Management of Posterior Urethral Injuries

Educational Objectives

The goals of this program are to improve diagnosis and treatment of posterior urethral injuries. After hearing and assimilating this program, the clinician will be better able to:

1. Illustrate mechanisms of injury that commonly result in posterior urethral trauma.

2. Formulate an emergent assessment and management plan for a patient with known or suspected posterior urethral injury.

3. Use preoperative imaging findings to counsel a patient undergoing urethroplasty on planned surgical maneuvers and the likelihood of a positive outcome.

Summary

Etiology: traumatic posterior urethral strictures primarily due to pelvic fracture; most injuries complete tears; causes of strictures and trauma differ in industrial and developing countries; pedestrian or bicycle injuries more common in developing countries; motor vehicle accidents more common in industrialized nations, but severity decreasing due to seat belts and air bags; proportion of simple strictures 68% in industrialized and 14% in developing nations

Mechanisms of injury: 5% to 25% of patients with pelvic fracture have urethral injury; injuries less common in women because urethra shorter and well protected; 4 mechanisms of pelvic injury produce urethral injury; most common Malgaigne fracture with fractures anterior and posterior to acetabulum, with upward displacement of pubis, rupture of puboprostatic ligament, and shearing of urethra; other mechanisms — bilateral fracture of superior and inferior pubic rami, resulting in rupture of puboprostatic ligaments; diastasis of symphysis in “open book” pelvic fracture; direct injury to posterior urethra from bony spicule

Prognosis: degree of pubic diastasis predicts risk for urethral compromise; extreme force required to produce urethral trauma, so associated injuries common; some series report 70% to 80% of patients also have intra-abdominal injury; consider morbidity and mortality before intervening

Anatomy: although external sphincter historically considered site of injury, cadaveric studies found ≈70% had disruption distal to external sphincter, affecting continence and prognosis

Signs: hallmark sign blood at meatus; injury suggested by significant diastasis on pelvic radiograph; in women, vaginal bleeding and labial edema possible

Imaging: proper performance and interpretation of retrograde urethrography (RUG) important; grades in recent in European guidelines; grade 1 — stretch injury with continuity of urethra and no leak; grade 2 — contusion with blood at meatus; grade 3 — partial disruption; grade 4 — complete disruption; grade 5 — complete disruption with involvement of bladder neck, rectum, or vagina; normal RUG shows filling of pendulous and bulbous urethra and bladder, steeple sign at sphincter, and no extravasation; with grade 1 injury, urethra stretched but can still see continuity without extravasation; with partial disruption, contrast extravasation and proximal contrast filling into bladder visible; when disruption complete, no proximal contrast observed

Evaluation: conflicting data on how to manage patient in whom injury suspected but not confirmed, such as patient without blood at meatus or patient who has voided since injury; always reasonable to obtain RUG; may attempt one gentle passage of Foley catheter by experienced person; 2004 consensus statement on urethral trauma recommends avoiding catheter because placement may convert partial injury into complete injury, but small studies refute this; maintain high degree of suspicion because missed injuries may lead to extravasation of urine or blood, abscess, fistula, or necrotizing fasciitis (Fournier gangrene)

Management: consider immediate, delayed, and deferred interventions; treatment options — include immediate open repair; suprapubic (SP) tube only, with deferred treatment months later; SP tube with primary endoscopic realignment

Immediate open repair: avoid due to high rates of incontinence, impotence, failures, and possibility of releasing pelvic hematoma; immediate intervention indicated for injury to rectum or bladder neck, but perform urethral realignment only; do not concomitantly repair or anastomose urethra

Placement of SP tube: gold standard for posterior urethral injury; repair completed after 3 mo; disadvantage ≈100% rate of stricture formation; when placing, avoid pelvic hematoma; may perform mini-cystotomy or create cystotomy higher than normal under ultrasonographic guidance; avoids hematoma and mobilization of urethra and prostate; may decrease scarring, incontinence, and impotence; patient must have SP tube for 3 to 6 mo, then undergo urethroplasty

