muscle from the prostate. The ureA more integrated concept considers all types of pelvic thral sphincter is not a horizontal plane associated just with fracture urethral injuries merely as successive stages of the the membranous urethra but it extends from the bladder same insult. Thus, urethral rupture is assumed always to be to the perineal membrane and is associated throughout with preceded by stretching of the membranous urethra cephalad the pr~state.:'~ Also, whereas the muscles lining and sur- and usually to occur at the bulbomembranous junction.'" In rounding the membranous urethra are directly continuous cases of partial rupture the membranous urethra is still with similar muscles of the prostatic urethra, they end stretched and extravasation is usually localized to the uroabruptly a t the perineal membrane and are not in the bul- genital diaphragm. In cases of complete rupture the proximal bous urethra.3" Hence, it is not the prostatomembranous but urethral end retracts upward while the distal end remains rather the bulbomembranous junction which is the weak spot fixed to the perineal membrane and extravasation is seen in at which the posterior urethra is liable to rupture.13,35 It is the pelvis.'3 Although these assumptions may be made when noteworthy that in urethral strictures which complicate pel- the perineal membrane remains intact, it may be disrupted vic fracture the fibrous process consistently involves the in severe trauma and the distal urethral end may become membranous as well as proximal bulbous urethra which was unfixed and retract into the perineum. In such cases extravthe site of original rupture.13 asation will be seen in the perineum and pelvis (figs. 2 and 3). With any major force causing pelvic fracture the pelvis is Injuries proximal to the membranous urethra, including compressed and the soft contents, including the bladder and those to the bladder neck and prostatic urethra, occur only in prostate, are squeezed. Because the membranous urethra is children,37.38 and they are almost always anterior longitudifixed to the tough perineal membrane which is attached nal slits of the prostate gland.13 However, some believe that firmly to the pubic arch and, conversely, the bladder and these proximal injuries are transverse and describe them as prostatic base are loosely attached to the bony pelvis, the transprostatic urethral disruptions but no urethrographic only way for the squeezed prostate to go is upward. This evidence of the injury site has been obtained.4" Even somovement causes sudden and severe stretch and strain of the called strictures of the mid-prostatic urethra, assuming they membranous urethra which is necessarily stretched cepha- are the result of disruption across the prostate, are in fact lad. Stretching may be of considerable length due to the high bulbomembranous prostatic (proximal bulbous plus membraelasticity of the membranous urethra if the concomitant nous plus inframontanal urethra) strictures. It is difficult to stretched puboprostatic ligaments are disrupted.2 However, understand how the shearing force of pelvic trauma could if maximum elasticity is reached and the force of trauma transect the whole thickness of the prostate even when it is continues, the urethra will be disrupted partially or com- underdeveloped rather than snap off the stretched delicate pletely at the fixed and frail bulbomembranous junction. urethra at the frail bulbomembranous junction.25 Classification of injuries to the female urethra. In women After complete rupture the prostate will be displaced upward with loss of urethral alignment. Disruption of the peripros- partial rupture is probably the most common urethral injury tatic venous plexus, resulting in a large hematoma which associated with pelvic fracture. It is usually an anterior urefrequently displaces the prostate gland cephalad and poste- thral tear at the 12 o'clock position extending for a varying length of the urethra.Is Complete urethral disruption is uncomrior, is associated with this condition.36 Occasionally the urethra and bladder neck are directly mon and only 32 cases have been described in the literature, all torn by the sharp edges of bone fragments. In men this direct of which were accompanied by vaginal lacerations and pelvic injury occurs only in boys whose small prostates offer less fractures.18.44 Although rupture may occur at any level, avulprotection."7.38 On the other hand, in women it is the main sion of the proximal urethra, which sometimes involves the mechanism of urethral injury associated with pelvic frac- bladder neck, has been the most common type of injury (26 of 31 tures and in some exploration has revealed a bony spicule cases, 844). Complete avulsion of the distal urethra usually near the urethral laceration.18The shearing force responsible occurs about 5 mm. proximal to the external meatus.44 for injuries to the male urethra does not have the same effect on the female urethra because of its homogeneous structure DIAGNOSIS with no frail point. Clinical diagnosis of urethral injury associated with pelvic Classification of posterior urethral injuries. Posterior urethral injuries have been traditionally considered complete or fracture is often complicated by multiple injuries, some of partial ruptures of the urethra at the prostatomembranous which require urgent attention. However, diagnosis in men is junction above the urogenital diaphragm.'.3' Rupture is com- not difficult, and usually is suspected by history, confirmed plete when the urethra is transected with no trace of conti- by abdominal and digital rectal examination, and docunuity between the 2 ends, partial when a full thickness tear mented on retrograde urethrography. Posterior urethral ininvolves only part of the urethral circumference and incom- jury should be suspected when a patient presents to the plete when contusions or lacerations are not full thickness. emergency room after a motor vehicle accident or fall from a Two review articles of 429 posterior urethral injuries in 14 height with inability to void and blood at the urethral meatus series revealed an average of 27% partial and 73% complete or gross hematuria. Inability to void may be caused by urethral injury but may occur from pain or shock from the tears.39.40 In 1977 Colapinto and McCallum suggested a new classifica- fractured pelvis or simply because the patient does not have tion of injuries as type I-the posterior urethra is stretched but a full bladder.15 However, with partial rupture voiding may remains intact,type 11-the membranous urethra is partidy or be normal but the urine is usually bloody.'* Urethral bleedcompletely ruptured at the upper aspect of the Urogenital dia- ing or gross hematuria is the best indicator of urological

