Postpubertal genitourinary function following posterior urethral disruptions in children

Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial

OBJECTIVE

To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children.

METHODS

This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding the development of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding.

RESULTS

Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002).

CONCLUSION

Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

Traumatic Posterior Urethral Strictures in Children and Adolescents

Background: Management of partial or complete traumatic urethral disruptions of the posterior urethra in children and adolescents, secondary to pelvic fracture poses a challenge. Controversy exists as to the correct acute treatment of posterior urethral injuries and delayed management of PFPUDDs. We reviewed the urological literature related to the treatment of traumatic posterior urethral injuries and delayed repair of these distraction defects in children and adolescents. Material and Methods: There are few long-term outcomes studies of patients who underwent PFPUDDs repairs in childhood; most reports included few cases with short follow up. We excluded studies in which the cohort of patients was heterogeneous in terms of stricture disease, etiology and location. Results: Primary cystostomy and delayed urethroplasty is the traditional management for PFPUIs. Immediate repair is rarely possible to perform. Realignment of posterior urethral rupture in children is indicated in special situations: (a) concomitant bladder neck tears, (b) associated rectal lacerations, (c) long disruptions of the urethral ends. Before delayed reconstruction ascending urethrography and micturating cystourethrogram along with retrograde and antegrade urethroscopy define site and length of the urethral gap. However, the most accurate evaluation of the characteristics of the distraction defect is made when surgical exposure reveals the complexity of the ruptured urethra. Partial ruptures may be managed with urethral stenting or suprapubic cystostomy, which may result in a patent urethra or a short stricture treated by optical urethrotomy. The gold standard treatment for PFPUDDs in children is deferred excision of pelvic fibrosis and bulbo-prostatic tension-free anastomosis, provided a healthy anterior urethra is present. Timing of delayed repair is at 3 to 4 months after trauma. Some urologists prefer either the perineal access or the transpubic approach to restore urethral continuity in children with PFPUDDs. Substitution urethroplasties are used in children with PFPUDDs, when anastomotic repair can't be achieved due to severe damage of the bulbar urethra. Conclusion: As evidenced in this review the progressive perineo-abdominal partial transpubic anastomotic repair has advantages over the isolated perineal anastomotic approach in patients with "complex" PFPUDD. This approach provides wider exposure and facilitates reconstruction of long or complicated posterior urethral distraction defects.

Management of complex and redo cases of pelvic fracture urethral injuries

Objectives

Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios.

Methods

Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995–2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included.

Results

Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia.

Conclusion

The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Pelvic-fracture urethral injury in children

OBJECTIVE

To review paediatric posterior urethral injuries and the current potential management options; because urethral injury due to pelvic fracture in children is rare and has a low incidence, the management of this type of trauma and its complications remains controversial.

METHODS

We reviewed previous reports identified by searching the PubMed Medline electronic database for clinically relevant articles published in the past 25 years. The search was limited to the keywords 'pediatric', 'pelvic fracture', 'urethral injury', 'stricture', 'trauma' and 'reconstruction'.

RESULTS

Most paediatric urethral injuries are a result of pelvic fractures after high-impact blunt trauma. After the diagnosis, immediate bladder drainage via a suprapubic cystotomy, or urethral realignment, are the initial management options, except for a possible immediate primary repair in girls. The common complications of pelvic fracture-associated urethral injury include urethral stricture formation, incontinence and erectile dysfunction. Excellent results can be achieved with delayed urethroplasty for pelvic fracture-associated urethral injuries.

CONCLUSION

Traumatic injury to the paediatric urethra is rare and calls for an immediate diagnosis and management. These devastating injuries have a high complication rate and therefore a close follow-up is warranted to assure adequate delayed repair by a reconstructive urologist.

The incidence, causes, mechanism, risk factors, classification, and diagnosis of pelvic fracture urethral injury

Background

Pelvic fracture urethral injury (PFUI) is an uncommon but potentially devastating result of pelvic fracture. It ranges in severity based on the cause and the mechanism of injury.

Methods

We reviewed previous reports to identify the incidence, causes, mechanisms of injury and risk factors of PFUI. In addition, we reviewed the current classification systems and diagnostic methods that have been described to assess the severity of PFUI, to identify optimal management strategies and evaluate outcomes.

Results

PFUI occurs more commonly in men, but is more likely to be severe in children. The most common cause is motor vehicle collisions, and the mechanism is typically a ligament rupture at the attachment to the urethra. There is no reliable classification system to differentiate partial and complete PFUI. Retrograde urethrography is the standard imaging method but it has its limitations.

Conclusions

Despite many reports describing this injury, there is still a need to further clarify the incidence, aetiology and mechanism of injury to better determine optimal management strategies and evaluate outcomes. Consensus in the diagnosis of PFUI is lacking, and outcomes of primary realignment and the role of flexible cystoscopy as a diagnostic method are still to be determined.

