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References

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15. Barbagli G, Vallasciani S, Romano G, Fabbri F, Guazzoni G, Lazzeri M. Morbidity of oral mucosa graft harvesting from a single cheek. Eur Urol. 2010;58(1):33–41. https://doi.

org/10.1016/j.eururo.2010.01.012. Epub 2010 Jan 19. PMID: 20106587.

16. Kulkarni SB, Barbagli G, Sansalone S, Joshi PM.Harvesting oral mucosa for one-stage anterior urethroplasty. Indian J Urol. 2014;30(1):117–21. https://doi.org/10.4103/0970- 1591.124222. PMID: 24497698; PMCID: PMC3897044.

17. Monseur J.La reconstitution du canal de l’urètre au moyen des lames sus-urétérales et de la gouttière sous-caverneuse. J Urol Nephrol. 1968;74:755–7.

18. El-Kassaby A-W, Fath-Alla M, Maged W, Abdel-Aal A.Traitement des sténoses de l’urètre pénien par urétroplastie avec patch pédiculé dorsal : «Urétroplastie en toit». Prog Urol. 1998;8:1022–8.

19. Aldaqadossi H, El Gamal S, El-Nadey M, El Gamal O, Radwan M, Gaber M.Dorsal onlay (Barbagli technique) versus dorsal inlay (Asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: a prospective randomized study. Int J Urol. 2014;21(2):185–8.

https://doi.org/10.1111/iju.12235. Epub 2013 Aug 12. PMID: 23931150.

20. Barbagli G, Palminteri E, Rizzo M.Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol. 1998;160:1307–9.

21. Asopa HS, Garg M, Singhal GG, etal. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology. 2001;58:657–9.

22. Horiguchi A.Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493–503. https://doi.

org/10.1111/iju.13356. Epub 2017 Jun 10. PMID: 28600871.

23. Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int. 2009;104(8):1150–5. https://doi.org/10.1111/

j.1464- 410X.2009.08590.x. Epub 2009 Apr 17. PMID: 19388990.

24. Palminteri E, Berdondini E, Lumen N, Maruccia S, Florio M, Franco G, Montanaro V, Di Pierro GB. Kulkarni dorsolateral graft urethroplasty using penile skin. Urology. 2016;90:179–83.

https://doi.org/10.1016/j.urology.2015.12.014. Epub 2015 Dec 29. PMID: 26743395.

25. Zumrutbas AE, Ozlulerden Y, Celen S, Kucuker K, Aybek Z. The outcomes of Kulkarni’s one-stage oral mucosa graft urethroplasty in patients with panurethral stricture: a single centre experience. World J Urol. 2020;38(1):175–81. https://doi.org/10.1007/s00345- 019- 02758- y. Epub 2019 Apr 8. PMID: 30963228.

26. Kulkarni S, Joshi P, Surana S, Hamouda A.Management of panurethral strictures. Afr J Urol. 2016;22(1):33–9. issn:1110-5704. https://doi.org/10.1016/j.afju.2016.01.001.

27. Barbagli G, De Stefani S, Sighinol MC, Annino F, Micali S, Bianchi G.Bulbar urethroplasty with dorsal onlay buccal mucosal graft and brin glue. Eur Urol. 2006;50:467–74.

28. Barbagli G, Sansalone S, Kulkarni SB, Romano G, Lazzeri M. Dorsal onlay oral mucosal graft bulbar urethroplasty. BJU Int. 2012;109(11):1728–41. https://doi.org/10.1111/

j.1464- 410X.2012.11006.x. PMID: 22564323.

29. Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol. 2008;53(1):81–9. https://doi.org/10.1016/j.eururo.2007.05.033. Epub 2007 Jun 8. PMID:

17583417.

30. Waterloos M, Verla W. Female urethroplasty: a practical guide emphasizing diagnosis and surgical treatment of female urethral stricture disease. Biomed Res Int. 2019;2019:6715257.

