The document provides detailed information on the anatomy, injuries, evaluation, and management of male and female urethral injuries. It describes the anatomy of the male and female urethra, classifications of posterior urethral injuries in males, clinical evaluation, and treatment approaches including early management with catheterization or repair and deferred repair after several months of suprapubic diversion. Complications of different treatment strategies are also discussed.
2. ANATOMY OF MALE URETHRA
• Length:18-20 cm
• Diameter: 8 to 9 mm
• The anterior urethra
– 16 cm long
– a) Bulbar urethra
– b) Penile urethra
• The posterior urethra
– 4cm long
3. Posterior urethra
• Preprostatic part
– 1- 1.5 cm in length
– Surrounded by internal
urethral sphincter
• Prostatic part
– 3-4 cm in length
– Greater proximity to the
anterior surface of the
prostate
5. • Membranous Urethra
– 1.5 cm in length
– least dilatable
• External urethral sphincter
mechanism consist of
– Urethral smooth muscle
– Urethral striated muscle
(of rhabdosphincter)
– Pubourethral part of
levetor ani
9. Innervation
• Greater cavernous nerves
are sympathetic to
preprostatic sphicter
• Rhabdosphincter is supplied
by neurons in Onuf’s
nucleus situated in 2nd
sacral segment of spinal
cord : Fibres pass via
perineal branch of pudendal
nerve
10. Histology
• The urethral epithelium is transitional in type
• Becomes squamous where it traverses the glans penis
11. ANATOMY OF FEMALE URETHRA
• 4cm long , 6mm diameter
• Proximal urethral sphincter
is lacking in female
Arterial supply
• Superior vesical and vaginal
arteries
Veinous drainage
• Vesical venous plexus –
internal pudendal vein –
internal iliac vein
12. Lymphatic Drainage
• Internal and external iliac nodes
Innervation
• Parasympathetic preganglionic fibres from 2nd and 4th sacral
segments of spinal cord
• Somatic fibres from same segment( S2-4) reach the striated
muscle
• Sensory fibres in pelvic splanchnic nerve reach to 2nd – 4th
sacral segment of spinal cord
13. POSTERIOR URETHRAL INJURIES IN MALE
Epidemiology, aetiology and pathophysiology
• Exclusively related to pelvic fractures with disruption of the
pelvic ring(10%)
• These injuries are referred to as pelvic fracture urethral
injuries (PFUI), and are mainly caused by MVAs, High impact
falls
• Divided into partial or complete ruptures
• In complete ruptures, there is a gap between the disrupted
ends of the urethra, which fills up with scar tissue
14. MECHANISM OF INJURY
• Prostatomembranous disruption occurs from major shearing
forces (necessary to fracture the pelvis) at two fixation points
of the posterior urethra
• One point is the prostatomembranous junction, where the
urogenital diaphragm is adherent to the ischiopubic rami
• The second point is the fixation point of the prostatic urethra
to the anterior pubic arch, the puboprostatic ligaments
16. • The most frequent point of distraction is at the departure of
the bulbous urethra from the membranous urethra
• Concomitant injuries to the head, thorax, abdomen and/or
spine are frequent (up to 66%)
• Other causes:
– Penetrating: Gunshot wounds
– Induced: Urethral foreign body
– Iatrogenic: Endoscopic evaluation
17. Colapinto and McCallum classification
Type Description
I Stretched membranous urethra without rupture
II Complete rupture of the membranous urethra with an intact urogenital
diaphragm
III Membranous urethral rupture with urogenital diaphragm disruption
19. Chapple et al. suggested the following
modifications
• Anterior urethra
– 1. partial disruption
– 2. complete disruption
• Posterior urethra
– 1. posterior urethra stretched but intact
– 2. partial disruption
– 3. complete disruption
– 4. complex injury involving bladder neck or rectum
20. American association of surgery of trauma
(AAST)classification
l Contusion: blood at urethral meatus and retrograde urethrography is normal
ll Stretch injury: elongation of the urethra with no extravasation on urethrography
lll Partial disruption: extravasation of urethrography contrast medium at the injury
site, with visualization in the bladder
lV Complete disruption: extravasation of urethrography contrast medium at the
injury site with no visualization in the bladder; <2 cm of urethra separation
V Complete disruption; complete transection with >2 cm of urethral separation or
extension into the prostate or vagina
21. FEMALE URETHRAL INJURIES
• PFUIs in females are rare and less common than in males
– Urethra is short and mobile, without any significant
attachments to the pubic bone
• Female urethral injuries are classified into two types:
– Longitudinal or partial (most frequent)
– Transverse or complete injuries
• Concomitant bladder or vaginal injury is possible
• At risk of developing urinary incontinence and urethrovaginal
fistula
23. Clinical signs
• Blood at the meatus
– Cardinal sign
– The absence of it doesn’t
rule out a urethral injury
• Inability to void
– Often associated with a
complete rupture
• Haematuria and pain on
urination
– May be present in
incomplete ruptures
• Urinary extravasation and
bleeding
– Result in scrotal, penile
and/or perineal swelling
and ecchymosis
24.
