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A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury. J Trauma Acute Care Surg 2023; 94:344-349. [PMID: 36121280 DOI: 10.1097/ta.0000000000003774] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Ma Y, Jian Z, Zhou L, Luo D, Jin X, Xiang L, Li H, Wang K. A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis. World J Urol 2021; 39:4227-4234. [PMID: 34146123 DOI: 10.1007/s00345-021-03764-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/11/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations. MATERIALS AND METHODS Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression. RESULTS Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%. CONCLUSIONS PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.
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Affiliation(s)
- Yucheng Ma
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Zhongyu Jian
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Liang Zhou
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Deyi Luo
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Xi Jin
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Liyuan Xiang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Hong Li
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China
| | - Kunjie Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, People's Republic of China.
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Johnsen NV, Moses RA, Elliott SP, Vanni AJ, Baradaran N, Greear G, Smith TG, Granieri MA, Alsikafi NF, Erickson BA, Myers JB, Breyer BN, Buckley JC, Zhao LC, Voelzke BB. Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury. World J Urol 2019; 38:1073-1079. [PMID: 31144093 DOI: 10.1007/s00345-019-02824-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/25/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success. METHODS Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated. RESULTS Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure. CONCLUSIONS Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.
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Affiliation(s)
- Niels Vass Johnsen
- Departments of Urology, University of Washington, Seattle, WA, USA. .,Harborview Medical Center, Box 359868, 325 Ninth Ave, Seattle, WA, 98104, USA.
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Nima Baradaran
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | - Bryan B Voelzke
- Departments of Urology, University of Washington, Seattle, WA, USA
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Horiguchi A. Management of male pelvic fracture urethral injuries: Review and current topics. Int J Urol 2019; 26:596-607. [PMID: 30895658 DOI: 10.1111/iju.13947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/22/2019] [Indexed: 12/25/2022]
Abstract
Pelvic fractures from high-energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
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Ma L, Ma L, Chen Y, Jiang Y, Su Q, Wang Q, Zhu Y. A cost minimization analysis comparing minimally-invasive with open reduction surgical techniques for pelvic ring fracture. Exp Ther Med 2019; 17:1802-1812. [PMID: 30783452 PMCID: PMC6364252 DOI: 10.3892/etm.2019.7151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/14/2018] [Indexed: 12/24/2022] Open
Abstract
The aim of the present study was to compare the in-hospital direct medical costs of patients with pelvic fracture treated with minimally invasive surgery (MIS) or open reduction and internal fixation (ORIF). A retrospective, single-center, cohort, and comparative study was performed. Administrative information and clinical results, in addition to cost data, were collected and analyzed. A cost minimization analysis method was used to evaluate the costs of two different surgical techniques. A total of 128 patients diagnosed with pelvic fracture were included in this study; 62 were treated with MIS and 66 underwent ORIF. No significant difference was observed between the 2 groups in terms of patients' clinical baseline characteristics. The operative time, length of incision, intra-operative blood loss, and post-operative length of stay in the MIS group were significantly different compared with those in the ORIF group. The cost-minimization analysis demonstrated that the cost effectiveness of MIS was better than ORIF as the MIS was associated with a significantly lower total in-hospital direct medical cost ($8,900 vs. $5,786, P=0.032), compared with ORIF. The cost-minimization analysis demonstrated that for similar clinical baseline characteristics as well as outcomes, there were differences in direct hospitalization cost of two surgical techniques, and MIS had a lower cost on average than ORIF.
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Affiliation(s)
- Liang Ma
- School of Public Health, Shanghai Jiao Tong University, Shanghai 200025, P.R. China.,Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
| | - Lei Ma
- Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
| | - Yu Chen
- Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
| | - Yifeng Jiang
- Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
| | - Qiang Su
- School of Economics and Management, Tongji University, Shanghai 200092, P.R. China
| | - Qian Wang
- Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
| | - Yanhong Zhu
- Department of Scientific Research Management, Shanghai General Hospital, Shanghai 200080, P.R. China
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Dixon AN, Webb JC, Wenzel JL, Wolf JS, Osterberg EC. Current management of pelvic fracture urethral injuries: to realign or not? Transl Androl Urol 2018; 7:593-602. [PMID: 30211049 PMCID: PMC6127541 DOI: 10.21037/tau.2018.01.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The acute management of pelvic fracture urethral injuries (PFUIs) remains a controversial topic. Currently, suprapubic tube (SPT) placement with delayed repair or primary realignment (PR) represents the strategies used to treat patients. While many will advocate the use of one technique over the other, the 2014 American Urological Association (AUA) Guidelines give providers the option for the management PFUI. Current literature evaluates these two interventions, focusing on the incidence of re-stricture formation, erectile dysfunction, and urinary incontinence. Here we perform a comprehensive review of the current management for PFUI, as well as, discuss the limitations of the studies and need for more prospective studies on this debated topic.
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Affiliation(s)
- Ashley N Dixon
- Dell Medical School at The University of Texas, Austin, TX, USA
| | - Jack C Webb
- Dell Medical School at The University of Texas, Austin, TX, USA
| | | | - J Stuart Wolf
- Dell Medical School at The University of Texas, Austin, TX, USA
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Bhatt NR, Merchant R, Davis NF, Leonard M, O'Daly BJ, Manecksha RP, Quinlan JF. Incidence and immediate management of genitourinary injuries in pelvic and acetabular trauma: a 10-year retrospective study. BJU Int 2018; 122:126-132. [DOI: 10.1111/bju.14161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Rajiv Merchant
- Department of Trauma and Orthopaedics; Tallaght Hospital; Dublin Ireland
| | - Niall F. Davis
- Department of Urology; Tallaght Hospital; Dublin Ireland
| | - Michael Leonard
- Department of Trauma and Orthopaedics; Tallaght Hospital; Dublin Ireland
| | - Brendan J. O'Daly
- Department of Trauma and Orthopaedics; Tallaght Hospital; Dublin Ireland
| | - Rustom P. Manecksha
- Department of Urology; Tallaght Hospital; Dublin Ireland
- Department of Surgery; Trinity College; Dublin Ireland
| | - John F. Quinlan
- Department of Trauma and Orthopaedics; Tallaght Hospital; Dublin Ireland
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