Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Abstract

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Keywords: Pelvic fracture; classification; outcomes; treatment; urethral injury.

Figure 1

Young-Burgess pelvic fracture classification. LC, lateral compression; APC, anteroposterior compression; VS, vertical shear.

Figure 2

Complete PFUI. PFUI, pelvic fracture urethral injury.

Figure 3

Partial PFUI. PFUI, pelvic fracture urethral injury.

Figure 4

Pie in the sky bladder.

Figure 5

Epithelial lined cavity following primary realignment.

Figure 6

Stricture post SPC placement prior to delayed urethroplasty. SPC, suprapubic catheter.

Figure 7

Method for progressive perineal bulboprosatatic anastomotic urethroplasty repair for PFUI. (A) Urethra divided at site of stricture, which is excised. All of urethra anterior to stricture is mobilised to the level of the suspensory ligament (BPA Step 1); (B) midline raphe between the corpora cavernosi bilaterally is divided anteriorly until the corpora coalesce (BPA Step 2); (C) inferior wedge pubectomy is performed (Step 3); (D) the distal urethra is rerouted under one corpora cavernosus (Step 4); (E) the bulboprostatic anastomosis is performed using interrupted small calibre absorbable sutures; (F) the final appearance. BPA, bulbo-prostatic anastomotic. PFUI, pelvic fracture urethral injury.