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. Introduction
Pelvic fracture urethral distraction defect (PFUDD) is a challenging urologic problem
May be associated with Erectile dysfunction, Recurrent stricture urethra, and incontinence
Urethral injury : 10% of male patients and up to 6% of female patients with pelvic fractures
Fracture of the anterior pelvic ring or pubic diastasis are almost always present ( >90%) when
urethral disruption is encountered
Girls younger than age 17 years have a higher risk of urethral injury compared with women -
greater compressibility of the pelvic bones
Dept Of Urology, KMC and GRH, Chennai
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4. Etiology
Occur in conjunction with multisystem trauma from vehicular accidents, falls, or industrial accidents
Distraction : caused by pelvic fracture between pubic symphysis & pubic rami
Direct laceration by pelvic bone fragments
Shearing force
Straddle fractures - involving all four pubic rami and fractures resulting in vertical and rotational
pelvic instability are associated with the highest risk of urologic injury
Dept Of Urology, KMC and GRH, Chennai
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5. Site of injury
Distraction injuries are unique to the membranous urethra
Because of Posterior urethra is densely adherent to the pubis via the urogenital diaphragm and
the puboprostatic ligaments bulbomembranous junction is more vulnerable to injury than the
prostatomembranous junction
In children – Prostatomembraneous junction & extend proximally to the bladder neck because of
the rudimentary nature of the prostate
Endoscopic and urodynamic evaluation - membranous urethral sphincter complex remain
functionally intact while being avulsed vertically, posteriorly, or laterally from the underlying bulb
Dept Of Urology, KMC and GRH, Chennai
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6. Pelvic Fracture - Classifications
TILE’S CLASSIFICATION Based on
- Stability of the pelvic ring
- Integrity of the posterior sacroiliac complex
TYPE A – Stable
A1 - Fractures of the pelvis bone not involving the ring
A2 - Stable, minimally displaced fractures of the ring
Dept Of Urology, KMC and GRH, Chennai
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11. TYPE C - Rotationally and vertically unstable ( Disruption of S.I. joint)
C1 - Unilateral
C2 - Bilateral
C3 - Associated with an acetabular fracture
Dept Of Urology, KMC and GRH, Chennai
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12. Urethral injury mechanisms
Vertical shear fractures
Injury due to traction distraction mechanism
Dept Of Urology, KMC and GRH, Chennai
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13. Young & Burgess Classification
Based on mechanism and direction of force of injury
Three vectors of force and how this disrupts the pelvic ring
- Lateral Compression (LC)
- Anterior posterior compression (APC)
- Vertical shear (VC)
Dept Of Urology, KMC and GRH, Chennai
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16. OPEN BOOK FRACTURE
Caused by A.P. compression
Diastasis of pubic symphysis
May be associated with ipsilateral S.I. joint disruption
Dept Of Urology, KMC and GRH, Chennai
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18. MALGAIGNE’S FRACTURE
Vertical shear fracture
Ipsilateral fracture of both superior
and inferior pubic rami
Ipsilateral fracture of S.I. joint
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20. CLINICAL FEATURES - PFUDD
