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Primary Realignment for Pelvic Fracture Urethral Injury Is Associated With Prolonged Time to Urethroplasty and Increased Stenosis Complexity
Accepted Manuscript Title: Primary Realignment for Pelvic Fracture Urethral Injury is Associated with Prolonged Time to Urethroplasty and Increased Stenosis Complexity Author: Akio Horiguchi, Masayuki Shinchi, Ayako Masunaga, Kazuki Okubo, Kazuki Kawamura, Kenichiro Ojima, Keiichi Ito, Tomohiko Asano, Ryuichi Azuma PII: DOI: Reference:
S0090-4295(17)30609-X http://dx.doi.org/doi: 10.1016/j.urology.2017.06.001 URL 20495
To appear in:
Urology
Received date: Accepted date:
13-4-2017 1-6-2017
Please cite this article as: Akio Horiguchi, Masayuki Shinchi, Ayako Masunaga, Kazuki Okubo, Kazuki Kawamura, Kenichiro Ojima, Keiichi Ito, Tomohiko Asano, Ryuichi Azuma, Primary Realignment for Pelvic Fracture Urethral Injury is Associated with Prolonged Time to Urethroplasty and Increased Stenosis Complexity, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.06.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Reconstructive Urology
Primary realignment for pelvic fracture urethral injury is associated with prolonged time to urethroplasty and increased stenosis complexity
Running head: Negative impact of primary realignment
Akio Horiguchi1, Masayuki Shinchi1, Ayako Masunaga1, Kazuki Okubo1, Kazuki Kawamura1, Kenichiro Ojima1, Keiichi Ito1, Tomohiko Asano1 and Ryuichi Azuma2
1
Department of Urology, National Defense Medical College, Saitama, Japan,
2
Department of Plastic Surgery, National Defense Medical College, Saitama, Japan
Correspondence and requests for reprints should be addressed to AKIO HORIGUCHI, Department of Urology, National Defense Medical College 3-2 Namiki, Tokorozawa-City, Saitama 359-8513 Phone: +81-4-2995-1676, Fax: +81-4-2996-5210, Email: [email protected]
Word count of abstract: 246 words Words count of the manuscript: 2998 words Key Words: pelvic fracture urethral injury; primary realignment; initial management, urethral reconstruction 1 Page 1 of 19
Acknowledgement This study was supported by a grant for scientific research from the Ministry of Education, Science, Sports and Culture (16H05467). We have no financial interests to disclose. ABSTRACT Objectives: To compare the clinical courses of patients with pelvic fracture urethral injury (PFUI) according to initial management strategy. Patients and Methods: We reviewed the clinical courses of 63 patients with PFUI who were initially treated elsewhere and underwent delayed anastomotic urethroplasty by a single surgeon between 2008 and 2015. Patients were grouped according to their initial treatment: by suprapubic tube placement alone (49 patients, SPT group) or primary realignment (14 patients, PR group). Time to urethroplasty was defined as the period between injury and delayed urethroplasty. Clinical data regarding the status of urethral stenosis, urethroplasty procedure, and treatment outcome were analyzed. Results: The mean time to urethroplasty in the PR group was about three times that in the SPT group (133 months vs 47 months, p = 0.035). Fifty percent of the PR group (7 of 14) had a history of repeated urethrotomy and/or dilation before referral, a percentage significantly higher than that of the SPT group (20.4%, 10 of 49, p = 0.027). The percentage of patients having a false passage and/or iatrogenic scar was significantly higher in the PR group (42.9% vs 16.3%, p = 0.035), but there was no significant between-group difference in urethral stenosis length, operative time, operative blood loss, or the percentage of patients requiring inferior pubectomy and/or urethral rerouting. 2 Page 2 of 19
Conclusions: PR does not facilitate delayed urethroplasty, and patients who undergo PR are at high risk of having a more complicated stenosis and longer time to urethroplasty, presumably because of repeated transurethral procedures. Introduction Acute management of pelvic fracture urethral injury (PFUI) remains a controversial and difficult issue for urologists. There are two treatment options: the first is to place a suprapubic tube (SPT) and perform delayed urethroplasty for subsequently developed urethral stenosis, and the second is to perform early primary realignment (PR) either by gentle simple retrograde catheterization or with the use of a cystoscope 1-4. Realignment is used to repair the injury and prevent stenosis 5. It has a lower stenosis rate than SPT placement alone, with which stenosis formation is almost certain 5, 6. Even if scarring and subsequent stenosis formation occur, the delayed urethroplasty is easier because urethral continuity is already restored, the stenosis length is shorter than when PFUI is treated with SPT placement alone, and the posterior urethra and the deformity of the prostate are well aligned 7. Some authors, however, think that most patients treated by PR have their acute injury turned into an unstable chronic disease state that usually requires daily self-dilation, regular office dilations, or repeated transurethral procedures 6, 8. Moreover, repeating transurethral manipulations can delay definitive treatment and complicate it 8-10. In the present study, we compared the clinical courses of patients with PFUI who underwent delayed urethroplasty at our referral center according to the initial management strategies and investigated the impact of PR on the subsequent delayed urethroplasty. 3 Page 3 of 19
Patients and Methods Patient selection and evaluation of the urethral gap After obtaining approval of our institutional review board, we retrospectively reviewed the clinical course of 73 consecutive patients with history of PFUI who were referred from elsewhere after acute PFUI management and underwent delayed urethroplasty, by a single surgeon (AH), for resulting urethral stenosis during 2008 to 2015 at National Defense Medical College or affiliate institutes. Ten patients had a history of prior failed urethroplasty and were excluded from analysis, so a total of 63 patients were included in this study. For patients in whom a suprapubic tube (SPT) had not been placed and voided with intermittent dilation or urethrotomy and those in whom a urethral catheter was placed at initial referral, an SPT was placed for urethral rest and any urethral manipulation was ceased 11. As a result, an SPT was placed in all patients preoperatively. At least 3 months after injury or last urethral manipulation, the length of urethral stenosis and presence of false passage and iatrogenic scarring was evaluated on the up-and-down urethrogram and/or MRI. The disruption site (bulbomembranous urethra or proximal to the membranous urethra) was determined by both retrograde and antegrade endoscopy through the SPT tract.
