Transpubic Repair of the Severed Prostatomembranous Urethra

Vol. 10!, Afar Pn:nted 'in L~ ):L/l..

THE JOURNAL OF UROLOGY

Copyright© 1969 by The Williams & Wilkins Co.

TRAXSPUBIC REPAIR OF THE SEVERED PR0STATO';\lEl\1BRANOUS URETHRA HAAKON RAGDE

AND

GEORGE F. McINNES

From the Departinenls of Surgery and Urology, University of Washington School of Medicine, Seatllc, Washington; and the Department of Surgery, Medical College of Georgia, A.ugusta, Georgia

Injuries to the lmver urinary tract occur less frequently than other bodily injuries. However, when mortality and morbidity rates are viewed, the injuries are often grave in nature, demanding immediate treatment. A particularly pernicious injury is the severed prostatomembranous urethra that is often associated with fractures of the bony pelvis but may also result from penetrating and perforating injuries to the abdomen and perineum (fig. 1). Accepted principles of treatment are early re-establishment of urethral continuity, adequate drainage of the retropubic space and temporary urinary diversion. Urethral continuity is usually attained by a splinting urethral catheter or by suture anastomosis. Retropubic, 1 perinea!' and combined perinealsuprapubic3 approaches have been proposed for primary repairs, Thi~ paper reports a transpubic approach to the posterior urethra. The approach was adopted while treating injured civilians in South Vietnam and evolved from the want of a operative procedure wherein complete regional hemostasis could be rapidly secured, the duration of catheter drainage lessened and the degree of urethral scarring hopefully minimized. These criteria were deemed essential since 1) whole blood was scarce, 2) the Vietnamese nurses had a propensity for removing urethral catheters during the first few postoperative days despite instructions to the contrary and 3) disregarding promises to return to the hospital for followup, the Vietnamese patient would return 011ly when voiding became impossible, usually from extensive scarring. Accepted for publication March 15, 1968. Read at annual meeting of American Urological Association, :Miami Beach, Florida., May 13-16, 1968. 1 Carswell, vV. R.: Primary repair of complete rupture of the deep urethra. Aust. New Zeal.. J. Surg., 26: 308, 1957. 2 Young, H. H.: Treatment of complete rupture of the posterior urethra, recent or ancient, by anastomosis. J" Urol., 21: 417, 1929. 3 Seitzman, D. ]VI.: Repair of the severed membranous urethra by the combined approach. J. Urol., 89: 433, 1963.

335

PROC,;DURE

The operation is done through a midliue abdominal incision that extends to the base of the penis. Transection of the symphysis in young patients is readily accomplished with a knife; 11 Gigli saw or similar instrument may be in the older patient. The pubic bones are depa rated 8 to 10 cm. using a rib retractor (fig. The bladder is opened and a Foley cathet0r is passed per urethram and guided across the toru ends. Removal of the periurethral hernatoimt permits accurate and complete hemostasis, and mobilization of the prostate and vesic:al neck allows the urethra to be re-anastomosed without tension. The urine is diverted suprapubically, the retropubic area is drained and the bladder and abdominal incisions are closed. Re-approxi mation of the symphysis was not done in aur of our cases. CLINICAL EXPERIENCIG

This procedure was performed on 8 patient,., all of whom had suffered multiple injuries. The urethral lesions had resulted from metallic missiles in 4 cases and were secondary to fractured pelves from blunt trauma in 4 cases. Half the patients were less than 14 years old, and the time that had elapsed since injury varied from l hour to 2 days. One patient had a tear in the rectal. wall, a lesion which possibly would have been missed had the symphysis not been divided. In another patient, in whom the internal puclendal artery had been lacerated, rapid control of bleeding which had not been controlled by packing was permitted. The frequent claim that traction on an in dwelling Foley catheter will coapt the margius of the severed membranous urethra at the lime of the operation was not substantiated in any of our 8 patients. Defects from 1.5 to 4 cm. were. observed despite maximal traction (fig. Apposition was possible only after the veHical neck and prostate had been mobilized from their ligamentous moorings.

336

RAGDE AND MCINNES

FIG. 1. Drawing depicts typical severed prostatomembranous urethra.

