Top

Published in:

01-04-2020 | Urethral Injury | Original Article

Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury

Authors: Niels Vass Johnsen, Rachel A. Moses, Sean P. Elliott, Alex J. Vanni, Nima Baradaran, Garrick Greear, Thomas G. Smith III, Michael A. Granieri, Nejd F. Alsikafi, Bradley A. Erickson, Jeremy B. Myers, Benjamin N. Breyer, Jill C. Buckley, Lee C. Zhao, Bryan B. Voelzke, For the Trauma Urologic Reconstruction Network of Surgeons(TURNS)

Published in: World Journal of Urology | Issue 4/2020

Abstract

Purpose

To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success.

Methods

Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated.

Results

Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure.

Conclusions

Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

Webster GD, Selli C (1983) Management of traumatic posterior urethral stricture by one stage perineal repair. Surg Gynecol Obstet 156(5):620–624PubMed

Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP (2007) Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol 178(5):2006–2010. https://doi.org/10.1016/j.juro.2007.07.020(discussion 2010) CrossRefPubMed

Flynn BJ, Delvecchio FC, Webster GD (2003) Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol 170(5):1877–1880. https://doi.org/10.1097/01.ju.0000091642.41368.f5 CrossRefPubMed

Kizer WS, Armenakas NA, Brandes SB, Cavalcanti AG, Santucci RA, Morey AF (2007) Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol 177(4):1378–1381. https://doi.org/10.1016/j.juro.2006.11.036(discussion 1381-1372) CrossRefPubMed

Kulkarni SB, Barbagli G, Kulkarni JS, Romano G, Lazzeri M (2010) Posterior urethral stricture after pelvic fracture urethral distraction defects in developing and developed countries, and choice of surgical technique. J Urol 183(3):1049–1054. https://doi.org/10.1016/j.juro.2009.11.045 CrossRefPubMed

Morey AF, McAninch JW (1997) Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 157(2):506–510CrossRef

Mundy AR (2005) Anastomotic urethroplasty. BJU Int 96(6):921–944. https://doi.org/10.1111/j.1464-410X.2005.05774.x CrossRefPubMed

Koraitim MM (2012) Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology 79(4):912–915. https://doi.org/10.1016/j.urology.2011.11.054 CrossRefPubMed

Fu Q, Zhang YM, Barbagli G, Zhang J, Xie H, Sa YL, Jin SB, Xu YM (2015) Factors that influence the outcome of open urethroplasty for pelvis fracture urethral defect (PFUD): an observational study from a single high-volume tertiary care center. World J Urol 33(12):2169–2175. https://doi.org/10.1007/s00345-015-1533-4 CrossRefPubMedPubMedCentral

10.

Zou Q, Zhou S, Zhang K, Yang R, Fu Q (2017) The immediate management of pelvic fracture urethral injury-endoscopic realignment or cystostomy? J Urol 198(4):869–874. https://doi.org/10.1016/j.juro.2017.04.081 CrossRefPubMed

11.

Johnsen NV, Firoozabadi R, Voelzke BB (2019) Treatment discrepancy for pelvic fracture patients with urethral injuries: a survey of orthopaedic and urologic surgeons. J Orthop Trauma. https://doi.org/10.1097/bot.0000000000001482 CrossRefPubMed

12.

Chung PH, Wessells H, Voelzke BB (2017) Updated outcomes of early endoscopic realignment for pelvic fracture urethral injuries at a level 1 trauma center. Urology. https://doi.org/10.1016/j.urology.2017.09.032 CrossRefPubMedPubMedCentral

13.

Johnsen NV, Dmochowski RR, Mock S, Reynolds WS, Milam DF, Kaufman MR (2015) Primary endoscopic realignment of urethral disruption injuries: a double-edged sword? J Urol 194(4):1022–1026. https://doi.org/10.1016/j.juro.2015.03.112 CrossRefPubMed

14.

Tausch TJ, Morey AF, Scott JF, Simhan J (2014) Unintended negative consequences of primary endoscopic realignment for men with pelvic fracture urethral injuries. J Urol 192(6):1720–1724. https://doi.org/10.1016/j.juro.2014.06.069 CrossRefPubMed

15.

Moses RA, Selph JP, Voelzke BB et al (2017) An American Association for the Surgery of Trauma (AAST) prospective multi-center research protocol: outcomes of urethral realignment versus suprapubic cystostomy after pelvic fracture urethral injury. Transl Androl Urol. .https://doi.org/10.21037/tau.22017.21011.21007

16.

