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References

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231

5. Transurethral resection of the prostate (TURP): Urethral stricture occurs in

3.1–10% of patients, possibly as the consequence of abrasions by oversized resectoscopes, electrical transmission through the sheath with urethral burn, or post-operative urinary tract infections.

6. Transurethral microwave therapy (TUMT)

7. Radical prostatectomy: anastomotic urethra-vesical stricture (occurs in 7–17%)

8. Insertion of the needle during TOT or TVT.

The WHO consensus summarizes the causes of urethral injury as [1]:

1. Posterior urethra injuries:

– Penetrating injuries: Gunshot wounds, stab wounds – PFUIs: road trafc accidents, falls from heights, industrial accidents – Iatrogenic injuries: endoscopic surgery (TURP), and radical prostatectomy

2. Anterior urethral injuries:

– Blunt trauma: fall astride, kicks in the perineum, go-kart injuries, skateboarding – Penetrating trauma: gunshot/stab wounds – Sexual excess: penile fractures – Urethral foreign bodies – Constriction bands (seen in paraplegics, etc.) – Iatrogenic injuries: urethral catheters, penile surgery, endoscopic

instrumentation

References

1. Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoro V, McAninch JW. Consensus statement on urethral trauma. BJU Int. 2004;93(9):1195–202. https://doi.

org/10.1111/j.1464- 410x.2004.04805.x. PMID: 15180604.

2. Gómez RG, Mundy T, Dubey D, El-Kassaby AW, Firdaoessaleh KR, Santucci R.SIU/ICUD consultation on Urethral strictures: pelvic fracture urethral injuries. Urology. 2014;83(3 Suppl):S48–58. https://doi.org/10.1016/j.urology.2013.09.023. Epub 2013 Nov 8. PMID:

24210734.

3. Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L.Contemporary urethral stricture characteristics in the developed world. Urology. 2013;81(1):191–6. https://

doi.org/10.1016/j.urology.2012.08.062. Epub 2012 Nov 13. PMID: 23153951.

4. Alwaal A, Blaschko SD, McAninch JW, Breyer BN. Epidemiology of urethral strictures. Transl Androl Urol. 2014;3(2):209–13. https://doi.org/10.3978/j.issn.2223- 4683.2014.04.07. PMID: 26813256; PMCID: PMC4708169.

5. Alwaal A, Zaid UB, Blaschko SD, Harris CR, Gaither TW, McAninch JW, Breyer BN.The incidence, causes, mechanism, risk factors, classication, and diagnosis of pelvic fracture urethral injury. Arab J Urol. 2015;13(1):2–6. https://doi.org/10.1016/j.aju.2014.08.006. Epub 2014 Sep 16. PMID: 26019970; PMCID: PMC4435767.

6. Stein DM, Thum DJ, Barbagli G, Kulkarni S, Sansalone S, Pardeshi A, Gonzalez CM.A geographic analysis of male urethral stricture aetiology and location. BJU Int. 2013;112(6):830–4.

https://doi.org/10.1111/j.1464- 410X.2012.11600.x. Epub 2012 Dec 18. PMID: 23253867.

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7. Kashe C, Messer K, Barden R, Sexton C, Parsons JK.Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254–7. https://doi.org/10.1016/j.juro.2008.01.108; discussion 2257–8. Epub 2008 Apr 18. PMID: 18423712.

8. McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001. Epub 2013 Jun 12. PMID: 23905930; PMCID: PMC4016766.

9. Najibi S, Tannast M, Latini JM.Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes. Urology. 2010;76(4):977–81; discussion 981. PMID: 20605196. https://doi.org/10.1016/j.urology.2010.01.092.

10. Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L.Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195(1):1–10. https://doi.org/10.1016/s1072- 7515(02)01197- 3. PMID: 12113532.

11. Webster GD, Mathes GL, Selli C.Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol. 1983;130(5):898–902. https://doi.

org/10.1016/s0022- 5347(17)51561- x. PMID: 6355512.

12. Koraitim MM, Marzouk ME, Atta MA.Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996;77(6):876–80.

13. Turner-Warwick R. Complex traumatic posterior urethral strictures. J Urol. 1977;118(4):564–74. https://doi.org/10.1016/s0022- 5347(17)58109- 4. PMID: 916051.