TRAID OF URETHRAL INJURY – Pelvic fracture
1. Blood at the meatus.
2. Inability to urinate
3.Palpable full bladder
Penile edema / swelling
Perineal hematoma - Butterfly hematoma
Vulval edema & Blood in vaginal introitus - Female
Dept Of Urology, KMC and GRH, Chennai
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21. If associated with anterior urethral injury
IF THE INJURY WITHIN BUCK’S FACIA
Edema / Discolouration of Penile shaft
IF THE INJURY BEYOND BUCK’S FACIA
- Butterfly Hematoma
- Swelling , discolouration & enlargement of
scrotum
Dept Of Urology, KMC and GRH, Chennai
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22. Look for bruising / swelling over the pelvic bone
Palpate – Bony crepitation
Pelvic compression test – Compress / press thwo iliac bones and greater trochonters medially
by two hands of clinician
Application of pelvic binder to avoid ongoing internal bleeding - shock
Dept Of Urology, KMC and GRH, Chennai
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25. DRE
Examine perineum for penetrating / Lacerating injury
Anal tone – Sphincter injury / Spinal injury
High riding prostate / Boggy, ill defined mass –
Vermooten sign
Assess the rectum for injury
Any bony spicules / fragment penetrating into rectum
After removal of finger – Examine for blood staining
Dept Of Urology, KMC and GRH, Chennai
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26. Management
Goals of Treatment
Stabilise the patient’s haemodynamic status
IV fluids & replace blood in case of massive blood loss
Identify associated injuries and properly triage the patient – Head, chest and abdomen
Xray pelvis / CT pelvis – Orthopedic surgeon opinion and stabilisation
Confirm the diagnosis of urethral injury
Dept Of Urology, KMC and GRH, Chennai
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27. Dynamic Retrograde urethrography
Blood at the urethral meatus - Immediate RUG should be performed to rule out urethral injury
16-Fr urethral catheter is placed unlubricated 1 cm into the fossa navicularis
Balloon is filled with 1 cm of water to achieve a snug fit
Patients should be placed in an oblique or lateral decubitus position
Perform the study under fluorography when it is available
25-30 mL of contrast medium is injected gently by a 60-mL catheter-tip syringe
Film is taken during injection
In Female : Direct inspection by urethroscopy is suggested in lieu of urethrography with suspected
urethral injury
Dept Of Urology, KMC and GRH, Chennai
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28. Colapinto and McCallum radiological classification
Based on radiological findings from retrograde urethrography
Type 1: the membranous urethra is stretched but not severed.
Type 2: the membranous urethra is ruptured above the urogenital diaphragm, the contrast
material extravasates into the pelvic extraperitoneal space above the urogenital diaphragm.
Type 3: the membranous urethra is ruptured and the injury extends into the bulbous urethra
due to a tear in the urogenital diaphragm. Contrast material leaks above and below the
urogenital diaphragm
Dept Of Urology, KMC and GRH, Chennai
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29. Extended anatomical classification
Goldman et al. modification - based on the anatomical description of traumatic urethral injuries
(I) - Posterior urethra is stretched but still intact (Colapinto-McCallum type 1).
(II) - Partial or complete pure posterior urethral injury with tear of the membranous urethra while the
urogenital diaphragm is intact. Contrast medium extravasates only above the urogenital diaphragm
(Colapinto-McCallum type 2)
(III) - Partial or complete anterior and posterior urethral injury with disruption of the urogenital diaphragm.
contrast agent leaks above and below the urogenital diaphragm (Colapinto-McCallum type 3)
(IV) - Bladder neck injury extending into the proximal urethra. The extravasation of contrast medium is
around the bladder neck.
(IV A) - Bladder base injury with periurethral extravasation similar to true type IV urethral injury
(V) - Partial or complete isolated anterior urethral injury ( Straddle injury )
Dept Of Urology, KMC and GRH, Chennai
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30. Type I
Puboprostatic ligament is ruptured, and the prostate is allowed to
move superiorly.
Membranous urethra only severely stretched
No extravasation of contrast material is seen
Dept Of Urology, KMC and GRH, Chennai
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31. Type II
Urethra is torn superior to the urogenital diaphragm
Contrast extravasation is seen within the extraperitoneal pelvis
Dept Of Urology, KMC and GRH, Chennai
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32. Type III
Most common
Extends through the urogenital diaphragm and includes the proximal
bulbous urethra.
Extravasation can be found within the extraperitoneal pelvis and
within the perineum.
Dept Of Urology, KMC and GRH, Chennai
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33. Type IV
Injury involving the bladder neck that extends into the proximal urethra.
Contrast-agent extravasation is seen in the extraperitoneal pelvis around the
proximal urethra
Dept Of Urology, KMC and GRH, Chennai
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34. American association of surgery of trauma (AAST) classification
• Type I—Contusion, no contrast leak
• Type II—Stretch injury but no disruption of urethra, no contrast leak
• Type III—Partial disruption of urethra
• Type IV—Complete disruption with urethral separation < 2 cm
• Type V—Complete disruption with urethral separation > 2 cm.