Urethroplasty All urethroplasties were anastomotic urethroplasties performed in a stepwise fashion as described elsewhere 12. The bulbar urethra was divided at the obliterated segment and 4 Page 4 of 19
then mobilized distally. The proximal urethral end was identified by palpitation with a metallic sound (Van Buren urethral sound) inserted through the SPT tract. The covering fibrotic scar tissue was completely removed and 8 anastomotic 4-0 polydioxanone sutures were placed to reapproximate the urethral mucosa over a 16Fr catheter. If the proximal urethral end was not palpated or a tension-free anastomosis could not be achieved, corporal splitting and/or inferior pubectomy were used in steps. When adequate access to the membranous urethra and the apex of the prostate could not be provided by these steps, an abdominoperineal approach with supracrural rerouting was used. Use of the bulbar urethral mobilization with/without corporal splitting was categorized as a simple perineal approach, and inclusion of the further steps was categorized as an elaborate approach 12.
Analysis Patients were stratified into two groups (SPT group and PR group) based on the initial method of treatment (the one used within 2 weeks after injury) according to the information sent at the first referral. The SPT group included patients treated only with SPT placement followed by elective delayed urethroplasty, while patients in whom a urethral catheter was successfully inserted blindly or under endoscopy and stenosis subsequently occurred were assigned to the PR group. Patients in whom catheter placement had been attempted but failed were assigned to the SPT group. Analyzed data included clinical information such as stenosis length and the presence/absence of periurethral fistula, the type of urethroplasty required, time to urethroplasty (defined as 5 Page 5 of 19
the time between the injury and urethroplasty), prior history of transurethral procedures (urethral stenting, endosopic urethrotomy, and self- or office dilation), and treatment outcome. Patients were followed up postoperatively at 3, 6, and 12 months and annually thereafter by using questionnaires, uroflowmetry, and flexible cystoscopes. Success was defined as the ability to void without the need for further intervention and having a urethral lumen large enough for passage of a flexible cystoscope. Urinary continence and erectile function were evaluated 6 months postoperatively in 38 patients. Urinary incontinence was defined as the need for any protective pads, and erectile dysfunction was defined as a score less than 21 on the 5-item version of International Index of Erectile Function 13. All statistical analyses were performed by using the JMP 11 (SAS Institute Inc. Cary, NC, USA). Data are presented as means and standard errors (SE). The Student t-test was used to evaluate the relations between continuous data, and a chi-square test was used to assess the association between clinical parameters and the status of urethral stenosis. P-values less than 0.05 were considered to indicate statistical significance.
Results Comparison of patient characteristics The patient characteristic in both groups was summarized in Table 1. A total of 49 (77.8%) had SPT placement alone, and the remaining 14 (22.2%) underwent PR and had subsequent urethral stenosis. PR was attempted but failed in 12 (19.0%), and those patients were assigned to the SPT group. Of the PR group, a urethral catheter was 6 Page 6 of 19
inserted blindly in 3 (21.4%) and under endoscopy in 11 (78.6%). There were no significant between-group differences in mean patient age (p = 0.199), body mass index (p = 0.611), fraction of current smokers (p = 0.087), or fraction having history of obstructive pulmonary disease (p = 0.222). In the PR group the fraction having history of diabetes (2 of 14, 14.3%) was significantly larger than it was in the SPT group (none, 0%, p = 0.046). In the PR group the fraction of patients who could void with intermittent dilation or urethrotomy at the initial referral to our institute (6 of 14, 42.9%) was significantly larger than it was in SPT group (4 of 49, 8.2%, p = 0.005). The mean time to urethroplasty in the PR group was about three times longer than that in the SPT group (133.1 months vs. 47.0 months, p = 0.035). Seven of the patients in the PR group (50.0%) had a history of repeated transurethral procedures such as urethrotomy, dilation, and/or urethral stenting before referral for reconstruction, and this fraction was significantly larger than that in the SPT group (10 of 49, 20.4 %, p = 0.027). Of note, the mean disease duration in patients in the SPT group without history of any transurethral procedure was only 15 months.
Comparison of the urethral gap and operative outcome Table 2 shows the stenosis characteristics at urethroplasty and the surgical outcome in both groups. There was no significant between-group difference in the percentage of patients who had opened bladder neck (12.2% in the SPT group vs 14.3% in the PR group, p = 0.839), the percentage of patients whose urethra was disrupted distal to the external sphincter (63.3% in the SPT group vs 78.6% in the PR group, p = 0.284), or the 7 Page 7 of 19
length of urethral stenosis (21.8 mm in the SPT group vs 17.2 mm in the PR group, p = 0.134). False passage was found in 5 (7.9%) and de novo iatrogenic scarring was found in 9 (17.3%). The fraction having a false passage and/or iatrogenic scar was significantly higher in the PR group (8 of 49, 16.3%, in the SPT group vs 6 of 14, 42.9%, in the PR group, p = 0.035). Figure 1 shows two representative PR-group cases showing false passage and de novo iatrogenic scarring. When only the 46 patients who had no history of prior transurethral procedures were considered, the fraction of those having false passage and/or iatrogenic scarring was significantly larger in the PR group (2 of 7, 28.6%) than it was in the SPT group (none of 39, 0%, p = 0.021, Table 3). On the other hand, when only the other 17 patients who had history of prior repeated transurethral procedures were considered, there was no significant between-group difference in the fraction having false passage and/or iatrogenic scaring (8 of 10, 80%, in the SPT group vs 4 of 7, 57%, in the PR group, p = 0.593). Regarding operative outcome, there was no significant between-group difference in operative time (mean 251.9 minutes in the SPT group vs 262.2 minutes in the PR group, p = 0.727), blood loss (mean 327.5 ml in the SPT group vs 414.2 ml in the PR group, p = 0.471), or the percentage of patients that required an elaborated approach (51.0% in the SPT group vs 64.3% in the PR group, p = 0.379). The success rate in SPT group (91.8%, 45 of 49) was slightly higher than that in the PR group (85.7%, 12 of 14), but the difference was not statistically significant (p = 0.491). When only the 46 patients who had no history of prior transurethral treatment were considered, the success rate in the SPT group (94.9%, 37 of 39) was significantly higher than that in the PR group (71.4%, 5 of 7, p = 0.042, 8 Page 8 of 19
Table 3). On the other hand, when only the 17 patients who had history of prior repeated transurethral procedures were considered, there was no significant between-group difference in the success rate (80.0% 8 of 10, in the SPT group vs 100.0%, 7 of 7, in the PR group, p = 0.485). Of note, no false passage or iatrogenic scar was found in SPT-group patients without any transurethral procedures and delayed urethroplasty, and the success rate for those patients was 94.6%. Data regarding postoperative continence and erectile function was available for 38 patients, and there was no significant between-group difference in the percentage with postoperative incontinence (20.0% in the SPT group vs 25.0% in the PR group, p = 0.757) or with erectile dysfunction (76.7% in the SPT group vs 62.5% in the PR group, p = 0.418).