25. • Rectal examination
– To exclude an associated rectal injury (up to 5% of cases)
– May reveal a ‘high-riding’ prostate, which is an unreliable
finding
• Difficulty or inability to pass a urethral catheter
• A female urethral injury should be suspected
– Unstable pelvic fracture with blood at the vaginal introitus
– vaginal laceration, haematuria, labial swelling
– urinary retention or difficulties passing a urethral catheter
26. Urethrography
• Retrograde urethrography (RUG)
– Standard in the early evaluation
– Any extravasation outside the urethra is pathognomonic
– Incomplete rupture extravasation from the urethra
which occurs while the bladder is still filling
– A complete rupture massive extravasation without
bladder filling
28. • Prior to deferred treatment, a combination of RUG and
antegrade cysto-urethrography is the standard
– To evaluate site and extent of the urethral stenosis
– To evaluate the competence of the bladder neck
29. The use of synchronous antegrade and retrograde urethral contrast studies
allows for an accurate assessment of the injury
30. Gapometry and anterior urethrometry in
the repair of posterior urethral defect
(Index of elastic lengthening)=
• < 0.35 simple perineal operation
• >0.35 elaborated perineal or transpubic
procedure
Bulboprostatic urethral gap
Length of bulbar urethra
31. Flexible cysto-urethroscopy
• A valuable alternative
• May distinguish between complete and partial rupture
• Preferred to RUG in suspected penile fracture-associated
urethral injury
• In females cysto-urethroscopy and vaginoscopy are the
diagnostic modalities of choice
32. • Prior to deferred treatment, if the competence of the bladder
neck is not clear upon antegrade cysto-urethrography, a
suprapubic cystoscopy is advised
33. Ultrasound and magnetic resonance
imaging
• In the acute phase, US scanning is used for guiding the
placement of a suprapubic catheter
• In complex PFUIs, MRI before deferred treatment provides
valuable additional information
– Better estimation of the length of the distraction defect
– Degree of prostatic displacement
– Presence/absence of a false passage
34. • Cavernosal injury noted on MRI strongly correlated with ED,
added value to pre-operative counseling and management of
ED
urethral defect corporal avulsion
35. Computed Tomography
• CT is the preferred initial radiographic modality to assess soft
tissue injury, organs of the pelvis and retroperitoneum, and
bony structures
• While urethral injury is not always evident on CT, it does
visualize the pelvic fracture and associated hematoma
• ‘Pie in the sky' sign an urethral rupture with cranial
displacement of the bladder
37. DISEASE MANAGEMENT
Male posterior urethral injuries
Emergency room management
• ABCD of trauma
• It is preferable to establish early urinary diversion to:
– Monitor urinary output
– Treat symptomatic retention if the patient is still conscious
– Minimise urinary extravasation and its secondary effects,
such as infection and fibrosis
38. • Single attempt at urethral catheterisation can be carried out
by experienced personnel
• Insertion of a suprapubic catheter is an accepted practice in
urgent situations
• If there is any difficulty, a suprapubic catheter should be
placed under US guidance or under direct vision, for example,
during laparotomy for associated injuries
39. Immediate urethroplasty
Urethroplasty within 48 hours is not indicated:
• Poor visualisation and Inability to accurately assess the degree
of urethral disruption, due to extensive swelling and
ecchymosis
• May result in extensive unjustified urethral debridement
• The risk of severe bleeding (average 3 L) following entry into
the pelvic haematoma
• High rates of impotence (23%), incontinence (14%) and
strictures (54%
40. Early urethral management (less than six
weeks after injury)
• For partial injuries, urinary diversion is sufficient
• A complete injury will not heal, and formation of an
obliterated segment is inevitable in case of suprapubic
diversion alone
• To avoid this obliteration and a long period of suprapubic
diversion followed by deferred urethroplasty, the urethral
ends can be sutured (urethroplasty) or approximated over a
transurethral catheter (re-alignment)