14. Mouraviev VB, Santucci RA.Cadaveric anatomy of pelvic fracture urethral distraction injury: most injuries are distal to the external urinary sphincter. J Urol. 2005;173(3):869–72. https://

doi.org/10.1097/01.ju.0000152252.48176.69. PMID: 15711300.

15. Andrich DE, Mundy AR.The nature of urethral injury in cases of pelvic fracture urethral trauma. J Urol. 2001;165:1492–5.

16. Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma. 2009;67(5):1033–9.

https://doi.org/10.1097/TA.0b013e3181bb8d6c. PMID: 19901665.

17. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161(5):1433–41. PMID: 10210368.

18. Alwaal A, Zaid UB, Blaschko SD, Harris CR, Gaither TW, McAninch JW, Breyer BN.The incidence, causes, mechanism, risk factors, classication, and diagnosis of pelvic fracture urethral injury. Arab J Urol. 2015;13(1):2–6. https://doi.org/10.1016/j.aju.2014.08.006.

19. Koraitim MM.Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol. 1997;157(2):641–5. PMID: 8996388.

20. Clark SS, Prudencio RF.Lower urinary tract injuries associated with pelvic fractures. Diagnosis and management. Surg Clin North Am. 1972;52(1):183–201. https://doi.org/10.1016/

s0039- 6109(16)39642- 6. PMID: 5013219.

21. Iselin CE, Webster GD.The signicance of the open bladder neck associated with pelvic fracture urethral distraction defects. J Urol. 1999;162(2):347–51. PMID: 10411036.

22. Rosenstein DI, Alsika NF.Diagnosis and classication of urethral injuries. Urol Clin North Am. 2006;33(1):73–85. https://doi.org/10.1016/j.ucl.2005.11.004, vi-vii. PMID: 16488282.

23. Pokorny M, Pontes JE, Pierce JM Jr. Urological injuries associated with pelvic trauma. J Urol. 1979;121(4):455–7. https://doi.org/10.1016/s0022- 5347(17)56822- 6. PMID: 439217.

24. Mundy AR, Andrich DE. Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management. BJU Int. 2011;108(3):310–27. https://doi.

org/10.1111/j.1464- 410X.2011.10339.x. PMID: 21771241.

25. Tile M.Pelvic ring fractures: should they be xed? J Bone Joint Surg Br. 1988;70:1–12.

26. Andrich DE, Day AC, Mundy AR.Proposed mechanisms of lower tract injury in fractures of the pelvic ring. BJU Int. 2007;100:567–73.

27. Priyadarshi V, Gupta D, Pal DK.Lower genitourinary tract trauma caused by Cow Horn injury. J Obstet Gynaecol India. 2016;66(Suppl 1):578–82. https://doi.org/10.1007/s13224- 015- 0748- z. Epub 2015 Sep 8. PMID: 27651664; PMCID: PMC5016394.

28 Etiology, Mechanisms, andAnatomopathology ofUrethral Injury

Classification ofUrethral Injury

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Many grading systems have been proposed for urethral injury, but they all suffer from the lack of high-level evidence and are merely based on the authors’ experience [1]. One of the oldest is the Colapinto and McCallum classication proposed in 1977, based on retrograde urethrography. It was exclusively proposed for the posterior urethra [2] (Table29.1).

The most popular classication was proposed by Goldman etal. in 1977, which is a modication and completion of the Colapinto and McCallum classication with the addition of more anatomical descriptions [3, 4] (Table29.2; Fig.29.1).

The AAST classication published by Moore et al. in 1995 emphasized the importance of the anatomopathological aspect of the injury being either a simple contusion, a partial or a total disruption, and for total disruption, more severe injuries are dened by a greater than 2-cm urethral gap [5].

Table 29.1 Colapinto and McCallum classication and description of posterior urethral injury

Type I The prostate or the urogenital diaphragm is dislocated, causing elongation and

tension of the bulbomembranous urethra. There may be urethral contusion or laceration (not full thickness)

Type II The membranous urethra is ruptured above the urogenital diaphragm, with or

without prostatic injury. The bulbous urethra is intact. The rupture may be partial or complete

Type III The membranous urethra is disrupted above and below the urogenital diaphragm.

