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I\/IANAGEIVIENT OF RUPTURED POSTERIOR URETHRA IN CHILDHOOD R so MALEK,* Mo Jo O'DEA
AND
Po Po KELALIS
From the Section of Pediatric Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Seven boys with fracture(s) of the bony pelvis and associated partial or complete rupture of the posterior urethra were managed by the time-honored technique of early suprapubic cystostomy and concomitant primary realignment of the urethra over a catheter. Of the 4 children who had a functionally significant urethral stricture 3 were cured within a few months by 1 or 2 simple urethral dilatations and 1 by subsequent transperineal lysis of the angulated urethra from its surrounding fibrous tissue" Followup data for 8 to 22 years (mean 14 years) indicate that all 7 patients void with an excellent stream and are continent, free of infection and potent. In fact, 3 of the 4 married boys have fathered childreno Much controversy surrounds the choice of treatment for posterior urethral rupture" Of the 2 principal techniques we prefer the time-honored early primary realignment of the ruptured posterior urethra" Herein we present a 24-year experience (1950 to 1974) with 7 injured children managed in this manner Attention to technical details is supplemented by much needed long-term followup information on the endangered functions of the genitourinary tract in these children" O
tic in each instance (figo 1, B)o Failure in attempts to pass a urethral catheter in the remaining child together with the clinical features and roentgenographic evidence of pubic fracture was considered sufficiently diagnostic" TREATMENT
All 7 patients underwent retropubic exploration within 6 hours of the time of hospitalization" Additional perineal exploration also was necessary in 1 child with multiple tears of MATERIALS AND METHODS the urogenital diaphragm" Another patient with a lacerated The ages of 7 boys, all of whom were seen within 12 hours spleen underwent splenectomy at the same timeo Evacuation of from the time of injury, ranged from 6 to 15 years" The hematoma and removal of loose bony fragments encroaching presenting symptoms and signs are outlined in table L Acute upon the urethra or urogenital diaphragm were followed by lower abdominal signs were present in 5 children and included cystotomy and periurethral insertion of Davis interlocking tenderness to palpation, rebound tenderness and rigidity" A sounds or rubber catheters in antegrade and retrograde fashpalpable suprapubic mass was present in 3 patients and ions" Care was taken not to bypass any of the longitudinal or tuconsisted of retained urine and extravasated blood" A high- bular segments or cuffs of the torn or avulsed urethra. lying prostate was not palpable by digital rectal examination in Five boys had suffered from complete avulsion and 1 from 4 older boys" The causes of injury are summarized in table 2, partial rupture of the prostatomembranous urethra (supradiawith automobile accident being the most common (4 of 7 cases)" phragmatic) 0 In the remaining child the urogenital diaphragm More than 1 associated bony injury involving the pelvic girdle had sustained multiple tears involving the prostatomembraand limbs or the clavicle was found in all 7 children" Every nous urethra, which itself had been severed partially at its child had fracture(s) of the bony pelvis" Most frequently the junction with the bulbous urethra (infradiaphragmatic)o Urepubic rami were fractured (bilaterally in 3 patients) and less thral realignment was achieved over a suitably small Foley often the ischium, sacrum or sacroiliac joint was fractured or catheter (10 to 22F) in the first 6 patients and a polyethylene dislocated" Wide separation of the symphysis pubis, which was tube in the last one" The tips of these catheters were secured to apparent in 6 children, was among the most obvious telltale a silk suture whose long end was brought out of the bladder roentgenographic signs" Additionally, l had a lacerated alongside a suprapubic cystostomy tube and tied over a small rubber or gauze cylinder on the abdominal walL This precauTwo 'Nere in shock and each responded to blood tion was taken to prevent inadvertent premature removal or volun1e restoration. Preoperative diagnosis was urethrai injury accidental falling out of the urethral catheter. Furthermore, period, it would allow for safe with-and 3 patients had been transferred to our emergency room during the nn,Rnarn°r~ with an indwelling urethral catheter. The tip of each catheter drawal of a plugged urethral catheter together with a part of was actually in the periprostatic space and its balloon was the suture whose proximal portion would be retained in the palpable rectally in 2 cases (fig" 1) 0 In 4 of 5 children who lumen of the healing urethra and, thus, act as an invaluable underwent excretory urography the presence of a high- guide for insertion of a new catheter (figo 4)0 riding or deformed (inverted teardrop-shaped) bladder, upWith adequate mobility of the prostate having been ensured, wardly displaced because of rupture of the puboprostatic the torn prostatomembranous urethral ends were apposed in ligaments and compressed by pelvic