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B

A

vz \,

URETHRAL SPHINCTER

PERINEAL MEMBRANE

C

FIG. 2. Successive stages of posterior urethral injury associated with pelvic fracture. A, normal anatomy. Note that prostate, membranous urethra and urethral sphincter constitute single anatomical unit. Perineal membrane limits undersurface of urogenital diaphragm, which has no distinct superior membrane separating it from prostate. B , stretching of intact membranous urethra facilitated by disruption of pub0 rostatic ligaments. C , partial rupture of still stretched membranous urethra a t level of perineal membrane. D , complete rupture of memgranous urethra which is retracted upward while bulbous urethra is still fixed to intact perineal membrane. E,disruption of perineal membrane with retraction of bulbous urethra into perineum.

injury, with incidence ranging from 91 to 100%of cases of urethral disruption.’5. The only fallacy in assessing urethral damage from the observation of blood at the external meatus is the risk of making a diagnosis of a ruptured urethra when there is only a mucosal contusion.” The amount of urethral bleeding correlates poorly with the seventy of injury as a mucosal contusion or small partial tear may be accom-

panied by copious bleeding, while total transection of the urethra may result in little bleeding.2.23.36 Physical examination may reveal malrotation of the hemipelvis and compression of the iliac crests will indicate any existing gross instability. Shortening of the extremity without an obvious fracture to the long bones is due to a displaced pelvic ring.27 Abdominal examination usually re-

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FIG.3. Retrograde urethrography of pelvic fracture urethral injury. A, stretching (arrows)of membranous urethra with no rupture. B , incomplete rupture of still stretched membranous urethra (long arrow) at bulbomembranous junction (curved arrow). Note intact rosta tomembranous junction (short arrow) and extravasation mainly in region of urogenital diaphragm with some extension into peks. C complete rupture of posterior urethra at bulbomembranous junction (arrow)with extravasation into pelvis. D,complete rupture of posterior urethra with extravasation into pelvis (curved arrow) and perineum (straight arrows).

veals muscle guarding and suprapubic dullness due to a pelvic hematoma, which may mask a full bladder. Perineal hematoma or swelling due to extravasated urine or blood may be demonstrated and is usually in the anal and not urogenital triangle when blood from the pelvis enters the ischiorectal fossa through separation of the levator ani muscle.36 This condition may not be seen if the patient reaches the emergency room shortly after the accident.'$ Lowe et a1 reported that patients examined within 1 hour of injury were much less likely to have positive physical findings than those examined later.30 Inspection and palpation of the anus are mandatory, as blood may be noted in the anus and lacerations, bruises or abrasions may be seen.36 Also, bony spicules may be palpated and occasionally may result in rectal injury.45 On digital rectal examination a boggy mass is usually palpated without recognition of a prostate gland.36 This finding can be misleading as not infrequently it is assumed that the prostate has been displaced upward and out of reach. In fact the pelvic hematoma often obliterates the outline of the prostate and the gland is still not far from its normal position. Rectal palpation of a free-floating prostate obviously is diagnostic of complete urethral rupture but this is rarely noted with certainty because of tenderness and pelvic hematorna.l5 Also, a high riding prostate does not definitely indicate a ruptured urethra because sometimes the posterior urethra has been stretched considerably without disruption of its Retrograde urethrography is the cornerstone of diagnosis of posterior urethral injury. It is recommended in all men with pelvic fractures associated with inability to urinate, blood a t the meatus or gross hematuria, perineal swelling or a nonpalpable prostate.46 Retrograde urethrography is per-

