Functional Urology
Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome Mamdouh M. Koraitim and Mohamed I. Kamel* Department of Urology and *Occupational and Enviromental Medicine, College of Medicine, University of Alexandria, Alexandria, Egypt
Objective To determine perioperative factors that may optimize the outcome after delayed perineal repair of a pelvic fracture urethral injury (PFUI).
Patients and Methods
analysis, four variables were significant factors influencing the outcome: excision of scarred tissues, prostatic displacement, condition of the bulbar urethra and fixation of the mucosae. On multivariate analysis only two remained strong and independent factors namely complete excision of scarred tissues and prostatic displacement in a lateral direction.
In all, 86 consecutive patients who underwent perineal repair of a PFUI between 2004 and 2011 were prospectively enrolled in this study. The mean (range) patient age was 23 (5–50) years. The mean (range) follow-up was 5.5 (2–8) years. We examined seven perioperative variables that might influence the outcome including: prior failed treatment, condition of the bulbar urethra, displacement of the prostate, excision of scarred tissues, fixation of the mucosae of the two urethral ends, and the number and size of sutures used for urethral anastomosis. Univariate and multivariate analyses were used to identify factors that influence postoperative outcome.
Meticulous and complete excision of scar tissue is critically important to optimise the outcome after perineal urethroplasty. This is particularly emphasised in cases associated with lateral prostatic displacement. Six sutures of 3/0 or 4/0 polyglactin 910 are usually sufficient to create a sound urethral anastomosis. Prior treatment and scarring of the anterior urethra do not affect the outcome.
Results
Keywords
Of the patients, 76 (88%) had successful outcomes and 10 (12%) were considered treatment failures. On univariate
urethral injury, pelvic fracture, perineal repair, outcome
Introduction A post pelvic fracture urethral injury (PFUI) essentially is a fibrous segment formed between a potentially normal prostatic and bulbar urethra. Thus, resection of this segment and bulbo-prostatic urethral anastomosis is considered the ideal repair for these cases offering the highest rates of successful outcomes [1–7]. However, meticulous technique and careful attention to certain operative details are essential to achieve these success rates. It has been suggested that of these details three constitute the ‘golden triad’ contributing to a successful outcome, namely complete excision of scarred tissues, lateral fixation of mucosae of the two urethral ends and creation of a tension-free anastomosis [1]. Also, certain perioperative factors have been reported to affect the final result of the repair including urinary infection, types of sutures used for the anastomosis, and size and material of the urethral stent [8]. In addition, it has been claimed that prior treatment has a profound negative effect on the outcome of urethroplasty [8]. © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12679 Published by John Wiley & Sons Ltd. www.bjui.org
Conclusions
On the other hand, it has been found that the length of the stricture/distraction defect has only minimal influence on the results [8]. However, most of the reported studies were based on non-homogeneous series including strictures of different aetiology (inflammatory, post-traumatic, and iatrogenic) and location (penile, bulbar, and posterior urethra) that were corrected by various surgical techniques (anastomosis, substitution in one or two stages) and performed by more than one surgeon. In the present study, we attempted to determine the perioperative factors that might optimise the outcome after delayed perineal repair of a PFUI.
