- Email: [email protected]
Traumatic Rupture of the Supramembranous Urethra
Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE SUPRAMEMBRANOUS URETHRA P. 0. CRASSWELLER, G. A. FARROW, C. J. ROBSON, J. L. RUSSELL
AND
V. COLAPINTO
From the Department of Urology, University of Toronto, Toronto General Hospital, Toronto Western Hospital and St. Michael's Hospital, Toronto, Ontario, Canada
ABSTRACT
We reviewed 38 patients treated by an immediate realignment of the urethra after a traumatic rupture by urethrography, panendoscopy and clinical assessment. Of these 38 patients 19 have not required urethral dilatation for 4 years or more and 26 for 2 years or more, thus accomplishing with 1 operation satisfactory urinary tract function without stricture. We believe that an immediate repair offers the best results to patients with minimum surgical procedures insofar as the formation of strictures is concerned. Evaluation of the interference with potency will have to await further study. The violent disruption of a fibroelastic tube the caliber of the male urethra and its associated vessels and nerves involves a seemingly inevitable risk of imperfect function in the future - stricture, impotency or incontinence. Classically, this injury has been treated by an early realignment with an open operation on the urethra over a stent, with or without attempts to replace the prostate and to fix it to the urogenital diaphragm and protected by suprapubic cystotomy with drainage of the space of Retzius. New therapeutic proposals involving suprapubic bladder drainage alone, as immediate treatment, with late urethral repair give testimony to the lack of universal satisfaction with the classical method. 1 · 2 It is pertinent, therefore, to examine the alternatives and to develop a method of therapy that offers the best chance to obtain the desired objectives continence, potency and absence of morbidity from stricture with a minimum number of operative procedures. Determining continence will be the extent of damage to the urogenital diaphragm and bladder neck. Preservation of the bladder neck integrity permits continence no matter what damage has occurred to the distal sphincter, although voluntary interruption of micturition may be impossible. If the injury spared the bladder neck it is fundamental that treatment does not compromise it. Stricture formation will be influenced by the extent of injury to the urethra, the degree to which surgical restoration of continuity can be achieved and, possibly, the interval the stent is left indwelling. Jackson and Williams noted that patients with incomplete injuries stented for short intervals (10 days) had as high a rate of stricture formation as patients with complete ruptures stented longer. 3 Inevitably, a stricture will be present when no immediate approximation is attempted and this is equally true for the completely severed urethra and the stretched but intact supramembranous segment, which leads to a sigmoid conformation as the apex of the prostate settles back to its normal position. Potency will be influenced entirely by the degree of damage to vessels and nerves, excluding cases of psychogenic impotence that are not uncommon after a serious injury. The Leriche syndrome provides good evidence of the effect of vascular deficiency on potency. Thus, injuries to the pudental arteries or their branches to the bulb, cavernous bodies and deep penile artery can affect erectile potential. The accompanying pudendal nerves supply sensation to the glans and muscular branches to the bulbocavernosus and ischiocavernosus muscles and can affect erectile activity when injured. The Accepted for publication February 11, 1977. Study was made possible by the cooperation and financial support of the Workmen's Compensation Board of Ontario. 770
pelvic nerves, proceeding to their targets via the paraprostatic plexus, penetrate the urogenital diaphragm by 2 pathways: 1) in contact with the urethra to supply the bulb and crus and 2) branches pass beneath the pubic arch, remote from the urethra, to reach the corpora cavernosa and spongiosum. 4 It would seem inevitable that a completely torn urethra must result in disruption of the periurethral nervi erigentes to the bulb, and since impotence is not universal with the injury it is evident that other pathways and mechanisms are available to achieve erection. Since various types of pelvic fractures can occur in trauma cases damage to the neurovascular supply will be variable. The butterfly type fracture probably results in a higher incidence of injury to the pudendal vessels and nerves bilaterally, and hence a higher incidence of impotence (see figure). Todd's analysis tends to validate this observation. 5 With bilateral pubic ramus fractures 11 of 17 patients were impotent, as opposed to 1 of 7 patients when only a single pubic ramus fracture or symphysis pubis separation occurred. The type of investigation of the injury, such as passage of a catheter, and the type of treatment also may be implicated since such methods may cause further injury to any of the neurovascular structures involved in erection. To satisfy ourselves on these points we reviewed 42 of 63 patients treated by various surgeons in 3 hospitals. Of these 63 patients 14 have been lost to followup and 7 have died of associated injuries. Of the remaining 42 patients 38 were treated by immediate realignment and 4 by suprapubic cystotomy alone. Alignment was accomplished by an open suprapubic exploration with transvesical and per-urethral manipulations to achieve Foley catheter bridging of the defect, usually with debridement and drainage of the retropubic space. All patients were reviewed by panendoscopy and urethrography. Of the 38 patients 26 (approximately 70 per cent) have not needed urethral dilatations for at least 2 years and 19 (50 per cent) have gone 4 years or longer without a dilatation. Although this is not a guarantee of freedom from future stricture, with normal urethrograms and normal appearance by panendoscopy it seems unlikely that future morbidity will occur. Twelve patients (32 per cent) have undergone or will require urethroplasty. If this procedure is compared to the method proposed by Johanson, as reported and popularized by Morehouse and associates, 2 one finds that of the 131 cases described and treated initially by suprapubic cystotomy alone 131 have had the stricture inherent in the method and have undergone a 2stage urethroplasty to achieve a stricture-free state. Fifteen of these patients required revision of the second stage procedure (table 2). Since the long-term results of urethroplasty by
TRAUMATIC RUPTURE OF SUPRAMEMBRANOUS URETHRA
TlJ
Pudenda! vessels within Alcock's canal (dotted line) are at risk bilaterally with butterfly fragment fracture TABLE
1.