31. Navarro-Galmes MA, Hernandez-Hernandez D, Padilla-Fernandez B, Castro-Diaz DM.Female urethroplasty: anterior vaginal wall ap (Blandy ap)—simpler tends to be better. Urol Int. 2022;106(3):313–6. https://doi.org/10.1159/000515994. Epub 2021 May 6. PMID:

33957637.

32. Orandi A. One-stage urethroplasty. Br J Urol. 1968;40(6):717–9. https://doi.org/10.1111/

j.1464- 410x.1968.tb11872.x. PMID: 4883846.

33. Maheshwari PN, Shah HN.Immediate endoscopic management of complete iatrogenic anterior urethral injuries: a case series with long-term results. BMC Urol. 2005;5:13. https://doi.

org/10.1186/1471- 2490- 5- 13.

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34. Milroy EJ, Chapple CR, Cooper JE, Eldin A, Wallsten H, Seddon AM, Rowles PM.A new treatment for urethral strictures. Lancet. 1988;1(8600):1424–7. https://doi.org/10.1016/

s0140- 6736(88)92238- 6. PMID: 2898583.

35. Badlani GH, Press SM, Defalco A, Oesterling JE, Smith AD.Urolume endourethral prosthesis for the treatment of urethral stricture disease: long-term results of the north American multicenter urolume trial. Urology. 1995;45(5):846–56. issn:0090-4295. https://doi.org/10.1016/

S0090- 4295(99)80093- 4.

36. Wilson TS, Lemack GE, Dmochowski RR. Urolume stents: lessons learned. J Urol. 2002;167(6):2477–80. PMID: 11992061.

37. Frankiewicz M, Karolina M, Marcin M. Diagnosis and management of urolume urethral stent complications using ultrasonography and magnetic resonance imaging. Urology. 2020;144:e4–5. https://doi.org/10.1016/j.urology.2020.06.043. Epub 2020 Jul 7. PMID:

32650016.

38. Elliott SP, Coutinho K, Robertson KJ, D’Anna R, Chevli K, Carrier S, Aube-Peterkin M, Cantrill CH, Ehlert MJ, Te AE, Dann J, DeLong JM, Brandes SB, Hagedorn JC, Levin R, Schlaifer A, DeSouza E, DiMarco D, Erickson BA, Natale R, Husmann DA, Morey A, Olsson C, Virasoro R.One-year results for the ROBUST III randomized controlled trial evaluating the Optilume® drug-coated balloon for anterior urethral strictures. J Urol. 2022;207(4):866–75.

https://doi.org/10.1097/JU.0000000000002346. Epub 2021 Dec 2. PMID: 34854748.

39. Pastorek D, Culenova M, Csobonyeiova M, Skuciova V, Danisovic L, Ziaran S.Tissue engineering of the urethra: from bench to bedside. Biomedicine. 2021;9(12):1917. https://doi.

org/10.3390/biomedicines9121917. PMID: 34944733; PMCID: PMC8698949.

40. Bhargava S, Chapple CR, Bullock AJ, Layton C, MacNeil S.Tissue-engineered buccal mucosa for substitution urethroplasty. BJU Int. 2004;93:807–11.

41. Bhargava S, Patterson JM, Inman RD, MacNeil S, Chapple CR. Tissue-engineered buccal mucosa urethroplasty-clinical outcomes. Eur Urol. 2008;53(6):1263–9. https://doi.

org/10.1016/j.eururo.2008.01.061. Epub 2008 Feb 4. PMID: 18262717.

42. Ram-Liebig G, Barbagli G, Heidenreich A, Fahlenkamp D, Romano G, Rebmann U, Standhaft D, van Ahlen H, Schakaki S, Balsmeyer U, Spiegler M, Knispel H.Results of use of tissue- engineered autologous oral mucosa graft for urethral reconstruction: a multicenter, prospective, observational trial. EBioMedicine. 2017;23:185–92. https://doi.org/10.1016/j.

ebiom.2017.08.014. Epub 2017 Aug 16. PMID: 28827035; PMCID: PMC5605371.