Patients and Methods All consecutive patients with PFUI who underwent delayed anastomotic repair between January 2004 and December 2011 at a single tertiary academic centre were prospectively enrolled in this study. Of 120 patients, 34 were excluded from the study because a tension-free anastomosis could not be
BJU Int 2015; 116: 265–270 wileyonlinelibrary.com
Koraitim and Kamel
achieved from the perineum, and the operation was progressed to a perineo-abdominal transpubic procedure. Overall 86 patients were included in this study. The mean (range) age of the patients was 23 (5–50) years. All patients had sustained a urethral injury associated with fracture of the pelvic bones caused by a motor vehicle in 75 (87%) patients, a fall from a height in six (7%) and collapse of a wall in four (5%). Another patient sustained a gunshot injury that caused posterior urethral disruption as well as a comminuted fracture of the ischiopubic ramus. All 86 patients presented with a suprapubic catheter in place, and 38 (44%) of them had undergone prior surgical attempts at cure, elsewhere. The intervals between original trauma and repair in new cases, and intervals since the last attempt at repair in recurrent cases varied from 6 to 20 months. Preoperative assessment included urine culture, plain and excretory urography, upand-down urethrography, urethroscopy and cystourethroscopy per pre-existing suprapubic tract. Also, 26 patients underwent MRI of the pelvis. Operative and Postoperative Data The operative technique has been previously described in detail [4]. Briefly, under epidural anaesthesia and with the patient in the lithotomy position, a midline perineal incision was made. The bulbar urethra was circumferentially mobilised proximally up to its blind proximal end, and the pathological fibrous segment was sharply dissected in continuity with the mobilised urethra (Fig. 1A). The urethra was transected at the proximal end of the fibrous segment, which led to the apex of the prostate. Then, the apex of the prostate was incised over the tip of a Van Buren sound passed down transvesically, the fibrosed prostatic apex was excised (Fig. 1B) and the two urethral ends were spatulated. On excising the fibrous Fig. 1 Perineal repair of posterior urethral distraction defect. A, scarred pathological segment (arrow) involves urethral gap and prostatic apex. B, complete excision of scarred tissue including the prostatic apex to a level just short of verumontanum (V). C, lateral fixation of mucosae of the bulbar (yellow) and prostatic (blue) urethral ends. Koraitim 2005 [4].
B
A
C
prostatic apex, including its adherent mucosa, the free edge of the healthy pliable mucosa has the tendency to retract proximally. Then, this edge was pulled down and anchored to the prostatic edge by 4–6 sutures of 4/0 chromic catgut (Fig. 1C). After circumferentially mobilising the bulbar urethra distally up to the penoscrotal junction, its end was trimmed and mucosa fixed to urethral wall. Then a tensionfree end-to-end urethral anastomosis was made over a silicone Foley catheter, 16 F for adults and 8–12 F for children. The operation was completed by inserting a suprapubic catheter through the tract ordinarily present in these patients. The urethral catheter was usually removed 3–4 weeks postoperatively after doing pericatheter urethrography to exclude leakage at the site of anastomosis. This was followed by voiding and retrograde urethrography and the suprapubic catheter was removed after confirmation of the absence of leakage or obstruction at the site of anastomosis. The postoperative data were collected by direct questioning and retrograde urethrography, when indicated, through office visits during the follow-up periods which ranged from 2 to 8 years (mean 5.5). In this study we adopted rather strict criteria for success vs failure. The result was classified as successful when the patient had no urinary symptoms, voided as before pelvic trauma and the urethrogram showed a wide calibre urethra at the site of repair. The need for periodic dilatation, direct optical urethrotomy or repeat urethroplasty was considered treatment failure [4]. Clinical Variables For every patient we examined seven perioperative variables that might influence the postoperative outcome. These variables included prior failed surgical repair, condition of the bulbar urethra (normal vs scarred), displacement of the prostate (no or superior displacement vs lateral displacement), excision of scarred tissues (complete vs incomplete), fixation of the mucosae of the two urethral ends, number of sutures used for urethral anastomosis, and suture size. The bulbar urethra was categorised as being scarred when it showed irregular outline and decreased expansion on urethrography, pale mucosa on endoscopy, or tough texture and loss of the normal pink colour during surgery. Excision of scarred tissues was considered complete when the distal end of prostatic urethra was healthy looking, no remnants of tough tissue and its mucosa was pliable. Statistical Analysis Univariate analysis using odds ratios (ORs) and Mantel Haenszel tests were used to assess the value of the investigated variables in the optimisation of the outcome. The significant factors were subsequently entered into multivariate analysis using a forward likelihood multiple logistic regression
266
© 2014 The Authors BJU International © 2014 BJU International
Perineal repair of pelvic fracture urethral injury
model to identify independent significant factors. All tests were two-sided with P < 0.05 considered to indicate statistical significance. All data were analysed using SPSSâ version 17.
