|
|
|
| Management of complex and redo cases of pelvic fracture urethral injuries |
B. Kulkarni Sanjay,Surana Sandesh,J. Desai Devang,Orabi Hazem,Iyer Subramanian,Kulkarni Jyotsna,Dumawat Ajit,M. Joshi Pankaj( )
|
| Department of Reconstructive Urology, Kulkarni Reconstructive Urology Centre, Pune, India |
|
|
|
|
Abstract Objective s Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. Methods Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995-2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. Results Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. Conclusion The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.
|
|
Received: 31 December 2016
Published: 09 June 2018
|
|
|
|
|
MRI of pelvis with empty bladder (A) and with our protocol with full bladder and jelly in urethra (B). The left arrow means bulbar urethra; The right arrow means the injury is at the level of bulbo membranous junction.
|
| Year | Success rate of primary (n = 541) | Success rate of redo (n = 521) | | 1995-2013 | 81.00 | 77.00 | | 2014 | 84.65 | 85.07 | | 2015 | 86.59 | 74.28 | | 2016 | 90.25 | 80.20 | | Overall | 85.60 | 79.13 |
|
|
|
|
|
Steps of anastomotic urethroplasty. (A) Distal area shows normal tissue signifying that bulbar urethra was not mobilized in previous surgery until penoscrotal junction; (B) RGU MCU showing high bladder and posterior urethra-complex PFUI; (C) Mastoid retractor applied to retract bulbospongiosus muscle; (D) Finger passed between urethra and corpora in stretched penis to locate penoscrotal junction, which marks upper limit of bulbar mobilization; (E) Use of Babcock's forceps to lift bulbar urethra; (F) Dissection of bulb with finger in rectum finger in rectum; (G) Accurate transection at level of block to prevent urethral loss; (H) Retrograde bleeding; (I) Knife used to perform crural separation; (J) Preservation of dorsal vein; (K) Periosteal elevation using bent electrocautery tip; (L) Inferior pubectomy; (M) Membranous urethra is not spatulated. Mastoid retractor applied in reverse way to facilitate crural separation. Dorsal penile vein is seen retracted to left corpora; (N) Tension free bulbo membranous anastomosis. RGU, retrograde urethrography; MCU, micturating cysto urethrogram; PFUI, pelvic fracture urethral injuries.
|
|
|
|
|
|
Bulbar urethral necrosis. (A) RGU showing bulbar urethral necrosis; (B) RGU showing bulbar urethral stenosis; (C) Inner and outer circumcision for pedicled preputial flap; (D) Pedicled preputial flap based on dartos; (E) Preputial flap transposed to perineum; (F) Flap tubularised on a catheter; (G) Pedicled preputial flap based on dartos pedicle used as tubularised substitution urethroplasty; (H) BMG applied on scrotum in first stage; (I) BMG mobilized on midline scrotal incision and the oral mucosa flap is applied as dorsal onlay to the stenosed urethra; (J) RGU showing BMG flap in another patient where it was tubularised as substitution urethroplasty; (K) Sigmoid colon tubularised: Enterourethroplasty pedicle of prepucial flap; (L) RGU of a patient with enterourethroplasty. BMG, buccal mucosa graft; RGU, retrograde urethrography.
|
| Procedure | Number | Success rate | | Pedicled preputial tube | 37 | 82.40% | | Oral mucosa flap | 10 | 58.56% | | Pedicled prepuce as onlay augmentation with dorsal BMG | 15 | 89.12% | | Scrotal drop back | 5 | 33.33% | | Enterourethroplasty | 2 | 2/2 | | Forearm flap with micro vascular anastomosis | 3 | 3/3 | | Pedicled anterolateral thigh flap | 1 | 1/1 | | Dorsal BMG with ventral BMG on gracilis muscle transposed to perineum | 2 | 2/2 | | Total | 75 | 76.67% |
|
|
|
|
|
(A) Transpubic urethroplasty with omental wrap in a child with pelvic fracture urethral injuries (PFUI); (B) Step 4—Supracrural rerouting in a child with PFUI.
