Updated Outcomes of Early Endoscopic Realignment for Pelvic Fracture Urethral Injuries at a Level 1 Trauma Center

Lower urinary tract injuries in patients with pelvic fractures at a level 1 trauma center - an 11-year experience

BACKGROUND

Urological injuries can occur in patients with pelvic fractures. Treatment recommendations lack solid evidence and is often pragmatical. There is a continuous need to describe short- and long-term morbidity following lower urinary tract trauma.

OBJECTIVE

To describe incidence, diagnosis, treatment, and morbidity following lower urinary tract injuries in pelvic fractures.

PATIENTS AND METHODS

Retrospective study including patients with pelvic, including acetabular, fractures admitted to a Level I Trauma Centre covering 2.8 million citizens between 2009 and 2020. Outcome measurements comprised primary management, treatment trajectory, short- and long-term complications and outcomes.

RESULTS

A total of 39 (5%) patients with pelvic fractures had concomitant urethral and/or bladder injuries, and one patient with an acetabular fracture had a bladder injury. The management of urethral injuries varied vastly, and complete urethral ruptures were associated with severe short- and long-term complications. Only one patient with bladder injury experienced severe long-term complications.

CONCLUSIONS

Management of lower urinary tract injuries in patients with major pelvic fractures remains a major challenge. Special attention should be focused on urethral injuries where we uncovered an unsystematic treatment and follow-up even in a highly experienced centre, although this is also attributed to complicated multidisciplinary patient trajectories. There is a continuous need to reduce long-term complications following urethral trauma which should be addressed in multicenter studies.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury

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.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS)

OBJECTIVES

To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury.

METHODS

Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs. minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score.

RESULTS

There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (p< 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (p<0.001).

CONCLUSIONS

In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Temporal trends in the incidence of severe pelvic fracture urethral injuries in the United States from 1998 to 2014

OBJECT

To use a contemporary population-based cohort to investigate temporal trends in the national incidence of pelvic fracture urethral injuries (PFUIs) in the United States.

METHODS

Using the NIS (National Inpatient Sample), we identified patients with a severe PFUI by a combination of an ICD-9 diagnosis code for pelvic fracture (808.xx) and ICD-9 procedure code for suprapubic tube (57.17 or 57.18) from 1998 to 2014. We compared the annual rates of PFUIs and the annual rates of pelvic fractures alone.

RESULTS

An estimated total of 6052 ± 347 males with PFUIs were identified. The average age was 38.4 ± 0.5 years. 9.1% ± 0.8% of patients died while hospitalized. In the time frame studied, the rate of PFUI significantly decreased during from 532 patients in 1998 to 255 patients in 2014. Sensitivity analysis excluding patients with bladder repairs identified a similar trend. The annual rate of PFUI per 1000 pelvic fractures has also decreased from 14.6 ± 1.6 in 1998 to 6.5 ± 0.9 in 2014 (p = 0.001).

CONCLUSIONS

In this population level study, the number of severe PFUIs has decreased in the United States from 1998 to 2014, which coincides with the implementation and enforcement of seat belt and air bag regulations. Given the rarity of these cases, there is a strong need for collaborative efforts in research and teaching at tertiary care centers for reconstructive urology.

