Pelvic fracture posterior urethral injury repaired by progressive perineal approach: A brief review of the literature
Lesiones de uretra posterior secundarias a fractura pélvica tratadas a través de abordaje perineal progresivo. Breve revisión de la literatura
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Fernández Fernández, J. Ángel, Tocuyo Campero, Y. E., Suárez Montero, V. T., & Pérez Medina, M. M. (2017). Pelvic fracture posterior urethral injury repaired by progressive perineal approach: A brief review of the literature. Journal of Medicine and Surgery Repertoire, 26(3), 131–137. Retrieved from https://revistas.fucsalud.edu.co/index.php/repertorio/article/view/43
Published:
Sep 1, 2017
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Review Articles
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Abstract
Objective: To evaluate the postoperative outcomes of our patients with posterior urethral traumatic rupture repaired by progressive perineal approach, and to conduct a brief review of the literature.
Materials and methods: The clinical records of 7 patients aged between 2 to 12 years with urethral injuries due to pelvic fracture produced between March 2005 and January 2017, were reviewed. A suprapubic cystostomy for urinary drainage was constructed in the 7 patients immediately after diagnosis; two of them had concomitant rectum injuries thus a Hartmann’s colostomy was also performed in them. The preliminary urologic appraisal for definite urethroplasty included a synchronous anterograde and retrograde cysto-urethrogram to determine separation of the urethral segments. The final selection of surgical procedure was delayed urethral repair by progressive perineal approach minimum 6 months after the trauma event.
Results: The mechanism of injury was, blunt trauma after being struck by a moving vehicle in 6 patients and a crash injury caused by an oil rocker in one patient. The urethral disruption was complete in all patients. Three patients developed surgical complications: 2 urethral strictures which improved with dilatation and one urethral-perineal fistula with spontaneous closure and no associated complications. All patients remain asymptomatic; no patient has required a redo urethroplasty.
Commentaries: Our findings through the implementation of this therapeutic approach are consistent with those reported in the literature.
Conclusions: Progressive perineal access allows performing an anastomotic urethroplasty with good clinical outcomes in most patients.
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References
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2. Koraitim M. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161:1433–41.
3. Alwaal A, Zaid UB, Blaschko SD, Harris CR, Gaither TW, McAninch JW, et al. The incidence, causes, mechanism, risk factors, classification, diagnosis of pelvic fracture urethral injury. Arab J Urol. 2015;13:2–6. Epub 2015/05/29.
4. Koraitim M, Marzouk M, Atta M, Orabi S. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996;77:876–80.
5. Koraitim M. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol. 1997;157:641–5.
6. Boone T, Wilson W, Husmann D. Postpubertal genitourinary function following posterior urethral disruptions in children. J Urol. 1992;148:1232–4.
7. Bond S, Gotschall C, Eichelberger M. Predictors of abdominal injury in children with pelvic fracture. J Trauma. 1991;31:1169–73.
8. Tarman G, Kaplan G, Lerman S, Mcaleer I, Losasso B. Lower genitourinary injury and pelvic fractures in pediatric patients. Urology. 2002;59:123–6.
9. Webster G. Urethral injuries. En: Whitfield HN, Hendry WF, Kirby RS, Duckett JW, editores. Textbook of genito-urinary surgery. 2. nd edition. Oxford: Blackwell Scientific; 1998. p. 1323–40.
10. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96. Epub 2009/07/30.
11. Mcaninch J, Santucci R. Genitourinary trauma. En: Walsh PC, Wein AJ, Vaughan ED Jr, Retik AB, editores. Campbell’sUrology. 8 ed. Philadelphia: WB Saunders Company; 2002. p. 3707–44.
12. Ranjan P, Ansari M, Singh M, Chipde S, Singh R, Kapoor R. Post- traumatic urethral strictures in children, what have we learned over the years? J Pediatr Urol. 2012;8:234–9.
13. Avanoglu A, Ulman I, Herek O, Ozok G, Gökdemir A. Posterior urethral injuries in children. Br J Urol. 1996;77:597–600.
14. Clark S, Prudencio R. Lower urinary tract injuries associated with pelvic fractures Diagnosis management. Surg Clin N Am. 1972;52:183–201.
15. Pichler R, Fritsch H, Skradski V, Horninger W, Schlenck B, Rehder P, et al. Diagnosis and management of pediatric urethral injuries. Urol Int. 2012;89:136–42. Epub 2012/03/22.
16. Webster G, Mathes G, Selli C. Prostatomembranous urethral injuries. A review of the literature and a rational approach to their management. J Urol. 1983;130:898–902.
17. Pritchett T, Shapiro R, Hardy B. Surgical management of traumatic posterior urethral strictures in children. Urology. 1993;42:59–62.
18. Webster G, Guralnick M. Reconstruction of posterior urethral disruption. UrolClin North Am. 2002;29:429–41.
19. Morey A, Mcaninch J. Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol. 1997;157:506–10.
20. Griebling T, Kreder K. Urethral reconstruction after pelvic fracture with urethral disruption: the gold standard. SeminUrol. 1995;13:45–55.
