The Journal of Urology Copyright © 1977 by The Williams & Wilkins Co.
Vol. 118, October Printed in U.SA.
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES RICHARD TURNER-WARWICK From the London University Institute of Urology, St. Paul's Hospital and the Middlesex Hospital, London, England ABSTRACT
A distinction between simple and complex posterior urethral strictures is proposed. The development of a complex stricture, requiring an extensive transpubic repair, must be regarded as a less than admirable result of the initial treatment, even if it is occasionally inevitable. However, it is particularly important that our endeavors to improve the end result of the relatively rare severe urethral injuries should not result in over-management of the relatively common minor injuries, since this could increase the stricture potential of many. Therefore, we must keep our over-all concepts of the initial management of urethral injuries under careful review. Posterior urethroplasty should be regarded as a specialist procedure. It can be made to appear beguilingly simple but it cannot be recommended for occasional or general use. Even the relatively simple free patch graft technique is inadvisable for use in the sphincter area for surgeons who do not have considerable experience of it in the relatively forgiving bulbourethral area. The results of repair of posterior urethral strictures, even the complex ones, by anastomotic procedures can be excellent but real competence depends upon a particular aptitude of the surgeon for the minutiae of reconstructive techniques, appropriate training in a specializing department, a real ongoing numerical experience and special instrumentation with facilities for detailed urodynamic evaluation of this sphincter active area of the urethra. The outlook for the patient with a traumatic posterior urethral stricture has improved almost beyond recognition in the last decade as a result of the development of a variety of anastomotic techniques for urethral reconstruction. The combination of the relatively restricted surgical access together with its inherent sphincter function makes any reconstruction of the posterior (prostatomembranous) urethra a much more complicated procedure than the re-creation of the relatively simple subcutaneous conduit tube involved in anterior (bulbopenile) urethroplasty. The difficulties are compounded when a posterior urethral stricture is complex. The majority of pelvic fracture strictures are "simple" and, unlike the "complex" strictures, they are suitable for 1-stage perineal anastomotic or patch graft repair. The distinction between simple and complex posterior urethral strictures seems valid. Although the results of the transpubic anastomotic repair of complex strictures are remarkably good, i--4 it is a relatively formidable abdominoperineal procedure and the occasional need for it has focused attention upon the development and the prevention of these strictures. Some of these complex problems are the inevitable consequence of extensive damage; others can be avoided by appropriate management of the initial injury; however, they can also be created by the over-treatment of less severe injuries. Thus, even if inevitable, the development of a complex stricture must be regarded as a less then admirable outcome of initial management and one that we must endeavor to avoid as often as possible. Sphincter mechanisms extend throughout the length of the posterior urethra; any injury in this area must impair their function to some extent. From a purely urological viewpoint the primary concern of the initial and delayed treatment of such injuries is to avoid further injury to any of these mechanisms that have survived the original accident; now that a stricture-free result can almost always be achieved by one of a variety of procedures, the chief residual problem of posterior urethroplasty is sphincter deficiency incontinence. DEVELOPMENT OF POSTERIOR
URETHRAL
STRICTURES
AFTER
PELVIC FRACTURE INJURIES
In men the bladder base and the prostatic urethra tend to behave as a mechanical unit so that it is relatively rare for the Accepted for publication April 7, 1977. 564
prostatic urethra itself to be damaged in a pelvic fracture injury; thus, the primary urethral injury is usually in the supramembranous area at the apex of the prostate. The incidence of proximal posterior urethral damage seems to be higher in children; this may relate to the immaturity of the prostate. 5 The initial extent of prostatic dislocation resulting from a pelvic fracture may be considered broadly as minimal, moderate or severe. The urethra is only injured in the minority of cases and the damage is not severe in most of these so that, even when the rupture is circumferential, the initial dislocation of the urethral ends is often only 1 or 2 cm.; nevertheless, if these cases are inappropriately managed a complex stricture may result. Fortunately, severe urethral injuries, associated with a wide separation of the urethral ends by a massive pelvic hematoma, are rare; such injuries have a natural tendency to result in complex strictures at the final stage of healing but if they are properly identified and appropriately managed initially they can heal with no stricture or a short simple stricture that can be resolved by a relatively simple 1-stage perinea! procedure. The end result of a urethral injury cannot be assessed until the healing process is complete. The time necessary for healing is naturally dependent upon the extent of the lesion. After a relatively minor urethral injury the length of any resulting stricture is unlikely to shrink much after the first few months but the shrinking process of organization of a massive unevacuated hematoma associated with severe upward dislocation of the prostate is often incomplete at the end of a year. Irrespec-, tive of the method of the initial treatment and of the healing time involved, the various end results of posterior urethral injuries resulting from pelvic fractures can be summarized as indicated in figure 1. No stricture: no sphincter damage. Minor incomplete injuries of the supramembranous urethra may heal without a stricture and without a compromising degree of damage to the intrinsic mechanism of the distal urethral sphincter. No stricture: distal sphincter damage. Scarring of the supramembranous urethra may compromise the function of its intrinsic mechanism without creating a stricture. This impaired function is likely to pass unnoticed at the time but may be revealed by impaired urinary control after prostatectomy years later because, in the absence of a competent bladder
COIVlPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
the
565
control of urine is
stricture: little surrounding circumferential damage to the suprnm.embranous ,,,.,u.u~,,,,., results in a short supramernbranous stricthe efficiency of the intrinsic mechanism. Generally, short supramembranous strictures do not tend to be surrounded dense fibrosis, presumably because they usually result from minimal dislocation injuries that are not associated with large pelvic floor hematoma. However, when the initial injury was treated by primary reanastomosis, the tissues surrounding even a short stricture are sometimes quite densely scarred. Such strictures may be regarded as "simple". Complex posterior urethral strictures. Posterior urethral strictures may be regarded as complex for 3 main reasons: 1) strictures more than 2 cm. long and surrounded by dense fibrosis usually resulting from organization of a pelvic floor hematoma, 2) strictures, long or short, associated with extravasation diverticula, false passages or fistulas and 3) extensive sphincter damage involving the bladder neck and the distal intrinsic urethral mechanisms. Any complete urethral rupture may result in complete obstruction but this, in itself, does not add to the complexity of the repair. Any pelvic fracture may result in loss of potency; while this is serious for the patient it does not affect the surgical complexity of the stricture. It is important to consider the natural processes involved in the resolution of gross prostatic dislocation and the reabsorption of the mass of the pelvic floor hematoma separating the distracted urethral ends. Take an arbitrary example in which the initial urethral gap associated with a high rise "pie-in-the-sky" bladder is radioFm. 2. "Pie-in-sky" bladder upwardly dislocated by pelvic hematoma demonstrated by synchronous excretory urogram and retro-
grade uretlrrogram. END RESULT OF PELVIC FRACTURE URETHRAL lNJURIBS
No sphincter damage
No stricture
Sphincter damage
Sphincter damage
No stricture
& Short stricture
4
COMPLEX STRICTURES
d
Fm. l
graphically proved to be 10 to 15 cm. The natural contraction of an uninfected intervening blood clot reduces its size considerably in the first few weeks (fig. 2); its n1ass continues to shrink, progressively more slowly, for a year or more before the final state of organization of any residual hematoma re sults in a dense pelvic floor hematoma fibrosis around the prostate that ultimately may separate the proximal and distal ends of the urethra by 3 to 4 cm. or more. Thus, in the course of the first year of healing the bladder base gradually descends into the pelvis with a beguiling degree of reapproxirnation of the urethral ends. This descension is sometimes over-interpreted as a satisfactory resolution. Unfortunately, the distracted ends of a ruptured urethra do not possess a reliable "homing instinct", so that even quite short strictures may be malaligned and their interim management dilatation may prove difficult as a result. In practice an attempt to discontinue catheter drainage usually is made after a few weeks so that the patient then voids through the hematoma; voiding cystourethrography at this stage will often show nary extravasation into a pelvic floor cavity (fig. 3). The ultimate effect of this can sometimes be beneficial since part of the hematoma may be washed out. In other cases the restoration of early voiding creates tracks in the pelvic floor hematoma, which can persist as epithelialized diverticulations when the healing processes are complete 4). Such extravasation diverticula are not uncommon after severe injuries and they are themselves a potential source of "v''"I""·ac,w.w. 1) Calculi may develop or accumulate in them, the urine is infected. 2) Infection in them may result in urethral abscesses, the natural drainage of which can create fistulas into the perineum, the thigh or the rectum occasionally, even an osteomyelitic sinus into the pubic fracture. All of these tend to cause persistent urine infection and
566
TURNER-WAR WICK
unlikely to be self-resolving. 3) Paraurethral diverticula create natural false passages that greatly increase the difficulty of treating the almost inevitable resulting stricture by routine dilatation and energetic attempts to achieve this can create secondary false passages into the bladder base or the rectum. 3
PROGRESS OF HEALING OF SUPRA-MEMBRANOUS URETHRAL STRICTURE
URETHROCUTANEOUS FISTULAS
Infection associated with the traumatized pelvic floor tissue around a closed urethral injury may result in abscesses that track into the perineum or the inner aspect of the thigh, subsequently discharging to form persistent urinary fistulas. These fistulas rarely present a serious problem at the time of definitive bulboprostatic anastomosis, especially when omental support is used in association with a transpubic repair, because they usually heal once the fistulous communication with the urinary tract has been separated at its source and the tracks have been curetted. CHRONIC PERIURETHRAL ABSCESS WITH OSTEOMYELITIS
One patient in our series presented with bilateral infective branched renal calculi and a chronic urine infection dating from a pelvic fracture 20 years previously. The patient voided asymptomatically. Investigation showed an extensive paraurethral abscess freely communicating with extensive osteomyelitic cavities in the pubis and with the proximal posterior urethra (fig. 5); the distal posterior urethra was normal without stricture or sphincter damage. The situation was resolved simply by excision of the affected bone and paraurethral abscess and its replacement by an omental pedicle graft. RECTAL FISTULAS
Rectal fistulas may develop as a result of concomitant rectal injury at the time of the initial accident, rectal drainage of a subsequent paraurethral abscess or urethral instrumentation (fig. 6). Their repair in the final healed state does not usually add much to the resolution of a complex stricture by a transpubic bulboprostatic anastomosis when the omentum is used to support it. 3 • 8 However, it is important that any immediate defunctioning colostomy should use the pelvic colon in the left iliac fossa because a transverse colostomy adds considerably to the effort involved in mobilizing the omental pedicle for the definitive resolution of this complication at a later stage.