Types I and II injuries together constitute about 25% of cases, type III injuries account for another
25% of cases and the remaining 50% are types IV and V injuries (as per the AAST grading)
Dept Of Urology, KMC and GRH, Chennai
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35. RUG – Partial tear – one attempt of gentle catheterisation can be tried
Catheterisation – successful , do cystogram to asses the bladder
If cystogram normal - keep catheter for 4-6 weeks , if patient developed stenosis can be
managed later
App. 10 % of bladder base injury missed in cystogram – CT cystogram with retrograde filling
Dept Of Urology, KMC and GRH, Chennai
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36. Risk of diagnostic catheterisation
Converting partial injury into a complete tear
Increasing risk of further haemorrhage
Increasing the possibility of contamination of previously sterile pelvic hematoma
Dept Of Urology, KMC and GRH, Chennai
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37. Points favouring for catheterisation
Due to relative lack of evidence of conversion of partial tear into complete rupture of urethra
Total distraction of the entire circumference of the urethra appears not to occur with many injuries.
Instead, a strip of epithelium is left intact. In these patients, the placement of an aligning catheter
may allow the urethra to heal virtually unscarred or with an easily managed stenosis
Dept Of Urology, KMC and GRH, Chennai
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38. Aim of treatment
Re-establish urethral continuity
Reducing risk of urethral stenosis, incontinence and impotence.
However, the ideal method as well as the timing of repair is controversial
Dept Of Urology, KMC and GRH, Chennai
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39. Definitive management of urethral injury
Immediate primary treatment : within 48 hours of injury / SPC , Endoscopic alignment
Delayed primary treatment : 2 – 14 days of injury / Endoscopic realignment
May avoid urethroplasty
Deferred / Delayed treatment : Three months or more after the injury, Anastomotic urethroplasty
SPC + Open surgical repair at 4-6months – GOLD STANDARD
Dept Of Urology, KMC and GRH, Chennai
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40. Indications for early intervention
Rectal injury
Associated bladder neck injury
Perineal degloving injury
Penetrating injuries
Double transection injury
Female urethral injury
Dept Of Urology, KMC and GRH, Chennai
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41. Reasons for immediate repair in female
In female urethral disruption - immediate primary repair, or at least urethral realignment over a
catheter, to avoid subsequent urethrovaginal fistulae or urethral obliteration
Concomitant vaginal lacerations - must be closed acutely to prevent vaginal stenosis.
Delayed reconstruction - problematic because the female urethra is too short (about 4 cm) to
be amenable for mobilization during an anastomotic repair when it becomes embedded in scar
Dept Of Urology, KMC and GRH, Chennai
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42. Immediate urethral realignment
Injury explored at time of presentation
Evacuation of pelvic hematoma
Realignment of urethra over a stenting catheter
Flexible endoscopic catheter placement
RAIL-ROADING technique - obsolete
Dept Of Urology, KMC and GRH, Chennai
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43. Primary repair -Technique
1.Open rail-roading
2.Endoscopic realignment
3.Blind realignment procedures
-davis inter-locking sounds
-magnetic tip catheters
Dept Of Urology, KMC and GRH, Chennai
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44. Open ‘railroading’ / realignment
Prevesical space is explored and haematoma & debris are
evacuated
Cystotomy made and foley catheter passed antegradely
Retrogradely another catheter is passed and tied to the previous one
Catheter is brought in and bulb inflated
Disadvantage:
1.Tamponade effect of haematoma lost and bleeding may occur
2.Planes not well defined and high chance of injury to neurovascular
structures leading to impotence and incontinence
3. Restenosis of urethra
Dept Of Urology, KMC and GRH, Chennai
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45. Early endoscopic realignment
Safe and effective and first option in stable patients
Minority – heal without urethral stricture requiring no further treatment
Subsequent stricture – easier to treat because of short stricture with small amount of scar
tissue
Dept Of Urology, KMC and GRH, Chennai
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46. PFUDD
If this fails Suprapubic tube in the OR.
If this fails --> Another attempt at cystoscopy using rigid instruments in OR.
If this fails bedside placement of a catheter using flexible cystoscopy.
Contrast entering the bladder single careful attempt at urethral catheter insertion
Retrograde urethrogram
Dept Of Urology, KMC and GRH, Chennai
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47. ENDOSCOPIC REALIGNMENT
Stable patient
Flexible cystoscopy through SPC tract
Attempt a two-cystoscope technique where the flexible cystoscope is passed from above
and the rigid cystoscope from below
Turn off the light of suprapubic flexible scope, aiming toward the light of rigid scope.