41. Early urethroplasty
• Criteria for early urethroplasty :
– If associated injuries have been stabilised
– The distraction defect is short
– The perineum is soft
– The patient is able to lie down in the lithotomy position
• As the results (complications, stricture recurrence,
incontinence and impotence) are equivalent to delayed
urethroplasty
42. Early re-alignment
• Open or endoscopic technique
• In a partial injury avoids extravasation of urine in the
surrounding tissues reducing the inflammatory response
• In complete injuries correct severe distraction injuries
rather than to prevent a stricture
• The duration of catheterisation
– partial 3 weeks
– complete 6 weeks
• Voiding urethrography upon catheter removal
43. • Stricture formation is reduced and of shorter length
• No evidence of increase in incontinence and ED
• 50% of strictures after endoscopic re-alignment can be
treated endoscopically (DVIU)
44. Deferred management (greater than three
months after injury)
• The standard treatment remains deferred urethroplasty
• After at least three months of suprapubic diversion
– The pelvic haematoma is nearly always resolved
– The prostate has descended into a more normal position
– The scar tissue has stabilised and
– The patient is clinically stable and able to lie down in the
lithotomy position
45. • Perineal anastomotic repair is the surgical technique of choice
• Combined abdominoperineal approach is necessary :
– Cases of concomitant bladder neck injury
– Recto-urethral fistula
46. Female urethral injuries
• Emergency room management of PFUIs in females is the same
as in males however, subsequent management differs
• Early repair (less than or equal to seven days)
– Complication rate is the lowest
– Preferred once the patient is hemodynamically stable
• Delayed repair (greater than seven days)
– Often requires complex abdominal or combined
abdominal-vaginal reconstruction
– Elevated risk of urinary incontinence and vaginal stenosis
48. Recommendations Strength rating
Provide appropriate training to reduce the risk of traumatic
catheterisation
Strong
Evaluate male urethral injuries with flexible cysto-urethroscopy
and/or retrograde urethrography
Strong
Evaluate female urethral injuries with cysto-urethroscopy and
vaginoscopy
Strong
Treat pelvic fracture urethral injuries (PFUIs) in
hemodynamically unstable patients by transurethral or
suprapubic catheterisation initially
Strong
Perform early endoscopic re-alignment in male PFUIs when
feasible
Weak
Do not repeat endoscopic treatments after failed re-alignment
for male PFUI
Strong
49. Recommendations Strength rating
Treat partial posterior urethral injuries initially by suprapubic or
transurethral catheter
Strong
Do not perform immediate urethroplasty (< 48 hours) in male
PFUIs
Strong
Perform early urethroplasty (two days to six weeks) for male
PFUIs with complete disruption in selected patients (stable, short
gap, soft perineum, lithotomy position possible)
Weak
Manage complete posterior urethral disruption in male PFUIs
with suprapubic diversion and deferred (at least three months)
urethroplasty
Strong
Perform early repair (within seven days) for female PFUIs (not
delayed repair or early re-alignment)
Strong
52. End to end urethroplasy
• If possible, it is desirable to proceed within 4 to 6 months
after trauma
• The classic reconstruction consists of a spatulated
anastomosis of the proximal anterior urethra to the apical
prostatic urethra
• The patient is consented for urethral repair via a perineal
approach and warned of the specific risks of erectile
dysfunction, incontinence, and recurrence of stricture
53. EQUIPMENT
1. Turner Warwick ring retractor with six rake blades
2. Self-retaining retractor (e.g., Travers)
3. Fine metal suction with a terminal fenestration hole
4. Haygrove staff
5. Ear, nose, and throat (ENT) speculum
6. Hammer and chisel together and bone rongeurs
7. Bone wax
54. PATIENT POSITIONING AND SURGICAL
INCISION
• The patient is placed in the lithotomy position
• The suprapubic catheter is removed, and the abdomen and
perineal skin are prepared
• A 16 fr catheter is placed in distal urethra
• An 18- to 20-Fr urethral sound is placed into the suprapubic
catheter tract ( Antegrade cystoscopy )
55.
