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References
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21. Asopa HS, Garg M, Singhal GG, etal. Dorsal free graft urethroplasty for urethral stricture by
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stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493–503. https://doi.
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23. Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: a new
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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.
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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.
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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/
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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.
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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.
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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.
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34. Milroy EJ, Chapple CR, Cooper JE, Eldin A, Wallsten H, Seddon AM, Rowles PM.A new
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
Complications ofUrethral Injury
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33
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 signicant
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
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_33
285
286
ab
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33 Complications ofUrethral Injury
– calculi formation: stone formation can be prevented by acidication 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 etal. [4], with
permission from the Indian Journal of Urology)
References
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Fig. 33.2 Urethrography of a 34-year-old man with a history of road trafc 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 ofUrethral Injury
Summary ofExperts Panels’
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Recommendations fortheManagement
34
ofUrethral 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 dening 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.
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_34
289
290
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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 3–6weeks [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 denitive 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 (2days to 6weeks) 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 (3–6months) 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 5h to avoid lower limbs vascular and neurological complications [3].
For females with PFUIs, an early repair (within 7days) 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 Uroowmetry at 3, 6, 9, and 12months and
then yearly, to reassess the stricture urethra and considers values of >12mL/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 articial 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.
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.
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