formed with the patient in the 45-degree oblique position and the penis stretched perpendicular t o the femur. However, it is not always possible to position all trauma victims oblique, and so urethrography may be performed with the patient flat and the penis stretched perpendicular to the lower extremity.46About 20 ml. of a diluted water soluble contrast medium are instilled into the urethra and a film is obtained while instilling the last few milliliters. Ideally the examination should be performed under fluoroscopic control but in patients with multiple injuries this frequently is not feasible, and so fixed radiographic or even portable equipment in the emergency room must be used.4i Retrograde urethrography will not only demonstrate the presence or absence but also the type of urethral injury (stretching, partial or complete rupture, fig. 3).Extravasation of contrast medium without its presence in the bladder and proximal urethra is diagnostic of complete urethral disruption. Partial disruption is diagnosed in the presence of extravasation with partial filling of the bladder and proximal ~ r e t h r a .However, ~ ~ . ~ ~ Herschorn et al have questioned the accuracy of retrograde urethrography after trauma in distinguishing complete from partial injuries.40 They suggested that extension of the contrast medium proximal to the partial rupture may be prevented by spasm of the external sphincter and gross extravasation may obscure the proximal urethra. The inability to pass a catheter into the bladder used t o be considered diagnostic of posterior urethral injury. However, it is now well established that diagnostic catheterization should not be done as the catheter may be pushed into the area of partial rupture making it a complete rupture, be passed easily into the bladder without detecting partial rupture, exit through the torn urethra to lie in the periprostatic