56. OPERATIVE TECHNIQUE
• Incision and Dissection of the Distal Urethra
• Excision of Scar Tissue and Identification of the Proximal
Urethra
• Anastomosis of the Urethra
• Closure and Reduction of Tension on the Anastomosis and
Postoperative Care
57.
58.
59. A λ-shaped incision extends from the midline of the scrotum to the ischial tuberosities
60. Colles fascia has been opened to expose the midline fusion of the bulbospongiosus
muscles and the tunica of the corpus spongiosum distal to the edge of the muscles
61. The scissors are introduced to develop the space between the muscle and the bulb
of the urethra
62. An incision is made in the midline with the scissors, exposing the length of the bulb
64. The self-retaining retractor is placed to expose the inferior fascia of the genitourinary
diaphragm. The bulb of the corpus spongiosum (bulbospongiosum) can be mobilized
to gain access to the fibrosed area of the urethra
67. The Haygrove staff has been passed through the suprapubic cystostomy. Resection
of the fibrotic distraction defect has allowed it to pass into the perineum
68. When the prostatic urethra is displaced and the arc that the urethra must
Traverse must be shortened, that length can be shortened by incision of the
triangular ligament
69. Incision and mobilization of the perichondrium and periosteum of the symphysis
pubis to allow placement of retractors without trauma to the erectile bodies.
Lateral displacement of the crura exposes the dorsal vein of the penis; after careful
identification, the vein can be ligated and divided
70. Completion of the dissection affords additional exposure for resection of the fibrosis
that surrounds the apex of the prostate and the proximal end of the disrupted urethra
71. If the prostate is elevated behind the symphysis pubis ,the inferior aspect of the
symphysis is resected with a Kerrison rongeur
72. As much of the bone can be removed as necessary to afford a simple approximation
of the ends of the urethra
73. Resection of the pubis and rerouting of the urethra around the crus. When the prostate is
markedly displaced, it may be necessary to expand the infrapubectomy. Sometimes, despite
separation of the crura to the full extent possible, the two ends of the urethra do not meet
when they are brought directly through the crus. It is necessary to bring the urethra lateral to
one of the crura to make up this length
74. • Closer
• Drain palcement
• Compression bandage
• Urine is diverted via the suprapubic cystostomy, and the
urethral catheter is plugged and serves as a stent only
75. Postoperative Management
• Initially kept at bed rest for 24 to 48 hours
• Drugs to prevent erection
• Ambulated and discharged with the suprapubic catheter and
stenting urethral catheter in place
• Patients are discharged on a regimen of oxybutynin and oral
antibiotic
• The drains are removed as drainage allows
76. • A voiding trial with contrast material is performed between 21
and 28 days postoperatively
• The voiding film is examined to ensure that there is no
extravasation and that the anastomosis appears widely patent
• A urine culture specimen is also obtained, and the suprapubic
catheter is plugged
• The patient is allowed to void through the urethra for 5 to 7
days, and the suprapubic catheter is then removed
78. With the use of the techniques discussed or similar techniques, curative rates for
reconstruction of posterior PFUIs are in the high 90% range. In large centers, failures are not
due to technical problems (i.e., anastomotic restenosis). In general, failures are indicative of
ischemia of the proximal corpus spongiosum with ensuing stenosis of the mobilized corpus
spongiosum
82. Factors responsible for failed posterior
urethroplasty
• Inadequate mobilisation of bulbar urethra
• Inadequate excision of scar
• Inadequate use of Inferior Pubectomy
83. Re do urethroplasty
• If bulbar mobilization alone is insufficient to achieve tension
free and water tight anastomosis:
– Crural separation
– Inferior pubectomy
– Supracrural rerouting
– Transpubic urethroplasty
84. • If BUN (bulbar urethral necrosis) also known as long gap or
unsalvageable bulbar urethra is encountered then a
tubularized flap is selected using
– Preputial non hair-bearing skin/BMG
– Sigmoid colon
– Inner thigh flap
85. TAKE HOME MASSAGE
• High index of suspicion in pelvic fracture
• SPC and deferred urethroplasty
• Tension free anastomosis
• Take care of blood supply of corpus spongiosum
• Excellent outcome
The anterior urethra
Begins at the perineal membrane and continues distally to the urethral meatus
16 cm long,a) Bulbar urethra b) Penile urethra
The posterior urethra
Begins distal to the bladder neck and the transition to the anterior urethra is made at the perineal membrane
Contraction of preprostatic urethra serves to prevent retrograde flow of ejaculate through proximal urethra into bladder.