Method and result of therapy for42 patients with traumatic rupture of the urethra No. Cases Cystotomy and urethroplasty Immediate realignment: No dilatations required for 10 yrs. No dilatations required for 8 yrs. No dilatations required for 6 yrs. No dilatations required for 4 yrs. No dilatations required for 2 yrs. Dilatations at intervals of 1 yr. Dilatations at intervals of 6 mos. Required urethroplasty
TABLE
4 38 8
4 3 4
7 1 2
9
2. Operations required to achieve stricture-free state No. Operations
No. Cases Johanson* Morehouse and associates2 Current series
2
3
4
0 0
105
15
11
0 0
11
0
38
29
0
7
2
120
* Cited by Morehouse and associates.
2
any of the various inlay techniques remain unsettled it is µv'"'""c that further surgery will be required for some in that group. Whitehead and Morales had 6 failures in 32 patients so 3 of whom failed because of recurrent stricture." On the other hand, Blandy and associates had 21 patients so treated who had no recurrent strictures after 3 years of followup. 7 It seems clear then that to produce a good result insofar as stricture is concerned immediate realignment over a stent is the initial procedure of choice. A review of the literature indicated that about 50 per cent of the victims of this injury have some degree of impotence, with total impotence being present in about 30 per cent. 8 Our own results are somewhat better, with 14 of the 42 patients (33 cent) having some degree of impotence and 5 (12 per suffering total loss. The incidence of impotence in the experience of Johanson, and of Morehouse and associates with bladder drainage and late repair as the method of
treatment gives pause for thought. Only 4 (approximately 3 per cent) of 120 patients in Johanson's series and none of 11 in the series of Morehouse and associates suffered loss of potency. If continued experience reveals that this low incidence will be maintained then modification of the method of immediate repair will be mandatory, especially in young and sexually active men. The significant difference in approach of Johanson, More· house and associates and Mitchell is the total avoidance of the area of injury either by investigative manipulation or immediate operative management by suprapubic cystotomy alone, lessening greatly the chances of further damage to the neurovascular pathways concerned with potency. However, the results insofar as stricture formation is concerned make irn.mediate realignment attractive. It is further attractive to speculate that by repositioning the prostate by transvesical manipulation only and of the defect by a guided catheter avoiding totally exposure, debridement and manipulation within the depths of the retropubic space, comparable results in regard to potency could be obtained using the method of immediate realignment. REFERENCES
1. Mitchell, J. P.: Injuries to the urethra. Brit. J. Urol., 40: 649, 1968. 2. Morehouse, D. D., Belitsky, P. and MacKinnon, K. J.: Rupture of the posterior urethra. J. Urol., HJ7: 255, 1972. 3. Jackson, D. H. and Williams, J. L.: Urethral injury: a retrospective study. Brit. J. Urol., 46: 665, 1974. 4. Basmajian, J. V.: Grant's Method of Anatomy, 8th ed. Baltimore: The Williams & Wilkins Co., 1971. 5. Todd, I. A.: The genitourinary complications of blunt pelvic trauma. Canad. J. Surg., 7: 43, 1964. 6. Whitehead, E. D. and Morales, P.A.: Complications ofurethroplasty for stricture. J. Urol., 107: 412, 1972. 7. Blandy, J. P., Singh, M., Notley, R. G. and Tresidder, G. C.: The results and complications of scrotal-flap urethroplasty foi stricture. Brit. J. Urol., 43: 52, 1971. · 8. Gibson, G. R.: Impotence following fractured pelvis and rnptured urethra. Brit. J. Urol., 42: 86, 1970.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE SUPRAMEMBRANOUS URETHRA P. 0. CRASSWELLER, G. A. FARROW, C. J. ROBSON, J. L. RUSSELL
AND
V. COLAPINTO
From the Department of Urology, University of Toronto, Toronto General Hospital, Toronto Western Hospital and St. Michael's Hospital, Toronto, Ontario, Canada
ABSTRACT
We reviewed 38 patients treated by an immediate realignment of the urethra after a traumatic rupture by urethrography, panendoscopy and clinical assessment. Of these 38 patients 19 have not required urethral dilatation for 4 years or more and 26 for 2 years or more, thus accomplishing with 1 operation satisfactory urinary tract function without stricture. We believe that an immediate repair offers the best results to patients with minimum surgical procedures insofar as the formation of strictures is concerned. Evaluation of the interference with potency will have to await further study. The violent disruption of a fibroelastic tube the caliber of the male urethra and its associated vessels and nerves involves a seemingly inevitable risk of imperfect function in the future - stricture, impotency or incontinence. Classically, this injury has been treated by an early realignment with an open operation on the urethra over a stent, with or without attempts to replace the prostate and to fix it to the urogenital diaphragm and protected by suprapubic cystotomy with drainage of the space of Retzius. New therapeutic proposals involving suprapubic bladder drainage alone, as immediate treatment, with late urethral repair give testimony to the lack of universal satisfaction with the classical method. 