History of primary endoscopic realignment: early efforts to align ends of torn urethra used sound to sound, sound to finger, or antegrade and retrograde catheters; using traction or vest sutures to approximate ends compromised bladder neck; high rates of restricture, erectile dysfunction (ED), and incontinence; modern practice uses flexible scopes from above and below

Studies of primary realignment: comparison — of SP and deferred repair to endoscopic treatment; reported stricture rate ≈50% with endoscopic treatment, without increased incontinence or ED; study results skewed by inclusion of nonposterior injuries and use of weekly “self-hydrodilation” and self-dilation; large series (Elliott et al, 1997) — 57 patients with posterior injuries treated with primary realignment within 6 hr of injury; stricture rate 68%; 4 patients required urethroplasty; others treated with observation, direct visual internal urethrostomy (DVIU), or office dilation; potency rates similar to those observed with SP tube only; no patient required intervention for incontinence; study of 19 consecutive patients (Leddy et al 2012) — underwent realignment within 2 days using flexible scopes above and below; failure rate (defined as stricture) 78% at 2-yr follow-up; 4 patients had successful realignment; among 14 patients with failed realignment, 6 had subsequent DVIU, and procedure successful in 3; therefore, if 1 endoscopic intervention permitted after realignment, failure rate only 58%; all urethroplasties successful at 2-yr follow-up; potency rate similar to that of patients treated with SP tube; no incontinence reported and no additional complex repairs required

Timing of realignment: no consensus on when to perform; earlier intervention possibly better because inflammation less pronounced; however, timing dictated by stability of patient; avoid emergent realignment; instead, insert SP tube and repair later when operating room (OR) and surgical team available

Disadvantages of realignment: opponents cite higher failure rate of urethroplasty in patients with previous endoscopic or open urethral manipulation; success rate 90% in patients with SP tube and deferred repair vs 60% in patients with previous urethral manipulation; lower success rate in patients with previous intervention demonstrated in several series; possibly related to longer length of stricture (2.5 cm vs 2,0 cm) in patients with previous manipulation or compromised blood supply to urethra caused by manipulation; however, other studies find high success rates after urethroplasty, even in patients treated with realignment

Conclusions on primary realignment: primary realignment may save 30% to 50% of patients from urethroplasty; for those who need urethroplasty, realignment may make procedure easier; however, studies small and evaluated inhomogeneous populations; risk for seeding of pelvic hematoma means sterile environment needed for repair; increased failure rate of urethroplasty not confirmed in most recent series; close follow-up required after removal of catheter; when rescarring occurs, it happens soon after catheter removal, so follow symptoms and flow rates; final verdict on primary realignment unclear; 2004 consensus statement states SP tube standard of care, but recent guidelines make no definitive statement

Posterior urethoplasty: usually performed 3 to 5 mo after intervention; first repair has highest probability of success; determine length of defect and condition of bladder neck with RUG and voiding cystourethrogram (VCUG); if patient cannot void for VCUG, use magnetic resonance imaging (MRI); ultrasonography not helpful; MRI costly, so use only if patient cannot void; surgical approaches — perineal, abdominoperineal, or substitution urethroplasty; approach depends on severity and complexity of injury; most injuries amenable to commonly used perineal approach, and several maneuvers facilitate extra length to bridge anastomosis

Procedure: dissection — dissect urethra as distally as possible; avoid dissection beyond suspensory ligament to prevent chordee; transect urethra and create distally based flap supplied by retrograde flow from glans; compromise of flap possible in patients with previous urethral manipulation, anterior urethroplasty, hypospadias, or younger patient in whom retrograde flow inadequate; identify perineal scar using flexible scope from above, palpating scope in defect; when cutting through scar, avoid injury to rectum; anastomosis — identify proximal aspect with nasal speculum and cut to healthy mucosa, almost to verumontanum; place 6 to 8 anastomotic sutures with J-hook needle; maneuvers — required for defects >2.5 cm; separation of corporal bodies needed in 20% to 30% of cases; splitting avascular plane between corpora provides 1 to 1.5 cm of length; to gain another centimeter, perform inferior pubectomy; if additional length needed, perform supracrural rerouting; with these maneuvers, can bridge defects up to 7 to 8 cm