It may maintain continence when external sphincter has been damaged. It is extensively disrupted in vast majority of men with :
Bladder neck surgery b) TURP
So retrograde ejaculation occurs in such patients.
Made up of thickened circular smooth muscle, synonymous with the internal urethral sphincter
Parasympathetic preganglionic fibres from 2nd and 4th sacral segments of spinal cord, runs through pelvic splanchnic nerves and synapse in vesical venous plexus. Postganglionic fibres reach smooth muscle
Somatic fibres from same segment( S2-4) reach the striated muscle through pelvic splanchnic nerves that do not synapse in vesical plexus
Sensory fibres in pelvic splanchnic nerve reach to 2nd – 4th sacral segment of spinal cord
The anterior urethra is surrounded by corpora spongiosa and the narrowing of theurethral lumen due to spongiofibrosis is called a stricture.
The posterior urethra is devoid of corpora spongiosa and the urethral narrowing is termed as stenosis
The bladder and prostate are mobilized and displaced (“high-riding prostate”) with this injury, with extraperitoneal urine leakage, and hematoma resulting from shearing of the dorsal venous complex
Young and Burgess Classification. A, Lateral compression force. Type I, a posteriorly
directed force causing a sacral crushing injury and horizontal pubic ramus fractures ipsilaterally. This injury is stable. Type II, a more anteriorly directed force causing horizontal pubic ramus fractures with an anterior sacral crushing injury and either disruption of the posterior sacroiliac joints or fractures through the iliac wing. This injury is ipsilateral. Type III, an anteriorly directed force that is continued and leads to a type I or type II ipsilateral fracture with an external rotation component to the contralateral side; the sacroiliac joint is opened posteriorly, and the sacrotuberous and spinous ligaments are disrupted. B, AP compression fractures. Type I, an AP-directed force opening the pelvis but with the posterior ligamentous structures intact. This injury is stable. Type II, continuation of a type I fracture with disruption of the sacrospinous and potentially the sacrotuberous ligaments and an anterior sacroiliac joint opening. This fracture is rotationally unstable. Type III, a completely unstable or vertical instability pattern with complete disruption of all ligamentous supporting
structures. C, A vertically directed force at right angles to the supporting structures of the pelvis leading to vertical fractures in the rami and disruption of all the ligamentous structures. This injury is equivalent to an AP type III or a completely unstable and rotationally unstable fracture. (Adapted from Young JWR, Burgess AR: Radiologic management of pelvic ring fractures, Baltimore, 1987, Urban and Schwarzenberg.)
Delayed morbidities of posterior urethral injuries include strictures, incontinence and erectile dysfunction
Classification of pelvic fracture urethral injuries: Is there an effect on the type of delayed urethroplasty?