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but should not apply to the more controlled circumstances of delayed primary repair.55 He believes that the operation should be performed 7 to 10 days after injury when patients are more likely to be in relatively good general condition and the operative view is no longer obscured by initial bleeding but before fibrosis appears.55 Primary realignment was first introduced by Ormond and Cothran in 1934. Correction of the displaced prostate and close apposition of the torn ends of the urethra were achieved and maintained by a urethral catheter and traction with concomitant suprapubic cystostomy.12 Since then several investigators have used different techniques of “railroading”t o manipulate the catheter across the urethral gap during open operation, including retrograde catheter placement under direct vision, sound to sound, sound to finger and combined antegrade tied to retrograde catheter procedures.4R,sti,siThe sound to sound technique is better attempted with a pair of Davis matching sounds, 1 of which has a concave tip to receive the convex tip of the other.49 The urethral catheter is left indwelling for 4 to 8 weeks and removed only when a retrograde urethrogram around the catheter demonstrates healing of the urethral disruption with no extravasation of contrast medium.57 The suprapubic tube then is clamped but left in place until the patient is voiding normally. However, it should be stressed that most so-called realignment techniques are simply reestablishments of urethral continuity. Actual realignment can be achieved only under fluoroscopic guidance to keep the instruments in the proximal and distal urethral segments on the same cephalocaudad axis.“ Realignment may be done with or without traction, which generally is obtained via an indwelling Foley catheter and a 500 gm. weight, and maintained for 4 to 7 days. Traction should be at a 45-degree angle from the horizontal plane to avoid undue tension against the suspensory ligament of the penis.s6 However, sustained traction on the balloon catheter has been noted TREATMENT to produce pressure damage to the only remaining sphincter The 3 main risks of complication are stricture, inconti- mechanism at the bladder neck.S*Also, in patients with tears of nence and impotence in every case of pelvic fracture urethral the urogenital diaphragm and, therefore, lack of support for the injury. They may result directly from original and/or iatro- prostate the gland may be pulled by traction into an abnormal genic trauma induced by immediate treatment. Therefore, position.~SFor these reasons this method of traction has been treatment should be directed toward minimizing the risk of abandoned by most investigators and replaced with so-called late complications to achieve a patent continent urethra vest sutures, which are introduced through the apex of the and brought out through the perineum.60 Similarly, while maintaining pre-traumatic sexual p o t e n ~ y . l ~ Cur. ~ l * ~prostate ~ rent options include primary suturing of the separated ure- vest sutures may cause misalignment or malrotation of the thral ends, surgical or endoscopic primary realignment with prostate about a transverse axis.56 The aim of realignment is to pull the proximal urethra down urethral splinting and suprapubic cystostomy with delayed repair. The oldest method is primary suturing of the dis- snugly against the distal stump so that healing will occur with rupted urethral ends, which was first performed by Young in minimal stricture. Most investigators believe that early realign1929 via a perineal approach.53 Later investigators advo- ment not only decreases the incidence of stricture formation but cated the retropubic route and rejected the perineal approach also significantly decreases its length and, thus, facilitates later because the lithotomy position was considered hazardous in r e ~ a i r . ~ ~However, .*O Husmann et a1 failed to find any notable patients with pelvic fracture.36 Some authors reported satis- advantages of this procedure for urethral continuity with longfactory results and stressed that approximation and suturing term followup.61Specifically,more than half of their 17 patients of the separated urethral ends should be attempted because treated with primary realignment had an impassable stricture, they may result in a good urethral lumen, and if a stricture the remaining majority required substantial efforts to keep the occurs it is usually correctable.3* channel open and only 1 fully achieved a good result. Also, Primary suturing necessarily involves exploration of the Ragde and Mclnnes reported that realignment even with tracinjury site with release of the tamponade effect of the hema- tion is not sufficient to coapt completely the margins of the toma and control of bleeding, and attempts to suture the ends severed urethra, and 1.5 to 4 cm. defects were observed.6” This of the urethra together are not easy. Also, dissection of the finding agrees with experimental data which proved that when periprostatic and periurethral tissues to anastomose the 2 the canine posterior urethra was transected and apparently urethral ends may damage the neurovascular bundles and good urethral coaptation was achieved by catheter traction increase the risk of impotence, which already is substantial there was no evidence of epithelialization of the mucosal gap with this injury.”4 Furthermore, any surviving elements of but rather the intervening area was filled with fibrous tissue.”$ the intrinsic urethral sphincter mechanism may be damaged The disadvantages of primary realignment include the risk by mobilizing and trimming the tom urethral ends before of accelerating blood loss, enhancing urethral injury and use suturing. Another consideration is that incomplete ruptures of operative time that is better spent on associated critical may be converted to complete ruptures during dissection to injuries of more vital organs. However, the main criticism is define the anatomy and attempt repair.5‘ However, Mundy that primary realignment might damage the neurovascular believes that these criticisms might be true under the rela- bundles with an increased incidence of impotence. Also, the tively uncontrolled circumstances immediately after injury procedure might increase the incidence of incontinence by

region and introduce infection into a previously sterile hematoma. Elliott and Barrett reported that in 11 of 57 patients with posterior urethral disruption a urethral catheter was placed outside the bladder before arrival to the emergency room.48 Of greater concern is the use of a Foley catheter which has particular risks if it is held up or diverted at the site of rupture as distention of the balloon will increase the extent of a minor urethral injury and may critically compromise the urethral sphincter mechanism or create an avoidable stricture.49 There has been a false sense of security among physicians that pelvic fracture urethral injury in women rarely if ever occurs.*XThis belief as well as the fact that voiding is usually maintained and continence is not at risk with rupture of the distal urethra may explain why many cases are overlooked. However, a high index of suspicion should be maintained and rupture of the urethra should be suspected when pelvic fracture, vaginal bleeding and laceration, inability to void and urethrorrhagia and/or hematuria is present. Also, labial edema in women after pelvic trauma, which probably represents extravasation of urine from a urethral fistula, should increase awareness of a possible urethral injury.18 Unfortunately careful vaginal examination is usually not performed in severely injured patients and often the gynecologist rather than uroloDst is consulted for vaginal bleeding or injuries. Thus, vaginal tears may be promptly sutured while the urinary tract is not examined. There have been contradictory opinions about the diagnostic reliability of urethrography in women. Although it may reveal extravasation of contrast medium and vesical compression by pelvic hematoma, McAninch believes that suspected injury in women with pelvic fractures based on physical examination should be confirmed on urethroscopy.50