|
|
|
PFUI in girls and females. (A) MRI of a girl with vaginal and urethral stenosis and urine in vagina; (B) Posterior pubectomy in a girl with pelvic fracture urethral injuries (PFUI); (C) Distal urethra with forceps in vagina fistula after disconnection of urethra vaginal fistula; (D) Urethral anastomosis. Omentum was seen being held by the Babcock's forceps.
|
| Injury | Type of surgery | Outcome | | Urethral transection | Anastomotic urethroplasty | 5 successful,
2 failed | | Injury at the level of vaginal introitus with distal urethral stenosis | Meatotomy | Occasional dilatation |
|
|
|
|
|
Steps of urethroplasty in patients with double block at bulbo membranous urethra and bladder neck prostate junction. (A) MRI of a child with double block at bladder neck-prostate junction and prostato-Membranous junction. Prostate filled with semen appeared like a cyst; (B) Abdominal approach. Needle was inserted and Seminal fluid was aspirated to locate the sequestered prostate; (C) Needle inserted through perineum was seen coming exactly at membranous urethra seen through intraprostatic scopy; (D) Abdominal approach. Forceps showed base of prostate and suction was inserted at bladder neck; (E) Bulbo membranous anastomosis through perineum; (F) In preparation for prostate vesical anastomosis; (G) Follow-up RGU. RGU, retrograde urethrography.
|
|
|
Laparosocpic omentoplasty in patients with recto urethral fistula. (A) RGU showing recto urethral fistula; (B) Right angled clamp passed from rectum through the RUF. The fistula was closed; (C) Right angled clamp was passed from perineum in to the retroperitoneum space lateral to bladder as seen in simultaneous laparoscopy. The mobilised omentum was transposed to perineum laparoscopically; (D) Laparoscopic omentoplasty as interposition flap in RUF. RGU, retrograde urethrography; RUF, Recto urethral fistula.
|
|
|
(A) Open bladder neck in pelvic fracture urethral injuries (PFUI); (B) Combined anterior with posterior urethroplasty; (C) 3D CT reconstruction showing bone chip indenting the bladder neck; (C) and (D) 3D CT reconstruction showing bone chip indenting the bladder neck.
|
| No | Primary pathology | Anterior stricture site | Follow up | Type of urethroplasty | | 1 | PFUI | Panurethral | 72 months
Qmax18 mL/s | Panurethral with anastomotic step 1 | | 2 | PFUI | Iatrogenic injury at penoscrotal Junction | 62 months
Qmax 28 mL/s | Dorsal onlay BMG with anastomotic step 3 | | 3 | PFUI | Bulbar stricture | 58 months
Qmax 16 mL/s | Dorsal onlay BMG with anastomotic step 1 | | 4 | PFUI | Panurethral | 35 months
Qmax 31 mL/s | Panurethral with anastomotic step 3 | | 5 | PFUI | Panurethral stricture | 33 months
Qmax 10 mL/s
One DVIU
Two dilatations | Panurethral stricture with anastomotic step 3 | | 6 | PFUI | Fistula at penoscrotal junction | 12 months
Qmax 11 mL/s
One small fistula
Needed redo Urethroplasty | Ventral closure, dorsal graft and anastomotic step 2 | | 7 | PFUI | Complete block at penoscrotal junction | 4 months
Qmax 11 mL/s
Distal anastomotic narrowing requiring one dilatation | Anastomosis at penoscrotal junction, one side mobilization and step 2 at bulbo membranous junction |
|
|
|
| [1] |
D. Demetriades, M. Karaiskakis, K. Toutouzas, K. Alo, G. Velmahos, L. Chan , Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes, J Am Coll Surg, 195(2002), pp. 1-10.
