Pelvic-fracture urethral injury in children

Utilising anterolateral bladder flap to create a continent cutaneous diversion in a patient with pelvic fracture urethral injury

A male child in the first decade of life presented to us with a history of a pelvic fracture and urethral injury resulting from a road traffic accident 4 months prior. He had previously undergone an exploratory laparotomy and suprapubic cystostomy at another medical centre. He was circumcised and exhibited a substantial urethral defect on the retrograde urethrogram, as well as on the micturating cystourethrogram. Following a careful assessment of the patient's and caregivers' expectations, a continent cutaneous catheterisable channel was planned. This procedure involved the use of an anterolateral bladder flap, and continence was achieved through the creation of a Nissen-type seromuscular invagination. Three months postoperatively, the child remains continent, can easily catheterise the stoma and has resumed his education.

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.

Paediatric pelvic fractures - an updated literature review

BACKGROUND

Pelvic fractures in children are indicative of significant trauma. Patients will often have associated injuries - some of which require urgent intervention to prevent death and disability. Paediatric and adult pelvises respond to traumatic forces differently and distinct approaches are required for each population. Historically, pelvic fractures have been treated conservatively, but this trend is changing with a better understanding of the pelvis' inability to remodel significant deformity, as well as new techniques for operative fixation.

METHODS

A comprehensive search of the literature was conducted for articles published between 2000 and 2020 on paediatric pelvic fractures using medical databases including PubMed, Embase and the Cochrane Library.

RESULTS

We included 143 studies in our literature review and summarized the incidence, pathophysiology, assessment, management and complications associated with paediatric pelvic fractures.

CONCLUSIONS

The rarity of paediatric pelvic fractures corresponds with a paucity of randomized clinical trials covering this topic. Trends such as the screening pelvic x-ray are derived from adult populations but are now questioned in children. Other aspects of assessment and management of these children warrant such levels of scrutiny.

Surgical and Patient-Reported Outcomes of Delayed Anastomotic Urethroplasty for Male Pelvic Fracture Urethral Injury at a Japanese Referral Center

We aimed to assess the surgical and patient-reported outcomes of delayed anastomotic urethroplasty (DAU) for pelvic fracture urethral injury (PFUI). We included 211 male patients who underwent DAU for PFUI. DAU success was considered when the urethral lumen was sufficiently large for the passage of a flexible cystoscope, without additional treatment required. The patients completed the lower urinary tract symptoms (LUTS)-related quality of life (QOL) questionnaire (scores: 0, not at all; 1, a little; 2, somewhat; 3, a lot), EuroQol-5 dimensions (EQ-5D), and EQ-5D visual analog scale (EQ-VAS). Postoperative overall satisfaction was evaluated using the following responses: “very satisfied,” “satisfied,” “unsatisfied,” or “very unsatisfied.” DAU was successful in 95.3% cases, with a median postoperative follow-up duration of 48 months. Multivariate logistic regression analysis revealed that “greater blood loss” was an independent predictor of failed urethroplasty. Questionnaire responses were obtained from 80.1% patients. The mean LUTS-related QOL, EQ-5D score and EQ-VAS improved significantly from 2.8, 0.63 and 54.4 at baseline to 0.9, 0.81 and 76.6 postoperatively (p < 0.0001 for all parameters). Moreover, 35.5% and 59.2% of the patients responded being “satisfied” and “very satisfied,” respectively, with their DAU outcomes. DAU not only had a high surgical success rate, but also a significant beneficial effect on both LUTS-related QOL and overall health-related QOL.

Pelvic Fracture Urethral Distraction Defects in Preschool Boys: How to Recognize and Manage?

OBJECTIVE

To share the cases of pelvic fracture urethral distraction defect (PFUDD) in preschool boys and evaluate the transperineal anastomotic urethroplasty strategy for the treatment of these cases.

MATERIALS AND METHODS

Between January 2010 and May 2021, 8 preschool boys (<6 years) with PFUDD underwent the transperineal anastomotic urethroplasty in our center were retrospectively reviewed. Etiology was traumatic pelvic fracture in all boys. The type of trauma included: fall injury in 1 and vehicle crush injury in 7. Urethroplasty was performed at least 3 months after initial trauma or the last failed intervention. One of them suffered from PFUDD associated with urethrorectal fistula received urethroplasty combined with fistula repair. A successful urethroplasty was defined as restoring the patency and continuity of urethra and no further interventions were needed.

RESULTS

Follow-up was obtained in all the 8 preschool boys for 3-135 (median: 65) months. The average age was 4.1 years old (range 1-5). After operation, the final success rate was 100%. Neither stenosis recurrence nor urinary fistulas were reported during follow-up. Of the 8 boys, 1 developed urinary incontinence, only occurring after high-intensity exercise such as running. Potency state could not be evaluated for all boys due to the young age. One boy reported having normal morning erection after a follow-up of 135 months.

CONCLUSION

PFUDD in preschool boys is a challenge for both the urologist and parent. Our study preliminarily confirmed that the progressive anastomotic urethroplasty strategy can ensure a high success rate.

Outcome of Delayed Perineal Anastomotic Urethroplasty in Children with Post-Traumatic Urethral Stricture in a Tertiary Center, Addis Ababa, Ethiopia

Background

Urethral stricture is a challenging urologic problem resulting from congenital, idiopathic, traumatic, iatrogenic,and inflammatory causes. Road traffic accidents and falling-down accidents are the most common traumatic causes. Although most management principles are extrapolated from adults, stricture in children has a unique anatomic challenge. The outcome of urethroplasty is reported to be good in nearly all patients according to different studies. Since there is no study from Ethiopia on this subject, our work will show our experience with the problem.