The rupture usually is complete and may be associated with a rupture of the urogenital diaphragm and/or rupture of the bulbous urethra

From Colapinto V and McCallum RW [2], with permission from Wolters Kluwer Health

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Table 29.2 Urethral trauma grading by Goldman SM etal. [3], with permission from Wolters Kluwer Health

I Posterior urethra intact but stretched II Partial or complete pure posterior injury with a tear of the membranous urethra above the

urogenital diaphragm

III Partial or complete combined anterior/posterior urethral injury with disruption of the

urogenital diaphragm

IV Bladder neck injury with extension into the urethra

An injury of the base of the bladder with periurethral extravasation simulating a true type IV urethral injury is called type IVA injury

V Partial or complete pure anterior urethral injury

29 Classication ofUrethral Injury

Fig. 29.1 Type IV urethral injury. (a) Retrograde cystographic image obtained few days after admission shows contrast leakage around the prostatic urethra (arrow). Also, note bilateral superior pubic rami fracture (arrowhead). (b) Sagittal CT cystographic image shows bladder neck laceration with extension to the proximal urethra as well as contrast extravasation (arrow). (From Wongwaisayawan S etal. [4], with permission from Springer Nature)

Classication ofUrethral Injury

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235

Goldman’s classication has been endorsed by the WHO consensus committee in 2004 because of its predictive value for incontinence [6]. However, the same committee suggested the following simplication:

(a) Anterior urethra: (1) partial disruption, (2) complete disruption (b) Posterior urethra: (3) posterior urethra stretched but intact, (4) partial disrup-

tion, (5) complete disruption, (6) complex (involves bladder neck/rectum)

In 2001 Al Rifaei etal. proposed a new functional and anatomical classication of urethral injury secondary to pelvic fracture adding an emphasis on the sphincteric mechanism [7] (Table29.3).

The multiplicity of these classications reects the lack of consensus as none is perfect and universally accepted. Moreover, they don’t clearly provide an answer to the ideal technique and timing of reconstructive surgeries for PFUIs and are therefore considered by certain researchers to have only little impact on the technique selection and the surgical outcome prediction [1].

The European Association of Urology (EAU) attempted to reach a consensus by summarizing the most relevant points of the above classications with the purpose to have direct implications for clinical management [8] (Table29.4).

In addition to the classication of urethral injury, there is also an EAU endoscopic classication of urethral stricture, regardless of the etiology [9] (Table29.5).

This classication has an important bearing as prior evaluation of the stricture using a small caliber ureteroscope (4.5 and 6 Fr) has shown signicant benets in the selection of the surgical approach and helps also counseling the patient about expectations and realistic results [10].

Table 29.3 Anatomical and functional classication for urethral injury secondary to pelvic fracture

Type I Injury to the prostate

Type Ia Proximal avulsion of the prostate from the bladder neck

Type Ib Incomplete or complete transverse trans-prostatic urethral rupture Type II Stretching of the membranous urethra Type III Incomplete or complete pure rupture of the prostatomembranous junction (classic

injury) Type IV Incomplete or complete pure rupture of the bulbo-membranous urethra

(infradiaphragmatic) Type V Incomplete or complete variable combined urethral injuries affecting >1 level of

the urethra

From Al Rifaei M etal. [7], with permission from Taylor and Francis

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Table 29.4 Classication of blunt anterior and posterior urethra with management according to injury grade

Description Appearance

Grade I Stretch injury Elongation of the urethra without

extravasation on urethrography

II Contusion Blood at the urethral meatus; no

extravasation on urethrography

III Partial disruption Extravasation of contrast at injury

IV Complete

disruption

V Complete or partial

disruption of posterior urethra with associated tear of the bladder neck, rectum or vagina

From Martínez-Piñeiro L etal. [8], with permission from Elsevier

Table 29.5 EAU classication according to the degree of urethral narrowing

Category 0 Normal urethra on imaging – – 1 Subclinical strictures Urethral narrowing but >16 Fr Low 2 Low-grade strictures 11–15 Fr 3 High-grade or signicant strictures 4–10 Fr High 4 Nearly obliterative strictures 1–3 Fr 5 Obliterative strictures No urethral lumen (0 Fr)

From the EAU guidelines [9], with permission from the EAU

Description Urethral lumen (French [Fr])

site with contrast visualized in the proximal urethra or bladder

Extravasation of contrast at injury site without visualization of proximal urethra or anterior urethra or bladder