Results Preoperative urethrography revealed a bulbo-prostatic urethral gap separating the two distracted urethral ends in all patients. The mean (range) length of the gap was 1.8 (0.9– 3.0) cm, which was confirmed during surgery. The mean (range) operative time was 3.5 (2.5–5.5) h and the mean (range) blood loss was 500 (300–1000) mL. There was no operative complication apart from temporary suprapubic leakage of urine, which was encountered in four patients. Patients were discharged home after 3 to 6 days. The postoperative results were successful in 76 (88%) patients and unsuccessful in 10 (12%). The results for the studied variables are shown in Table . On univariate analysis, four variables were found to be significant factors for a successful outcome: excision of scarred tissues, prostatic displacement, condition of the bulbar urethra and fixation of the mucosae of the two urethral ends. However, on multivariate analysis only two
variables remained strong and independent factors, namely excision of scarred tissues and prostatic displacement. The results of analyses showed that these two variables were significant with ORs of 122 and 34, respectively (Table ). The forward likelihood multiple logistic regression models succeeded in correctly predicting all (100%) successful cases and 90% of unsuccessful cases. When the model with the two factors combined was used for prediction of the outcome, the accuracy was 99%.
Discussion Excision of Scar Tissue In the present study, multivariate analysis showed good evidence for an independent effect of two variables, namely complete excision of scar tissue and lateral prostatic displacement on the outcome after perineal urethroplasty. Considering these two independent factors, together with the creation of a tension-free anastomosis, are prerequisite for a successful outcome. Notably, 90% of failed cases in this series had lateral prostatic displacement, as well as incomplete excision of scar tissue (Table ). The factor of complete
Table 1 Univariate analysis of perioperative factors that might optimise the outcome after perineal urethroplasty. Variables
Successful, n (%)
Failure, n (%)
OR (95% Cl)
34 (89) 42 (88)
04 (11) 06 (12)
0.824 (0.215–3.156) –
74 (93) 02 (33)
06 (07) 04 (66)
– 24.667 (3.725–163.333)
Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome Mamdouh M. Koraitim and Mohamed I. Kamel* Department of Urology and *Occupational and Enviromental Medicine, College of Medicine, University of Alexandria, Alexandria, Egypt
Objective To determine perioperative factors that may optimize the outcome after delayed perineal repair of a pelvic fracture urethral injury (PFUI).
Patients and Methods
analysis, four variables were significant factors influencing the outcome: excision of scarred tissues, prostatic displacement, condition of the bulbar urethra and fixation of the mucosae. On multivariate analysis only two remained strong and independent factors namely complete excision of scarred tissues and prostatic displacement in a lateral direction.
In all, 86 consecutive patients who underwent perineal repair of a PFUI between 2004 and 2011 were prospectively enrolled in this study. The mean (range) patient age was 23 (5–50) years. The mean (range) follow-up was 5.5 (2–8) years. We examined seven perioperative variables that might influence the outcome including: prior failed treatment, condition of the bulbar urethra, displacement of the prostate, excision of scarred tissues, fixation of the mucosae of the two urethral ends, and the number and size of sutures used for urethral anastomosis. Univariate and multivariate analyses were used to identify factors that influence postoperative outcome.
Meticulous and complete excision of scar tissue is critically important to optimise the outcome after perineal urethroplasty. This is particularly emphasised in cases associated with lateral prostatic displacement. Six sutures of 3/0 or 4/0 polyglactin 910 are usually sufficient to create a sound urethral anastomosis. Prior treatment and scarring of the anterior urethra do not affect the outcome.
