7. RTA in India
• 16 citizens get killed and 53 injured every hour in India due to road
traffic accidents
Public health crisis of road traffic accidents in India, J Family Med Prime Care, 2019
30. Clinical features
• Hemodynamically stable vs unstable
• Polytrauma
• Blood at meatus (sensitivity of 37-93%) – does not correlate with
severity of injury
• Palpable bladder and inability to void
• Perineal bruising
• DRE – elevated or displaced prostate in 34% of cases or even an
impalpable prostate due to pelvic hematoma
• Blood on examining finger – rectal injury
Lim PHC, Chung HC. Initial management of acute urethral injuries. Br J Urol 1989
Kotkin L, Koch MO. Impotence and incontinence after immediate realignment of posterior
urethral trauma: result of injury or management? J Urol1996
35. • Supine
• Pelvis elevated 300-450 in horizontal plane
• Thigh closest to table is flexed to 900 and upper thigh is straight
• Scout film to ensure proper positioning
36. Techniques of contrast injection
1. 60 cc syringe directly into the meatus – exposure to radiographer’s
hand more
2. 14F Foley with 2 cc balloon inflation in fossa navicularis
37. • Do not inject lubricant as the catheter
may slip out
• 30 ml of iodinated contrast agent
• Injected slowly under flouro
• Injection should continue till contrast
gets past the sphincter into the bladder
when image acquisition should be started
• Spasm of external sphincter can prevent
bladder filling – gentle positive pressure
will help
38. Urethrography in trauma setting
• Foam cushions underneath the left side of patient for a 300-450 tilt
• If movement is impossible or a spinal injury is suspected, the II should
be rotated to left anterior oblique angulation
41. Limitations of contrast based studies
• Poor retrograde filling
• Failure of bladder opening
• Prostate 3D location in relation to urethra
• Secondary passages may be overlooked
• Organic causes of post traumatic impotence missed
Oh et al. Magnetic resonance urethrography to assess obliterative posterior urethral
stricture: comparison to conventional retrograde urethrography with voiding
cystourethrography. J Urol. 2010
45. Colapinto Maccullum classification
TYPE 1 Stretch only; intact urethra
TYPE 2 Membranous urethra ruptures above UGD and so, contrast extravasates into pelvic extraperitoneal space
TYPE 3 Membranous urethra ruptures in the UGD and so, contrast extravasates into perineum
46. Pitfalls of Colapinto Maccullum
• Type 3 injury is not a pure posterior urethral injury as it can extend
into bulbar urethra
• Bladder neck injuries are not included
47. Goldman classification
TYPE 1 Colapinto-Maccullum 1
TYPE 2 Colapinto-Maccullum 2
TYPE 3 Colapinto-Maccullum 3 but extends into bulbar(anterior) urethra
TYPE 4 Bladder neck injury
TYPE 4A Bladder base injury
TYPE 5 Pure anterior urethral injury
48. AAST
1 Contusion
2 Stretch
3 Partial disruption
4 Complete disruption and <2 cm urethral
distraction
5 Complete disruption and >2 cm urethral
distraction or extension into prostate or vagina
EAU
1 Stretch
2 Contusion
3 Partial disruption
4 Complete disruption
5 Complete/Partial disruption with associated tear
of bladder neck, rectum or vagina
65. Correlation with RGU
Distortion of UGD fat plane 88%
Hematoma of ischiocavernosus 88%
Distortion of prostatic contour 59%
Distortion of bulbocavernosus/ischiocavernosus 47%
Obturator internus hematoma 53%
Ali et al, CT signs of urethral injury, Radiographics, July-Aug 2003
67. Predictors of urethral injury
Basta et al, Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma, J Urol, 2007
68. Relationship between pubic diastasis and
urethral injury
Basta et al, Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma, J Urol, 2007
69. Relationship between inferomedial pubic
ramus fracture and urethral injury
Basta et al, Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma, J Urol, 2007
74. Primary realignment(PR) vs Suprapubic
cystostomy-Delayed urethroplasty(SCDU)
Alexander et al, Outcomes following primary realignment versus SPC with delayed urethroplasty for pelvic
fracture associated posterior urethral injury : A systematic review with meta analysis, Curr Urol, 2019
75. Stricture rates
PR vs SCDU PER vs SCDU
Alexander et al, Outcomes following primary realignment versus SPC with delayed urethroplasty for pelvic
fracture associated posterior urethral injury : A systematic review with meta analysis, Curr Urol, 2019
76. • Multiple studies showed that the stricture rates following PR are
either higher or equal to SCDU but definitely not lower
• PER had a stricture rate of 71%
• Multiple subsequent procedures and might worsen the actual
stricture
77. Erectile dysfunction
PR vs SCDU PER vs SCDU
Alexander et al, Outcomes following primary realignment versus SPC with delayed urethroplasty for pelvic
fracture associated posterior urethral injury : A systematic review with meta analysis, Curr Urol, 2019
78. ED rates
• PR vs SCDU vs PER = 17.5% vs 13.2% vs 71.2%
• More of a consequence of injury than that of management
79. Urinary incontinence
PR vs SCDU PER vs SCDU
Alexander et al, Outcomes following primary realignment versus SPC with delayed urethroplasty for pelvic
fracture associated posterior urethral injury : A systematic review with meta analysis, Curr Urol, 2019