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denervation of the striated sphincter or direct sphincteric i n j ~ r y . "However, ~ there has been increasing evidence that primary realignment is not associated with significant impact on potency and urination, and that the injury and not the method of management is responsible for potency loss and incontinence after urethral traurna.40.64.65 Also, recent studies with magnetic resonance imaging and duplex ultrasound have demonstrated significant injuries to the corporeal bodies and surrounding tissues in impotent patients after pelvic trauma, denoting that the nature of impotence appears to be primarily vasculogenic and not neurogenic as previously believed.lo Primary realignment remained the most widely used treatment of posterior urethral disruption until 30 years ago when it lost favor at many centers because of its impact on potency and urinary continence. This disfavor facilitated the introduction of an alternative treatment method, namely suprapubic cystostomy and delayed repair. With this method, which was first advocated by Johanson of Sweden in 1953, no attempt is made to explore or manipulate the urethra but urine simply is diverted with a suprapubic tube introduced through a small suprapubic incision or by trocar if the bladder is palpably distended.52 The Johanson principle accepts the inevitability of stricture formation following complete urethral rupture, which is repaired electively several months later. The need for delayed repair can be regarded as a reasonable price to pay for the assurance that if impotence supervenes, it is a natural complication of the accident and not the intervention.s8 If rupture is incomplete, spontaneous urethral voiding may ensue upon clamping the suprapubic tube as early as 10 to 14 days after injury.52 This hands-off policy has gained wide acceptance, and during the last 3 decades it has become the standard approach to the management of posterior urethral disruption. Perceived advantages include avoiding entry into the pelvic hematoma with the risk of infection and excessive blood loss, speed and simplicity of suprapubic tube placement, and avoiding mobilization of the prostate and urethra with resultant lower impotence and incontinence rates.s7 The disadvantages include the need for suprapubic drainage for 3 t o 6 months with the possibility of infection and stone formation as well as the approximately 100% risk of formation of strictures, many of which are complex and require urological expertise for repair.17 Recent reports have suggested innovative combined transurethral and transvesical endourological and radiological procedures to achieve primary realignment without the risk of exploring the disrupted urethra.3-9 In endoscopic approaches a 4F ureteral catheter is passed via the suprapubic route down through the lumen of a Goodwin hollow metal sound or a cystoscope, and fed into a urethroscope or grasped by forceps out of the distal urethra. Then the ureteral catheter is used as a guide to pass an 18 to 20F silicone balloon catheter into the bladder.4.s.g.9In radiological realignment a retrograde guide wire loaded onto a special catheter is steered into the bladder using multiplane fluoroscopy and during intermittent injection of contrast medium through the catheter. If this procedure is unsuccessful, another catheter and guide wire are introduced into the bladder through the suprapubic tract and used as a guide to probe with the more distal catheter and guide wire. Thus, a guide wire can be advanced retrograde or antegrade out of the urethral meatus. A balloon catheter is then placed over the wire and into the bladder." Also, realignment can be accomplished with magnets attached to the ends of 16F coaxial urethral catheter^.^ The antegrade and retrograde catheters are manipulated under fluoroscopic guidance until the tips meet in the area of disruution and a distinctive click is noted. The urethral catheter ;'s then pulled into the bladder and a side port in the catheter allows antegrade passage of a guide wire. The magnetic urethral catheters are removed and a balloon catheter

is passed over the guide wire across the urethral disruption into the bladder. In endourological and radiological realignment access to the bladder may be obtained percutaneously or via a previous suprapubic cystostomy tract.g Because of orthopedic injuries patients may be placed in a moderate lithotomy position or supine with the thighs separated and elevated over sand bags.:l," Realignment, whether surgical or endoscopic, is better performed 1 or 2 weeks after injury when the pelvic hematoma should have begun to resolve, Scarring should be minimal and the patient should be in better physical condition.8 However, an associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. Endourological and radiological procedures should not adversely affect erectile function since there is no manipulation of periprostatic tissues and no additional trauma to the cavernous nerves. Also, on endoscopy the surgeon may identify partial urethral rupture which can be stented safely under vision. However, there is the potential for extravasation of irrigating fluid into the pelvic hematoma during endoscopic maneuver^.^ This risk does not apply to radiological techniques, which have additional advantages as no general anesthesia is required and the patient is supine. Endourological and radiological procedures have produced encouraging results so far but clinical experience is limited. All reports include only a few cases, most of which have been followed for only a few months. More experience with a sufficient number of cases and longer followup are needed to confirm early reports and to compare these approaches with conventional methods. Obviously the results of treatment methods should be evaluated based on a statistical study of a large number of cases but most series of pelvic fracture urethral injuries include only a few cases and, thus, cannot contribute valid statistics to resolve the treatment controversy. The first comprehensive literature review on this issue was attempted in 1983 by Webster et a1 who analyzed the results of 538 cases in 19 reported series.:1YThey suggested that realignment techniques should be reserved for cases of high riding bladder, associated rectal tear or bladder neck injury and that all others be managed with suprapubic cystostomy and delayed repair. This approach was confirmed recently in a review of the literature on this subject from 1953 to 1995 which included 871 patients, of whom 508 (58.3%)were treated with initial suprapubic cystostomy, 326 (37.49) with primary realignment and 37 (4.3%)with primary suturing.17 Primary suturing had the greatest complication rates of incontinence (214, p ~ 0 . 0 5 and ) impotence (56%,p <0.0001). Primary realignment had almost double the incidence of impotence and half that of stricture compared to suprapubic cystostomy (36 versus 19 and 53 versus 97%,respectively, p <0.0001). The nearly equal low incidence of incontinence after primary realignment and suprapubic cystostomy (5 versus 4 4 , p = 0.41) indicated that this complication was related more to the original trauma than to either treatment (see table). In women treatment modalities are determined by the level of urethral injury as this has major implications for