Gelman J, Wisenbaugh ES (2015) Posterior urethral strictures. Adv Urol 2015:628107. https://doi.org/10.1155/2015/628107 CrossRefPubMedPubMedCentral

17.

Nelson AK, Wessells H, Friedrich JB (2011) Review of microsurgical posterior urethral reconstruction. J Reconstr Microsurg 27(3):179–186. https://doi.org/10.1055/s-0030-1270535 CrossRefPubMed

18.

Kulkarni SB, Surana S, Desai DJ, Orabi H, Iyer S, Kulkarni J, Dumawat A, Joshi PM (2018) Management of complex and redo cases of pelvic fracture urethral injuries. Asian J Urol 5(2):107–117. https://doi.org/10.1016/j.ajur.2018.02.005 CrossRefPubMedPubMedCentral

19.

Shenfeld OZ, Kiselgorf D, Gofrit ON, Verstandig AG, Landau EH, Pode D, Jordan GH, McAninch JW (2003) The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol 169(6):2173–2176. https://doi.org/10.1097/01.ju.0000067660.51231.05 CrossRefPubMed

20.

Zuckerman JM, McCammon KA, Tisdale BE, Colen L, Uroskie T, McAdams P, Jordan GH (2012) Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries. Urology 80(6):1369–1373. https://doi.org/10.1016/j.urology.2012.07.059 CrossRefPubMed

21.

Culty T, Boccon-Gibod L (2007) Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol 177(4):1374–1377. https://doi.org/10.1016/j.juro.2006.11.092 CrossRefPubMed

22.

Singh BP, Andankar MG, Swain SK, Das K, Dassi V, Kaswan HK, Agrawal V, Pathak HR (2010) Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology 75(1):179–182. https://doi.org/10.1016/j.urology.2009.06.081 CrossRefPubMed

23.

Mundy AR (1999) Pelvic fracture injuries of the posterior urethra. World J Urol 17(2):90–95CrossRef

24.

Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR (2017) Cost-effective management of pelvic fracture urethral injuries. World J Urol 35(10):1617–1623. https://doi.org/10.1007/s00345-017-2022-8 CrossRefPubMed

25.

Wessells H, Angermeier KW, Elliott S, Gonzalez CM, Kodama R, Peterson AC, Reston J, Rourke K, Stoffel JT, Vanni AJ, Voelzke BB, Zhao L, Santucci RA (2017) Male urethral stricture: American Urological Association Guideline. J Urol 197(1):182–190. https://doi.org/10.1016/j.juro.2016.07.087 CrossRefPubMed

26.

Koraitim MM (2005) On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 173(1):135–139. https://doi.org/10.1097/01.ju.0000146683.31101.ff CrossRefPubMed

27.

Pratap A, Agrawal CS, Tiwari A, Bhattarai BK, Pandit RK, Anchal N (2006) Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol 175(5):1751–1754. https://doi.org/10.1016/s0022-5347(05)00974-2(discussion 1754) CrossRefPubMed

28.

Webster GD, Guralnick ML (2002) Reconstruction of posterior urethral disruption. Urol Clin North Am 29(2):429–441, viiiCrossRef

Title: Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury
Authors: Niels Vass Johnsen
Rachel A. Moses
Sean P. Elliott
Alex J. Vanni
Nima Baradaran
Garrick Greear
Thomas G. Smith III
Michael A. Granieri
Nejd F. Alsikafi
Bradley A. Erickson
Jeremy B. Myers
Benjamin N. Breyer
Jill C. Buckley
Lee C. Zhao
Bryan B. Voelzke
For the Trauma Urologic Reconstruction Network of Surgeons(TURNS)
Publication date: 01-04-2020
Publisher: Springer Berlin Heidelberg
Keywords: Urethral Injury
Urethral Stricture
Published in: World Journal of Urology / Issue 4/2020
Print ISSN: 0724-4983
Electronic ISSN: 1433-8726
DOI: https://doi.org/10.1007/s00345-019-02824-5

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 4/2020

Feasibility of holmium laser enucleation of the prostate as a 1-day surgery

Identification of ureteral stones at reduced radiation exposure: a pilot study comparing conventional versus digital low-dosage linear slot scanning (Lodox®) radiography

Role of phosphodiesterase inhibitors in stent-related symptoms: a systematic review and meta-analysis

Long-term oncologic outcomes of robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD): a multi-center study

Development of a model to predict prostate cancer at the apex (PCAP model) in patients undergoing robot-assisted radical prostatectomy

Effects of the addition of quantitative apparent diffusion coefficient data on the diagnostic performance of the PI-RADS v2 scoring system to detect clinically significant prostate cancer