81. Arguments
In favour of PER
• Decreased rate of stenosis
• Shorter strictures
• Decreased need for major
reconstruction
Against PER
• High failure rates
• Delay the time to definitive repair
• Subsequent repairs become difficult
83. Is it the injury or the management?
• Urethral diaphragm injury
• Hematoma and nervous
entrapment
• Sacroiliac jt disruption and pelvic
plexus injury
• Internal iliac artery injury
• Internal iliac artery embolization
• Retropelvic dissection
84. Embolisation and ED
• Selective embolization is the preferred modality
• This is not always the case
• Temporary vessel spasm cloaking an active bleed
• No increased risk of post embolization ED
Ramirez et al. Male sexual function after
bilateral internal iliac artery embolization for pelvic fracture. J Trauma, 2004
85. Incidence
• Difficult to estimate
• 5-20% with pelvic fracture only
• 42-62% with PFUI also
Shenfeld et al. The incidence and causes of erectile
dysfunction after pelvic fractures associated with posterior
urethral disruption. J Urol 2003
Mark et al. Impotence following pelvic fracture urethral injury:
incidence, aetiology and management. Br J Urol 1995
86. Predictors of ED post PFUI
• Sacroiliac fractures (OR = 4)1
• Pubic diastasis (OR = 15.89)2
• Lateral prostatic displacement (OR = 6.9)2
• Long urethral gap (OR = 2)2
• Increased risk when pubic diastasis is >1 inch
1Wright et al. Specific fracture configurations predict sexual and excretory
dysfunction in men and women 1 year after pelvic fracture. J Urol 2006
2Koraitim MM. Predictors of erectile dysfunction post pelvic fracture urethral
injuries: a multivariate analysis. Urology 2013
87. N=120 ( 2009 – 2013)
↓
IIEF questionnaire
↓
NPT
↓ ↓
80% organic ED 20% psychogenic ED
↓
Penile duplex and neurophysiological testing
↓ ↓ ↓
Neural Vascular Mixed
42.7% 30% 27.1%
↓ ↓ ↓
Arterial VOD Mixed
12.7% 56.4% 30.9%
Guan et al. The vascular and neurogenic factors associated with
erectile dysfunction in patients after pelvic fractures. Int Braz J Urol
2015
88. Management of ED post PFUI
• NPT - ≥1 erection lasting at least 10 minutes with ≥60% rigidity at the
tip of penis as normal1
• ICI – deformities of penis, etiological diagnosis, can be coupled with
duplex(PSV<25 cm/s – arteriogenic; EDV >5 cm/s – veno occlusive)
• Penile angiography – isolated arterial insufficiency in duplex with no
venous leak
1Yaman et al. Effect of aging on quality of nocturnal erections: evaluation with NPTR
testing. Int J Impot Res 2004;16:150-153.
89. Shenfeld et al. The role of sildenafil in the treatment of erectile dysfunction in patients with pelvic fracture
urethral disruption. J Urol 2004;172:2350-2352.
• PDE5i trial
• Most patients also have psychogenic component of the trauma
90. Surgical techniques
• Penile revascularisation - 82% success rate1
• Penile implants
1Zuckerman et al. Outcome of penile revascularization for arteriogenic erectile
dysfunction after pelvic fracture urethral injuries; Urology 2012
110. Koraitim
The golden triad of posterior urethroplasty
• Complete scar resection
• Fixation of healthy mucosa of both urethral ends
• Tension free anastomosis
Koraitim MM. On the art of anastomotic posterior urethroplasty: a 27-year
experience. J Urol 2005;173:135–9.
111. To conclude
• Radiographs can predict incidence of urethral injury
• CECT can predict urethral injury in polytrauma patients
• SPC-DU is the preferred mode of treatment
Blood at meatus : spasm of sphincter can prevent blood at meatus or there can be a minor injury which can produce blood at meatus
Palpable bladder : due to spasm of bladder neck bladder may be full or bladder may be empty due to decreased renal perfusion and obviously cant be elicited in an unconscious patient.
DRE – young males; prostate can be flat
Colapinto – 1977
Goldman - 1997
Dis
16 patients test group and 32 patients in control group
All patients had embolization with gelatin which is temporary
No pre injury IIEF scores
1- short term follow up. Patients can recover upto 2 years after injury
Young perineal
Uncomfortable position
Virgin territory