Comment Although recent PFUI treatment guidelines regarding the initial management list PR as an option for haemodynamically stable patients 1, 2, 4, there are no randomized controlled studies comparing PR and SPT placement. A recent meta-analysis confirmed that subsequent stenosis rate was significantly lower in the PR group and there was no significant difference between the two interventions with regards to erectile dysfunction or incontinence 5. PR decreases the risk of urethral stenosis by approximately 30%, but the price to be paid by the remaining 70% is to undergo repeated futile and harmful transurethral procedures before definitive treatment by delayed urethroplasty, suggesting that it is a double-edged sword 6. Reported PR procedures range widely from gentle Foley catheterization to 9 Page 9 of 19
realignment through an open cystostomy and include the use of catheter pull-through, interlocking sounds, and the sound-to-finger method 5. Regardless of the type, PR has the potential to cause significant additional morbidity by further damaging recently traumatized tissues and can make matters worse, since clinical experience reveals that PR makes straddle injuries of the bulbar urethra worse than they would be if treated only by SPT placement 14. The degree of urethral damage done by PR might also depend on the surgeon’s experience. A recent review demonstrated that the incidence of PFUI is much lower, 1.54%, than previously reported 15. Moreover, the incidence and severity of traffic and industrial accidents in developed countries is decreasing 16, the number of patients who undergo PR is limited even in Level 1 trauma hospitals in the US 10, and most urologists are therefore likely to be inexperienced in PR. Although PR recently gains popularity, Arora showed a case of severe complication of PR and raised an alarm that its widespread use is not advisable for everyone and SPT placement may still be the safer option for inexperienced surgeons. 17. We strongly agree that PR should be done in an optimal setting by an experienced physician if subsequent fibrosis of the surrounding tissue is to be avoided; otherwise, nothing other than SPT placement should be done 10. In addition to being associated with urethral damage occurring during catheter passage, PR is associated with long-term catheterization for completion of urethral continuity, which increases the risk of developing adverse events including de novo iatrogenic urethral stricture 6, 10. In our cohort, the percentage of patients with a complicated stricture accompanying false passage and/or iatrogenic scarring in the PR group (42.9%) was three times greater than that in the SPT group (16.3%). Although 10 Page 10 of 19
complicated stenosis can be due both to PR itself and to subsequent transurethral procedures, the percentage of patients with complicated stenosis in the PR group (28.6%) remained higher than that in the SPT group (0%) even when the patients who underwent subsequent transurethral procedures were excluded. One of the advantages of PR has been reported to be an earlier return to voiding 18. Most patients treated with PR certainly tend to maintain some degree of urethral patency and can void with weak stream after catheter removal, but it could trigger the introduction of numerous futile and harmful transurethral procedures needed to maintain urethral patency 8. In our cohort, the fraction of patients who could void with intermittent dilation in the PR group was significantly larger than that in the SPT group. Repeated transurethral procedures are associated with not only poor QOL but also increased risk of complicating stenosis and prolonging time to urethroplasty 6, 8, 19. Tausch et al. reported that most patients treated with PR who underwent multiple transurethral procedures showed signs of iatrogenic trauma—false passages, complexity at the injury site, and/or the development of synchronous stenosis—which was never seen in patients treated only by SPT placement 8. Analysis of our cohort, too, revealed that patients treated with PR underwent transurethral procedure more frequently and tended to have more complex stenosis than did those treated only by SPT placement. In addition, patients treated with PR were 5 times more likely to have a delay of more than 1 year before urethroplasty than were those who underwent only SPT placement 8. Johnsen also reported that the mean time to urethroplasty was significantly shorter in an SPT group (5.8 months) than it was in a PR group (14.6 months) 6. The same trend was 11 Page 11 of 19
also found in our cohort, but the time to urethroplasty was much longer than it was in other studies (47.0 months in our SPT group and 133.1 months in our PR group). In Japan, 27% of consultant urologists have no experience with surgical treatment for PFUI during their whole careers and only 5% have treated more than 11 patients 20. Although guidelines clearly discourage transurethral procedures because of their disappointing results 1, 2, 4, Japanese urologists tend to use them for as long as possible, even in cases with complete obstruction after SPT placement 20. Because most patients with PFUI are young (overall mean age: 39), delay in treatment not only leads to low QOL and difficulty getting a job and low QOL but may also negatively influence social productivity. Some patients treated with PR had not experienced symptomatic urethral obstruction, and obstruction was incidentally identified by their inability to pass a urethral catheter. Patients treated with PR should be followed up closely and in the event of stricture formation be referred to a reconstructive subspecialist promptly 8. PR has been reported to restore urethral continuity and facilitate urethroplasty. Koraitim recently analyzed 120 patients with PFUI who underwent delayed urethroplasty and reported that PR decreased the stenosis length and facilitated its delayed repair 7. However, our experience showed that PR did not facilitate urethroplasty in terms of stenosis length, required urethroplasty type, or operative time and blood loss and that there was no difference in postoperative continence or erectile function consistent with previous reports 6, 8. Instead, we felt that urethroplasty in patients treated with PR was difficult because the urethral mucosa was widely scarred, making the border between healthy and damaged urethra unclear, and that additional 12 Page 12 of 19
resection is required even the urethra is patent. Some investigators have found that PR also has a negative impact on the outcome of delayed urethroplasty 21, 22. Koraitim et al. reported that prior treatment does not affect the outcome after urethroplasty but by scarring and/or shortening the available anterior urethra may influence the choice of the surgical approach 23, 24. In our cohort, no significant difference of success rate was found in overall patients, but when only patients without transurethral procedures were considered, the success rate in the PR group was significantly lower than that in the SPT group, suggesting PR has negative impact on the success rate of urethroplasty. Our study has several limitations. Firstly, because our institute is a referral center, information regarding the percentage of patients who avoided stenosis formation after PR, the severity of urethral injury (complete or incomplete) at initial diagnosis, the reason for selecting PR or SPT placement in each patient (technical difficulty or patient instability), and the details of the methods of PR remain unknown. Secondly, the number of patients in the PR group was small compared with that in the SPT group. Thirdly, a clear comparison could not be made because the SPT group included patients with failed PR. Despite these limitations, we believe this study provides an important message to urologists treating PFUI. Trauma centers performing PR and urologists who take over follow-up care need to know that repeated endoscopic interventions seem to do more harm than good. We strongly believe that SPT placement and delayed urethroplasty remains the gold standard treatment for patients with PFUI.