A Modified Endoscopic Primary Realignment of Severe Bulbar Urethral Injury

Purpose: Male urethral injury is a common urologic emergency in developing countries. Whether early or late treatment of urethral injuries is often multifactorial and controversial. The goal of this study is to determine whether early realignment can reduce postsurgical complications and evaluate the clinical feasibility of emergency endoscopic urethroplasty using single rigid ureteroscopy in the treatment of bulbar urethral severe injury. Patients and Methods: Between September 2013 and March 2019, 15 male adult patients (mean age 35 years; from 21 to 62 years) with severe bulbar urethral injury were enrolled into the current study. The patients mainly presented with dysuria or painful urination (15/15, 100%), urethral bleeding (13/15, 86.7%), and urinary retention (11/15, 73.3%). Six of them had swelling of perineal or scrotal soft tissue, while four had testicular contusion. No pelvic fracture was found in all cases with CT scanning of the pelvic cavity. The bulbar urethral at grade IV was confirmed to be completely ruptured in all cases by endoscopy during operation. The modified endoscopic primary realignment was performed. Results: This new urethral repair technique was effectively performed in all patients and none converted to open operation. Mean operation time was 42.3 ± 11.5 minutes (28-52 minutes) and the mean Foley catheter indwelling time was 34.5 ± 6.9 days (28-42 days). During a follow-up of 41.3 ± 22.8 months (12-64 months), mild urethral strictures (grade I) (19.7 ± 9.5 weeks, 10-27 weeks postsurgery) developed in 8 patients (53.3%) and then were all improved 2.1 ± 0.8 months (1.3-2.9 months) after periodic dilatations of the urethra (4-10 times). Erectile dysfunction (ED) occurred in three patients (20%) after surgery, who recovered from mild ED to normal by administration with oral sildenafil (100 mg, three times a week) for 12 weeks. The International Index of Erectile Function-5 (IIEF-5) score was significantly improved after surgery (M ± SD, 25 ± 3) compared with before (16.4 ± 3.5) (p < 0.05). No incontinence and other complications occurred in all cases. Conclusions: Early endoscopic realignment via suprapubic puncture cystostomy by single rigid ureteroscopy provides an effective, feasible, and safe procedure for severe bulbar urethral injury.

Treatment Discrepancy for Pelvic Fracture Patients With Urethral Injuries: A Survey of Orthopaedic and Urologic Surgeons

OBJECTIVES

In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI.

METHODS

An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making.

RESULTS

Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient.

CONCLUSIONS

There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury

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.

Risk of infectious complications in pelvic fracture urethral injury patients managed with internal fixation and suprapubic catheter placement

BACKGROUND

There exists significant controversy regarding the use of suprapubic tubes (SPT) in pelvic fracture urethral injury (PFUI) patients undergoing internal fixation (IF) as to the potential risk of infection. Using the National Trauma Data Bank, we sought to examine if placement of SPT in patients with traumatic urethral injuries undergoing IF of pelvic fractures increases the risks of infectious complications during the index hospitalization.

PATIENTS AND METHODS

Using International Classification of Disease, version 9 and Abbreviated Injury Scale codes, patients with PFUI were identified in the National Trauma Data Bank between 2002 and 2014. International Classification of Disease, version 9 codes were used to identify patients who underwent IF of pelvic fractures, as well as those who underwent SPT placement. Covariates analyzed included age, Injury Severity Score (ISS), diabetes, hypertension, coronary artery disease, obesity, smoking status, associated colorectal injuries, and pelvic angioembolization. Demographics, management and infectious complications were compared between IF patients who did or did not undergo SPT placement using χ and t tests. Poisson regression analysis was performed to identify independent predictors of infectious complications.

RESULTS

Six hundred ninety-six PFUI patients were identified. Two hundred four (29.3%) patients underwent IF during the index hospitalization, of which 35 underwent concomitant SPT placement during that same admission. There was no difference in likelihood of undergoing IF in patients with or without SPT (p = 0.36). Multivariate analysis revealed that only ISS (Relative risk [RR], 4.00; 95% confidence interval, 1.25-12.77) and smoking status (RR, 2.45; 95% confidence interval, 1.11-5.43) were significant predictors of infectious complications, while SPT placement was not.

CONCLUSION

Among patients with PFUI undergoing IF, SPT placement does not appear to increase the risk for acute infectious complications during the index hospitalization, while higher ISS and smoking are significantly associated. Further longitudinal studies are required to provide definitive recommendations regarding the long-term safety of SPT placement in this patient population.

LEVEL OF EVIDENCE

Prognostic, level IV.

Management of male pelvic fracture urethral injuries: Review and current topics

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.