hematoma, was highly the first 6 patients by traction on the urethral catheter whose suggestive of the diagnosis (fig" 2)" One patient underwent inflated balloon (5 to 30 ml.), in turn, impinged on the vesical conventional retrograde urethrography (fig" 3) 0 In 5 others neck In 1 of these patients additional stabilization was retrograde urethrocystography with a catheter was attempted achieved by placing sutures at the lateral aspects of the and typical extravasation of the contrast medium was diagnos- prostate near its apex and tying them externally onto the perineum (the so-called Vest sutures)" The remaining child with multiple tears of the urogenital diaphragm and bulAccepted for publication May 14, 1976" bomembranoprostatic urethral rupture was managed by a Read at annual meeting of American Urological Association, Las combined retropubic and perinea! exploration with direct Vegas, Nevada, May 16-20, 1976" * Requests for reprints: Mayo Clinic, 200 First SL, So WO, Rochester, suture anastomosis of the urethral ends over a polyethylene Minnesota 5590L catheter" No traction was used in this case but the urethral 105
106
MALEK, O'DEA AND KELALIS
catheter in the first 6 children was maintained on gentle traction (225 to 450 gm.) at a 45-degree angle from the horizontal for 4 to 7 days, during which time the patients were bedridden (fig. 4, B). Subsequently, all urethral catheters were removed 4 to 6 weeks postoperatively. The ability to void spontaneously and satisfactorily was then tested by clamping the suprapubic cystostomy tube followed by its removal 2 days later in the absence of significant residual urine, fever or urinary leakage around the tube while it was clamped. Urinary infection at this stage and subsequently was vigorously treated with bactericidal antibiotics, thus sterilizing the tubefree urinary tract.
significant posterior urethral stricture was a late complication in 4 children and required 1 or 2 urethral dilatations from 3 to 6 months later. Of these children 3 were cured in this manner and 1 achieved trouble-free voiding only after dense periurethral fibrous tissue and the so-called Vest sutures, which caused prostatomembranous urethral angulation, were lysed perineally 8 months after the initial operation. All 7 patients are continent, have no urinary infection and can void with an excellent stream (figs. 1, C, 2, B and 3, B). Potency-defined as the ability to acquire and adequately maintain an erection-and seminal ejaculation have developed normally in all patients. Of the 4 boys who have married 3 have fathered children.
RESULTS
A urethral fistula was the only early postoperative complication and that closed spontaneously in 4 weeks. All 7 children were followed for 8 to 22 years (mean 14 years). A functionally TABLE
1. Presenting signs and symptoms in 7 patients with ruptured posterior urethra Signs and Symptoms
No. Pts.*
Acute urinary retention Acute lower abdominal signs Prostate not palpable Shock Blood at urethral meatus Contusions of lower abdomen Perinea! hematoma Suprapubic mass
7 5 4 3 2
2 2
3
* All 7 patients had more than 1 form of presentation. TABLE
2. Causes of injury resulting in ruptured posterior urethra Causes of Injury Automobile accident Crush injury Fall
No. Pts. 4 2 1
DISCUSSION
Rupture of the prostatomembranous urethra is encountered in 5 to 25 per cent of individuals who sustain fracture(s) of the bony pelvis or a symphyseal diathesis (or both). 1 • 2 The wide or subtle separation of the symphysis pubis followed by concomitant forward or backward movements of the pubic bones and their attached puboprostatic ligaments shear the prostate partially or completely off the relatively immobile membranous urethra (supradiaphragmatic rupture). The ligaments are frequently torn, allowing the prostate to be pulled up by the bladder and later pushed up by pelvic hematoma (6 cases). Infrequently, the rigid and fixed urogenital diaphragm also is torn. The tear(s) may extend into the enclosed membranous urethra and may be accompanied by an infradiaphragmatic bulbomembranous urethral avulsion (1 caf;e). Characteristically, a child who has sustained such injuries presents with urinary retention and lower abdominal symptoms and signs. Despite earlier claims the presence of blood at the urethral meatus is an infrequent index of posterior urethral injury. More reliably, an impalpable or barely palpable prostate in older boys that rises high in the pelvis and thereby occasionally allows the examining finger to reach abnormally the deep posterior aspects of the pubic bones or to feel the
FIG. 1. Adolescent boy with splenic laceration, fractured bony pelvis and ruptured posterior urethra sustained in car accident. A, IVP. B, retrograde urethrogram. Note distended high-riding bladder and extravasated contrast medium injected via Foley catheter (balloon is in periprostatic space above urogenital diaphragm). (From Emmett, J. L. and Witten, D. M.: Clinical Urography: An Atlas and Textbook of Roentgenologic Diagnosis, 3rd ed. Philadelphia: W. B. Saunders Co., vol. 3, p-. 1753, 1971. By permission.) C, retrograde urethrogram 2 years after primary realignment shows minor deformity in membranous urethr'a. Patient is free of trouble.