Conclusions
13 Page 13 of 19
PR does not facilitate delayed urethroplasty, and patients who undergo PR and repeated transurethral procedures are at high risk of having a more complicated stenosis and longer disease duration. No matter the method of initial treatment chosen, patients with urethral stenosis following PFUI should be referred to reconstructive experts without delay rather than subjected to futile transurethral procedures.
Conflicts of Interest None declared.
14 Page 14 of 19
References
1.
Gomez RG, Mundy T, Dubey D, et al. SIU/ICUD consultation on urethral strictures: pelvic fracture urethral injuries. Urology. 2014;83:S48-58.
2.
Morey AF, Brandes S, Dugi DD, 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192:327-335.
3.
Bryk DJ, Zhao LC. Guideline of guidelines: A Review of Urologic Trauma Guidelines. BJU Int. 2015.
4.
Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67:925-929.
5.
Barrett K, Braga LH, Farrokhyar F, Davies TO. Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis. Urology. 2014;83:924-929.
6.
Johnsen NV, Dmochowski RR, Mock S, Reynolds WS, Milam DF, Kaufman MR. Primary endoscopic realignment of urethral disruption injuries: a double-edged sword? J Urol. 2015;194:1022-1026.
7.
Koraitim MM. Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology. 2012;79:912-915.
8.
Tausch TJ, Morey AF, Scott JF, Simhan J. Unintended negative consequences of primary endoscopic realignment for men with pelvic fracture urethral injuries. J Urol. 2014;192:1720-1724.
9.
Tausch TJ, Morey AF. The case against primary endoscopic realignment of pelvic fracture urethral injuries. Arab J Urol. 2015;13:13-16.
10.
Leddy LS, Vanni AJ, Wessells H, Voelzke BB. Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. J Urol. 2012;188:174-178.
11.
Terlecki RP, Steele MC, Valadez C, Morey AF. Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology. 2011;77:1477-1481.
12.
Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145:744-748.
15 Page 15 of 19
13.
Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822-830.
14.
Park S, McAninch JW. Straddle injuries to the bulbar urethra: management and outcomes in 78 patients. J Urol. 2004;171:722-725.
15.
Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. The Journal of trauma. 2009;67:1033-1039.
16.
Kulkarni SB, Barbagli G, Kulkarni JS, Romano G, Lazzeri M. Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique. The Journal of Urology. 2010;183:1049-1054.
17.
Arora R, John NT, Kumar S. Vesicourethral fistula after retrograde primary endoscopic realignment in posterior urethral injury. Urology. 2015;85:e1-2.
18.
Hadjizacharia P, Inaba K, Teixeira PG, Kokorowski P, Demetriades D, Best C. Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. The Journal of trauma. 2008;64:1443-1449; discussion 1449-1450.
19.
Lubahn JD, Zhao LC, Scott JF, et al. Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol. 2014;191:143-147.
20.
Kitahara S, Sato R, Yasuda K, Arai G, Nakai H, Okada H. Surgical treatment of urethral distraction defect associated with pelvic fracture: a nationwide survey in Japan. Int J Urol. 2008;15:621-624; quiz 624.
21.
Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol. 2007;177:1374-1377.
22.
Singh BP, Andankar MG, Swain SK, et al. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology. 2010;75:179-182.
23.
Koraitim MM. Predictors of surgical approach to repair pelvic fracture urethral distraction defects. J Urol. 2009;182:1435-1439.
24.
Koraitim MM, Kamel MI. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int. 2015;116:265-270. 16 Page 16 of 19
Figure legends Figure 1. Representative cases of complicated stenosis in patients who underwent PR and, thereafter, repeated transurethral procedures. Arrows indicate urethral stenosis caused by PFUI. Dotted arrows in the left panel indicate periurethral false passage and the one in the right panel indicates de novo iatrogenic spongiofibrosis.
17 Page 17 of 19
Table 1. Comparison of patients’ characteristics in the PR and SPT groups No. pts (%) Age (SE) Body mass index (kg/m2) (SE) No. of smokers (%) No. with chronic obstructive pulmonary disease (%) No. with diabetes (%) No. that void with intermittent dilation (%) Disease duration (SE) No. having repeated transurethral procedures
SPT 49 (77.8) 38 (2.3) 22.3 (0.5) 23 (46.9)
PR 14 (22.2) 44 (4.5) 22.9 (1.0) 3 (21.4)
p value
0 (0)
1 (7.1)
0.222
0 (0)
2 (14.3)
0.046
4 (8.2)
6 (42.9)
0.005
47.0 (18.8)
133.1 (35.3)
0.035
10 (20.4)
7 (50.0)
0.027
0.199 0.611 0.087
Table 2. Urethral stenosis status and urethroplasty outcome
No. pts (%) Months of follow up (SE) Stenosis length (mm) No. with opened bladder neck (%) No. with disruption distal to external sphincter (%) No. with false passage and/or iatrogenic scar Operative time (min) Mean blood loss (ml) No. successful (%) No. that required elaborate approach (%) No. that needed to use pads (%) * No. with IIEF-5 score < 21 (%) *
SPT
PR
49 (78) 28.6 (2.8) 21.8 (1.4) 6 (12.2)
14 (22) 25.9 (5.3) 17.2 (2.6) 2 (14.3)
p value 0.656 0.134 0.839
31 (63.3)
11 (78.6)
0.284
8 (16.3)
6 (42.9)
0.035
251.9 (12.9) 327.5 (51.9) 45 (91.8)
262.2 (26.6) 414.2 (107.5) 12 (85.7)
0.727 0.471 0.491
25 (51.0)
9 (64.3)
0.379
6 (20.0) 23 (76.7)
2 (25.0) 5 (62.5)
0.757 0.418
* n = 38
18 Page 18 of 19
Table 3. Comparison in patients without prior transurethral procedures
No. pts (%) Months to urethroplasty (SE) Stenosis length (mm) No. with false passage and/or iatrogenic scar Operative time (mins) Mean blood loss (ml) No. that required elaborate approach (%) No. successful (%)
p value
SPT
PR
39 (84.8) 15.8 (14.0) 21.9 (1.6)
7 (15.2) 97.1 (33.1) 17.3 (3.7)
0.028 0.246
0 (0.0)
2 (28.6)
0.021
246.6 (13.9) 296.4 (55.0)
287.2 (37.9) 574.8 (149.6)
0.321 0.088
19 (48.7)
5 (71.4 )
0.268
37 (94.9)
5 (71.4)
0.042
19 Page 19 of 19
S0090-4295(17)30609-X http://dx.doi.org/doi: 10.1016/j.urology.2017.06.001 URL 20495
To appear in:
Urology
Received date: Accepted date:
13-4-2017 1-6-2017
Please cite this article as: Akio Horiguchi, Masayuki Shinchi, Ayako Masunaga, Kazuki Okubo, Kazuki Kawamura, Kenichiro Ojima, Keiichi Ito, Tomohiko Asano, Ryuichi Azuma, Primary Realignment for Pelvic Fracture Urethral Injury is Associated with Prolonged Time to Urethroplasty and Increased Stenosis Complexity, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.06.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Reconstructive Urology
Primary realignment for pelvic fracture urethral injury is associated with prolonged time to urethroplasty and increased stenosis complexity
Running head: Negative impact of primary realignment