21. Ennemoser O, Colleselli K, Reissigl A, Poisel S, Janetschek G, Bartsch G. Posttraumatic posterior urethral stricture repair: anatomy, surgical approach and long-term results. J Urol. 1997;157:499–505.
22. Martinez-Pineiro L, Djakovic N, Plas E, Mor Y, Santucci RA, Serafetinidis E, et al. EAU Guidelines on Urethral Trauma. Eur Urol. 2010;57:791–803. Epub 2010/02/04.
23. Kulkarni S, Joshi P, Hunter C, Surana S, Shahrour W, Alhajeri F. Complex posterior urethral injury. Arab J Urol. 2015;13: 43–52.
24. Webster G, Goldwasser B. Perinealtranspubic repair: a technique for treating post-traumatic prostatomembranous urethral strictures. J Urol. 1986;135:278–9.
25. Webster G, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145:744–8.
26. Webster G, Peterson A. Simple perineal and elaborated perineal posterior urethroplasty. Arab J Urol. 2015;13:17–23.
27. Flynn B, Delvecchio F, Webster G. Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol. 2003;170:1877–80.
28. Kizer W, Armenahas N, Brandes S, Cavalcanti A, Santucci A, Morey A. Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol. 2007;177:1378–82.
29. Koraitim M. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005;173:135–9.
30. Aggarwal S, Sinha S, Kumar A, Pant N, Borkar N, Dhua A. Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures. J PediatrUrol. 2011;7:356–62.
31. Cooperberg M, Mcaninch J, Alsikafi N, Elliott S. Urethral reconstruction for traumatic posterior urethral disruption outcomes of a 25-year experience. J Urol. 2007;178:2006–10.
32. Onofre L, Leao J, Gomes A, Heinisch A, Leao F, Carnevale J. Pelvic fracture urethral distraction defects in children managed by anterior sagittal transanorectal approach a facilitating and safe access. J Pediatr Urol. 2011;7:349–55.
33. Subasi M, Arslan H, Necmioglu S, Onen A, Ozen S, Kava M. Long- term outcomes of conservatively treated paediatric pelvic fractures. Injury. 2004;35:771–81.
34. Mamdouh M, Koraitim M. Optimising the outcome after anastomotic posterior urethroplasty. Arab J Urol. 2015;13:27–31.
35. Koraitim M, Kamel M. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int. 2015;116:265–70.
36. Roehrborn C, Mcconnell J. Analysis of factors contributing to success or failure of one-stage urethroplasty for urethral stricture disease. J Urol. 1994;151:869–74.
37. Corriere J. 1-Stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year follow up. J Urol. 2001;165:404–7.
38. Shenfeld O, Kiselgorf D, Gofrit O. The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol. 2003;169:2173–6.
39. Koraitim M. Predicting the risk of erectile dysfunction after pelvic fracture urethral injury in children. J Urol. 2014;192:519–23.
40. Onen A, Öztürk H, Kaya M, OtU S. Long-term outcome of posterior urethral rupture in boys: A comparison of different surgical modalities. Urology. 2005;65:1202–7.
41. Abdalla M. Posterior sagittal pararectal approach with rectal mobilization for repair of rectourethral fistula: an alternative approach. Urology. 2009;73:1110–4.
42. Helmy T, Sarhan O, Dawaba M, Wadie B. Urethrorectal fistula repair in children: urologic perspective. J Trauma. 2010;69:1300–3.
2. Koraitim M. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161:1433–41.
3. Alwaal A, Zaid UB, Blaschko SD, Harris CR, Gaither TW, McAninch JW, et al. The incidence, causes, mechanism, risk factors, classification, diagnosis of pelvic fracture urethral injury. Arab J Urol. 2015;13:2–6. Epub 2015/05/29.
4. Koraitim M, Marzouk M, Atta M, Orabi S. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996;77:876–80.
5. Koraitim M. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol. 1997;157:641–5.
6. Boone T, Wilson W, Husmann D. Postpubertal genitourinary function following posterior urethral disruptions in children. J Urol. 1992;148:1232–4.
7. Bond S, Gotschall C, Eichelberger M. Predictors of abdominal injury in children with pelvic fracture. J Trauma. 1991;31:1169–73.
8. Tarman G, Kaplan G, Lerman S, Mcaleer I, Losasso B. Lower genitourinary injury and pelvic fractures in pediatric patients. Urology. 2002;59:123–6.
9. Webster G. Urethral injuries. En: Whitfield HN, Hendry WF, Kirby RS, Duckett JW, editores. Textbook of genito-urinary surgery. 2. nd edition. Oxford: Blackwell Scientific; 1998. p. 1323–40.
10. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96. Epub 2009/07/30.
11. Mcaninch J, Santucci R. Genitourinary trauma. En: Walsh PC, Wein AJ, Vaughan ED Jr, Retik AB, editores. Campbell’sUrology. 8 ed. Philadelphia: WB Saunders Company; 2002. p. 3707–44.