Traction1

t

FIG. 2. Diagram depicts extent of urethral defect despite maximal tension on indwelling Foley catheter. Note retractor separating pubic bones. CASE REPORT

N. T., a 26-year-old male Vietnamese civilian, was admitted to the Dammg Civil Hospital approximately 12 hours after he was injured by a mortar blast. The patient complained of abdominal pain and inability to void. Physical examination disclosed a small jagged wound in the left buttock with a larger gaping wound in

the wing of the right ilium. The suprapubic area was markedly swollen and discolored and the abdomen was distended, tender and silent. A hematoma was apparent in the perineum and dried blood was present at the urethral meatus. A boggy mass was palpable in the region of the prostate on rectal examination and blood was present on the examining finger. A urethral catheter could not be passed into the bladder. Exploration of the peritoneal cavity revealed multiple small bowel lacerations, two of which were repaired by resection and anastomosis, and the remainder were closed with interrupted silk sutures. The bowel was decompressed through a gastrostomy tube. The left ischium and the wing of the right ilium were fractured. The bladder was high in the pelvis, its left wall was ecchymotic but intact and it contained clear urine. The pubic symphysis was transected and the bones were separated with a rib separator. The urethral defect was bridged with a 22F Foley catheter and the periurethral hematoma was evacuated. Several large venous bleeders were ligated, affording complete hemostasis. A laceration in the anterior rectal wall was debriclecl and closed with chromic catgut sutures and the fecal stream was diverted through a proximal colostomy. The urethra was completely severed just proximal to the triangular ligament. The ends were widely separated and maximal traction on the 30 cc bag Foley catheter failed to bring them into apposition, leaving a defect of approximately 2 cm. Apposition was only possible by mobilizing the vesical neck and prostate. Devitalized tissue, present in both urethral margins, was excised and the ends were anastomosecl by interrupted chromic catgut sutures. The urine was diverted by a suprapubic catheter and the retropubic area was drained through the perineum; the bladder and abdominal incisions were closed and the entrance and exit wounds were debrided. The urethral catheter was removed 10 clays postoperatively and, after the patient was observed to void without difficulty, the suprapubic tube and drains were removed. The wounds had healed well enough for the patient's discharge 25 clays postoperatively, at which time he was still voiding with ease. DISCUSSION

All patients had their catheters removed between 10 and 18 days postoperatively. Following

TRANSPUBIC REPAIR OF SEVERED PROSTATOMEJ\IBRANOUS URETHRA

removal they were able to em]Jty their bladders completely as determined by mea~urement of residual urine, although the urinary stream was judged as good i11 only 2 patient~. The other 6 patients initially exhibited an intcnnittent type of voiding pattern, but within 2 ,.wek~ they also had full and free voiding. The patients 1Yere follmvecl for the' length of their hospital stay which lasted from 25 days to 4 montb, varying with the extent and severity of the initial injury. At the time of discharge all patients emptied their bladclern rnrn]Jletely and hacl 110 complaints regarding the urinary tract. No ill-effects were observed from transecting the s_1·rn physis. Symphysiotomy is nothing 1w1Y; it has been US('C1 sporadically in obstetrical practice since it ,ms fir::;t. employed 1he French physician Sigault in 1777. 4 • 5 It has abo been used to Greig, D. S.: Symphysio1omy; a stndv based " Brit. Emp., 61: 192, 1954. 5 Ortiz-Perez, J. · culL forceps. Amer. 1053. 4

on 11 personal cases. J_ Obst. &

facilitate resection of prostatic 6 and rectaF cancers, urethral valves 8 and to control ma~sivl' bleeding associated with pelvic fractures." 8UThIMAHY

The use of syrnphysiotomy for repair of tlie severed pros ta tomembra11ou~ urethra permitt; rapid debrideme11t and re-anastomosis Ull(for conditions of complete hemostasis and excellen1 visualization of the urethra all(! the imclerl.1·ing, rectum. The early results with this procedme tll 8 patients arc encouraging. 6 vValker, G.: Trallspnbic removal of the pro~tate for carcinoma. Ann. Surg., 78: 795, Hl2:J_ 7 Wangensteen, 0. H. and Gilbertseri, Y. Results of snrgery for cancer of tbe colon and rectum at the University of :Vfinnesota :\Tedical Center 1940-1954. X ational Cancer lnsti tu i c JHonograph, 15: :325, 19(i4. 8 Gross, H.. E.: The Surgery of lnfancy aud Childhood: Its Principles and Techniques. Phil8 delphia: W. B. Saunders Co., 1953. 9 Spencer, F. C. aud Robinson, R. A .. Divisio11 of the pubis for massive hemorrhage from fractmes of the pelvis. Arch. Surg., 78: 535, Hl59,