doi: 10.1016/S1072-7515(02)01197-3
|
| [2] |
P.M. Joshi, D.J. Desai, D. Shah, D. Joshi, S.B. Kulkarni , Injury in pelvic fracture urethral injury is membranobulbar: fact or myth, Urology, 102(2017), pp. e9-10.
doi: 10.1016/j.urology.2017.01.004
pmid: 28088555
|
| [3] |
S.B. Kulkarni, P.M. Joshi, C. Hunter, S. Surana, W. Shahrour, F. Alhajeri , Complex posterior urethral injury, Arab J Urol, 13(2015), pp. 43-52.
doi: 10.1016/j.aju.2014.11.008
|
| [4] |
S. Kulkarni, G. Barbagli, J. Kulkarni, G. Romano, M. Lazzeri , Posterior urethral stricture after pelvic fracture urethral distraction defects in developing and developed countries, and choice of surgical technique, J Urol, 183(2010), pp. 1049-1054.
doi: 10.1016/j.juro.2009.11.045
pmid: 20092843
|
| [5] |
W.S. Kizer, N.A. Armenakas, S.B. Brandes, A.G. Cavalcanti, R.A. Santucci, A.F. Morey, Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting, J Urol , 177 ( 2007), pp. 1378-1381, discussion 1381-1382.
|
| [6] |
V. Krishnamoorthy, P.B. Joshi , Length of urethra in the Indian adult male population, Indian J Urol, 28(2012), pp. 297-299.
doi: 10.4103/0970-1591.102706
pmid: 63
|
| [7] |
T.S. Kohler, M. Yadven, A. Manvar, N. Liu, M. Monga, , The length of the male urethra, Int Braz J Urol 34 ( 2008), pp. 451-454, discussion 455-456.
doi: 10.1590/S1677-55382008000400007
pmid: 18778496
|
| [8] |
G. Barbagli , History and evolution of transpubic urethroplasty: a lesson for young urologists in training, Eur Urol, 52(2007), pp. 1290-1292.
doi: 10.1016/j.eururo.2007.07.001
pmid: 17630102
|
| [9] |
A.R. Mundy, D.E. Andrich , Entero-urethroplasty for the salvage of bulbo-membranous stricture disease or trauma, BJU Int, 105(2010), pp. 1716-1720.
doi: 10.1111/j.1464-410X.2009.09005.x
pmid: 19930173
|
| [10] |
R. Turner-Warwick , The principles of urethral reconstruction, C. Rob, R. Smith, W. Scott McDougal (Eds.), Rob and smith's operative surgery, urology, Butterworths, London(1986), pp. p480-519.
|
| [11] |
Y. Zhe, L. Yangqun, T. Yong, Z. Muxin, C. Wen, M. Ning , et al., The pedicled anterolateral thigh flap for penile reconstruction, Chin J Plast Surg, 11(2015), pp. 406-410.
pmid: 27055315
|
| [12] |
A. Chauhan, E. Sham, J. Chee , Microsurgical urethroplasty for complex bulbar urethral strictures using the radial forearm free flap prelaminated with buccal mucosa, J Reconstr Microsurg, 32(2016), pp. 378-385.
doi: 10.1055/s-0036-1571355
pmid: 26848566
|
| [13] |
D. Nikolavsky , Prelaminated gracilis flap with buccal mucosal graft for salvage of devastated urethra, Case Rep Urol, 2015 ( 2015), p. 490518.
doi: 10.1155/2015/490518
pmid: 4519531
|
| [14] |
B.J. Flynn, F.C. Delvecchio, G.D. Webster , Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years, J Urol, 170(2003), pp. 1877-1880.
doi: 10.1097/01.ju.0000091642.41368.f5
pmid: 14532797
|
| [15] |
T.B. Boone, W.T. Wilson, D.A. Husmann , Postpubertal genitourinary function following posterior urethral disruptions in children, J Urol, 148(1992), pp. 1232-1234.
doi: 10.1089/end.1992.6.377
pmid: 1404642
|
| [16] |
M.M. Koratim , Posttraumatic posterior urethral strictures in children: a 20-year experience, J Urol, 157(1997), pp. 641-645.
