Traumatic complete urethral disruption: the West Virginia experience.
Urethral disruption is an uncommon injury that primarily results from pelvic trauma. The incidence ranges from 2%-25%, and can be associated with significant morbidities such as urinary incontinence and erectile dysfunction. (1) Urethral disruption can be categorized into three classes. In type I, the urogenital diaphragm is dislocated and the membranous urethra is stretched; in type II, the membranous urethra is ruptured above the urogenital diaphragm at the apex of the prostate; and in type III, the membranous urethra is ruptured above and below the urogenital diaphragm, causing a complete disruption. (2)
Urethral disruption should be suspected in patients with a history of trauma and gross hematuria or blood at the urethral meatus, which is present in 91%-100% of cases. Rectal palpation of a high-riding prostate is also characteristic but not diagnostic. (3)
Traditionally, there have been several approaches to the management of urethral disruption, including aggressive intervention with immediate reconstruction. The currently established protocol advocates retrograde urethrography as the initial step, with Foley catheter placement at the presence of urethral injury. Failure of Foley catheter placement would then be an indication for a suprapubic catheter.
This retrospective review analyzes the current protocol and patient outcomes for the initial management of traumatic urethral disruption. The established protocol should be modified to minimize complications of subsequent urinary and erectile dysfunction.
Material and Methods
A retrospective chart review was performed from West Virginia University Hospital (WVUH). WVUH had 13 patients with urethral disruption from a 10 year retrospective review of approximately 17,000 patients first seen from January 1995-August 2004. Of those 13 patients determined to have urethral disruption from traumatic pelvic injuries, 6 were noted to have complete urethral disruption. Data on these 6 patients were then collected and analyzed regarding the mechanism of injury, initial management, and long-term sequelae.
Pelvic trauma occurred in 845 of the total 17,000 cases reviewed. Traumatic urethral disruption occurred in 13 of those cases, which resulted in a 1.5% incidence of urethral disruption in pelvic traumas. However, two other patients in the chart review were determined to have urethral disruptions without associated pelvic trauma. Therefore, traumatic urethral disruption occurred in approximately 0.1% of all traumas.
All 13 cases of urethral disruption were in males 20-80 years of age, with a mean age of 43 years. All of the cases were due to blunt trauma. Five (39%) patients had a Type I urethral injury, 2 (15%) had a Type II, and 6 (46%) had a Type III. Initial management for patients with a Type III injury, was either placement of a Foley catheter in only 2 or a suprapubic catheter in only 4. Endoscopic realignment was performed in 3 patients, and open urethroplasty in 3 patients.
The mean follow-up time was 16 months, with a range of 6-42 months. Full return of urinary function was noted in all 3 patients managed endoscopically, and in 1 patient managed with open urethroplasty. Erectile function was preserved in 2 of patients managed with endoscopic repair, and in none of the patients managed with open urethroplasty. The most common surgical urologic complication was traumatic urethral stricture.
Urethral disruption is a rare sequelae of pelvic trauma nationwide. The most common cause of urethral disruption is currently from motor vehicle collisions that result in blunt trauma. Historically, urethral injury was seen more commonly in falls or mining injuries (3). This may have resulted in an increased incidence of urethral disruption in WVUH before the escalation of motor vehicle use. Husmann and colleagues concluded in their study of pelvic fracture and urethral disruption that the nature of these injuries and quality of repairs were more indicative of outcome than the order of management. (4)
Conversely, other studies have shown that initial conservative management decreases future morbidities. Podesta and coworkers recommended a suprapubic cystostomy tube as initial management after a traumatic urethral disruption. They noted that patients in their study treated with urinary diversion and urethral realignment developed obliterative strictures, similar to the patients in WVUH. (1)
Koraitim also reported significantly higher rates of impotence among patients who underwent primary open urethroplasty compared with conservative management. (5) This finding was consistent with the patients in WVUH as well, since erectile function was not maintained in the patients who underwent open repair. Although conservative management has been shown to be beneficial, several challenges do exist, including hematomas, edema, tissue friability, and overall patient instability. As a result, delayed endoscopic procedures are typically not successful because of extensive fibrosis. (6)
Thus, the mainstay of therapy over the past 25 years of suprapubic cystostomy, followed by delayed open urethroplasty up to 3-4 months later, has not proved to be effective. Endoscopic realignment has, however, been shown to achieve early, non-invasive realignment that decreases the risks of stricture, erectile dysfunction, and incontinence. Additionally, it has not been shown to later preclude the success of a delayed urethroplasty after endoscopic failure. (7)
Therefore, our proposed protocol would implement the placement of a suprapubic cystostomy tube initially following urethral disruption, and then attempt endoscopic realignment within 72 hours. If unsuccessful, endoscopic realignment should again be attempted within 3 months. Failure of urethral realignment within 3 months time should then be an indication for open urethroplasty.
Type III urethral disruption is an uncommon injury that occurs primarily in male patients with pelvic trauma. Management should initially be conservative with a catheter placement in all cases. Urinary and erectile function are, subsequently, better preserved with non-surgical management. If conservative management is not feasible, endoscopic repair is the treatment of choice.
(1.) Podesta ML, Medel R, Castera R, Ruarte A. Immediate management of posterior urethral disruptions due to pelvic fracture: therapeutic alternatives. J Urol 1997 Apr;157(4):1444-8.
(2.) Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis: a new classification. J Urol 1977 Oct;118(4):575-80.
(3.) Koraitim M. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999 May;161(5):1433-41 (Review).
(4.) Husmann DA, Wilson WT, Boone TB, Allen TD. Prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty. J Urol 1990 Jul;144(1):76-8.
(5.) Koraitim M. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996 Oct;156(4):1288-91 (Review).
(6.) Cooperberg M, McAninch J, Alsikafi N, Elliott S. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25 year experience. J Urol 2007 Nov;178(5):2006-10.
(7.) Jepson B, Boullier J, Moore R, Parra R. Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up. Urology 1999 Jun;53(6):1205-10 (Review).
Can Talug, MD
Assistant Professor, Division of Urology, Department of Surgery, WVU, Morgantown
Elizabeth T. Brown, MD, MPH
Resident, LSU/Oshner Clinic, New Orleans, LA
Alison M. Wilson, MD
Associate Professor, Division of Trauma & Critical Care, Department of Surgery, WVU, Morgantown
Julio Davalos, MD
Clinical Assistant Professor, Division of Urology, Department of Surgery, WVU, Charleston
Stanley Zaslau, MD, MBA
Associate Professor, Division of Urology, Department of Surgery, WVU, Morgantown
Stanley J. Kandzari, MD
Professor, Division of Urology, Department of Surgery, WVU, Morgantown
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|Title Annotation:||Scientific Article|
|Author:||Talug, Can; Brown, Elizabeth T.; Wilson, Alison M.; Davalos, Julio; Zaslau, Stanley; Kandzari, Stanl|
|Publication:||West Virginia Medical Journal|
|Date:||Jan 1, 2010|
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