Akio Horiguchi1, Masayuki Shinchi1, Ayako Masunaga1, Kazuki Okubo1, Kazuki Kawamura1, Kenichiro Ojima1, Keiichi Ito1, Tomohiko Asano1 and Ryuichi Azuma2
1
Department of Urology, National Defense Medical College, Saitama, Japan,
2
Department of Plastic Surgery, National Defense Medical College, Saitama, Japan
Correspondence and requests for reprints should be addressed to AKIO HORIGUCHI, Department of Urology, National Defense Medical College 3-2 Namiki, Tokorozawa-City, Saitama 359-8513 Phone: +81-4-2995-1676, Fax: +81-4-2996-5210, Email: [email protected]
Word count of abstract: 246 words Words count of the manuscript: 2998 words Key Words: pelvic fracture urethral injury; primary realignment; initial management, urethral reconstruction 1 Page 1 of 19
Acknowledgement This study was supported by a grant for scientific research from the Ministry of Education, Science, Sports and Culture (16H05467). We have no financial interests to disclose. ABSTRACT Objectives: To compare the clinical courses of patients with pelvic fracture urethral injury (PFUI) according to initial management strategy. Patients and Methods: We reviewed the clinical courses of 63 patients with PFUI who were initially treated elsewhere and underwent delayed anastomotic urethroplasty by a single surgeon between 2008 and 2015. Patients were grouped according to their initial treatment: by suprapubic tube placement alone (49 patients, SPT group) or primary realignment (14 patients, PR group). Time to urethroplasty was defined as the period between injury and delayed urethroplasty. Clinical data regarding the status of urethral stenosis, urethroplasty procedure, and treatment outcome were analyzed. Results: The mean time to urethroplasty in the PR group was about three times that in the SPT group (133 months vs 47 months, p = 0.035). Fifty percent of the PR group (7 of 14) had a history of repeated urethrotomy and/or dilation before referral, a percentage significantly higher than that of the SPT group (20.4%, 10 of 49, p = 0.027). The percentage of patients having a false passage and/or iatrogenic scar was significantly higher in the PR group (42.9% vs 16.3%, p = 0.035), but there was no significant between-group difference in urethral stenosis length, operative time, operative blood loss, or the percentage of patients requiring inferior pubectomy and/or urethral rerouting. 2 Page 2 of 19
Conclusions: PR does not facilitate delayed urethroplasty, and patients who undergo PR are at high risk of having a more complicated stenosis and longer time to urethroplasty, presumably because of repeated transurethral procedures. Introduction Acute management of pelvic fracture urethral injury (PFUI) remains a controversial and difficult issue for urologists. There are two treatment options: the first is to place a suprapubic tube (SPT) and perform delayed urethroplasty for subsequently developed urethral stenosis, and the second is to perform early primary realignment (PR) either by gentle simple retrograde catheterization or with the use of a cystoscope 1-4. Realignment is used to repair the injury and prevent stenosis 5. It has a lower stenosis rate than SPT placement alone, with which stenosis formation is almost certain 5, 6. Even if scarring and subsequent stenosis formation occur, the delayed urethroplasty is easier because urethral continuity is already restored, the stenosis length is shorter than when PFUI is treated with SPT placement alone, and the posterior urethra and the deformity of the prostate are well aligned 7. Some authors, however, think that most patients treated by PR have their acute injury turned into an unstable chronic disease state that usually requires daily self-dilation, regular office dilations, or repeated transurethral procedures 6, 8. Moreover, repeating transurethral manipulations can delay definitive treatment and complicate it 8-10. In the present study, we compared the clinical courses of patients with PFUI who underwent delayed urethroplasty at our referral center according to the initial management strategies and investigated the impact of PR on the subsequent delayed urethroplasty. 3 Page 3 of 19
Patients and Methods Patient selection and evaluation of the urethral gap After obtaining approval of our institutional review board, we retrospectively reviewed the clinical course of 73 consecutive patients with history of PFUI who were referred from elsewhere after acute PFUI management and underwent delayed urethroplasty, by a single surgeon (AH), for resulting urethral stenosis during 2008 to 2015 at National Defense Medical College or affiliate institutes. Ten patients had a history of prior failed urethroplasty and were excluded from analysis, so a total of 63 patients were included in this study. For patients in whom a suprapubic tube (SPT) had not been placed and voided with intermittent dilation or urethrotomy and those in whom a urethral catheter was placed at initial referral, an SPT was placed for urethral rest and any urethral manipulation was ceased 11. As a result, an SPT was placed in all patients preoperatively. At least 3 months after injury or last urethral manipulation, the length of urethral stenosis and presence of false passage and iatrogenic scarring was evaluated on the up-and-down urethrogram and/or MRI. The disruption site (bulbomembranous urethra or proximal to the membranous urethra) was determined by both retrograde and antegrade endoscopy through the SPT tract.
Urethroplasty All urethroplasties were anastomotic urethroplasties performed in a stepwise fashion as described elsewhere 12. The bulbar urethra was divided at the obliterated segment and 4 Page 4 of 19
then mobilized distally. The proximal urethral end was identified by palpitation with a metallic sound (Van Buren urethral sound) inserted through the SPT tract. The covering fibrotic scar tissue was completely removed and 8 anastomotic 4-0 polydioxanone sutures were placed to reapproximate the urethral mucosa over a 16Fr catheter. If the proximal urethral end was not palpated or a tension-free anastomosis could not be achieved, corporal splitting and/or inferior pubectomy were used in steps. When adequate access to the membranous urethra and the apex of the prostate could not be provided by these steps, an abdominoperineal approach with supracrural rerouting was used. Use of the bulbar urethral mobilization with/without corporal splitting was categorized as a simple perineal approach, and inclusion of the further steps was categorized as an elaborate approach 12.
