Gu trauma- urethra- initial management

1. URETHRAL INJURIES-
INITIAL MANAGEMENT
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai
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3. ANATOMY OF MALE URETHRA:
• Anterior urethra-
penile and bulbar
urethra
• Posterior urethra-
membranous and
prostate.
Dept Of Urology, KMC and GRH,
Chennai
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4. ANATOMY OF FEMALE URETHRA:
Dept Of Urology, KMC and GRH,
Chennai
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5. TYPES OF URETHRAL
INJURIES
• Anterior urethral injuries.
• Posterior urethral injuries.
Dept Of Urology, KMC and GRH,
Chennai
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6. Anterior Urethral Injuries.
• Commonly involves Bulbar Urethra.
• Causes –
1. Straddle injuries.
2. Direct blow to the perineum.
3. Penetrating injuries.
4. Cycling accidents.
5. Gymnasium accidents.
6. Road traffic accidents.
7. Crush injuries.
Dept Of Urology, KMC and GRH,
Chennai
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7. Pathophysiology
In straddle injuries, bulbar
urethra is compressed
against pubic rami.
Dept Of Urology, KMC and GRH,
Chennai
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8. Clinical features:-
Classic TRIAD:
1. Blood at urethral meatus
2. Distended bladder
3. Perineal haematoma.
Extravasation limited by Bucks or Colles Facia
- Bucks fasia limitation- upto base of penis
- Colles fasia limitation- involvement of penis,
scrotum,abdominal wall upto thigh and clavicle.
Dept Of Urology, KMC and GRH,
Chennai
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9. INVESTIGATIONS:
• Retrograde Urethrogram
- 10 – 20 ml of water soluble contrast
- flouroscopic guidance ideal.
- extravasation seen at the site of injury.
• Diagnostic catheterization
- should not be attempted
- may convert partial into complete tear.
- infect perineal haematoma
- increase prostatic bleeding.
Dept Of Urology, KMC and GRH,
Chennai
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10. MANAGEMENT:
• Partial urethral injury
- suprapubic
cystostomy
- if extravasation
occurs- drainage and anti
biotics
Dept Of Urology, KMC and GRH,
Chennai
10

11. • Complete Urethral Transection
Management options:
a . Immediate urethral repair:
Indication - Concomitant penile fracture.
- Penetrating injuries in stable patient
- Associated rectal injuries.
Surgical technique
-Midline perineal Incision
-Drainage perineal hematoma..
-Debridement of urethral margins.
-Mobilisation of urethra.
-Tension free spatulated anastomosis.
with 16 F silicone catheter.
Dept Of Urology, KMC and GRH,
Chennai
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12. b.SPC and delayed repair:
- Most advised method of management
- Delayed repair afterwards.
Dept Of Urology, KMC and GRH,
Chennai
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13. POSTERIOR URETHRAL
INJURIES
 90 % Posterior urethral injuries usually due to
pelvic fractures.
 But only 10% of pelvic fractures are associated
with urethral injuries.
 Prostato-membranous junctional injuries-
common.
Dept Of Urology, KMC and GRH,
Chennai
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14. PATHOPHYSIOLOGY
• Opposing forces between
prostatic and membranous
urethra.
Dept Of Urology, KMC and GRH,
Chennai
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15. CLINICAL FEATURES
CLASSIC TRIAD:
-BLOOD AT URETHRAL MEATUS
-DISTENDED BLADDER
-PERINEAL HEMATOMA
High riding prostate.
Boggy mass in the pelvis.
Dept Of Urology, KMC and GRH,
Chennai
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16. DIAGNOSIS
• Retrograde urethrogram - Extravasation of contrast
• IVU-To evaluate upper tracts & bladder, since10% association with
bladder injuries.
• Urethral injuries are classified according to retrograde urethrogram.
Type1 - Urethra stretched, but intact.
TypeII - Disruption proximal to UG Diaphragm.