Complications according to treatment method in 871 patients between 1953 and 1995" ___ _ _ ~ ~

__-

__-

No. Pts~TotalNo. ('2

Suprapubic Cystostomy

Total No. pts.

I

-_____.__

Primary Realignment

Primary Suturing

p Value

508 326 37 493 (97) 174 (53) 18 (49)
1440

PELVIC FRACTURE URETHRAL INJURIES

I 8

I

e

I

.

Cy stography

I Part Rupturej

bompl Rupture]

1 Wide Distraction

r

Stretch

I

1

Mild Distraction

B N inpry

Recfai injury

!

subsequent urinary continence."" For rupture of the proximal urethra suprapubic cystostomy and delayed repair are not advised. Such an approach is almost always complicated by urethrovaginal fistula with distal urethral stenosis and reconstruction presents particular problems.44 Therefore, immediate retropubic exploration with realignment of the urethral ends or end-to-end anastomosis over a stenting urethral catheter should be attempted. It is important to repair simultaneously any vaginal laceration to prevent subsequent development of a urethrovaginal fistula. For rupture of the distal urethra, when the continence mechanism is not at risk, treatment is directed at establishing an adequate external meatus, which can be achieved by advancement of the proximal urethra and development of a neomeatus or catheterization of the proximal urethral stump with closure of the vaginal laceration around the hypospadiac neomeatus.ZHBoth procedures may be performed via a transvaginal approach.29 CONCLUSIONS

The data suggest that inflexible policies of 1 procedure or another are inappropriate for the treatment of pelvic fracture urethral injuries in men. Various procedures do not compete but rather complement each other for treatment of different injuries under different circumstances. Success depends on proper selection and assignment which in turn depend on certain factors, including type of injury (stretching, complete or partial rupture), separation of urethral ends (narrow or wide), associated injuries (inside or outside the urinary tract), patient condition, available facilities and surgeon experience. Stretching of the posterior urethra requires no more than an indwelling catheter for a few days. Partial rupture of the urethra may be managed with endoscopic urethral stenting initially or suprapubic cystostomy, which may result in a patent urethra or at most a short stricture easily correctable with visual urethrotomy. For complete rupture with minimal urethral distraction the benefit of exploration of the injury site for realignment is outweighed by the inherent disadvantages of this procedure. Such cases may be

!

treated with endoscopic realignment or suprapubic cystostomy and delayed repair, depending on the availability of a n experienced endourologist. Both procedures would result in a short stricture that could be corrected later with visual urethrotomy or perineal urethroplasty and should not compromise sexual potency or urinary continence. For complete rupture with marked urethral separation there is a high risk that suprapubic cystostomy alone or an endoscopic procedure will cause a complex stricture requiring extensive transpubic repair. Such injuries should be explored for primary realignment. No blind urethral catheterization, primary suturing or catheter traction should be performed as it would increase the incidence of stricture formation, impotence and incontinence, respectively. On the other hand, in women a conservative policy is not advised. Surgical exploration should be attempted via the retropubic route for proximal and the vaginal route for distal injuries (fig. 4). REFERENCES