32 Treatment ofUrethral Injury. II: TheAnterior Urethra

Complications ofUrethral Injury

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Before the rst use of urinary drainage techniques such as suprapubic cystostomy and antegrade-retrograde railroading of perineal catheter into the bladder by Verguin in Toulon (France) in 1757, PFUI was always fatal due to urinary obstruction and extravasation, sepsis and uremia. The PFUI mortality recorded a signicant decrease, from almost 100% in 1757, to 78% in 1907 and to 23% in 1942 because of better management of the trauma with the introduction of the following advances: Early and accurate diagnosis, adequate treatment of trauma shock, urinary drainage, debridement of devitalized tissues, and immobilization of the bony pelvis. This fatality applied also to anterior urethral injury depending on the grade [1, 2]. Further improvement has been achieved nowadays with better management of associated injuries, the introduction of antibiotics, the generalized use of blood transfusions, the improvement of techniques in the stabilization of fractures, and the creation of intensive care units, etc.

Late complications such as stricture, incontinence, and impotence are also avoided by the application of the abovementioned principles, and the early conservation of the urethral channel by a splinting catheter is of equal importance.

Nowadays the complications of urethral injuries are often intermingled with the complications of the procedures to alleviate or treat them. They consist of:

1. In the immediate presentation

– hemorrhage and hypovolemic shock – hematoma and urinary extravasation – sepsis

2. In the mid- or long term [3]

– Urinary incontinence – sexual impotence – urethral stricture – recurrent infection

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33 Complications ofUrethral Injury

– calculi formation: stone formation can be prevented by acidication of the

urine and vesical lavage. – chronic periurethral abscess – chronic pubis osteomyelitis – false passages into the bladder base or the prostate etc. – stulae between the urethra and the skin or neighboring hollow organs:

urethro- cutaneous, urethro-vaginal, urethro-rectal stulae, etc. (repair may

require interposition of a gracilis muscle ap or a porcine small intestinal

submucosal graft [4] (Fig.33.1) – Urethral diverticula (Fig.33.2)

In a comprehensive review, Koraitim found the following complications in rela-

tion to the conventional treatment method of PFUI [5]:

– Primary anastomosis of the disrupted ends: incontinence 21%, impotence 56% – Primary realignment: impotence 36%, stricture 53% – Suprapubic cystostomy and delayed repair: impotence 19%, stricture 97%

In another study, he demonstrated that the direct effect of PFUI resulted in 40%

of the patients becoming impotent, while urethroplasty made only 4% of the potent patients become impotent. More interestingly urethroplasty even allowed 63% of the impotent patients to regain their potency [6]. The relative innocence of urethroplasty has been further substantiated by another study that showed that

Fig. 33.1 (a) Cystourethrogram delineates the communication between the bulbomembranous urethra and rectum with urethral distraction defect. (b) Postoperative voiding cystourethrogram (after the interposition of a porcine small intestinal submucosa) showing completely healed anastomosis with the absence of contrast extravasation into the rectum. (From Rajaian S etal. [4], with permission from the Indian Journal of Urology)

References

https://t.me/medicina_free

Fig. 33.2 Urethrography of a 34-year-old man with a history of road trafc accident with polytrauma and PFUI in 2011. Underwent an abdomino-perineal transpubic urethroplasty in 2012 complicated with a recto-urethro-cutaneous stula managed with a defunctioning colostomy. Then the rectal stula was repaired and underwent a Turner-Warwick posterior urethroplasty using scrotal invagination. This failed and a penile skin urethroplasty was performed in 2014 ending in a large diverticulum that empties by manual pressure

287

hazards related to this procedure occur in 6.6% of men only, mainly consisting of surgical or wound complications (5.2%), and are associated with old age, and the presence of comorbidities. Mortality following urethroplasty is exceedingly rare (0.07%) [7].

References

1. McCague EJ, Semans JH. The management of traumatic rupture of the urethra and bladder complicating fracture of the pelvis. J Urol. 1944;52:36–41.

2. Barratt RC, Bernard J, Mundy AR, Greenwell TJ.Pelvic fracture urethral injury in malesmechanisms of injury, management options and outcomes. Transl Androl Urol. 2018;7(Suppl

1):S29–62. https://doi.org/10.21037/tau.2017.12.35. PMID: 29644168; PMCID: PMC5881191.

