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- 1. PELVIC FRACTURE URETHRAL DISTRACTIONDEFECT 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 2
- 3. Introduction Pelvic fractureurethral 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 3
- 4. Etiology Occur inconjunction 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 4
- 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 5
- 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 6
- 7. Dept Of Urology,KMC and GRH, Chennai 7
- 8. TYPE B -Rotationally unstable, vertically stable ( S.I. joint not disrupted) B1- Open book ( External rotation ) B2- Lateral compression : Ipsilateral ( Internal rotation ) B3- Lateral compression : Contralateral (Bucket-handle) Dept Of Urology, KMC and GRH, Chennai 8
- 9. Urethral injury mechanisms DeptOf Urology, KMC and GRH, Chennai 9
- 10. Urethral injury mechanisms DeptOf Urology, KMC and GRH, Chennai 10
- 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 11
- 12. Urethral injury mechanisms Vertical shear fractures Injury due to traction distraction mechanism Dept Of Urology, KMC and GRH, Chennai 12
- 13. Young & BurgessClassification 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 13
- 14. Young burgess classification Dept OfUrology, KMC and GRH, Chennai 14
- 15. Dept Of Urology,KMC and GRH, Chennai 15
- 16. OPEN BOOK FRACTURE Causedby A.P. compression Diastasis of pubic symphysis May be associated with ipsilateral S.I. joint disruption Dept Of Urology, KMC and GRH, Chennai 16
- 17. BUTTERFLY FRACTURE STRADDLEFracture A.P. compression Fracture of B/L superior & inferior pubic rami Butterfly shaped intact pubic symphysis 17
- 18. MALGAIGNE’S FRACTURE Verticalshear fracture Ipsilateral fracture of both superior and inferior pubic rami Ipsilateral fracture of S.I. joint 18
- 19. BUCKET HANDLE FRACTURE Fracture of anterior arch and contralateral posterior arch 19
- 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 20
- 21. If associated withanterior 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 21
- 22. Look forbruising / 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 22
- 23. Butterfly Hematoma Dept OfUrology, KMC and GRH, Chennai 23
- 24. Dept Of Urology,KMC and GRH, Chennai 24
- 25. DRE Examine perineumfor 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 25
- 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 26
- 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 27
- 28. Colapinto and McCallumradiological 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 28
- 29. Extended anatomical classification Goldmanet 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 29
- 30. Type I Puboprostaticligament 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 30
- 31. Type II Urethrais torn superior to the urogenital diaphragm Contrast extravasation is seen within the extraperitoneal pelvis Dept Of Urology, KMC and GRH, Chennai 31
- 32. Type III Mostcommon 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 32
- 33. Type IV Injuryinvolving 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 33
- 34. American association ofsurgery 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 34
- 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 35
- 36. Risk of diagnosticcatheterisation 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 36
- 37. Points favouring forcatheterisation 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 37
- 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 38
- 39. Definitive management ofurethral 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 39
- 40. Indications for earlyintervention Rectal injury Associated bladder neck injury Perineal degloving injury Penetrating injuries Double transection injury Female urethral injury Dept Of Urology, KMC and GRH, Chennai 40
- 41. Reasons for immediaterepair 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 41
- 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 42
- 43. Primary repair -Technique 1.Openrail-roading 2.Endoscopic realignment 3.Blind realignment procedures -davis inter-locking sounds -magnetic tip catheters Dept Of Urology, KMC and GRH, Chennai 43
- 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 44
- 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 45
- 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 46
- 47. ENDOSCOPIC REALIGNMENT Stablepatient 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 47
- 48. ENDOSCOPIC REALIGNMENT Dept OfUrology, KMC and GRH, Chennai 48
- 49. Describing ismuch 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 49
- 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 50
- 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 51
- 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 52
- 53. Late surgical repairof 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 53
- 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 54
- 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 55
- 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 56
- 57. Principles of openrepair 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 57
- 58. PFUDD - OPPOSINGURETHEROGRAM Dept Of Urology, KMC and GRH, Chennai 58
- 59. Dept Of Urology,KMC and GRH, Chennai 59
- 60. Progressive Perineal Urethroplasty(Webster’s procedure) EXAGGERATED LITHOTOMY POSITION Dept Of Urology, KMC and GRH, Chennai 60
- 61. PPU= WEBSTER (Cardinal steps) 1. Complete Bulbar urethral mobilisation 2. Corporal/crural separation 3. Inferior pubectomy 4. Corporal rerouting Dept Of Urology, KMC and GRH, Chennai 61
- 62. Dept Of Urology,KMC and GRH, Chennai 62
- 63. Inverted Y incisionand exposure of Midline fusion of Bulbospongiosus muscle Dept Of Urology, KMC and GRH, Chennai 63
- 64. Division of fusionof Bulbospongiosus muscle Dept Of Urology, KMC and GRH, Chennai 64
- 65. Exposure of fulllength of bulb Dept Of Urology, KMC and GRH, Chennai 65
- 66. Incision of fibrosedurethra- freeing of bulb Dept Of Urology, KMC and GRH, Chennai 66
- 67. Opening of theanterior urethra Dept Of Urology, KMC and GRH, Chennai 67
- 68. Incision of fibroticdefect and antegrade passage of Haygrove staff 68
- 69. Incision and seperationof triangular ligament 69
- 70. PFUDD Step 1- Bulbarurethral mobilization Dept Of Urology, KMC and GRH, Chennai 70
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- 74. End to endanastomosis 74
- 75. Perineo-Abdominal Progression-Approach (PAPA) INDICATIONS: Longdistraction defects > 8cms To allow a tension free anastomosis in long distraction defects To aid in excision of fistulas and cavities Dept Of Urology, KMC and GRH, Chennai 75
- 76. Perineo-Abdominal Progression-Approach (PAPA) 1. Bulbarurethra mobilisation 2. Corporal separation 3. Inferior pubectomy 4. Supracrural rerouting 5. Total pubectomy Midline infraumblical incision 6. Omental wrapping Dept Of Urology, KMC and GRH, Chennai 76
- 77. Waterhouse procedure Dept OfUrology, KMC and GRH, Chennai 77
- 78. Waterhouse procedure Dept OfUrology, KMC and GRH, Chennai 78
- 79. Waterhouse procedure Dept OfUrology, KMC and GRH, Chennai 79
- 80. Omental wrapping Dept OfUrology, KMC and GRH, Chennai 80
- 81. Post-operative Management Siliconcatheter – 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 81
- 82. Dept Of Urology,KMC and GRH, Chennai 82
- 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 83
- 84. 3. Incontinence - urinaryincontinence rates after reconstruction are low—less than 4% Dept Of Urology, KMC and GRH, Chennai 84
- 85. THANK YOU Dept OfUrology, KMC and GRH, Chennai 85