Management of traumatic urethral injuries in children using different techniques: A case series and review of literature

Abstract

Introduction: Most pediatric urethral injuries are a result of pelvic fracture after high-impact blunt trauma, mainly due to motor vehicle accidents. The management of urethral injuries depends on if the rupture is complete or partial as well as the timing of surgical intervention.

Presentation of cases: Three male children with urethral trauma caused by motor vehicles accidents are presented in this article. Preoperative suprapubic catheterization was initially carried out in all patients. Each patient then received one of three different techniques during the deferred time to surgical intervention: anterior sagittal transanorectal approach (ASTRA) for end-to-end urethral anastomosis, perineal approach for urethroplasty using buccal mucosa, and urethroplasty with preputial skin flap. The three techniques were successfully performed.

Discussion: In the initial management suprapubic cystostomy has been a good solution in urgent situations. Deferred urethroplasty is the procedure of choice for the definite treatment of posterior urethral distraction defects. The anterior sagittal transanorectal approach provides excellent exposure of the posterior urethra and retrovesicular region, and allows the surgeon to perform dissection under direct vision.

Conclusion: It's very important for the pediatric urologist to be familiar with the different techniques available in order to choose the best approach for each particular patient.

Keywords: Pediatric urethral trauma; Urethral injuries; Urethral reconstruction in children; Urethroplasty.

Fig. 1

Patient 1 preoperative urethrocystography showing a short urethral gap (*) between the urethral stumps with possibility of primary anastomosis.

Fig. 2

Intraoperative photograph of patient 1 showing the urethral stricture. Anterior sagittal approach without splitting the rectal wall was performed and primary anastomosis between the two pervious urethral segments was successfully achieved.

Fig. 3

Patient 2 preoperative urethrocystography showing a long urethral gap (*) between the urethral stumps.

Fig. 4

Follow-up cystoscopy of patient 2 two weeks post-operatively demonstrating a pervious urethra without visualization of strictures. The hypochromic area (+) corresponds to the location where the graft was placed.

Figs. 5 and 6

Patient 3 intraoperative photographs showing ventral penile curvature as result of urethral shortening (Fig. 5) and resolution of curvature after the buccal mucosa graft (Fig. 6).

Figs. 5 and 6

Patient 3 intraoperative photographs showing ventral penile curvature as result of urethral shortening (Fig. 5) and resolution of curvature after the buccal mucosa graft (Fig. 6).

Fig. 7

Patient 3 follow-up cystoscopy five months post-operatively of the buccal mucosa graft showing stricture in the proximal anastomosis.

Fig. 8

Aesthetical aspect of the erect penis of patient 3, five months post-operatively of the buccal mucosa graft, without any curvature.