TypeIII - Combined disruption proximal and distal to
UG diaphragm
Type IV - Bladder neck injury with extention in to urethra..
Dept Of Urology, KMC and GRH,
Chennai
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17. Dept Of Urology, KMC and GRH,
Chennai
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18. MANAGEMENT;
• INITIAL MANAGEMENT:
Hemodynamic stability
Associated injuries
In multiple injuries the order of priorities are :
1.Airway
2.Treatement of shock.
3.Treatment of associated injuries like
a.Cerebral
b.Thoracic
c.Abdominal organs including kidney.
d.Orthopaedic
e.Urologic
In acute phase just above all other injuries take precedence over the
urethra but the patient survives the urethral injury can cause him the
greatest disability. Dept Of Urology, KMC and GRH,
Chennai
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19. MANAGEMENT (contd)
• Primary re-alignment:
Indications- Associated bladder neck injuries
-Vascular injuries
- Rectal injuries
Surgical technique:
Urethral re-alignment with catheters
- midline incision
- bladder opened
- 16 F foleys catheter passed via urethra and retrieved
through retropubic space.
- Catheter passed from internal meatus and retrieved
through retropubic space.
- Both catheters tied and rail roaded. SPC catheter kept.
Dept Of Urology, KMC and GRH,
Chennai
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20. Railroad by interlocking sounds
are given up because of
associated injuries to the
surrounding tissues.
Dept Of Urology, KMC and GRH,
Chennai
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21. DIRECT (OPEN primary re-alignment):
 Open repair by removing pelvic haematoma,
dissecting and tissue suturing the severed urethra
under vision.
 Not followed nowadays because of complications
a. Impotence
b. Incontinence
c. Stricture formation
d. Operative blood loss
Dept Of Urology, KMC and GRH,
Chennai
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22. INDIRECT (Endoscopic primary re-
alignment) :
- Present definiton.
- Urethral gap bridged by urethral catheter to
promote urethral healing.
Advantages:
Less complications.
Shortens the length of the stricture
Eases subsequent urethroplasty
- Impotence
- Anejacualtion
- Incontinence are not worsened.
Dept Of Urology, KMC and GRH,
Chennai
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23. TECHNIQUE
• Midline incision
• Open cystotomy
• Direct urethral catheterisation
• Ante-grade flexible cystoscopy and guide wire passed to
urethral meatus.
• Retrograde urethral catheterisation with 16 Fr foley
catheter.
• SPC for 6 weeks.
Dept Of Urology, KMC and GRH,
Chennai
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24. DELAYED REPAIR
• SPC followed by delayed or secondary repair after
3 – 6 months.
- At present most accepted procedure.
- Less blood loss and infection
- Reduced post-op stricture.
- Less impotence and incontinence.
Dept Of Urology, KMC and GRH,
Chennai
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25. MANAGEMENT
• SPC alone-
96% develops urethral stricture, which require posterior urethroplasty.
• SPC + Initial Primary Re-alignment
Heals without stricture
Heals with mild stricture [Dilatation + O.I.U]
Eases Subsequent urethroplasty.
• SPC followed by delayed or secondary repair after 3 – 6 months.
Dept Of Urology, KMC and GRH,
Chennai
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26. Female Urethral Injuries
• Rare
• Accompanied by bony
pelvic disruption
• Injury to bladder neck
& vagina
• Common in young
girls
Dept Of Urology, KMC and GRH,
Chennai
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27. MANAGEMENT
• Immediate reconstruction of bladder neck
• Repair of all vaginal lacerations
• Retropubic repair with urethral catheter
stenting & SPC
• Urethrovaginal fistula – secondary closure
Dept Of Urology, KMC and GRH,
Chennai
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28. • AUG
• No diagnostic Catheterisation
• SPC diversion & Delayed endoscopic repair
Dept Of Urology, KMC and GRH,
Chennai
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29. Dept Of Urology, KMC and GRH,
Chennai
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