Fm.4
PARAURETHRAL BLADDER BASE FISTULAS
False passages into the bladder base can create serious problems, whether they arise as a direct result of the initial
Fm. 5. Chronic, infected bladder neck osteomyelitic sinus 20 years in duration resulting from fracture.
Fm. 3. Patient voiding freely through pelvic hematoma cavity after discontinuation of suprapubic cystotomy drainage 6 weeks after severe pelvic fracture urethral injury. Patient was continent at bladder neck level, cavity gradually reduced in size to form epithelialized paraurethral diverticulum and rather long fibrotic stricture, which later was resolved by transpubic anastomotic urethroplasty.
injury or as a consequence of misdirected urethral dilatation. 1) The close proximity of such a passage to the bladder neck may damage its sphincter mechanism and create proximal posterior urethral sphincter (bladder neck) incompetence and consequent incontinence (fig. 7). 2) Urinary leakage along a fistulous track which bypasses the bladder neck mechanism may suggest erroneously that this sphincter is incompetent (fig. 8). Unless the nature of this situation is identified accurately, urinary diversion may be undertaken on the supposition of total sphincter incompetence. 3) Once established as a sizable epithelialized track, false passages into the bladder base are likely to require resolution at the time of urethral repair, either because they short-circuit the bladder neck
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
567
Fm. 6. A, long supramembranous stricture 6 years in duration surrounded by dense pelvic floor fibrosis, containing infected pockets and rectal fistula. This patient had ~tenosed i1;Iay urethroplasty at time of reference. Situation was resolved by transpubic exposure, excision of extens1".E: fibros_is, bulboprostauc reanascomos1s and omental support replacement of excised tissue and rectal closure. B, result after transpub1c repair and omental support. SPHINCTER MECHANISMS AND POSTERIOR URETHROPLASTY
Fm. 7. Short supramembranous pelvic fracture urethral injury associated with 2 false passages resulting from treatment by repeated dilation. True prostatic urethra is not easy to identify since it lies between the 2 false passages.
mechanism or because they collect calculous debris. When a false passage emerges close to the internal urethral meatus it traverses the bladder neck mechanism and great care must be taken to avoid further damaging the sphincteric function of this area. When the false passage is large and irregular or the function of the bladder neck mechanism obviously is impaired there is no alternative to excising it with an attempt at bladder neck reconstruction; otherwise simple curettage of its epithelial lining may be preferable in the hope that it will close itself. 4) When a paraurethral bladder base fistula exists it is most important that the true posterior urethra is identified accurately for urethral reconstruction. This should involve the unequivocal identification of the verumontanum or the visualization of the internal urethral meatus, either dior suprapubic cystoscopy. We have seen several examples urethral reconstruction to a false passage.