Patients and Methods

We conducted a retrospective study of children who underwent delayed urethroplasty for post-traumatic urethral stricture from November 2011 to November 2019. A retrospective study was conducted on boys for whom delayed perineal anastomotic urethroplasty was performed after they sustained trauma. Sociodemographic data, pre-operative presentation of patients, and intraoperative conditions were assessed. The need of any further procedure to micturate, stream of urine and urethral caliber on post-operative cystourethrography were parameters used to measure the outcome. Data were entered into SPSS version 24 and analyzed, taking a p-value of 0.05 as statistically significant.

Results

Nineteen boys had delayed perineal anastomotic urethroplasty in the study period, with a mean age at the time of surgery being 9.8 years. Out of these 19 patients, nine had been involved in road traffic accidents, eight had fallen from a height, and two had bullet injuries. The membranous urethra was the most commonly affected part and, in seven of them, associated pelvic bone fracture was documented. The affected urethral segment length ranged from 1–3 cm, with a mean of 1.77 cm. For all of them delayed perineal urethroplasty was performed after a minimum of 3 months. Successful outcome after primary surgery and re-do surgery was 58% and 82%, respectively.

Conclusion

Urethral stricture is an uncommon condition in children but is one of the challenging conditions a pediatric urologist faces. Our study showed that perineal urethroplasty can be done safely in most children with urethral stricture, but unless adequate pre-operative evaluation and strict surgical principles are followed the outcome will be poor.

Urethral injury in children: Experience in a teaching hospital in Enugu, Nigeria

Background:

Urethral injury in children is uncommon, and its treatment is challenging. This study evaluated our experience in the management of urethral injuries in children who presented at the paediatric surgical unit of a teaching hospital in Enugu, Nigeria.

Methods:

The medical records of patients younger than 15 years old admitted to our centre with urethral injury from January 2008 and December 2017 were reviewed retrospectively.

Results:

During the period of the study, 11 cases (all male) were managed. The mean age of the patients at presentation was 11 years. Road traffic accident was the most common mechanism of injury, and the bulbar urethra was the most injured part of the urethra. All the patients had urethroplasty through the perineal approach. There was 90% success at first instance. One patient required redo urethroplasty.

Conclusion:

Urethral trauma is associated with considerable morbidity. Road traffic accident was the most common mechanism of injury, and the bulbar urethra was the part of the urethra most affected. Transperineal urethroplasty was an effective modality of treatment.

Anatomic, diagnostic and management challenges in paediatric pelvic injuries: a review

Pelvic injuries have an incidence of 1: 100 000 children per year in the UK, of which 10% are unstable. A literature review was conducted. Clinical examination alone in a stable patient precludes the need for imaging. Imaging options in the acute pelvic injury are critically reviewed. Where appropriate Judet views or limited exposure computed tomography scan remain of diagnostic benefit. Displacement greater than 1 cm should be reduced and held with an appropriate method. Closed reduction and external fixation for rotationally unstable fractures, and closed or open reduction with internal fixation of two columns should be considered for rotationally and vertically unstable fractures.

Urethroplasty for urethral injuries and trauma-related strictures in children and adolescents: a single-institution experience

INTRODUCTION

Urethral injuries and trauma-related strictures (UITSs) in children are rare. The treatment is challenging but crucial to avoid life-long urinary complications such as recurrent stricture formation, urinary incontinence, and impotence.

OBJECTIVE

The aim was to report on the surgical and functional outcome of urethroplasty for UITSs and to provide data on patient-reported outcome measures (PROMs).

MATERIAL AND METHODS

Between November 2001 and October 2017, 18 male children (≤18 years; median: 13 years) underwent urethroplasty for UITSs at a single tertiary referral center. Etiology was iatrogenic in five (27.8%), perineal straddle injury in six (33.3%) and pelvic fracture urethral injury (PFUI) in seven (38.8%) patients. PFUIs and short (≤3 cm) bulbar strictures were treated by transperineal anastomotic repair (n = 15; 83.3%), whereas a long bulbar stricture and a penile stricture were treated by, respectively, a preputial skin graft and flap urethroplasty. A penetrating penile urethral injury during circumcision underwent early exploration with primary repair of the laceration. Failure was defined as need for additional urethral instrumentation. PROMs were sent to patients ≥16 years at the latest evaluation.

RESULTS

Median follow-up was 57 (range: 8-198) months. No complications and grade 1, 2, and 3 were present in, respectively, 13 (72.2%), two (11.1%), one (5.6%), and two (11.1%) patients. The success rate in a tertiary referral center was 94.4%. An immediate failure was observed in a patient with a PFUI and concomitant bladder neck injury. PROMs were available in 12 patients. Four patients (33.3%) reported erectile dysfunction. Post-void dribbling (25%) and urgency (50%) were the most frequently reported complaints. All patients were satisfied after urethroplasty and stated that they would undergo the surgery again.

DISCUSSION

This series corroborates the recent trend in favor of transperineal anastomotic repair for PFUI, with combined abdominoperineal approach reserved for complex situations (e.g. bladder neck injury). For anterior UITSs, adaption of the technique to the characteristics of UITSs (etiology, location, length, and quality of graft bed) yielded excellent outcomes. Future systematic use of PROMs is also needed in children to elucidate the impact of urethroplasty on the urinary and sexual function.

CONCLUSION

External trauma is the most important etiology of UITSs, but iatrogenic causes should not be neglected. Urethroplasty, mainly by anastomotic repair (AR) but with the technique adapted to local stricture characteristics if necessary, has an excellent long-term success rate in experienced hands. Functional disturbances are frequent, but despite this, patient satisfaction is high after urethroplasty.

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.

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.