Dept Of Urology, KMC and GRH, Chennai
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49. Describing is much easier than doing the procedure
Navigating through hematoma and soft tissue injury is frequently unproductive,
frustrating and even dangerous.
NO ATTEMPT FOR LONGER THAN 30 MINUTES AT A TIME
Placement of a suprapubic tube and trying again in 2–3 days if the initial attempts fail.
Dept Of Urology, KMC and GRH, Chennai
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50. Delayed Primary Repair
SPC at time of injury
2 – 14 days of injury
After stabilisation of patient GC
Endoscopic realignment over a stenting catheter
Dept Of Urology, KMC and GRH, Chennai
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51. Late endoscopic management ( secondary repair )
Non-obliterative memb. urethral strictures / partial tear → OIU / Dilatation
Obliterative memb. urethral defects → OIU
‘Cut for Light’ technique
Dept Of Urology, KMC and GRH, Chennai
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52. PFUDD- LATE MANAGEMENT
Repair determined by the type and extent of associated injuries.
Desirable to proceed within 4 to 6 months after trauma
Primary anastomosis – Gold standard
Dept Of Urology, KMC and GRH, Chennai
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53. Late surgical repair of PFUDD
Gold standard – SPC + Delayed reconstruction
Two common approaches
Perineal ( WEBSTER) - upto 8 cm.
Abdomino-perineal ( WATERHOUSE) ->8 cm
Dept Of Urology, KMC and GRH, Chennai
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54. SPC
Midline – Facilitate suprapubic scopy / avoid temporary vesicostomy during reconstruction
Not less than 16Fr catheter
2 finger breaths above pubic symphysis – To avoid acute angulation during sound / Spc scopy
placement
Tract maturation / stable tract – 1 month
Dept Of Urology, KMC and GRH, Chennai
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55. Preop Evaluation
VCUG + RGU : Up and down –o gram
- Location / length of distraction defect
- status of bladder neck and proximal urethra
Preoperative vascular evaluation
- Penile doppler
- Penile revascularisation procedure – in ED + PFUDD
Dept Of Urology, KMC and GRH, Chennai
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56. MRI pelvis
- To define the length of the defect and to determine the extent and direction of urethral dislocation and
the extent of prostatic displacement and it may help in planning the surgical approach
Urethroscopy + Antegrade scopy
- bladder calculi
- Mucosal coaptation at bladder neck
- open bladder neck at rest – Increased risk of postoperative incontinence – counsel preop
Dept Of Urology, KMC and GRH, Chennai
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57. Principles of open repair
Reconstruction after min. 4 months after the event
Exact delineation of the defect
Status of bladder neck
Status of erectile function
Complete excision of all scar tissue
Tension free & water-tight anastomosis
Asepsis
Dept Of Urology, KMC and GRH, Chennai
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58. PFUDD - OPPOSING URETHEROGRAM
Dept Of Urology, KMC and GRH, Chennai
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81. Post-operative Management
Silicon catheter – plugged- only used as a stent
Urine diverted by SPC
Bed rest – 24 to 48 hours , 3 rd day – drain removed
Discharged with SPC and urocath
21- 28 days – voiding trial with contrast/ pericatheteric study
If trial normal – SPC clamping for 5-7 days & urethral voiding
SPC removal
Flexible endoscopy after 6 months and 1 year
Dept Of Urology, KMC and GRH, Chennai
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83. Complications
1. Erectile Dysfunction
Some degree of impotence is noted in 82% of patients with pelvic fracture and urethral distraction injury / the
average reported rate is approximately 50%
Etiology - multifactorial , attributed to cavernous nerve injury, arterial insufficiency, venous leak, and direct
corporeal injury
2. Recurrent Stenosis
After posterior urethroplasty, 5% to 15% of patients have recurrent stenosis at the anastomosis
Endoscopic treatment (e.g., with direct-vision internal urethrotomy) is often successful in this setting because
most fibrotic tissue has been eliminated
Dept Of Urology, KMC and GRH, Chennai
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84. 3. Incontinence
- urinary incontinence rates after reconstruction are low—less than 4%
Dept Of Urology, KMC and GRH, Chennai
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