Adel Elbakry
Classification Description Notes
Type 1Stretching injury to the prostatic urethra, but no disruptionRupture of the puboprostatic ligaments
Type 2Disruption of the prostatic urethra Contrast extravasates above the UG Diaphragm
Type 3Disruption of the membranous urethra Contrast extravasates into and below the UG Diaphragm
Type 4Disruption involving the bladder neck Repaired surgically because internal sphincter maintains continence
Type 4aBladder base rupture not involving bladder neck Can be managed conservatively
Type 5Disruption of the anterior urethra
This is usually attributed to the flexibility provided by the vagina
and the greater inherent elasticity of the female urethra, it may also be the result of less severe
and more frequent stable pelvic fractures in females
The presentation of these clinical symptoms may be delayed (> 1 hour)
Failure to detect a rectal injury can cause significant morbidity and even mortality. A rectal injury is suggested by blood on the
examining finger and/or a palpable laceration
A female urethral injury should be suspected from the combination of a (unstable) pelvic fracture with blood at the vaginal introitus, vaginal laceration, haematuria, urethrorrhagia, labial swelling, urinary retention or difficulties passing a urethral catheter .
Vaginal examination is indicated to assess vaginal lacerations
is conducted by injecting 20-30 mL of contrast material while occluding the meatus. Films should be taken in a
30° oblique position. In patients with PFUI, it is important to move the X-ray beam to the 30° angle rather than
the patient
Although RUG is able to reliably identify the site of injury (anterior vs. posterior), the distinction between a complete and
partial rupture is not always clear. Therefore, any proposed classification system based on RUG is
not reliable. In females, the short urethra and vulvar oedema makes adequate urethrography nearly
impossible.
In an unstable patient should be postponed until the patient has been stabilised
Retrograde urethrogram of the male urethra demonstrating urethral anatomy. 1, Prostatic urethra; 2, verumontanum, into which enter the ejaculatory ducts; 3, membranous urethra, note physiologic narrowing of urethral luminal diameter resulting from external striated sphincter; 4, bulbar urethra; 5, pendulous urethra
Koraitim MM. Predictors of surgical approach to repair pelvic fracture urethral distraction defects. J. Urol. 2009;182:1435–9.
Koraitim MM. Gapometry and anterior urethrometry in the repair of posterior urethral defects. J. Urol. 2008;179:1879–81.
Preferred to RUG in suspected penile fracture-associated urethral injury as RUG is associated with a high false-negative rate
In females, where the short urethra often precludes adequate radiological visualisation, cysto-urethroscopy and vaginoscopy are the diagnostic modalities of choice
In complex PFUIs, MRI before deferred treatment provides valuable additional information, which can help to determine the most appropriate surgical strategy
Urethral injury is typically associated with significant trauma
As these injuries are usually associated with other severe injuries, resuscitation and immediate treatment of life-threatening injuries have absolute priority
There is no urgency to treat the urethral injury and urinary diversion is not essential during the first hours after trauma
monitor urinary output, since this is a valuable sign of the haemodynamic condition and the renal function of the patient;
Penetrating injuries especially have a very high likelihood of associated injuries requiring immediate exploration
However, insertion of a suprapubic catheter is not without risk, especially in the unstable trauma patient where the bladder is often displaced by a pelvic haematoma or because of poor bladder filling due to haemodynamic shock or concomitant bladder injury
For partial injuries, urinary diversion (suprapubic or transurethral) is sufficient as these injuries can heal without significant scarring or obstruction
Re-alignment can be done by an open or endoscopic technique [249, 250]. The open technique
is associated with longer operation times, more blood loss and longer hospital stays; as such, endoscopic
re-alignment is now preferred [239]. Using a flexible/rigid cystoscope and biplanar fluoroscopy, a guidewire
is placed inside the bladder under direct visual control, over this, a catheter is placed. If necessary, two
cystoscopes can be used: one retrograde (per urethra) and one antegrade (suprapubic route through the
bladder neck
With contemporary endoscopic re-alignment procedures, stricture formation is reduced to 44-49% compared to a 89-94% stricture rate with suprapubic diversion
There is no evidence that early re-alignment increases the risk of urinary incontinence (4.7-5.8%) or erectile dysfunction (16.7-20.5%)
In light of this, repetitive endoscopic treatments after failed re-alignment are not recommended; instead, urethroplasty must be performed
In the case of a complete rupture, treated with an initial period of three months suprapubic diversion, obliteration of the posterior urethra is almost inevitable
The assessment of sexual function and the decision on definitive treatment (e.g. penile prosthesis), should be undertaken two years after the trauma because of the potential return of potency within that time
The overall success rate for deferred urethroplasty is 86%
a small proportion (< 7%) of patients report de novo erectile dysfunction after delayed urethroplasty, others (6-20%) have recovery of erectile dysfunction after delayed urethroplasty
Incontinence is rare with deferred urethroplasty (approximately 5%), and is usually due to incompetence of the bladder neck
The approach (vaginal, abdominal or combined) for early repair depends on the location of the injury.