12. Ranjan P, Ansari M, Singh M, Chipde S, Singh R, Kapoor R. Post- traumatic urethral strictures in children, what have we learned over the years? J Pediatr Urol. 2012;8:234–9.
13. Avanoglu A, Ulman I, Herek O, Ozok G, Gökdemir A. Posterior urethral injuries in children. Br J Urol. 1996;77:597–600.
14. Clark S, Prudencio R. Lower urinary tract injuries associated with pelvic fractures Diagnosis management. Surg Clin N Am. 1972;52:183–201.
15. Pichler R, Fritsch H, Skradski V, Horninger W, Schlenck B, Rehder P, et al. Diagnosis and management of pediatric urethral injuries. Urol Int. 2012;89:136–42. Epub 2012/03/22.
16. Webster G, Mathes G, Selli C. Prostatomembranous urethral injuries. A review of the literature and a rational approach to their management. J Urol. 1983;130:898–902.
17. Pritchett T, Shapiro R, Hardy B. Surgical management of traumatic posterior urethral strictures in children. Urology. 1993;42:59–62.
18. Webster G, Guralnick M. Reconstruction of posterior urethral disruption. UrolClin North Am. 2002;29:429–41.
19. Morey A, Mcaninch J. Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol. 1997;157:506–10.
20. Griebling T, Kreder K. Urethral reconstruction after pelvic fracture with urethral disruption: the gold standard. SeminUrol. 1995;13:45–55.
21. Ennemoser O, Colleselli K, Reissigl A, Poisel S, Janetschek G, Bartsch G. Posttraumatic posterior urethral stricture repair: anatomy, surgical approach and long-term results. J Urol. 1997;157:499–505.
22. Martinez-Pineiro L, Djakovic N, Plas E, Mor Y, Santucci RA, Serafetinidis E, et al. EAU Guidelines on Urethral Trauma. Eur Urol. 2010;57:791–803. Epub 2010/02/04.
23. Kulkarni S, Joshi P, Hunter C, Surana S, Shahrour W, Alhajeri F. Complex posterior urethral injury. Arab J Urol. 2015;13: 43–52.
24. Webster G, Goldwasser B. Perinealtranspubic repair: a technique for treating post-traumatic prostatomembranous urethral strictures. J Urol. 1986;135:278–9.
25. Webster G, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145:744–8.
26. Webster G, Peterson A. Simple perineal and elaborated perineal posterior urethroplasty. Arab J Urol. 2015;13:17–23.
27. Flynn B, Delvecchio F, Webster G. Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol. 2003;170:1877–80.
28. Kizer W, Armenahas N, Brandes S, Cavalcanti A, Santucci A, Morey A. Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol. 2007;177:1378–82.
29. Koraitim M. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005;173:135–9.
30. Aggarwal S, Sinha S, Kumar A, Pant N, Borkar N, Dhua A. Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures. J PediatrUrol. 2011;7:356–62.
31. Cooperberg M, Mcaninch J, Alsikafi N, Elliott S. Urethral reconstruction for traumatic posterior urethral disruption outcomes of a 25-year experience. J Urol. 2007;178:2006–10.
32. Onofre L, Leao J, Gomes A, Heinisch A, Leao F, Carnevale J. Pelvic fracture urethral distraction defects in children managed by anterior sagittal transanorectal approach a facilitating and safe access. J Pediatr Urol. 2011;7:349–55.
33. Subasi M, Arslan H, Necmioglu S, Onen A, Ozen S, Kava M. Long- term outcomes of conservatively treated paediatric pelvic fractures. Injury. 2004;35:771–81.
34. Mamdouh M, Koraitim M. Optimising the outcome after anastomotic posterior urethroplasty. Arab J Urol. 2015;13:27–31.
35. Koraitim M, Kamel M. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int. 2015;116:265–70.
36. Roehrborn C, Mcconnell J. Analysis of factors contributing to success or failure of one-stage urethroplasty for urethral stricture disease. J Urol. 1994;151:869–74.
37. Corriere J. 1-Stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year follow up. J Urol. 2001;165:404–7.
38. Shenfeld O, Kiselgorf D, Gofrit O. The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol. 2003;169:2173–6.
39. Koraitim M. Predicting the risk of erectile dysfunction after pelvic fracture urethral injury in children. J Urol. 2014;192:519–23.
40. Onen A, Öztürk H, Kaya M, OtU S. Long-term outcome of posterior urethral rupture in boys: A comparison of different surgical modalities. Urology. 2005;65:1202–7.
41. Abdalla M. Posterior sagittal pararectal approach with rectal mobilization for repair of rectourethral fistula: an alternative approach. Urology. 2009;73:1110–4.
42. Helmy T, Sarhan O, Dawaba M, Wadie B. Urethrorectal fistula repair in children: urologic perspective. J Trauma. 2010;69:1300–3.