Extravasation of contrast at urethral injury site±presence of blood in the vaginal introitus in women. Extravasation of contrast at bladder neck during suprapubic cystography±rectal or vaginal lling with contrast material

29 Classication ofUrethral Injury

Management No treatment required

Grades II and III can be managed conservatively with suprapubic cystostomy or urethral catheterization

Suprapubic cystostomy and delayed repair or primary endoscopic realignment in selected patients±delayed repair

Primary open repair

Degree

References

1. Elbakry A. Classication of pelvic fracture urethral injuries: Is there an effect on the type of delayed urethroplasty? Arab J Urol. 2011;9(3):191–5. https://doi.org/10.1016/j.

aju.2011.06.001. Epub 2011 Aug 15. PMID: 26579295; PMCID: PMC4150576.

2. Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis: a new classication. J Urol. 1977;116:575.

3. Goldman SM, Sandler CM, Corriere JN Jr, McGuire EJ.Blunt urethral trauma: a unied, anatomical mechanical classication. J Urol. 1997;157(1):85–9. https://doi.org/10.1016/

s0022- 5347(01)65291- 1. PMID: 8976222.

4. Wongwaisayawan S, Krishna S, Sheikh A, etal. Imaging spectrum of traumatic urinary bladder and urethral injuries. Abdom Radiol (NY). 2021;46:681–91. https://doi.org/10.1007/

s00261- 020- 02679- 0.

References

https://t.me/medicina_free

5. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR, McAninch JW.Organ injury scaling. Surg Clin North Am. 1995;75(2):293–303. https://doi.

org/10.1016/s0039- 6109(16)46589- 8. PMID: 7899999.

6. Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoro V, McAninch JW. Consensus statement on urethral trauma. BJU Int. 2004;93(9):1195–202. https://doi.

org/10.1111/j.1464- 410x.2004.04805.x. PMID: 15180604.

7. Al Rifaei M, Eid NI, Al Rifaei A. Urethral injury secondary to pelvic fracture: anatomical and functional classication. Scand J Urol Nephrol. 2001;35(3):205–11. https://doi.

org/10.1080/003655901750291971. PMID: 11487073.

8. Martínez-Piñeiro L, Djakovic N, Plas E, Mor Y, Santucci RA, Serafetinidis E, Turkeri LN, Hohenfellner M, European Association of Urology. EAU guidelines on urethral trauma. Eur Urol. 2010;57(5):791–803. https://doi.org/10.1016/j.eururo.2010.01.013. Epub 2010 Jan 20. PMID: 20122789.

9. EAU guidelines. edn. Presented at the EAU annual congress Amsterdam 2022. isbn:978-94-92671-16-5. https://uroweb.org/guidelines/urethral- strictures/chapter/classications

10. Shahrour W, Joshi P, Hunter CB, Batra VS, Elmansy H, Surana S, Kulkarni S.The benets of using a small caliber ureteroscope in evaluation and management of urethral stricture. Adv Urol. 2018;2018:9137892. https://doi.org/10.1155/2018/9137892. PMID: 30584423; PMCID: PMC6280311.

237

Diagnosis ofUrethral Injury: Symptoms,

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Signs, andImaging Studies

30.1 Symptoms andSigns

The WHO experts’ consensus has recommended considering the following signs for the diagnosis of urethral injury: blood at the urethral meatus, difculty or inability to urinate, distended urinary bladder, buttery bruising of the perineum, high-riding prostate on digital rectal examination (DRE), pelvic fractures with displacement of the pubic rami, and pelvic hematoma on imaging [1]. Hematuria and/or urethral

bleeding remain the best indicator of urinary tract injury, and they have an incidence of 91 to 100% in urethral trauma [2].

In RTA, patients are likely to sustain multi-organ injuries and attention will naturally be immediately diverted to the most life-threatening injury (major vessels laceration, ruptured kidney, liver or spleen, hollow viscus). Stabilization of any fracture comes second, but when the pelvic arch is involved, attention should immediately be brought to the integrity of the urinary bladder and the urethra. The history of urination since the time of the accident should be elicited. The bladder should be palpated for fullness and the external organs and the perineal region should be examined for any painful swelling and skin discoloration (urinary extravasation, hematoma). A digital rectal examination (DRE) should be performed as well as a vaginal examination in females looking for associated rectal or vaginal injury.