Proximal and mid-urethral disruptions require immediate exploration and primary repair using the retropubic
and transvaginal routes, respectively, with primary suturing of the urethral ends or urethral laceration.
Concomitant vaginal lacerations are repaired (two-layer closure) transvaginally at the same time. Distal
urethral injuries can be left hypospadiac since they do not disrupt the sphincter mechanism, but a concomitant
vaginal laceration must be closed. In case of urethral injury during synthetic sub-urethral sling
insertion, immediate repair is warranted with abortion of sling insertion.
However, orthopedic injuries of the lower extremities often necessitate a delay in proceeding with urethral reconstruction
However, experience has demonstrated that anastomosis of the proximal anterior urethra to any segment of the posterior
urethra (apical, prostatic, or below) can be successfully accomplished by a widely spatulated anastomosis in which optimal
epithelial apposition is achieved
In most cases, PFUIs are not long, and the resultant obliteration is amenable to a technically straightforward mobilization of the corpus spongiosum with a primary anastomotic technique
1.A Turner Warwick ring retractor with six rake blades allows good exposure of the urethra
2.self-retaining retractor (e.g., Travers) is useful when the corpora are split to aid access. (Depending on surgical preference, other retractors may be favored.)
3.A fine metal suction with a terminal fenestration hole is useful for identifying bleeding in the infrapubic pelvic cavity and may be used to stabilize and retrieve sutures from the inner lumen of the urethra
4. A Turner Warwick needle holder has an offset, curved handle and allows visualization of a mounted needle when placing sutures in the limited space of the pelvic cavity
5. An ear, nose, and throat (ENT) speculum is useful for placement in the lumen of the urethra when performing urethral suture placement
6. A hammer and chisel together and bone rongeurs are required when performing an inferior pubectomy
7. Bleeding fromthe pubic bone may require bone wax for control.
At induction of anesthesia, broad-spectrum antibiotics are administered
Exaggerated lithotomy with lambda and other incisions are not necessary
because a single midline incision suffices
An 18- to 20-Fr urethral sound is place into the suprapubic catheter tract and by palpation into the bladder neck and prostatic fossa
DVT prevention
In anastomoses that are technically straightforward, the trial is performed at 21 days, and in cases with more rostral distraction of the proximal urethra, the trial is delayed for 3 to 5 days longer
The trial involves removing the urethral catheter, filling the patient’s bladder with contrast material, and instructing him to void
We do not use pericatheter retrograde urethrography to evaluate patients who have undergone urethral reconstruction
Patients are directed to stop taking oxybutynin 24 hours before the voiding trial
Acute complications include bleeding, hematoma, and infection. These are uncommon with the use of broad-spectrum antibiotics, hemostasis, and compression dressings
Long-term complications include:
Stenosis: The success rate at 5 years is 80% to 90% patency in experienced hands.
Incontinence: This is uncommon unless the bladder neck is damaged; the usual continence rate is greater than 90%.
Erectile dysfunction
Cordee
Definition of successful treatment and optimal follow-up after urethral reconstruction of urethral stricture disease
Bradley A. Erickson et al.
RE Re Do urethroplasty after multiple failed surgeries of pelvic fracture
urethral injury Sanjay B. Kulkarni1 · Hazem Orabi1 · Alex Kavanagh1 · Pankaj M. Joshi1