Analysis Patients were stratified into two groups (SPT group and PR group) based on the initial method of treatment (the one used within 2 weeks after injury) according to the information sent at the first referral. The SPT group included patients treated only with SPT placement followed by elective delayed urethroplasty, while patients in whom a urethral catheter was successfully inserted blindly or under endoscopy and stenosis subsequently occurred were assigned to the PR group. Patients in whom catheter placement had been attempted but failed were assigned to the SPT group. Analyzed data included clinical information such as stenosis length and the presence/absence of periurethral fistula, the type of urethroplasty required, time to urethroplasty (defined as 5 Page 5 of 19
the time between the injury and urethroplasty), prior history of transurethral procedures (urethral stenting, endosopic urethrotomy, and self- or office dilation), and treatment outcome. Patients were followed up postoperatively at 3, 6, and 12 months and annually thereafter by using questionnaires, uroflowmetry, and flexible cystoscopes. Success was defined as the ability to void without the need for further intervention and having a urethral lumen large enough for passage of a flexible cystoscope. Urinary continence and erectile function were evaluated 6 months postoperatively in 38 patients. Urinary incontinence was defined as the need for any protective pads, and erectile dysfunction was defined as a score less than 21 on the 5-item version of International Index of Erectile Function 13. All statistical analyses were performed by using the JMP 11 (SAS Institute Inc. Cary, NC, USA). Data are presented as means and standard errors (SE). The Student t-test was used to evaluate the relations between continuous data, and a chi-square test was used to assess the association between clinical parameters and the status of urethral stenosis. P-values less than 0.05 were considered to indicate statistical significance.
Results Comparison of patient characteristics The patient characteristic in both groups was summarized in Table 1. A total of 49 (77.8%) had SPT placement alone, and the remaining 14 (22.2%) underwent PR and had subsequent urethral stenosis. PR was attempted but failed in 12 (19.0%), and those patients were assigned to the SPT group. Of the PR group, a urethral catheter was 6 Page 6 of 19
inserted blindly in 3 (21.4%) and under endoscopy in 11 (78.6%). There were no significant between-group differences in mean patient age (p = 0.199), body mass index (p = 0.611), fraction of current smokers (p = 0.087), or fraction having history of obstructive pulmonary disease (p = 0.222). In the PR group the fraction having history of diabetes (2 of 14, 14.3%) was significantly larger than it was in the SPT group (none, 0%, p = 0.046). In the PR group the fraction of patients who could void with intermittent dilation or urethrotomy at the initial referral to our institute (6 of 14, 42.9%) was significantly larger than it was in SPT group (4 of 49, 8.2%, p = 0.005). The mean time to urethroplasty in the PR group was about three times longer than that in the SPT group (133.1 months vs. 47.0 months, p = 0.035). Seven of the patients in the PR group (50.0%) had a history of repeated transurethral procedures such as urethrotomy, dilation, and/or urethral stenting before referral for reconstruction, and this fraction was significantly larger than that in the SPT group (10 of 49, 20.4 %, p = 0.027). Of note, the mean disease duration in patients in the SPT group without history of any transurethral procedure was only 15 months.
Comparison of the urethral gap and operative outcome Table 2 shows the stenosis characteristics at urethroplasty and the surgical outcome in both groups. There was no significant between-group difference in the percentage of patients who had opened bladder neck (12.2% in the SPT group vs 14.3% in the PR group, p = 0.839), the percentage of patients whose urethra was disrupted distal to the external sphincter (63.3% in the SPT group vs 78.6% in the PR group, p = 0.284), or the 7 Page 7 of 19
length of urethral stenosis (21.8 mm in the SPT group vs 17.2 mm in the PR group, p = 0.134). False passage was found in 5 (7.9%) and de novo iatrogenic scarring was found in 9 (17.3%). The fraction having a false passage and/or iatrogenic scar was significantly higher in the PR group (8 of 49, 16.3%, in the SPT group vs 6 of 14, 42.9%, in the PR group, p = 0.035). Figure 1 shows two representative PR-group cases showing false passage and de novo iatrogenic scarring. When only the 46 patients who had no history of prior transurethral procedures were considered, the fraction of those having false passage and/or iatrogenic scarring was significantly larger in the PR group (2 of 7, 28.6%) than it was in the SPT group (none of 39, 0%, p = 0.021, Table 3). On the other hand, when only the other 17 patients who had history of prior repeated transurethral procedures were considered, there was no significant between-group difference in the fraction having false passage and/or iatrogenic scaring (8 of 10, 80%, in the SPT group vs 4 of 7, 57%, in the PR group, p = 0.593). Regarding operative outcome, there was no significant between-group difference in operative time (mean 251.9 minutes in the SPT group vs 262.2 minutes in the PR group, p = 0.727), blood loss (mean 327.5 ml in the SPT group vs 414.2 ml in the PR group, p = 0.471), or the percentage of patients that required an elaborated approach (51.0% in the SPT group vs 64.3% in the PR group, p = 0.379). The success rate in SPT group (91.8%, 45 of 49) was slightly higher than that in the PR group (85.7%, 12 of 14), but the difference was not statistically significant (p = 0.491). When only the 46 patients who had no history of prior transurethral treatment were considered, the success rate in the SPT group (94.9%, 37 of 39) was significantly higher than that in the PR group (71.4%, 5 of 7, p = 0.042, 8 Page 8 of 19
Table 3). On the other hand, when only the 17 patients who had history of prior repeated transurethral procedures were considered, there was no significant between-group difference in the success rate (80.0% 8 of 10, in the SPT group vs 100.0%, 7 of 7, in the PR group, p = 0.485). Of note, no false passage or iatrogenic scar was found in SPT-group patients without any transurethral procedures and delayed urethroplasty, and the success rate for those patients was 94.6%. Data regarding postoperative continence and erectile function was available for 38 patients, and there was no significant between-group difference in the percentage with postoperative incontinence (20.0% in the SPT group vs 25.0% in the PR group, p = 0.757) or with erectile dysfunction (76.7% in the SPT group vs 62.5% in the PR group, p = 0.418).