A urodynamic appreciation of sphincter function may be critical to the continent result of a posterior urethroplasty in difficult cases. 9 • 10 Competence of the bladder neck sphincter is essential to urinary continence when the distal sphincter is destroyed by a severe membranous urethral injury. This competence is not only dependent upon its anatomical and physio logical normality but also upon the stability of the detrusor because an entirely normal bladder neck mechanism is rendered incompetent when uninhibitable detrusor-trigonal contractions occur between voiding. 11 The effective functional length of the bladder neck mechanism extends throughout the proximal half of the posterior urethra, down to the level of the verumontanum, so that damage to this during the immediate management of a urethral injury, the definitive repair of a resulting stricture, or a subsequent bladder neck or prostatic operation, must carry the risk of urinary incontinence. Although the function of the bladder neck is critical to continence after surgical repair of a supramembranous traumatic stricture it is often difficult to assess preoperatively, particularly when urethral continuity is lacking. It obviously is reassuring if a cystogram shows the bladder neck to be closed at rest and to open as the patient attempts to void; however, it can appear patulous on this examination (fig. 9) and even equivocal on direct examination at the time of operation but, yet, subsequently prove competent. On 3 occasions in our transpubic series we have found the bladder neck to be rigid and wide open at the time of operation, as a result of its encasement by dense surrounding hematoma fibrosis. In 2 of these cases satisfactory function was restored by simple mobilization with excision of the anterolateral part of incarcerating fibrosis and its replacement by the supple support of an omental pedicle graft. In general, therefore, in the absence of gross intrinsic bladder neck scarring we avoid any attempt at bladder neck reconstruction at the time of stricture repair, preferring to observe progress and to re-evaluate the situation objectively urodynamically at a later time if necessary. If an attempt at restora-tion of bladder neck function proves necessary the best ap--
568
TURNER-WARWICK
Fm. 8. A, pelvic fracture ure~hral stricture 4 years after injury. Patient voided witl?- precarious .c?ntinence through~ bl~dder base fistulas into pelvic floor cavity. Prostatic urethr8: was normal.but.was not demonstrated on t~s x-ra;r., Posit10n ?fbladder ne~k mdi~t~ by arrow. It was repaired by transpubic bulboprostatic anastomosis with omental support after wide excis10n of pelvic floor fibrosis and its mfected stonecontaining tracks. B, result after transpubic repair and omental support.
the urethra is not too extensively involved in periurethral fibrosis. Sadly, one of the more common causes of bladder neck incompetence in stricture cases is still its erroneous surgical ablation, undertaken as a result of the misconception that the endoscopic appearance of hypertrophy of a bladder neck indicates that it is obstructive, when in fact it is merely part of a global detrusor hypertrophic response to the distal urethral stricture obstruction. 9 Unfortunately, many instances of this still occur in clinical practice and it is even advocated in current urological literature. An accurate diagnosis of bladder outflow obstruction must be based on urodynamic evaluation, endoscopic appearances alone being insufficient; 9 the practical observance of this truth is fundamental to good urological practice and particularly essential to the management of complex posterior urethral problems. Fortunately, traumatic injuries to the bladder neck often involve only a part of its circumference. Thus, a nearby false passage may affect only a quarter of its circumference and even the damage resulting from an erroneous transurethral resection of the bladder neck may be partial because it is technically easier to resect between the 3 and 9 o'clock positions. Consequently, it is sometimes possible to achieve a reasonable anatomical reconstruction by excising the scarred area on the basis of an elongated diamond-shaped incision extending from the verumontanum well into the bladder base and reapproximating the bladder neck margins as tightly as possible around a 12F urethral stent. COMPLICATIONS OF EARLY MANAGEMENT
Fm. 9. It is often difficult to evaluate function of bladder neck sphincter before repairing posterior urethral pelvic fracture stricture. In this case it was perfectly functional but overshadowed by paraurethral pockets in pelvic floor hematoma fibrosis.
proach to this in the male patient is usually transvesical and the re-exposure required for this is greatly facilitated by omental wrapping of the initial procedure. 3 When the proximal posterior urethral mechanism is obviously destroyed, by a previous prostatectomy for instance, a stricture in the membranous urethra is usually best treated by dilatation or urethrotomy rather than urethroplasty. 7 However, if dilatation proves impossible a simple resleeving "push in" bulboprostatic anastomosis (a modified Badenoch-SolovowMichelowsky procedure) 12 or a free patch graft is preferable to a formal bulboprostatic anastomosis in the hope of preserving the remnants of the distal sphincter function when this area of
All methods of treatment must carry some risk of complication. The potential complications of some routine procedures must be recognized if they are to be used with safety for posterior urethral injuries. Indwelling standard-shaft urethral catheters. In the supposed absence of a urethral injury the immediate day-to-day management of a pelvic fracture is often facilitated by urethral catheter urinary drainage. The fact that a catheter is passed into the bladder does not exclude an unsuspected partial urethral injury. The presence of a standard-shaft catheter within the urethra, even one of relatively small diameter, tends to obstruct the drainage of the urethral injury exudates from the peri-catheter space (fig. 10, A) and creates a real risk that the accumulation of these will become infected and compromise the urethral healing. Contrast radiography. When the urethra is injured the complications that may result from simple observation of the
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
clinical progress make further investigation and treatment mandatory despite the fact that diagnostic techniques themselves carry some risk of complications. Extravasation of contrast medium from a retrograde urethrogram will identify a urethral rupture accurately but it usually does not distinguish between a partial and a complete lesion. The risk of this investigation is, of course, that all contrast materials are tissue irritants; not only should the extent of the contrast extravasation be reduced to a diagnostic minimum but it is most important that it should be aqueous based and as dilute as possible so that extravasations are rapidly dispersed and absorbed. If a viscid contrast medium extravasates it disperses slowly and may cause extensive tissue necrosis that certainly can affect the development of a stricture and its extent. Ideally, an emergency urethrogram and cystogram should be conducted under s
Vol. 118, October Printed in U.SA.