Complex posterior urethral injury

Objective

To assess treatment strategies for seven different scenarios for treating complex pelvic fracture urethral injury (PFUI), categorised as repeat surgery for PFUI, ischaemic bulbar urethral necrosis (BUN), repair in boys and girls aged ⩽12 years, in patients with a recto-urethral fistula, or bladder neck incontinence, or with a double block at the bulbomembranous urethra and bladder neck/prostate region.

Patients and methods

We retrospectively reviewed the success rates and surgical procedures of these seven complex scenarios in the repair of PFUI at our institution from 2000 to 2013.

Results

In all, >550 PFUI procedures were performed at our centre, and 308 of these patients were classified as having a complex PFUI, with 225 patients available for follow-up. The overall success rates were 81% and 77% for primary and repeat procedures respectively. The overall success rate of those with BUN was 76%, using various methods of novel surgical techniques. Boys aged ⩽12 years with PFUI required a transpubic/abdominal approach 31% of the time, compared to 9% in adults. Young girls with PFUI also required a transpubic/abdominal urethroplasty, with a success rate of 66%. In patients with a recto-urethral fistula the success rate was 90% with attention to proper surgical principles, including a three-stage procedure and appropriate interposition. The treatment of bladder neck incontinence associated with the tear-drop deformity gave a continence rate of 66%. Children with a double block at the bulbomembranous urethra and at the bladder neck-prostate junction were all continent after a one-stage transpubic/abdominal procedure.

Conclusion

An understanding of complex pelvic fractures and their appropriate management can provide successful outcomes.

The spectrum of pelvic fracture urethral injuries and posterior urethroplasty in an Italian high-volume centre, from 1980 to 2013

OBJECTIVE

To describe the emergency and delayed treatment of patients with pelvic fracture urethral injuries (PFUI) presenting to an Italian high-volume centre.

PATIENTS AND METHODS

In a retrospective, observational study we evaluated the spectrum of PFUI and posterior urethroplasty in an Italian high-volume centre, from 1980 to 2013. Patients requiring emergency treatment for PFUI and delayed treatment for pelvic fracture urethral defects (PFUD) were included. Patients with incomplete clinical records were excluded from the study. Descriptive statistical methods were applied.

RESULTS

In all, 159 male patients (median age 35 years) were included in the study. A traffic accident was the most frequent (42.8%) cause of PFUI, and accidents at work were reported as the cause of trauma in 34% of patients. Agricultural accidents decreased from 24.4% to 6.2% over the course of the survey. A suprapubic cystostomy was the most frequent (49%) emergency treatment in patients with PFUI. The use of surgical realignment decreased from 31.7% to 6.2%, and endoscopic realignment increased from 9.7% to 35.3%. A bulbo-prostatic anastomosis was the most frequent (62.9%) delayed treatment in patients with PFUD. The use of the Badenoch pull-through decreased from 19.5% to 2.6%, and endoscopic holmium laser urethrotomy increased from 4.9% to 32.7%.

CONCLUSIONS

The spectrum of PFUI and subsequent treatment of PFUD has changed greatly over the last 10 years at our centre. These changes involved patient age, aetiology, emergency and delayed treatments, and were found to be related to changes in the economy and lifestyle of the Italian patients.

Predicting risk of erectile dysfunction after pelvic fracture urethral injury in children

PURPOSE

We sought to determine the incidence of erectile dysfunction following pelvic fracture urethral injuries in children, and to identify the related causes and risk factors.

MATERIALS AND METHODS

All consecutive children who had undergone repair of a pelvic fracture urethral injury between 1980 and 2010 were invited to participate in the study. All responders were queried after a median of 13 years (range 3 to 28) following trauma to assess erectile function using the erectile function domain of the International Index of Erectile Function. Patients who had erectile dysfunction underwent penile duplex ultrasonography. Medical records and imaging studies were reviewed with a focus on 4 variables, ie pattern of pelvic fracture, pubic diastasis, prostatic displacement and urethral gap length. Univariate and multivariate analyses were used to identify parameters predictive of erectile dysfunction at puberty.

RESULTS

A total of 60 patients participated in the study, of whom 28 (47%) had erectile dysfunction. On univariate analysis all 4 parameters were significant predictors of erectile dysfunction, while on multivariate analysis only 2 parameters remained strong and independent predictors, namely urethral gap length 2.5 cm or greater and prostatic displacement in a lateral direction. Duplex ultrasound revealed the cause of erectile dysfunction as arteriogenic in 19 patients (76%), arteriovenogenic in 2 (8%) and likely neurogenic in 4 (16%).