3. 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.

4. Rajaian S, Rajadoss MP, Nayak S, Kekre NS.Traumatic rectourethral stula repair: a potential application of porcine small intestinal submucosa. Indian J Urol. 2013;29(2):148–50. https://

doi.org/10.4103/0970- 1591.114041. PMID: 23956521; PMCID: PMC3737675.

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

288

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6. Koraitim MM. The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol. 1995;153(1):63–6. https://doi.org/10.1097/00005392- 199501000- 00024. PMID:

7966793.

7. Blaschko SD, Harris CR, Zaid UB, Gaither T, Chu C, Alwaal A, McAninch JW, McCulloch CE, Breyer BN. Trends, utilization, and immediate perioperative complications of urethroplasty in the United States: data from the national inpatient sample 2000-2010. Urology. 2015;85(5):1190–4. https://doi.org/10.1016/j.urology.2015.01.008. Epub 2015 Mar 4. PMID: 25746579; PMCID: PMC4917203.

33 Complications ofUrethral Injury

Summary ofExperts Panels’

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Recommendations fortheManagement

ofUrethral Injury

Considering the multiple controversies and the shadow areas that cover the management of urethral injuries, given the confusing grading systems, the low level of evidence of most of the publications, and the complexity and multiplicity of the described surgical approaches, a summary of the salient points of the guidelines will be of great help in order to cement the learning process of this pathological entity. In this chapter, an effort was made to combine and harmonize the recommendations enacted by various international expert panels, namely the European Association of Urology (EAU) [1], the American Urological Association (AUA) [2], the joint “Société Internationale d’Urologie-International Consultation on Urological Diseases” (SIU-ICUD) [3, 4], the World Society of Emergency Surgery and the American Association for the Surgery of Trauma (WSES-AAST) [5], the Urological Society of India (USI) [6], and WHO consensuses [7].

34.1 Prevention

The EAU panel strongly recommends training the medical and paramedical personnel in the proper technique of urethral catheterization in order to reduce

urethral trauma [1].

34.2 Investigations

– RUG is at present the best technique for dening the site and nature of the

urethral injury. It should be performed by an experienced operator for diagnos-

tic and staging purposes. Well-performed RUG should visualize the whole urethra, including the bladder neck when possible, to indicate the location and degree of the injury.

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34 Summary of Experts Panels’ Recommendations for the Management of Urethral…

– Clinicians should perform retrograde urethrography in patients with ure-

thral injuries (blood at the urethral meatus after pelvic trauma) [1–3, 5].

Alternatively, a exible cystourethroscopic evaluation can be performed, and additionally, a vaginoscopy can be offered in female patients [1, 3, 5]

34.3 Treatment

Prompt urinary drainage (transurethral catheterization or suprapubic urinary diversion) should be performed in iatrogenic and partial blunt anterior (straddle) or posterior urethral injuries [1–6]. If successfully inserted, the urethral catheter

should be kept for 3–6weeks [3].

Immediate urethroplasty (<48 h) should not be performed in males with

PFUI because of high morbidity [2, 3]. However, Complete blunt anterior urethral injuries (straddle type) can be managed by immediate urethroplasty pro- vided surgical expertise is available [4, 6]. Otherwise, it is safer to insert a

suprapubic catheter and consider referral to expert surgeons for delayed urethroplasty [7].

For uncomplicated penetrating trauma of the anterior urethra, experts recom-

mend performing immediate direct surgical repair [2, 5].

The SIU/ICUD recommends excision and primary anastomosis (EPA) urethro-

plasty as the optimal treatment for short bulbar strictures in healthy men since it is reported to have a success rate of >90% for primary procedures [4, 6].

Treat pelvic fracture urethral injuries (PFUIs) in hemodynamically unsta-

ble patients by transurethral or suprapubic catheterization initially. For stable patients, early endoscopic realignment can be attempted in males with PFUI.However, if this fails, repeat endoscopic treatment should be avoided [1,

2, 5]. The WSES-AAST recommends a primary repair for penetrating injuries of the

posterior urethra if the clinical conditions are favorable, an exception being made for complex pelvic fractures, where denitive surgical repair of the PFUI should be carried out only after healing of the pelvic ring [5].