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES RICHARD TURNER-WARWICK From the London University Institute of Urology, St. Paul's Hospital and the Middlesex Hospital, London, England ABSTRACT
A distinction between simple and complex posterior urethral strictures is proposed. The development of a complex stricture, requiring an extensive transpubic repair, must be regarded as a less than admirable result of the initial treatment, even if it is occasionally inevitable. However, it is particularly important that our endeavors to improve the end result of the relatively rare severe urethral injuries should not result in over-management of the relatively common minor injuries, since this could increase the stricture potential of many. Therefore, we must keep our over-all concepts of the initial management of urethral injuries under careful review. Posterior urethroplasty should be regarded as a specialist procedure. It can be made to appear beguilingly simple but it cannot be recommended for occasional or general use. Even the relatively simple free patch graft technique is inadvisable for use in the sphincter area for surgeons who do not have considerable experience of it in the relatively forgiving bulbourethral area. The results of repair of posterior urethral strictures, even the complex ones, by anastomotic procedures can be excellent but real competence depends upon a particular aptitude of the surgeon for the minutiae of reconstructive techniques, appropriate training in a specializing department, a real ongoing numerical experience and special instrumentation with facilities for detailed urodynamic evaluation of this sphincter active area of the urethra. The outlook for the patient with a traumatic posterior urethral stricture has improved almost beyond recognition in the last decade as a result of the development of a variety of anastomotic techniques for urethral reconstruction. The combination of the relatively restricted surgical access together with its inherent sphincter function makes any reconstruction of the posterior (prostatomembranous) urethra a much more complicated procedure than the re-creation of the relatively simple subcutaneous conduit tube involved in anterior (bulbopenile) urethroplasty. The difficulties are compounded when a posterior urethral stricture is complex. The majority of pelvic fracture strictures are "simple" and, unlike the "complex" strictures, they are suitable for 1-stage perineal anastomotic or patch graft repair. The distinction between simple and complex posterior urethral strictures seems valid. Although the results of the transpubic anastomotic repair of complex strictures are remarkably good, i--4 it is a relatively formidable abdominoperineal procedure and the occasional need for it has focused attention upon the development and the prevention of these strictures. Some of these complex problems are the inevitable consequence of extensive damage; others can be avoided by appropriate management of the initial injury; however, they can also be created by the over-treatment of less severe injuries. Thus, even if inevitable, the development of a complex stricture must be regarded as a less then admirable outcome of initial management and one that we must endeavor to avoid as often as possible. Sphincter mechanisms extend throughout the length of the posterior urethra; any injury in this area must impair their function to some extent. From a purely urological viewpoint the primary concern of the initial and delayed treatment of such injuries is to avoid further injury to any of these mechanisms that have survived the original accident; now that a stricture-free result can almost always be achieved by one of a variety of procedures, the chief residual problem of posterior urethroplasty is sphincter deficiency incontinence. DEVELOPMENT OF POSTERIOR
URETHRAL
STRICTURES
AFTER
PELVIC FRACTURE INJURIES
In men the bladder base and the prostatic urethra tend to behave as a mechanical unit so that it is relatively rare for the Accepted for publication April 7, 1977. 564
prostatic urethra itself to be damaged in a pelvic fracture injury; thus, the primary urethral injury is usually in the supramembranous area at the apex of the prostate. The incidence of proximal posterior urethral damage seems to be higher in children; this may relate to the immaturity of the prostate. 5 The initial extent of prostatic dislocation resulting from a pelvic fracture may be considered broadly as minimal, moderate or severe. The urethra is only injured in the minority of cases and the damage is not severe in most of these so that, even when the rupture is circumferential, the initial dislocation of the urethral ends is often only 1 or 2 cm.; nevertheless, if these cases are inappropriately managed a complex stricture may result. Fortunately, severe urethral injuries, associated with a wide separation of the urethral ends by a massive pelvic hematoma, are rare; such injuries have a natural tendency to result in complex strictures at the final stage of healing but if they are properly identified and appropriately managed initially they can heal with no stricture or a short simple stricture that can be resolved by a relatively simple 1-stage perinea! procedure. The end result of a urethral injury cannot be assessed until the healing process is complete. The time necessary for healing is naturally dependent upon the extent of the lesion. After a relatively minor urethral injury the length of any resulting stricture is unlikely to shrink much after the first few months but the shrinking process of organization of a massive unevacuated hematoma associated with severe upward dislocation of the prostate is often incomplete at the end of a year. Irrespec-, tive of the method of the initial treatment and of the healing time involved, the various end results of posterior urethral injuries resulting from pelvic fractures can be summarized as indicated in figure 1. No stricture: no sphincter damage. Minor incomplete injuries of the supramembranous urethra may heal without a stricture and without a compromising degree of damage to the intrinsic mechanism of the distal urethral sphincter. No stricture: distal sphincter damage. Scarring of the supramembranous urethra may compromise the function of its intrinsic mechanism without creating a stricture. This impaired function is likely to pass unnoticed at the time but may be revealed by impaired urinary control after prostatectomy years later because, in the absence of a competent bladder
COIVlPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
the
565
control of urine is
stricture: little surrounding circumferential damage to the suprnm.embranous ,,,.,u.u~,,,,., results in a short supramernbranous stricthe efficiency of the intrinsic mechanism. Generally, short supramembranous strictures do not tend to be surrounded dense fibrosis, presumably because they usually result from minimal dislocation injuries that are not associated with large pelvic floor hematoma. However, when the initial injury was treated by primary reanastomosis, the tissues surrounding even a short stricture are sometimes quite densely scarred. Such strictures may be regarded as "simple". Complex posterior urethral strictures. Posterior urethral strictures may be regarded as complex for 3 main reasons: 1) strictures more than 2 cm. long and surrounded by dense fibrosis usually resulting from organization of a pelvic floor hematoma, 2) strictures, long or short, associated with extravasation diverticula, false passages or fistulas and 3) extensive sphincter damage involving the bladder neck and the distal intrinsic urethral mechanisms. Any complete urethral rupture may result in complete obstruction but this, in itself, does not add to the complexity of the repair. Any pelvic fracture may result in loss of potency; while this is serious for the patient it does not affect the surgical complexity of the stricture. It is important to consider the natural processes involved in the resolution of gross prostatic dislocation and the reabsorption of the mass of the pelvic floor hematoma separating the distracted urethral ends. Take an arbitrary example in which the initial urethral gap associated with a high rise "pie-in-the-sky" bladder is radioFm. 2. "Pie-in-sky" bladder upwardly dislocated by pelvic hematoma demonstrated by synchronous excretory urogram and retro-
grade uretlrrogram. END RESULT OF PELVIC FRACTURE URETHRAL lNJURIBS
No sphincter damage
No stricture
Sphincter damage
Sphincter damage
No stricture
& Short stricture
4
COMPLEX STRICTURES
d
Fm. l
graphically proved to be 10 to 15 cm. The natural contraction of an uninfected intervening blood clot reduces its size considerably in the first few weeks (fig. 2); its n1ass continues to shrink, progressively more slowly, for a year or more before the final state of organization of any residual hematoma re sults in a dense pelvic floor hematoma fibrosis around the prostate that ultimately may separate the proximal and distal ends of the urethra by 3 to 4 cm. or more. Thus, in the course of the first year of healing the bladder base gradually descends into the pelvis with a beguiling degree of reapproxirnation of the urethral ends. This descension is sometimes over-interpreted as a satisfactory resolution. Unfortunately, the distracted ends of a ruptured urethra do not possess a reliable "homing instinct", so that even quite short strictures may be malaligned and their interim management dilatation may prove difficult as a result. In practice an attempt to discontinue catheter drainage usually is made after a few weeks so that the patient then voids through the hematoma; voiding cystourethrography at this stage will often show nary extravasation into a pelvic floor cavity (fig. 3). The ultimate effect of this can sometimes be beneficial since part of the hematoma may be washed out. In other cases the restoration of early voiding creates tracks in the pelvic floor hematoma, which can persist as epithelialized diverticulations when the healing processes are complete 4). Such extravasation diverticula are not uncommon after severe injuries and they are themselves a potential source of "v''"I""·ac,w.w. 1) Calculi may develop or accumulate in them, the urine is infected. 2) Infection in them may result in urethral abscesses, the natural drainage of which can create fistulas into the perineum, the thigh or the rectum occasionally, even an osteomyelitic sinus into the pubic fracture. All of these tend to cause persistent urine infection and
566
TURNER-WAR WICK
unlikely to be self-resolving. 3) Paraurethral diverticula create natural false passages that greatly increase the difficulty of treating the almost inevitable resulting stricture by routine dilatation and energetic attempts to achieve this can create secondary false passages into the bladder base or the rectum. 3
PROGRESS OF HEALING OF SUPRA-MEMBRANOUS URETHRAL STRICTURE
URETHROCUTANEOUS FISTULAS
Infection associated with the traumatized pelvic floor tissue around a closed urethral injury may result in abscesses that track into the perineum or the inner aspect of the thigh, subsequently discharging to form persistent urinary fistulas. These fistulas rarely present a serious problem at the time of definitive bulboprostatic anastomosis, especially when omental support is used in association with a transpubic repair, because they usually heal once the fistulous communication with the urinary tract has been separated at its source and the tracks have been curetted. CHRONIC PERIURETHRAL ABSCESS WITH OSTEOMYELITIS
One patient in our series presented with bilateral infective branched renal calculi and a chronic urine infection dating from a pelvic fracture 20 years previously. The patient voided asymptomatically. Investigation showed an extensive paraurethral abscess freely communicating with extensive osteomyelitic cavities in the pubis and with the proximal posterior urethra (fig. 5); the distal posterior urethra was normal without stricture or sphincter damage. The situation was resolved simply by excision of the affected bone and paraurethral abscess and its replacement by an omental pedicle graft. RECTAL FISTULAS
Rectal fistulas may develop as a result of concomitant rectal injury at the time of the initial accident, rectal drainage of a subsequent paraurethral abscess or urethral instrumentation (fig. 6). Their repair in the final healed state does not usually add much to the resolution of a complex stricture by a transpubic bulboprostatic anastomosis when the omentum is used to support it. 3 • 8 However, it is important that any immediate defunctioning colostomy should use the pelvic colon in the left iliac fossa because a transverse colostomy adds considerably to the effort involved in mobilizing the omental pedicle for the definitive resolution of this complication at a later stage.