RUPTURED :?OSTERIOR URETHRA
107
FIG. 2. Eight-year-old boy with fractured bony pelvis and ruptured posterior urethra sustained in car accident. A, IVP shows normal upper urinary tract. Bladder is compressed by pelvic hematoma and rides high in pelvis (inverted teardrop-shaped). Note fractures of left lower hemipelvis. Tip of urethral catheter is in periprostatic space to right of midline. B, normal retrograde urethrogram 1 year after primary realignment.
FIG. 3. Eight-year-old boy with fractured bony pelvis, disruption of urogenital diaphragm and ruptured bulbomembranoprostatic urethra sustained in car accident. A, IVP and retrograde urethrogram disclose normal lower ureters, high-riding distended bladder and supradiaphragmatic as well as infradiaphragmatic (perinea!) extravasation of contrast medium. (From Emmett, J. L. and D. M.: Clinical Urogrn.phy: An Atlas and Textbook of Roentgenologic Diagnosis, 3rd ed. Philadelphia: W. B. Saunders Co., vol. 3, p. 1752, By permission.) B, retrograde urethrogram 7 years after primary realignment reveals minor deformity (arrow).
balloon of a misplaced catheter is a specific finding. An occasional perineal hem.atom.a usualiy results from injury to the urogenital diaphragm or infradiaphragmatic bulbous urethra (or both). Rarely, it may result from unusually massive bleeding associated with supradiaphragmatic prostatomembranous urethral rupture, which later may track down the inguinal canal and become evident perineally. As many as 40 per cent of children who have sustained serious genitourinary trauma may have other non-urologic injuries 3 (100 per cent in this series) and, thus, a multidisciplinary approach to their management i~ a prerequisite to proper decision making and establishment of therapeutic priorities. Maintenance of adequate pulmonary function and restoration of blood volume along with treatment of other life and limbthreatening conditions are mandatory. Tetanus prophylaxis and broad-spectrum antibiotic coverage should be instituted appropriately. Since few children, if any, with posterior urethral injuries require immediate operation there is ample time
to Am-~~,m all the in most instances. Infusion IVP with tomography is necessary when to any of the urinary tract is suspected. In o.uuH,,vu to determining the status of the upper urinary tract, it often discloses the elevated and occasionally deformed (inverted teardrop-shaped) bladder (figs. 1, A and 2, A). The plain film reveals the bony injuries and the telltale sign of symphyseal separation. Diagnostic attempts to pass a urethral catheter and urethrocystography by this technique should be avoided. Only too often the catheter exits through the torn urethra to lie in the periprostatic region (fig. 1, A) and it may do more damage (for example, converting a partial to a complete tear) and introduce infection. Rt:trograde urethrography under sterile conditions by placement of the nozzle of a syringe just inside the meatus and injection of an intravenously administrable contrast medium is preferable. It can clearly outline, in addition to the posterior urethral injuries, any anterior urethral injuries that
108
MALEK, o'DEA AND KELALIS
FIG. 4. A, technique of primary urethral realignment. a, Davis male (urethral) sound is fitted into female (b_la~der) sound. Male sound is guided into bladder. b, catheter tip is attached to male sound and guided back into urethra. c, urethral cath~ter tip 1s detach_ed from sound ~nd sutured to tip of Foley catheter, which is guided transurethrally into bladder. B, completed ~rethral realignment. _Note silk suture securmg urethral catheter (tied over rubber tubing or rolled gauze on abdominal wall, not shown), which 1s kept on gentle tract10n at 45-degree angle. (By permission of W. B. Saunders Co. 9).