For blunt anterior urethral injury: urinary drainage (urethral catheter or SPC) and

attempt of endoscopic realignment before surgery and considering delayed surgical repair if failure of conservative and minimally invasive approaches [5].

Immediate surgery for urethral injury is also suggested by the WHO consensus

panel in the following circumstances: the need for debridement, open injury, associated penile fracture or other injuries, and emergency procedures performed for other indications (fractures, injury to other organs) [7].

Early urethroplasty (2days to 6weeks) can be performed by expert surgeons for

selected PFUIs patients with complete disruption who are stable, have a short urethral gap and a soft perineum, and can be put in a lithotomy position [1].

SIU-ICUD doesn’t recommend early open retropubic primary suture repair or

open retropubic catheter realignment because of the high morbidity but recommends immediate primary repair of the concomitant bladder, bladder neck, or rectal injuries and urethral catheter realignment of the PFUI to avoid subsequent urinary

References

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291

incontinence or pelvic sepsis [3]. SIU-ICUD also recommends early endoscopic and/or endourologic catheter realignment in stable patients which can be achieved by gentle simple retrograde catheterization or with the use of a exible cystoscope and retrograde passage of a guidewire, or through the combined use of a exible and rigid cystoscope introduced antegradely and retrogradely through a suprapubic tract [3].

Otherwise, the best management is to perform a suprapubic diversion and

deferred (3–6months) urethroplasty [1, 3, 6]. And for this delayed repair, the

perineal midline progressive approach is recommended by the SIU-ICUD which warns at the same time against prolonged extended lithotomy position which should not exceed 5h to avoid lower limbs vascular and neurological complications [3].

For females with PFUIs, an early repair (within 7days) is recommended, rather

than a simple realignment of a delayed repair [1].

34.4 Follow-Up

Patients should be monitored for complications arising from the urethral injury for

at least one year (stricture formation, incontinence, erectile dysfunction) [2] and urethroscopy or urethrography are the methods of choice to evaluate the ure-

thral repair and detect recurrent stenosis [5].

The USI recommends performing Uroowmetry at 3, 6, 9, and 12months and

then yearly, to reassess the stricture urethra and considers values of >12mL/s after a urethroplasty as optimal [6].

The SCI-ICUD recommends individualized management of post-traumatic

incontinence where bladder repair should be performed, or an articial urinary sphincter implanted, and when these procedures failed or are not feasible, continent urinary diversion should be contemplated [3]. The same expert panel suggests the early use of type 5-phosphodiesterase inhibitors to increase the chance of improvement of post-injury erectile dysfunction but recommends further evaluation of their effectiveness in this scenario [3]. For post-traumatic urethral stula, the panel rec- ommends ample exposure, complete excision of the tract, and interposition of a well-vascularized ap [3].

References

1. McCague EJ, Semans JH. The management of traumatic rupture of the urethra and bladder complicating fracture of the pelvis. J Urol. 1944;52:36–41.

2. Barratt RC, Bernard J, Mundy AR, Greenwell TJ.Pelvic fracture urethral injury in malesmechanisms of injury, management options and outcomes. Transl Androl Urol. 2018;7(Suppl

1):S29–62. https://doi.org/10.21037/tau.2017.12.35. PMID: 29644168; PMCID: PMC5881191.

3. 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.

292

https://t.me/medicina_free

34 Summary of Experts Panels’ Recommendations for the Management of Urethral…

4. Rajaian S, Rajadoss MP, Nayak S, Kekre NS.Traumatic rectourethral stula repair: a potential application of porcine small intestinal submucosa. Indian J Urol. 2013;29(2):148–50. https://

doi.org/10.4103/0970- 1591.114041. PMID: 23956521; PMCID: PMC3737675.

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

6. Koraitim MM. The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol. 1995;153(1):63–6. https://doi.org/10.1097/00005392- 199501000- 00024. PMID:

7966793.

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