CONCLUSIONS

For every 2 children sustaining a pelvic fracture urethral injury 1 will exhibit erectile dysfunction at puberty. The risk of erectile dysfunction is appreciably increased in the presence of a long urethral gap and/or lateral prostatic displacement. The cause of erectile dysfunction is most commonly primarily arteriogenic and less commonly neurogenic.

Transpubic posterior urethroplasty via perineal approach in children: a new technique

OBJECTIVE

To evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children.

METHODS

Of 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median = 8.5 years). The median distraction defect length was 4.8 cm (range 3.7-6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter.

RESULTS

Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9-3.2 h) with a mean blood loss of 200 ml (range 50-640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis.

CONCLUSIONS

Transpubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes.

Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring

OBJECTIVE

To investigate whether the observation of particular pelvic fracture patterns enables the clinician to predict the presence and type of injuries to the lower urinary tract, as the mechanisms of injury to the lower urinary tract in association with fractures of the pelvic ring are unclear.

PATIENTS AND METHODS

The case-notes and radiographs of 168 patients with either pelvic ring or acetabular fractures were reviewed; 108 pelvic ring fractures (81 men, 27 women) and 60 acetabular fractures (46 men, 14 women). The pelvic fractures were classified according to the system described by Tile and were correlated with the incidence and type of lower urinary tract injury (LUTI).

RESULTS

Overall, of the 108 men and women with pelvic ring fractures, 27 (25%) had a LUTI documented either radiologically or as an intraoperative finding. Of the 81 men with pelvic ring fractures, 24 (30%) had a LUTI, of whom six (7%) had an isolated bladder laceration, 14 (17%) a partial urethral injury (PUI) and four (5%) a complete urethral disruption (CUD). Five of the 18 men with urethral injuries also had bladder injuries and in three of these, the bladder neck was also injured. Three of 27 women (11%) had a LUTI, all of whom had isolated bladder lacerations. Of the 46 men with an acetabular fracture, one (2%) had a CUD, and three (7%) had a PUI. One of 14 of women with an acetabular fracture sustained a bladder laceration. None of the three men with a Tile Type-A pelvic ring fracture sustained a LUTI. Of the 28 men with 'open-book' (Tile Type-B1) fractures, 21 (75%) had no associated LUTI and seven (25%) had a LUTI (five partial urethral injuries and two bladder lacerations). Of the 10 men with 'lateral compression' (Tile Type-B2) fractures, six had no LUTI and four had a LUTI (two partial urethral injuries and two bladder lacerations). Of the 40 men with 'vertical shear' (Tile Type-C) fractures, 27 (68%) had no LUTI and 13 (32%) a LUTI (four complete urethral disruptions, seven partial urethral injuries, and two bladder lacerations) including all of the combined bladder and urethral injuries and all of the bladder neck injuries.

CONCLUSION

The pelvic fracture pattern alone does not predict the presence of a LUTI. When it occurs, the type of LUTI appears to be related to the fracture mechanism. The pattern of injury to the soft tissue envelope and specifically to the ligaments supporting the lower urinary tract offers the best correlation with the observed LUTI. We propose a mechanism for this.

[Recent traumatic injuries of the urethra]

Traumatic injuries of the urethra are uncommon. Most Lesions of the anterior (bulbar urethra) are straddle injuries and are initially dealt with by a suprapubic catheter with delayed treatment when urethral stenosis does ensue. Traumatic disruption of the posterior urethra is in most cases related to a pelvic fracture and is often associated with multiple life-threatening injuries, which receive priority treatment. Management of posterior urethral disruption remains a highly controversial issue: alternative treatments include early endoscopic realignment, early open surgical repair and suprapubic catheter and delayed open surgical repair. Management of urethral injuries is described and the different operative techniques are detailed.

Traumatic posterior urethral disruptions in boys: experience with the perineal/perineal-transpubic approach in ten cases

The management of traumatic posterior urethral disruption in children has ranged from primary realignment/repair to delayed urethroplasty. The operative approach may be perineal or transpubic; the advocates of either cite comparable outcome. The anatomic considerations in a child differ from the adult and the management is individualized. We present our experience with the perineal/perineal-transpubic approach in the management of traumatic posterior urethral disruptions in ten boys. A preliminary suprapubic cystostomy was followed by a delayed urethroplasty after comprehensive investigations to delineate the pathoanatomy of the disruption. The urethroplasty began with a perineal exposure and progressed to varying extents to achieve a satisfactory urethral anastomosis. Four cases of bulbomembranous disruption were repaired by perineal approach, whereas six cases of prostatomembranous disruption required a perineal-transpubic approach. Permutations of operative techniques (circumurethral mobilization, corporeal separation/urethral rerouting, pubectomy and omentoplasty) were used. The follow-up assessed micturition patterns, urinary continence and penile erections. At a mean follow-up of 5 years (1.5-12 years), all ten boys void in a good stream and are continent. All have normal penile erections, posture and gait. The paper discusses the rationale and outcome of our management.