Comment Although recent PFUI treatment guidelines regarding the initial management list PR as an option for haemodynamically stable patients 1, 2, 4, there are no randomized controlled studies comparing PR and SPT placement. A recent meta-analysis confirmed that subsequent stenosis rate was significantly lower in the PR group and there was no significant difference between the two interventions with regards to erectile dysfunction or incontinence 5. PR decreases the risk of urethral stenosis by approximately 30%, but the price to be paid by the remaining 70% is to undergo repeated futile and harmful transurethral procedures before definitive treatment by delayed urethroplasty, suggesting that it is a double-edged sword 6. Reported PR procedures range widely from gentle Foley catheterization to 9 Page 9 of 19
realignment through an open cystostomy and include the use of catheter pull-through, interlocking sounds, and the sound-to-finger method 5. Regardless of the type, PR has the potential to cause significant additional morbidity by further damaging recently traumatized tissues and can make matters worse, since clinical experience reveals that PR makes straddle injuries of the bulbar urethra worse than they would be if treated only by SPT placement 14. The degree of urethral damage done by PR might also depend on the surgeon’s experience. A recent review demonstrated that the incidence of PFUI is much lower, 1.54%, than previously reported 15. Moreover, the incidence and severity of traffic and industrial accidents in developed countries is decreasing 16, the number of patients who undergo PR is limited even in Level 1 trauma hospitals in the US 10, and most urologists are therefore likely to be inexperienced in PR. Although PR recently gains popularity, Arora showed a case of severe complication of PR and raised an alarm that its widespread use is not advisable for everyone and SPT placement may still be the safer option for inexperienced surgeons. 17. We strongly agree that PR should be done in an optimal setting by an experienced physician if subsequent fibrosis of the surrounding tissue is to be avoided; otherwise, nothing other than SPT placement should be done 10. In addition to being associated with urethral damage occurring during catheter passage, PR is associated with long-term catheterization for completion of urethral continuity, which increases the risk of developing adverse events including de novo iatrogenic urethral stricture 6, 10. In our cohort, the percentage of patients with a complicated stricture accompanying false passage and/or iatrogenic scarring in the PR group (42.9%) was three times greater than that in the SPT group (16.3%). Although 10 Page 10 of 19
complicated stenosis can be due both to PR itself and to subsequent transurethral procedures, the percentage of patients with complicated stenosis in the PR group (28.6%) remained higher than that in the SPT group (0%) even when the patients who underwent subsequent transurethral procedures were excluded. One of the advantages of PR has been reported to be an earlier return to voiding 18. Most patients treated with PR certainly tend to maintain some degree of urethral patency and can void with weak stream after catheter removal, but it could trigger the introduction of numerous futile and harmful transurethral procedures needed to maintain urethral patency 8. In our cohort, the fraction of patients who could void with intermittent dilation in the PR group was significantly larger than that in the SPT group. Repeated transurethral procedures are associated with not only poor QOL but also increased risk of complicating stenosis and prolonging time to urethroplasty 6, 8, 19. Tausch et al. reported that most patients treated with PR who underwent multiple transurethral procedures showed signs of iatrogenic trauma—false passages, complexity at the injury site, and/or the development of synchronous stenosis—which was never seen in patients treated only by SPT placement 8. Analysis of our cohort, too, revealed that patients treated with PR underwent transurethral procedure more frequently and tended to have more complex stenosis than did those treated only by SPT placement. In addition, patients treated with PR were 5 times more likely to have a delay of more than 1 year before urethroplasty than were those who underwent only SPT placement 8. Johnsen also reported that the mean time to urethroplasty was significantly shorter in an SPT group (5.8 months) than it was in a PR group (14.6 months) 6. The same trend was 11 Page 11 of 19
also found in our cohort, but the time to urethroplasty was much longer than it was in other studies (47.0 months in our SPT group and 133.1 months in our PR group). In Japan, 27% of consultant urologists have no experience with surgical treatment for PFUI during their whole careers and only 5% have treated more than 11 patients 20. Although guidelines clearly discourage transurethral procedures because of their disappointing results 1, 2, 4, Japanese urologists tend to use them for as long as possible, even in cases with complete obstruction after SPT placement 20. Because most patients with PFUI are young (overall mean age: 39), delay in treatment not only leads to low QOL and difficulty getting a job and low QOL but may also negatively influence social productivity. Some patients treated with PR had not experienced symptomatic urethral obstruction, and obstruction was incidentally identified by their inability to pass a urethral catheter. Patients treated with PR should be followed up closely and in the event of stricture formation be referred to a reconstructive subspecialist promptly 8. PR has been reported to restore urethral continuity and facilitate urethroplasty. Koraitim recently analyzed 120 patients with PFUI who underwent delayed urethroplasty and reported that PR decreased the stenosis length and facilitated its delayed repair 7. However, our experience showed that PR did not facilitate urethroplasty in terms of stenosis length, required urethroplasty type, or operative time and blood loss and that there was no difference in postoperative continence or erectile function consistent with previous reports 6, 8. Instead, we felt that urethroplasty in patients treated with PR was difficult because the urethral mucosa was widely scarred, making the border between healthy and damaged urethra unclear, and that additional 12 Page 12 of 19
resection is required even the urethra is patent. Some investigators have found that PR also has a negative impact on the outcome of delayed urethroplasty 21, 22. Koraitim et al. reported that prior treatment does not affect the outcome after urethroplasty but by scarring and/or shortening the available anterior urethra may influence the choice of the surgical approach 23, 24. In our cohort, no significant difference of success rate was found in overall patients, but when only patients without transurethral procedures were considered, the success rate in the PR group was significantly lower than that in the SPT group, suggesting PR has negative impact on the success rate of urethroplasty. Our study has several limitations. Firstly, because our institute is a referral center, information regarding the percentage of patients who avoided stenosis formation after PR, the severity of urethral injury (complete or incomplete) at initial diagnosis, the reason for selecting PR or SPT placement in each patient (technical difficulty or patient instability), and the details of the methods of PR remain unknown. Secondly, the number of patients in the PR group was small compared with that in the SPT group. Thirdly, a clear comparison could not be made because the SPT group included patients with failed PR. Despite these limitations, we believe this study provides an important message to urologists treating PFUI. Trauma centers performing PR and urologists who take over follow-up care need to know that repeated endoscopic interventions seem to do more harm than good. We strongly believe that SPT placement and delayed urethroplasty remains the gold standard treatment for patients with PFUI.