doi: 10.1016/S0022-5347(01)65239-X
pmid: 8996388
|
| [17] |
M.O. Perry, D.A. Husmann , Urethral injuries in female subjects following pelvic fractures, J Urol, 147(1992), pp. 139-143.
doi: 10.1089/end.1992.6.71
pmid: 1729508
|
| [18] |
P.C. Black, E.A. Miller, J.R. Porter, H. Wessells , Urethral and bladder neck injury associated with pelvic fracture in 25 female patients, J Urol, 175(2006), pp. 2140-2144.
doi: 10.1016/S0022-5347(06)00309-0
pmid: 16697821
|
| [19] |
A.R. Mundy, D.E. Andrich , Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management, BJU Int, 105(2010), pp. 1302-1308.
doi: 10.1111/j.1464-410X.2009.08970.x
pmid: 19874306
|
| [20] |
S.J. Hosseini, A. Kaviani, M. Jabbari, M.M. Hosseini , A. Haji-Mohammadmehdi-Arbab, N.R. Simaei, Diagnostic application of flexible cystoscope in pelvic fracture urethral distraction defects, J Urol, 3(2006), pp. 204-207.
|
| [21] |
M. Al-Ali, D. Kashmoula, I.J. Saoud , Experience with 30 posttraumatic recto urethral fistulas. Presentation of posterior transsphincteric anterior rectal wall advancement, J Urol, 158(1997), pp. 421-424.
doi: 10.1016/S0022-5347(01)64493-8
pmid: 9224315
|
| [22] |
Q. Fu, J. Zhang, Y.L. Sa, S.B. Jin, Y.M. Xu , Recurrence and complications after transperineal bulboprostatic anastomosis for posterior urethral strictures resulting from pelvic fracture: a retrospective study from a urethral referral centre, BJU Int, 112(2013), pp. E358-E363.
doi: 10.1111/bju.2013.112.issue-4
|
| [23] |
S.B. Kulkarni, G. Barbagli, P.M. Joshi, C. Hunter, W. Shahrour, J. Kulkarni , et al., Laparoscopic omentoplasty to support anastomotic urethroplasty in complex and redo pelvic fracture urethral defects, Urology, 85(2015), pp. 1200-1205.
doi: 10.1016/j.urology.2014.12.055
pmid: 25818909
|
| [24] |
D.E. Andrich, A.R. Mundy , The nature of urethral injury in cases of pelvic fracture urethral trauma, J Urol, 165(2001), pp. 1492-1495.
doi: 10.1016/S0022-5347(05)66334-3
|
| [25] |
C.E. Iselin, G.D. Webster , The significance of the open bladder neck associated with pelvic fracture urethral distraction defects, J Urol, 162(1999), pp. 347-351.
doi: 10.1016/S0022-5347(05)67928-1
pmid: 10647682
|
| [26] |
T. Deng, B. Liao, D. Luo, B. Liu, K. Wang, J. Liu , et al., Management for the anterior combined with posterior urethral stricture: a 9-year single centre experience, Int J Clin Exp Med, 8(2015), pp. 3912-3923.
pmid: 4443127
|
| [27] |
S. Kulkarni, J. Kulkarni, S. Surana, P.M. Joshi , Management of panurethral strictures, Urol Clin North Am., 44(2017), pp. 67-75
doi: 10.1016/j.ucl.2016.08.011
pmid: 27908373
|
| [1] |
Chen Shulian,Gao Rang,Li Hong,Wang Kunjie. Management of acquired rectourethral fistulas in adults[J]. Asian Journal of Urology, 2018, 5(3): 149-154. |
| [2] |
Cheng Li,Li Sen,Wang Zicheng,Huang Bingwei,Lin Jian. A brief review on anterior urethral strictures[J]. Asian Journal of Urology, 2018, 5(2): 88-93. |
|
|
|
|