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38. Devine, C. J., Jr., Jordan, G. H. and Devine, P. C.: Primary realignment of the disrupted prostatomembranous urethra. Urol. Clin. N. h e r . , 1 6 291, 1989. 39. Webster, G. D., Mathes, G. L. and Selli, C.: Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J . Urol., 130 898, 1983. 40. Herschorn, S., Thijssen, A. and Radomski, S. B.: The value of immediate or early catheterization of the traumatized posterior urethra. J. Urol., 148 1428, 1992. 41. Colapinto, V. and McCallum, R. W.: Injury to the male posterior urethra in fractured pelvis: a new classification. J. Urol., 118 575, 1977. 42. Goldman, S. M., Sandler, C. M., Comere, J. N., Jr. and McGuire, E. J.: Blunt urethral trauma: a unified, anatomical mechanical classification. J . Urol., 157: 85, 1997. 43. Boone, T. B., Wilson, W. T. and Husmann, D. A,: Postpubertal genitourinary function following posterior urethral disruptions in children. J. Urol., 148: 1232, 1992. 44. Pode, D. and Shapiro, A,: Traumatic avulsion of the female urethra: case report. J . Trauma, 30: 235, 1990. 45. Morehouse, D. D.: Management of posterior urethral rupture: a personal view. Brit. J. Urol., 61: 375, 1988. 46. Spirnak, J. P.: Pelvic fracture and injury to the lower urinary tract. Surg. Clin. N. Amer., 68:1057, 1988. 47. Sandler, C. M. and Comere, J . N., Jr.: Urethrography in the diagnosis of acute urethral injuries. Urol. Clin. N. Amer., 1 6 283, 1989. 48. Elliott, D. S. and Barrett, D. M.: Long-term followup and evaluation of primary realignment of posterior urethral disruptions. J. Urol., 157: 814, 1997. 49. Turner-Warwick, R.: A personal view of the immediate management of pelvic fracture urethral injuries. Urol. Clin. N. Amer., 4 81, 1977. 50. McAninch, J. W.: Urethral injuries in female subjects following pelvic fractures. (Editorial Comment). J . Urol., 147: 139, 1992. 51. Morehouse, D. D. and Mackinnon, K. J.: Posterior urethral injury: etiology, diagnosis, initial management. Urol. Clin. N. Amer., 4 69, 1977. 52. Weems, W. L.: Management of genitourinary injuries in patients with pelvic fractures. Ann. Surg., 1 8 9 717, 1979. 53. Young, H. H.: Treatment of complete rupture of the posterior urethra, recent or ancient, by anastomosis. J. Urol., 21: 417. 1929. 54. Cofield, K. S. and Weems, W. L.: Experience with management of posterior urethral injury associated with pelvic fracture. J. Urol., 117: 722, 1977. 55. Mundy, A. R.: The role of delayed primary repair in the acute management of pelvic fracture injuries of the urethra. Brit. J. Urol., 68:273, 1991. 56. DeWeerd, J. H.: Immediate realignment of posterior urethral injury. Urol. Clin. N. Amer., 4 75, 1977. 57. Follis, H. W., Koch, M. 0. and McDougal, W. S.: Immediate management of prostatomembranous urethral disruptions. J . Urol., 147: 1259, 1992. 58. Turner-Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries-and from their surgical management. Urol. Clin. N. Amer., 1 6 335, 1989. 59. Malek, R. S., ODea, M. J. and Kelalis, P. P.: Management of ruptured posterior urethra in childhood. J. Urol., 117: 105, 1977. 60. Turner-Warwick, R.: Complex traumatic posterior urethral strictures. J . Urol., 118 564, 1977. 61. Husmann, D. A., Wilson, W. T., Boone, T. B. and Allen, T. D.: Prostatomembranous urethral disruption: management by suprapubic cystotomy and delayed urethroplasty. J. Urol., 144: 76, 1990. 62. Ragde, H. and McInnes, G. F.: Transpubic repair of the severed prostatomembranous urethra. J . Urol., 101: 335, 1969. 63. MeRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of repair. J. Urol., 104: 724, 1970. 64. Kothn. L. and Koch, M. 0.:Impotence and incontinence after immediate realignment of posterior urethral trauma: result of injury or management? J. Urol., 1 5 5 1600, 1996. 65. Jenluns, B. J., Badenoch, D. F., Fowler, C. G. and Blandy, J. P.: Long-term results of treatment of urethral injuries in males caused by external trauma. Brit. J. Urol., 7 0 73, 1992.