Conclusions
13 Page 13 of 19
PR does not facilitate delayed urethroplasty, and patients who undergo PR and repeated transurethral procedures are at high risk of having a more complicated stenosis and longer disease duration. No matter the method of initial treatment chosen, patients with urethral stenosis following PFUI should be referred to reconstructive experts without delay rather than subjected to futile transurethral procedures.
Conflicts of Interest None declared.
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References
1.
Gomez RG, Mundy T, Dubey D, et al. SIU/ICUD consultation on urethral strictures: pelvic fracture urethral injuries. Urology. 2014;83:S48-58.
2.
Morey AF, Brandes S, Dugi DD, 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192:327-335.
3.
Bryk DJ, Zhao LC. Guideline of guidelines: A Review of Urologic Trauma Guidelines. BJU Int. 2015.
4.
Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67:925-929.
5.
Barrett K, Braga LH, Farrokhyar F, Davies TO. Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis. Urology. 2014;83:924-929.
6.
Johnsen NV, Dmochowski RR, Mock S, Reynolds WS, Milam DF, Kaufman MR. Primary endoscopic realignment of urethral disruption injuries: a double-edged sword? J Urol. 2015;194:1022-1026.
7.
Koraitim MM. Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology. 2012;79:912-915.
8.
Tausch TJ, Morey AF, Scott JF, Simhan J. Unintended negative consequences of primary endoscopic realignment for men with pelvic fracture urethral injuries. J Urol. 2014;192:1720-1724.
9.
Tausch TJ, Morey AF. The case against primary endoscopic realignment of pelvic fracture urethral injuries. Arab J Urol. 2015;13:13-16.
10.
Leddy LS, Vanni AJ, Wessells H, Voelzke BB. Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. J Urol. 2012;188:174-178.
11.
Terlecki RP, Steele MC, Valadez C, Morey AF. Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology. 2011;77:1477-1481.
12.
Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145:744-748.
15 Page 15 of 19
13.
Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822-830.
14.
Park S, McAninch JW. Straddle injuries to the bulbar urethra: management and outcomes in 78 patients. J Urol. 2004;171:722-725.
15.
Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. The Journal of trauma. 2009;67:1033-1039.
16.
Kulkarni SB, Barbagli G, Kulkarni JS, Romano G, Lazzeri M. Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique. The Journal of Urology. 2010;183:1049-1054.
17.
Arora R, John NT, Kumar S. Vesicourethral fistula after retrograde primary endoscopic realignment in posterior urethral injury. Urology. 2015;85:e1-2.
18.
Hadjizacharia P, Inaba K, Teixeira PG, Kokorowski P, Demetriades D, Best C. Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. The Journal of trauma. 2008;64:1443-1449; discussion 1449-1450.
19.
Lubahn JD, Zhao LC, Scott JF, et al. Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol. 2014;191:143-147.
20.
Kitahara S, Sato R, Yasuda K, Arai G, Nakai H, Okada H. Surgical treatment of urethral distraction defect associated with pelvic fracture: a nationwide survey in Japan. Int J Urol. 2008;15:621-624; quiz 624.
21.
Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol. 2007;177:1374-1377.
22.
Singh BP, Andankar MG, Swain SK, et al. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology. 2010;75:179-182.
23.
Koraitim MM. Predictors of surgical approach to repair pelvic fracture urethral distraction defects. J Urol. 2009;182:1435-1439.
24.
Koraitim MM, Kamel MI. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int. 2015;116:265-270. 16 Page 16 of 19
Figure legends Figure 1. Representative cases of complicated stenosis in patients who underwent PR and, thereafter, repeated transurethral procedures. Arrows indicate urethral stenosis caused by PFUI. Dotted arrows in the left panel indicate periurethral false passage and the one in the right panel indicates de novo iatrogenic spongiofibrosis.
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Table 1. Comparison of patients’ characteristics in the PR and SPT groups No. pts (%) Age (SE) Body mass index (kg/m2) (SE) No. of smokers (%) No. with chronic obstructive pulmonary disease (%) No. with diabetes (%) No. that void with intermittent dilation (%) Disease duration (SE) No. having repeated transurethral procedures
SPT 49 (77.8) 38 (2.3) 22.3 (0.5) 23 (46.9)
PR 14 (22.2) 44 (4.5) 22.9 (1.0) 3 (21.4)
p value
0 (0)
1 (7.1)
0.222
0 (0)
2 (14.3)
0.046
4 (8.2)
6 (42.9)
0.005
47.0 (18.8)
133.1 (35.3)
0.035
10 (20.4)
7 (50.0)
0.027
0.199 0.611 0.087
Table 2. Urethral stenosis status and urethroplasty outcome
No. pts (%) Months of follow up (SE) Stenosis length (mm) No. with opened bladder neck (%) No. with disruption distal to external sphincter (%) No. with false passage and/or iatrogenic scar Operative time (min) Mean blood loss (ml) No. successful (%) No. that required elaborate approach (%) No. that needed to use pads (%) * No. with IIEF-5 score < 21 (%) *
SPT
PR
49 (78) 28.6 (2.8) 21.8 (1.4) 6 (12.2)
14 (22) 25.9 (5.3) 17.2 (2.6) 2 (14.3)
p value 0.656 0.134 0.839
31 (63.3)
11 (78.6)
0.284
8 (16.3)
6 (42.9)
0.035
251.9 (12.9) 327.5 (51.9) 45 (91.8)
262.2 (26.6) 414.2 (107.5) 12 (85.7)
0.727 0.471 0.491
25 (51.0)
9 (64.3)
0.379
6 (20.0) 23 (76.7)
2 (25.0) 5 (62.5)
0.757 0.418
* n = 38
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Table 3. Comparison in patients without prior transurethral procedures
No. pts (%) Months to urethroplasty (SE) Stenosis length (mm) No. with false passage and/or iatrogenic scar Operative time (mins) Mean blood loss (ml) No. that required elaborate approach (%) No. successful (%)
p value
SPT
PR
39 (84.8) 15.8 (14.0) 21.9 (1.6)
7 (15.2) 97.1 (33.1) 17.3 (3.7)
0.028 0.246
0 (0.0)
2 (28.6)
0.021
246.6 (13.9) 296.4 (55.0)
287.2 (37.9) 574.8 (149.6)
0.321 0.088
19 (48.7)
5 (71.4 )
0.268
37 (94.9)
5 (71.4)
0.042
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