Results
Keywords
Of the patients, 76 (88%) had successful outcomes and 10 (12%) were considered treatment failures. On univariate
urethral injury, pelvic fracture, perineal repair, outcome
Introduction A post pelvic fracture urethral injury (PFUI) essentially is a fibrous segment formed between a potentially normal prostatic and bulbar urethra. Thus, resection of this segment and bulbo-prostatic urethral anastomosis is considered the ideal repair for these cases offering the highest rates of successful outcomes [1–7]. However, meticulous technique and careful attention to certain operative details are essential to achieve these success rates. It has been suggested that of these details three constitute the ‘golden triad’ contributing to a successful outcome, namely complete excision of scarred tissues, lateral fixation of mucosae of the two urethral ends and creation of a tension-free anastomosis [1]. Also, certain perioperative factors have been reported to affect the final result of the repair including urinary infection, types of sutures used for the anastomosis, and size and material of the urethral stent [8]. In addition, it has been claimed that prior treatment has a profound negative effect on the outcome of urethroplasty [8]. © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12679 Published by John Wiley & Sons Ltd. www.bjui.org
Conclusions
On the other hand, it has been found that the length of the stricture/distraction defect has only minimal influence on the results [8]. However, most of the reported studies were based on non-homogeneous series including strictures of different aetiology (inflammatory, post-traumatic, and iatrogenic) and location (penile, bulbar, and posterior urethra) that were corrected by various surgical techniques (anastomosis, substitution in one or two stages) and performed by more than one surgeon. In the present study, we attempted to determine the perioperative factors that might optimise the outcome after delayed perineal repair of a PFUI.
Patients and Methods All consecutive patients with PFUI who underwent delayed anastomotic repair between January 2004 and December 2011 at a single tertiary academic centre were prospectively enrolled in this study. Of 120 patients, 34 were excluded from the study because a tension-free anastomosis could not be
BJU Int 2015; 116: 265–270 wileyonlinelibrary.com
Koraitim and Kamel
achieved from the perineum, and the operation was progressed to a perineo-abdominal transpubic procedure. Overall 86 patients were included in this study. The mean (range) age of the patients was 23 (5–50) years. All patients had sustained a urethral injury associated with fracture of the pelvic bones caused by a motor vehicle in 75 (87%) patients, a fall from a height in six (7%) and collapse of a wall in four (5%). Another patient sustained a gunshot injury that caused posterior urethral disruption as well as a comminuted fracture of the ischiopubic ramus. All 86 patients presented with a suprapubic catheter in place, and 38 (44%) of them had undergone prior surgical attempts at cure, elsewhere. The intervals between original trauma and repair in new cases, and intervals since the last attempt at repair in recurrent cases varied from 6 to 20 months. Preoperative assessment included urine culture, plain and excretory urography, upand-down urethrography, urethroscopy and cystourethroscopy per pre-existing suprapubic tract. Also, 26 patients underwent MRI of the pelvis. Operative and Postoperative Data The operative technique has been previously described in detail [4]. Briefly, under epidural anaesthesia and with the patient in the lithotomy position, a midline perineal incision was made. The bulbar urethra was circumferentially mobilised proximally up to its blind proximal end, and the pathological fibrous segment was sharply dissected in continuity with the mobilised urethra (Fig. 1A). The urethra was transected at the proximal end of the fibrous segment, which led to the apex of the prostate. Then, the apex of the prostate was incised over the tip of a Van Buren sound passed down transvesically, the fibrosed prostatic apex was excised (Fig. 1B) and the two urethral ends were spatulated. On excising the fibrous Fig. 1 Perineal repair of posterior urethral distraction defect. A, scarred pathological segment (arrow) involves urethral gap and prostatic apex. B, complete excision of scarred tissue including the prostatic apex to a level just short of verumontanum (V). C, lateral fixation of mucosae of the bulbar (yellow) and prostatic (blue) urethral ends. Koraitim 2005 [4].