1 · 2 It is pertinent, therefore, to examine the alternatives and to develop a method of therapy that offers the best chance to obtain the desired objectives continence, potency and absence of morbidity from stricture with a minimum number of operative procedures. Determining continence will be the extent of damage to the urogenital diaphragm and bladder neck. Preservation of the bladder neck integrity permits continence no matter what damage has occurred to the distal sphincter, although voluntary interruption of micturition may be impossible. If the injury spared the bladder neck it is fundamental that treatment does not compromise it. Stricture formation will be influenced by the extent of injury to the urethra, the degree to which surgical restoration of continuity can be achieved and, possibly, the interval the stent is left indwelling. Jackson and Williams noted that patients with incomplete injuries stented for short intervals (10 days) had as high a rate of stricture formation as patients with complete ruptures stented longer. 3 Inevitably, a stricture will be present when no immediate approximation is attempted and this is equally true for the completely severed urethra and the stretched but intact supramembranous segment, which leads to a sigmoid conformation as the apex of the prostate settles back to its normal position. Potency will be influenced entirely by the degree of damage to vessels and nerves, excluding cases of psychogenic impotence that are not uncommon after a serious injury. The Leriche syndrome provides good evidence of the effect of vascular deficiency on potency. Thus, injuries to the pudental arteries or their branches to the bulb, cavernous bodies and deep penile artery can affect erectile potential. The accompanying pudendal nerves supply sensation to the glans and muscular branches to the bulbocavernosus and ischiocavernosus muscles and can affect erectile activity when injured. The Accepted for publication February 11, 1977. Study was made possible by the cooperation and financial support of the Workmen's Compensation Board of Ontario. 770
pelvic nerves, proceeding to their targets via the paraprostatic plexus, penetrate the urogenital diaphragm by 2 pathways: 1) in contact with the urethra to supply the bulb and crus and 2) branches pass beneath the pubic arch, remote from the urethra, to reach the corpora cavernosa and spongiosum. 4 It would seem inevitable that a completely torn urethra must result in disruption of the periurethral nervi erigentes to the bulb, and since impotence is not universal with the injury it is evident that other pathways and mechanisms are available to achieve erection. Since various types of pelvic fractures can occur in trauma cases damage to the neurovascular supply will be variable. The butterfly type fracture probably results in a higher incidence of injury to the pudendal vessels and nerves bilaterally, and hence a higher incidence of impotence (see figure). Todd's analysis tends to validate this observation. 5 With bilateral pubic ramus fractures 11 of 17 patients were impotent, as opposed to 1 of 7 patients when only a single pubic ramus fracture or symphysis pubis separation occurred. The type of investigation of the injury, such as passage of a catheter, and the type of treatment also may be implicated since such methods may cause further injury to any of the neurovascular structures involved in erection. To satisfy ourselves on these points we reviewed 42 of 63 patients treated by various surgeons in 3 hospitals. Of these 63 patients 14 have been lost to followup and 7 have died of associated injuries. Of the remaining 42 patients 38 were treated by immediate realignment and 4 by suprapubic cystotomy alone. Alignment was accomplished by an open suprapubic exploration with transvesical and per-urethral manipulations to achieve Foley catheter bridging of the defect, usually with debridement and drainage of the retropubic space. All patients were reviewed by panendoscopy and urethrography. Of the 38 patients 26 (approximately 70 per cent) have not needed urethral dilatations for at least 2 years and 19 (50 per cent) have gone 4 years or longer without a dilatation. Although this is not a guarantee of freedom from future stricture, with normal urethrograms and normal appearance by panendoscopy it seems unlikely that future morbidity will occur. Twelve patients (32 per cent) have undergone or will require urethroplasty. If this procedure is compared to the method proposed by Johanson, as reported and popularized by Morehouse and associates, 2 one finds that of the 131 cases described and treated initially by suprapubic cystotomy alone 131 have had the stricture inherent in the method and have undergone a 2stage urethroplasty to achieve a stricture-free state. Fifteen of these patients required revision of the second stage procedure (table 2). Since the long-term results of urethroplasty by
TRAUMATIC RUPTURE OF SUPRAMEMBRANOUS URETHRA
TlJ
Pudenda! vessels within Alcock's canal (dotted line) are at risk bilaterally with butterfly fragment fracture TABLE
1.