Fm.4
PARAURETHRAL BLADDER BASE FISTULAS
False passages into the bladder base can create serious problems, whether they arise as a direct result of the initial
Fm. 5. Chronic, infected bladder neck osteomyelitic sinus 20 years in duration resulting from fracture.
Fm. 3. Patient voiding freely through pelvic hematoma cavity after discontinuation of suprapubic cystotomy drainage 6 weeks after severe pelvic fracture urethral injury. Patient was continent at bladder neck level, cavity gradually reduced in size to form epithelialized paraurethral diverticulum and rather long fibrotic stricture, which later was resolved by transpubic anastomotic urethroplasty.
injury or as a consequence of misdirected urethral dilatation. 1) The close proximity of such a passage to the bladder neck may damage its sphincter mechanism and create proximal posterior urethral sphincter (bladder neck) incompetence and consequent incontinence (fig. 7). 2) Urinary leakage along a fistulous track which bypasses the bladder neck mechanism may suggest erroneously that this sphincter is incompetent (fig. 8). Unless the nature of this situation is identified accurately, urinary diversion may be undertaken on the supposition of total sphincter incompetence. 3) Once established as a sizable epithelialized track, false passages into the bladder base are likely to require resolution at the time of urethral repair, either because they short-circuit the bladder neck
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
567
Fm. 6. A, long supramembranous stricture 6 years in duration surrounded by dense pelvic floor fibrosis, containing infected pockets and rectal fistula. This patient had ~tenosed i1;Iay urethroplasty at time of reference. Situation was resolved by transpubic exposure, excision of extens1".E: fibros_is, bulboprostauc reanascomos1s and omental support replacement of excised tissue and rectal closure. B, result after transpub1c repair and omental support. SPHINCTER MECHANISMS AND POSTERIOR URETHROPLASTY
Fm. 7. Short supramembranous pelvic fracture urethral injury associated with 2 false passages resulting from treatment by repeated dilation. True prostatic urethra is not easy to identify since it lies between the 2 false passages.
mechanism or because they collect calculous debris. When a false passage emerges close to the internal urethral meatus it traverses the bladder neck mechanism and great care must be taken to avoid further damaging the sphincteric function of this area. When the false passage is large and irregular or the function of the bladder neck mechanism obviously is impaired there is no alternative to excising it with an attempt at bladder neck reconstruction; otherwise simple curettage of its epithelial lining may be preferable in the hope that it will close itself. 4) When a paraurethral bladder base fistula exists it is most important that the true posterior urethra is identified accurately for urethral reconstruction. This should involve the unequivocal identification of the verumontanum or the visualization of the internal urethral meatus, either dior suprapubic cystoscopy. We have seen several examples urethral reconstruction to a false passage.
A urodynamic appreciation of sphincter function may be critical to the continent result of a posterior urethroplasty in difficult cases. 9 • 10 Competence of the bladder neck sphincter is essential to urinary continence when the distal sphincter is destroyed by a severe membranous urethral injury. This competence is not only dependent upon its anatomical and physio logical normality but also upon the stability of the detrusor because an entirely normal bladder neck mechanism is rendered incompetent when uninhibitable detrusor-trigonal contractions occur between voiding. 11 The effective functional length of the bladder neck mechanism extends throughout the proximal half of the posterior urethra, down to the level of the verumontanum, so that damage to this during the immediate management of a urethral injury, the definitive repair of a resulting stricture, or a subsequent bladder neck or prostatic operation, must carry the risk of urinary incontinence. Although the function of the bladder neck is critical to continence after surgical repair of a supramembranous traumatic stricture it is often difficult to assess preoperatively, particularly when urethral continuity is lacking. It obviously is reassuring if a cystogram shows the bladder neck to be closed at rest and to open as the patient attempts to void; however, it can appear patulous on this examination (fig. 9) and even equivocal on direct examination at the time of operation but, yet, subsequently prove competent. On 3 occasions in our transpubic series we have found the bladder neck to be rigid and wide open at the time of operation, as a result of its encasement by dense surrounding hematoma fibrosis. In 2 of these cases satisfactory function was restored by simple mobilization with excision of the anterolateral part of incarcerating fibrosis and its replacement by the supple support of an omental pedicle graft. In general, therefore, in the absence of gross intrinsic bladder neck scarring we avoid any attempt at bladder neck reconstruction at the time of stricture repair, preferring to observe progress and to re-evaluate the situation objectively urodynamically at a later time if necessary. If an attempt at restora-tion of bladder neck function proves necessary the best ap--
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Fm. 8. A, pelvic fracture ure~hral stricture 4 years after injury. Patient voided witl?- precarious .c?ntinence through~ bl~dder base fistulas into pelvic floor cavity. Prostatic urethr8: was normal.but.was not demonstrated on t~s x-ra;r., Posit10n ?fbladder ne~k mdi~t~ by arrow. It was repaired by transpubic bulboprostatic anastomosis with omental support after wide excis10n of pelvic floor fibrosis and its mfected stonecontaining tracks. B, result after transpubic repair and omental support.