Posterior urethral injuries and the Mitrofanoff principle in children

OBJECTIVE

To report our experience of children with trauma causing posterior urethral injury who at some stage underwent a Mitrofanoff intervention, as post-traumatic urethral injuries can demand long-term treatment which (regardless of the surgical intervention) requires a period of dilatation of the reconstructed urethra.

PATIENTS AND METHODS

From 1992 to 2001, 14 patients with urethral injuries underwent a Mitrofanoff procedure. Thirteen had been run over by a motor vehicle and had severe hip injuries, and one had a direct non-penetrating perineal impact lesion (13 boys and one girl, aged 2-13 years at the time of the accident). In all cases the Mitrofanoff procedure involved interposing the appendix between the bladder and the umbilicus. Only one of the children (because of extremely high bladder filling pressures) also underwent an augmentation cystoplasty and closure of the bladder neck because there were bony fragments in the urethra.

RESULTS

The Mitrofanoff technique was considered useful in most cases. All patients during a given period used the Mitrofanoff conduit to empty their bladder every 3 h; 10 of the 14 are currently voiding urethrally, with an adequate flow, and four are not, but emptying the bladder periodically via the appendicovesicostomy. The only girl in the group has a major hip deformity and is unlikely to undergo urethroplasty; two patients are expecting definitive treatment and the other, although having a patent urethra, has no urinary flow. He is currently 19 years old and has no erections.

CONCLUSIONS

The treatment of posterior urethral injuries represents a challenge to surgical teams. Although primary suturing of the separated urethral ends is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases.

Transperineal end-to-end anastomotic urethroplasty for traumatic posterior urethral disruption and strictures in children

OBJECTIVE

To report the long-term results of transperineal end-to-end anastomotic urethroplasty for post-traumatic posterior urethral stenosis in children.

METHODS

From 1975 to 1996, 25 boys [aged 3 to 12 years] with post-traumatic posterior urethral stenosis or obliteration, and one boy [aged 7 years] with disrupted posterior urethra were treated with transperineal end-to-end anastomotic urethroplasty. Final follow-up assessments including voiding status, urinary continence and erectile function were performed in June 1999.

RESULTS

Smooth voiding was restored in 25 boys postoperatively. one child failed an ill-prepared repair and was waiting for further intervention. Among the 25 patients, seven were lost to the final follow-up. All seven boys had a single urethroplasty for simple urethral stenosis and had been followed for 3 to 5 years postoperatively with smooth voiding. The other 18 boys, including seven with complex urethral stenosis [three with a history of failed previous urethroplasties, three with urethrorectal fistula and one with urethroperineal fistula], underwent a total of 22 end-to-end anastomotic urethroplasties [one successful primary repair, 17 successful delayed repairs and four failed repairs]. Of the 17 patients with successful delayed repair, 14 succeeded with one repair, two with two repairs and one with three repairs. The success rate per repair for simple urethral strictures was 94.7% [18 of 19], and for complex strictures 63.6% [7 of 11]. Stress incontinence was found in three cases, impotence in two. Concomitant impotence and stress incontinence were found in one of the five patients.

CONCLUSION

Transperineal end-to-end anastomotic urethroplasty can achieve good long-term outcomes in children with simple post-traumatic posterior urethral stenosis. In experienced hands, good results can also be achieved for complex urethral strictures.

Psychosexual dysfunction in males with genital anomalies: late adolescence, Tanner stages IV to VI

OBJECTIVE

To assess psychosexual function in adolescent males with genital anomalies.

METHOD

Fourteen consecutive males with bladder exstrophy-epispadias, 14 to 19 years old, Tanner stages IV to VI, were assessed along with their parents, using a developmental questionnaire, Hollingshead socioeconomic status rating, Child Behavior Checklist, Youth Self-Report, semistructured psychiatric interview, detailed sexual history, and 5 written, open-ended questions.

RESULTS

All subjects showed psychosexual dysfunction in terms of genital satisfaction and genital touching; only 2 had ever undressed in front of anyone; only 2 had ever masturbated and only after age 16; 8 had few friends and only 5 considered any girls as friends; all expressed heterosexuality but only 4 had dated, 1 at age 17 and 2 after age 18; only the two 19-year-olds had experienced sexual intercourse, at the age of 19. All had an anxiety disorder. Half had experienced a major depressive disorder.

CONCLUSIONS

Psychosexual dysfunction and anxiety were universal and chronic in these males with genital anomalies, leading to social and sexual developmental impairment. Half had a mood disorder. Implications for adulthood as well as for children with other genital anomalies are unclear but deserve further study. Males with genital anomalies should be evaluated for psychosexual developmental impairment.