may indeed coexist and otherwise be missed. If the patient presents with an indwelling urethral catheter a peri-catheter urethrogram, made by injecting contrast medium through a ureteral catheter placed just inside the meatus alongside the urethral catheter, should first be attempted. In the unlikely event that the urethral catheter has properly traversed the injured urethra and entered the bladder (especially in the case of incomplete rupture), it should be left indwelling after retrograde . urethrocystography. Otherwise, it should be removed after adequate urethrographic studies to document the type and extent of the injury have been completed. Under these circumstances, typical periprostatic and subvesical extravasation becomes evident (figs. 1, B and 3, A). The much higher incidence of complete versus incomplete rupture in this series (6 to 1) agrees with the experience of Chambers and Balfour,• and Gibson 5 but not with that of Mitchell. 6 The controversy in management of the posterior urethral injuries currently surrounds 2 basically different methods: 1) early suprapubic cystostomy (without disturbing the retropubic hematoma) followed in 3 to 6 months by repair of the inevitable posterior urethral stricture and 2) concomitant 1-stage suprapubic cystostomy and urethral realignment with or without urethral suture anastomosis. The first method was introduced by Johanson 7 and has produced excellent results and found avid followers. 8 The second method is a time-honored technique, which also has produced excellent results•- 11 and was the method of repair in all 7 of our children. The technical details were described earlier in this paper; 6 of these patients were included in an earlier report of the incidence of urethral stricture. 10 The need for meticulous urethral realignment and use of an appropriately small silicone urethral catheter placed on gentle (225 to 450 gm.) traction at a 45-degree angle from the horizontal during the first 4 to 7 days of immobilization must be re-emphasized. Traction should be avoided in patients with tears of the urogenital diaphragm and, hence, lack of support· for the prostate, which may thus be pulled into an abnormal position (1 patient in this series). The result of using the socalled Vest sutures, as advocated by Turner-Warwick, 12 in 1 child was discouraging. Apparently, the resultant fixed angulation of the prostatomembranous urethra (in contrast to the less critical angulation of vesicomembranous urethral approximation with similar sutures after radical prostatectomy) produced a troublesome unresolving stricture that required surgical repair (lysis). Except for a temporary urinary fistula, the immediate postoperative course was unremarkable in our patients. The victims of posterior urethral rupture usually survive only to face a tragic series of life-long complications, including ure-
thral stricture and its sequelae, urinary incontinence and sexual impotence. These possibilities must be discussed frankly with the parents lest they blame the surgeon for the unfavorable outcome. The criteria for successful management are 1) satisfactory stream with freedom from stricture and urinary infection, 2) urinary continence and 3) sexual potency. In 4 of 7 children a functionally significant urethral stricture developed. However, 3 of these 4 boys were cured by 1 or 2 urethral dilatations and the remaining 1 by subsequent transperineal lysis of the angulated urethra from its surrounding fibrous tissue. Long-term (8 to 22 years) followup indicates that all criteria for successful management have been fulfilled in these 7 children. Our series is small and the eventual achievement of 100 per cent successful results with a minimum of morbidity is not comparable with the large number of adults who have sustained similar injuries and in whom the outcome has been less successful. 6 Perhaps future experience with a larger number of children will indicate that they are, with their superior capability for healing, among the more fortunate victims of such injuries. Despite opposing views as to the merits of primary realignment of the ruptured posterior urethra 8 this technique deserves serious consideration, at least in children. Meticulous attention to technical details and careful followup for several years to ensure freedom from functionally significant urethral stricture(s) and urinary infection are imperative. REFERENCES
1. Vermooten, V.: Rupture of the urethra, a new diagnostic sign. J. Urol., 56: 228, 1946. 2. Holdsworth, F. W.: Injury to the genito-urinary tract associated with fractures of the pelvis. Proc. Roy. Soc. Med., 56: 1044, 1963. 3. Javadpour, N., Guinan, P. and Bush, I. M.: Renal trauma in children. Surg., Gynec. & Obst., 136: 237, 1973. 4. Chambers, H. L. and Balfour, J.: The incidence of impotence following pelvic fracture with associated urinary tract injury. J. Urol., 89: 702, 1963. 5. Gibson, G. R.: Urological management and complications of fractured pelvis and ruptured urethra. J. Urol., 111: 353, 1974. 6. Mitchell, J.P.: Trauma to the abdomen: management of bladder and urethral injuries. Ann. Roy. Coll. Surg., 48: 13, 1971. 7. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technic. Acta Chir. Scand., suppl., 176, 1953. 8. Morehouse, D. D., Belitsky, P. and MacKinnon, K.: Rupture of the posterior urethra. J. Urol., 107: 255, 1972. 9. DeWeerd, J. H.: Management of injuries to the bladder, urethra and genitalia. Surg. Clin. N. Amer., 39: 973, 1959. 10. Myers, R. P. and DeWeerd, J. H.: Incidence of stricture following
RUPTURED FOST:SRIOE URETHRA
primary realignn1ent of the disrupted proximal urethra, J. Urol., 107: 265, 1972. lL Waterhouse, Kand Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. UroL, HH: 241, 1969. 12. Turner-Warwick, R T: Three approaches to the management of acute disruption of the membranous urethra. In: Current Controversies in Urologic Management. Edited by R Scott, Jr. Philadelphia: W. R Saunders Co., pp. 144~ 150, 1972. COMMENT This is a small group of children treated by the conventional method with a surprisingly successful outcome. The 15 adults treated at the Mayo Clinic by the same method produced only 2 failures. 10 It would at first seem to be a selected sample but this is not the case. Our
e:1::.perience in the last 6 years v;ith the conventional approach in children, 3 less than l year old, is much more discouraging. Those who advocate cystostomy with delayed elective urethroplasty'· 8 have ju.st as strong convictions for their method of treatment with impressive data also. The controversy is heated now and many urologists are confused. J. W.D.
REPLY BY AUTHORS Obviously, we cannot resolve the controversy. In our hands the conventional approach in children has worked well and we would continue to recommend it. It deserves emphasis that probably the single most important factor for a satisfactory outcome with this technique is an unangulated prostatomembranous urethral realignment as originally described by DeWeerd in 1959.'