the urethra is not too extensively involved in periurethral fibrosis. Sadly, one of the more common causes of bladder neck incompetence in stricture cases is still its erroneous surgical ablation, undertaken as a result of the misconception that the endoscopic appearance of hypertrophy of a bladder neck indicates that it is obstructive, when in fact it is merely part of a global detrusor hypertrophic response to the distal urethral stricture obstruction. 9 Unfortunately, many instances of this still occur in clinical practice and it is even advocated in current urological literature. An accurate diagnosis of bladder outflow obstruction must be based on urodynamic evaluation, endoscopic appearances alone being insufficient; 9 the practical observance of this truth is fundamental to good urological practice and particularly essential to the management of complex posterior urethral problems. Fortunately, traumatic injuries to the bladder neck often involve only a part of its circumference. Thus, a nearby false passage may affect only a quarter of its circumference and even the damage resulting from an erroneous transurethral resection of the bladder neck may be partial because it is technically easier to resect between the 3 and 9 o'clock positions. Consequently, it is sometimes possible to achieve a reasonable anatomical reconstruction by excising the scarred area on the basis of an elongated diamond-shaped incision extending from the verumontanum well into the bladder base and reapproximating the bladder neck margins as tightly as possible around a 12F urethral stent. COMPLICATIONS OF EARLY MANAGEMENT
Fm. 9. It is often difficult to evaluate function of bladder neck sphincter before repairing posterior urethral pelvic fracture stricture. In this case it was perfectly functional but overshadowed by paraurethral pockets in pelvic floor hematoma fibrosis.
proach to this in the male patient is usually transvesical and the re-exposure required for this is greatly facilitated by omental wrapping of the initial procedure. 3 When the proximal posterior urethral mechanism is obviously destroyed, by a previous prostatectomy for instance, a stricture in the membranous urethra is usually best treated by dilatation or urethrotomy rather than urethroplasty. 7 However, if dilatation proves impossible a simple resleeving "push in" bulboprostatic anastomosis (a modified Badenoch-SolovowMichelowsky procedure) 12 or a free patch graft is preferable to a formal bulboprostatic anastomosis in the hope of preserving the remnants of the distal sphincter function when this area of
All methods of treatment must carry some risk of complication. The potential complications of some routine procedures must be recognized if they are to be used with safety for posterior urethral injuries. Indwelling standard-shaft urethral catheters. In the supposed absence of a urethral injury the immediate day-to-day management of a pelvic fracture is often facilitated by urethral catheter urinary drainage. The fact that a catheter is passed into the bladder does not exclude an unsuspected partial urethral injury. The presence of a standard-shaft catheter within the urethra, even one of relatively small diameter, tends to obstruct the drainage of the urethral injury exudates from the peri-catheter space (fig. 10, A) and creates a real risk that the accumulation of these will become infected and compromise the urethral healing. Contrast radiography. When the urethra is injured the complications that may result from simple observation of the
COMPLEX TRAUMATIC POSTERIOR URETHRAL STRICTURES
clinical progress make further investigation and treatment mandatory despite the fact that diagnostic techniques themselves carry some risk of complications. Extravasation of contrast medium from a retrograde urethrogram will identify a urethral rupture accurately but it usually does not distinguish between a partial and a complete lesion. The risk of this investigation is, of course, that all contrast materials are tissue irritants; not only should the extent of the contrast extravasation be reduced to a diagnostic minimum but it is most important that it should be aqueous based and as dilute as possible so that extravasations are rapidly dispersed and absorbed. If a viscid contrast medium extravasates it disperses slowly and may cause extensive tissue necrosis that certainly can affect the development of a stricture and its extent. Ideally, an emergency urethrogram and cystogram should be conducted under s