B
A
C
prostatic apex, including its adherent mucosa, the free edge of the healthy pliable mucosa has the tendency to retract proximally. Then, this edge was pulled down and anchored to the prostatic edge by 4–6 sutures of 4/0 chromic catgut (Fig. 1C). After circumferentially mobilising the bulbar urethra distally up to the penoscrotal junction, its end was trimmed and mucosa fixed to urethral wall. Then a tensionfree end-to-end urethral anastomosis was made over a silicone Foley catheter, 16 F for adults and 8–12 F for children. The operation was completed by inserting a suprapubic catheter through the tract ordinarily present in these patients. The urethral catheter was usually removed 3–4 weeks postoperatively after doing pericatheter urethrography to exclude leakage at the site of anastomosis. This was followed by voiding and retrograde urethrography and the suprapubic catheter was removed after confirmation of the absence of leakage or obstruction at the site of anastomosis. The postoperative data were collected by direct questioning and retrograde urethrography, when indicated, through office visits during the follow-up periods which ranged from 2 to 8 years (mean 5.5). In this study we adopted rather strict criteria for success vs failure. The result was classified as successful when the patient had no urinary symptoms, voided as before pelvic trauma and the urethrogram showed a wide calibre urethra at the site of repair. The need for periodic dilatation, direct optical urethrotomy or repeat urethroplasty was considered treatment failure [4]. Clinical Variables For every patient we examined seven perioperative variables that might influence the postoperative outcome. These variables included prior failed surgical repair, condition of the bulbar urethra (normal vs scarred), displacement of the prostate (no or superior displacement vs lateral displacement), excision of scarred tissues (complete vs incomplete), fixation of the mucosae of the two urethral ends, number of sutures used for urethral anastomosis, and suture size. The bulbar urethra was categorised as being scarred when it showed irregular outline and decreased expansion on urethrography, pale mucosa on endoscopy, or tough texture and loss of the normal pink colour during surgery. Excision of scarred tissues was considered complete when the distal end of prostatic urethra was healthy looking, no remnants of tough tissue and its mucosa was pliable. Statistical Analysis Univariate analysis using odds ratios (ORs) and Mantel Haenszel tests were used to assess the value of the investigated variables in the optimisation of the outcome. The significant factors were subsequently entered into multivariate analysis using a forward likelihood multiple logistic regression
266
© 2014 The Authors BJU International © 2014 BJU International
Perineal repair of pelvic fracture urethral injury
model to identify independent significant factors. All tests were two-sided with P < 0.05 considered to indicate statistical significance. All data were analysed using SPSSâ version 17.
Results Preoperative urethrography revealed a bulbo-prostatic urethral gap separating the two distracted urethral ends in all patients. The mean (range) length of the gap was 1.8 (0.9– 3.0) cm, which was confirmed during surgery. The mean (range) operative time was 3.5 (2.5–5.5) h and the mean (range) blood loss was 500 (300–1000) mL. There was no operative complication apart from temporary suprapubic leakage of urine, which was encountered in four patients. Patients were discharged home after 3 to 6 days. The postoperative results were successful in 76 (88%) patients and unsuccessful in 10 (12%). The results for the studied variables are shown in Table . On univariate analysis, four variables were found to be significant factors for a successful outcome: excision of scarred tissues, prostatic displacement, condition of the bulbar urethra and fixation of the mucosae of the two urethral ends. However, on multivariate analysis only two
variables remained strong and independent factors, namely excision of scarred tissues and prostatic displacement. The results of analyses showed that these two variables were significant with ORs of 122 and 34, respectively (Table ). The forward likelihood multiple logistic regression models succeeded in correctly predicting all (100%) successful cases and 90% of unsuccessful cases. When the model with the two factors combined was used for prediction of the outcome, the accuracy was 99%.
Discussion Excision of Scar Tissue In the present study, multivariate analysis showed good evidence for an independent effect of two variables, namely complete excision of scar tissue and lateral prostatic displacement on the outcome after perineal urethroplasty. Considering these two independent factors, together with the creation of a tension-free anastomosis, are prerequisite for a successful outcome. Notably, 90% of failed cases in this series had lateral prostatic displacement, as well as incomplete excision of scar tissue (Table ). The factor of complete
Table 1 Univariate analysis of perioperative factors that might optimise the outcome after perineal urethroplasty. Variables
Successful, n (%)
Failure, n (%)
OR (95% Cl)
34 (89) 42 (88)
04 (11) 06 (12)
0.824 (0.215–3.156) –
74 (93) 02 (33)
06 (07) 04 (66)
– 24.667 (3.725–163.333)