Method and result of therapy for42 patients with traumatic rupture of the urethra No. Cases Cystotomy and urethroplasty Immediate realignment: No dilatations required for 10 yrs. No dilatations required for 8 yrs. No dilatations required for 6 yrs. No dilatations required for 4 yrs. No dilatations required for 2 yrs. Dilatations at intervals of 1 yr. Dilatations at intervals of 6 mos. Required urethroplasty
TABLE
4 38 8
4 3 4
7 1 2
9
2. Operations required to achieve stricture-free state No. Operations
No. Cases Johanson* Morehouse and associates2 Current series
2
3
4
0 0
105
15
11
0 0
11
0
38
29
0
7
2
120
* Cited by Morehouse and associates.
2
any of the various inlay techniques remain unsettled it is µv'"'""c that further surgery will be required for some in that group. Whitehead and Morales had 6 failures in 32 patients so 3 of whom failed because of recurrent stricture." On the other hand, Blandy and associates had 21 patients so treated who had no recurrent strictures after 3 years of followup. 7 It seems clear then that to produce a good result insofar as stricture is concerned immediate realignment over a stent is the initial procedure of choice. A review of the literature indicated that about 50 per cent of the victims of this injury have some degree of impotence, with total impotence being present in about 30 per cent. 8 Our own results are somewhat better, with 14 of the 42 patients (33 cent) having some degree of impotence and 5 (12 per suffering total loss. The incidence of impotence in the experience of Johanson, and of Morehouse and associates with bladder drainage and late repair as the method of
treatment gives pause for thought. Only 4 (approximately 3 per cent) of 120 patients in Johanson's series and none of 11 in the series of Morehouse and associates suffered loss of potency. If continued experience reveals that this low incidence will be maintained then modification of the method of immediate repair will be mandatory, especially in young and sexually active men. The significant difference in approach of Johanson, More· house and associates and Mitchell is the total avoidance of the area of injury either by investigative manipulation or immediate operative management by suprapubic cystotomy alone, lessening greatly the chances of further damage to the neurovascular pathways concerned with potency. However, the results insofar as stricture formation is concerned make irn.mediate realignment attractive. It is further attractive to speculate that by repositioning the prostate by transvesical manipulation only and of the defect by a guided catheter avoiding totally exposure, debridement and manipulation within the depths of the retropubic space, comparable results in regard to potency could be obtained using the method of immediate realignment. REFERENCES
1. Mitchell, J. P.: Injuries to the urethra. Brit. J. Urol., 40: 649, 1968. 2. Morehouse, D. D., Belitsky, P. and MacKinnon, K. J.: Rupture of the posterior urethra. J. Urol., HJ7: 255, 1972. 3. Jackson, D. H. and Williams, J. L.: Urethral injury: a retrospective study. Brit. J. Urol., 46: 665, 1974. 4. Basmajian, J. V.: Grant's Method of Anatomy, 8th ed. Baltimore: The Williams & Wilkins Co., 1971. 5. Todd, I. A.: The genitourinary complications of blunt pelvic trauma. Canad. J. Surg., 7: 43, 1964. 6. Whitehead, E. D. and Morales, P.A.: Complications ofurethroplasty for stricture. J. Urol., 107: 412, 1972. 7. Blandy, J. P., Singh, M., Notley, R. G. and Tresidder, G. C.: The results and complications of scrotal-flap urethroplasty foi stricture. Brit. J. Urol., 43: 52, 1971. · 8. Gibson, G. R.: Impotence following fractured pelvis and rnptured urethra. Brit. J. Urol., 42: 86, 1970.