Outcomes: success rates 40% to 100%; success rates ≈90% when 1 postoperative endoscopic treatment included; success rates lower in patients with previous surgery or complex surgery; knowing length of defect informs preoperative counseling

Complications: continence — concerns about additional sphincter damage from repairs unfounded; although previously believed that postoperative continence depended entirely on bladder neck because of injury to sphincter, studies suggest urethra contributes to continence in almost half these patients; 3% to 8% experience mild stress incontinence, but most require no intervention; incontinence associated with previous bladder neck surgery such as transurethral resection of prostate, injury to bladder neck, or widely incompetent bladder neck; counsel patients with open bladder neck about possibility of incontinence; ED — probably due to injury itself, not to repair; occurs in 25% to 60% of patients; rate of ED similar after primary realignment and posterior urethroplasty; most patients respond to phosphodiesterase-5 inhibitor; fertility — posterior urethral injuries common in young men; in study of 14 patients, normal sperm count reported in 78%; ejaculation sometimes less forceful; evaluate patients who report change in ejaculate

Conclusions: maintain high suspicion for urethral trauma, based on mechanism of injury and imaging findings; initial management controversial; SP tube and deferred treatment still gold standard, but recent guidelines support endoscopic realignment; follow all patients after surgery; most strictures recur within 12 mo

Questions and Answers

Concern about seeding pelvic hematoma: moot point because patient receiving SP tube in any case; neither urologic nor orthopedic literature confirms risk of seeding

Success of primary realignment: if not successful after 1.5 to 2 hr of effort, try once more in 2 to 3 days; successful realignment reported up to 2 wk after injury

Long-term consequences of leaving prostate unattached to urethra: avoid prostatectomy in patients who develop prostatic hypertrophy or prostate cancer later in life

Readings

Chapple C et al: Consensus statement on urethral trauma. BJU Int 2004;93(9):1195-202; Elliott DS, Barrett DM: Long-term followup and evaluation of primary realignment of posterior urethral disruptions. J Urol 1997 Mar;157(3):814; Hadjizacharia P et al: Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. J Trauma 2008;64(6):1443-9; discussion 1449-50; Hayn MH et al: Does previous robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology 2010;76(5):1111-6; Hayn MH et al: The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2010;58(2):197-202; Hellenthal NJ et al: Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. J Urol 2010;184(1):87-91; Hellenthal NJ et al: Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium BJU Int. 2011;107(4):642-6; Johar RS et al: Complications after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2013 Jan 16 [Epub ahead of print]; Jordan GH et al: Reconstruction and management of posterior urethral and straddle injuries of the urethra. Urol Clin North Am 2006;33(1):97-109; Koraitim MM: Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999;161(5):1433-41; Koraitim MM et al: Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77(6):876-80; Leddy et al: Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. J Urol 2012 Jul;188(1):174 [Epub ahead of print]; Martin AD et al: Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months. BJU Int 2010;105(12):1706-9; Martínez-Piñeiro L et al: European Association of Urology. EAU guidelines on urethral trauma. Eur Urol 2010;57(5):791-803; Mmeje CO et al: Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy. Curr Urol Rep 2013;14(1):26-31; Mouraviev VB et al: The treatment of posterior urethral disruption associated with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty. J Urol 2005;173(3):873-6; Roghmann F et al: Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol 2013 Mar 4 [Epub ahead of print]; Smith AB et al: Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients. J Laparoendosc Adv Surg Tech A 2012;22(1):17-21; Whitson JM et al: Mechanism of continence after repair of posterior urethral disruption: evidence of rhabdosphincter activity. J Urol 2008;179(3):1035-9.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Borawski spoke at the Tenth Annual Landes Symposium: Advances in Urology, sponsored by the Division of Urology, University of North Carolina at Chapel Hill, and held on June 22-23, 2012, in Chapel Hill, NC.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR361001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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