When the patient conrms being able to void, either clear urine or bloodstained, he/she should be catheterized. However, if he/she is not able to void and there is fresh blood coming out through the external meatus, a severe urethral injury should be suspected regardless of the importance of the bleeding, and therefore catheterization must be avoided. Blood at the external meatus is a very reliable sign of severe urethral injury despite there being a possibility of

fallacious overdiagnosis in presence of a simple mucosal contusion.

A frequent pitfall is when the examiner fails to palpate the prostate on DRE and thinks it has been displaced upward. There might just be a boggy hematoma that prevents this examination combined with the poor cooperativeness of the patient

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30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies

Table 30.1

associated with urethral injuries post blunt trauma

Clinical features

Sensitivity

Documented clinical variable Blood at the urethral meatus 10 37 Perineal hematoma 12 44.4 High-riding prostate 4 14.8 At least one of the above 18 66.7 Pubic symphysis disruption 25 92.5 Pubic symphysis disruption

or clinical sign

From Lückhoff C etal. [3], with permission from Elsevier

(%)

27 100

due to pain. However, the palpation of a free-oating prostate is almost pathog- nomonic of complete urethral rupture but remains a challenging nding taking into account the tenderness and the pelvic hematoma. Nonetheless, it is noteworthy to keep in mind that palpation of a high-riding prostate is always a reliable indicator of an injured urethra, and the posterior urethra might be signicantly stretched without disruption, allowing the prostate to be pushed cranially [2, 3].

The presence of any of the traditional signs of urethral injury, namely blood at the urethral meatus, perineal hematoma, and high-riding prostate, has been shown to have a sensitivity of 66.7% in the prediction of urethral injury. The presence of pubic symphysis disruption had a prediction sensitivity as higher as 92.5%, and when considering the presence of a pubic symphysis disruption or any of the above clinical signs, the sensitivity rises to 100% [3] (Table30.1).

In the pediatric population, there might be a buttery hematoma (bruising) at the supercial perineum associated with injuries to the urethra distal to the urogenital diaphragm. Scrotal or labial swelling in boys and girls, respectively, are also possible following the collection of extravasated uids after the rupture of Scarpa’s fascia and Dartos fascia in severe pelvic fractures [4].

Unlike the posterior urethral disruptions which are often associated with other organs’ trauma of pelvic fractures, blunt anterior urethral trauma is generally isolated or just associated with cavernosal injury. Moreover, this injury might be so mild that the patients neglect it, as they have no immediate symptoms; and the majority of them will seek medical help only when a stricture develops and causes voiding difculty, after several months or years [5, 6].

30.2 Imaging Investigations

Computed Tomography (CT) is routinely used as a rst initial imaging modality in polytrauma patients, but the best radiological means to diagnose a urethral injury is retrograde urethrography (RUG) either in an acute or chronic setting. This will demonstrate a normal urethra, extravasation with some contrast entering the bladder (partial rupture), extravasation of all the contrast with the proximal tract not visualized (complete rupture), or a narrow segment (stricture) with or without a complete obstruction of the urethral lumen.

30.2 Imaging Investigations

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241

If the management consists of an initial suprapubic catheter insertion and delayed nal treatment, a combined RUG and antegrade cystourethrography should be performed to dene the length of the urethral gap before undertaking the denitive reconstructive surgery. A exible ureteroscope can also be introduced through the SPC site to examine the bladder neck and assess its competence for medico-legal purposes as re-establishment of a patent urethral channel might unmask occult incontinence caused by sphincter damage at the time of the trauma [7].

1. Urethrographic approaches: Urethrography can be performed through an

ascending (retrograde technique), a descending (antegrade technique), or a combination of the two.

The standard technique includes the following steps [8, 9]:

(a) Retrograde or ascending urethrography (Figs.30.1a, b and 30.2a–e).

– Disinfection of the external meatus with the patient in a supine position. – Insertion of a 6–8 Fr Foley catheter, or a hysterosalpingographic catheter

in the external meatus and ination of its balloon with 1–2mL of saline

Fig. 30.1 Retrograde urethrography immediately after trauma in (a) a patient with partial disrup- tion and (b) a patient with complete disruption. Arrows indicate contrast medium extravasated from disrupted sites. (From Horiguchi A [9] with permission John Wiley and Sons)

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