Mamdouh M. Koraitim

PELVIC FRACTURE URETHRAL INJURIES: THE UNRESOLVED CONTROVERSY

PURPOSE The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.

Pelvic Fracture Urethral Injuries: Evaluation of Various Methods of Management

PURPOSE The results of various immediate treatments of urethral injuries complicating a fractured pelvis were evaluated. MATERIALS AND METHODS The records of 100 male patients with pelvic fracture urethral injury were reviewed, 73 of whom were treated by suprapubic cystostomy and delayed repair, 23 by primary realignment and 4 by primary suturing. Also, the findings of 771 patients reported in the literature were reviewed. RESULTS Urethral stricture was an almost inevitable consequence (97% of the cases) after suprapubic cystostomy. Primary realignment decreased the incidence of stricture to 53% but produced a 36% impotence rate. Primary suturing also decreased the incidence of stricture to 49% but produced the greatest complication rates for impotence (56%) and incontinence (21%). CONCLUSIONS Suprapubic cystostomy alone is indicated for incomplete urethral rupture, slight urethral distraction and critically unstable patients, and when there are inadequate facilities or inexperienced surgeons. Primary realignment is advised if there is wide separation of the urethral ends, or associated injury of the bladder neck or rectum. Primary suturing is not recommended for any condition.

The Lessons of 145 Posttraumatic Posterior Urethral Strictures Treated in 17 Years

We reviewed our experience with 145 posterior urethral strictures and disruptions complicating pelvic fracture urethral injury during 17 years. Stricture was corrected by optical urethrotomy in 12 cases, urethroscrotal inlay in 23, perineal anastomotic urethroplasty in 78 and transpubic urethroplasty in 32. Results were almost always successful after anastomotic urethroplasty, whether performed by the perineal (95%) or transpubic (97%) route. Therefore, this procedure deserves to be regarded as the gold standard for the treatment of posttraumatic posterior urethral strictures and disruptions. Urethral anastomosis should be attempted first through the perineum in every case, with the transpubic procedure done only when a tension-free bulbo-prostatic anastomosis could not be accomplished from below the stricture. Optical urethrotomy was successful (58%) in patients with mild strictures and a persistent opening between the bulbar and prostatic areas of the intact urethra. Therefore, this procedure should be reserved for such cases. Repeated urethrotomy of a long fibrous segment between a widely distracted prostatic and bulbar urethra would not only have a poor result but, by jeopardizing the elasticity of the anterior urethra, it also may undermine the chance for subsequent anastomotic urethroplasty. A urethroscrotal inlay procedure is doomed to failure in 57% of the cases and (with other substitution procedures) it should be restricted to strictures involving extensive segments of the posterior and/or anterior urethra. Sexual impotence usually (15%) resulted from the original pelvic fracture urethral injury and rarely (2.5%) from the urethroplasty itself.

POSTTRAUMATIC POSTERIOR URETHRAL STRICTURES IN CHILDREN: A 20-YEAR EXPERIENCE

PURPOSE We attempted to identify the particular features of strictures complicating pelvic fracture urethral injuries in children. MATERIALS AND METHODS A total of 68 boys 3 to 15 years old who had sustained pelvic fracture urethral disruption underwent 78 urethroplasties performed by bulboprostatic anastomosis through the perineum in 42, transpubically in 23 and by 2-stage urethroscrotal inlay in 13. RESULTS Perineal and transurethral urethroplasty was successful in 93 and 91% of cases respectively. There was a 54% failure rate after urethroscrotal inlay. CONCLUSIONS Urethral strictures were most commonly associated with Malgaignes fracture (35% of cases) and straddle fracture with or without diastasis of the sacroiliac joint (26%). Strictures were almost invariably inferior to the verumontanum with prostatic displacement in 44% of cases. Length of the strictured segment may be overestimated or underestimated on urethrography as a result of incomplete filling of the prostatic urethra or a urinoma cavity connected with the proximal segment, respectively. Perineal or transpubic bulboprostatic anastomosis is the best treatment for posttraumatic strictures, while internal urethrotomy should be avoided since it may compromise the chance of subsequent anastomotic urethroplasty. Repair of associated bladder neck incompetence may be deferred until the resumption of urethral voiding after urethroplasty, when incontinence can be documented.

The Male Urethral Sphincter Complex Revisited: An Anatomical Concept and its Physiological Correlate

PURPOSE The anatomy of the male urethral sphincter has not been stable since it was first described more than 150 years ago. Although 18th and 19th century historical descriptions of the urethral sphincter are most accurate and comprehensive, modern textbooks lack details and include inaccuracies and misleading illustrations. This is an attempt to achieve a revised concept of the male urethral sphincter complex. MATERIALS AND METHODS A thorough review of the English literature in the last 100 years, and of pertinent Germinal publications and textbooks of the 19th and 20th centuries was done. Also, we reviewed urodynamic findings in male patients in whom the urethral sphincters had been expectedly damaged in the proximal or distal part by surgery during the last 20 years. RESULTS The current concept of urethral sphincter anatomy does not differ much from that described and illustrated in the 19th century. The disagreement between the historical and recent descriptions is primarily concerned with the cranial extension of the skeletal muscle component and the caudal extension of the smooth muscle component in the urethral wall. CONCLUSIONS The male urethral sphincter complex is composed of an inner lissosphincter of smooth muscle and an outer rhabdosphincter of skeletal muscle. It extends in the form of a cylinder around the urethra from the vesical orifice to the perineal membrane. While the rhabdosphincter is most marked around the membranous urethra and becomes gradually less distinct toward the bladder, the lissosphincter has its main part at the vesical orifice and is thinner in its further course in the urethra. The lissosphincter is primarily concerned with the function of continence at rest. On the other hand, the rhabdosphincter has a dual genitourinary function, namely active continence during stress conditions and antegrade semen propulsion.

Failed posterior urethroplasty: lessons learned

OBJECTIVES To determine the factors contributing to unsuccessful results after posterior urethroplasty and to establish some guidelines for its prevention. METHODS From 1977 through 2000, 130 patients (3 to 58 years old) underwent 145 anastomotic urethroplasty procedures for post-traumatic posterior urethral distraction defects. Bulbo-prostatic anastomosis was performed through the perineum in 105 cases and by a perineo-abdominal transpubic procedure in 40. Factors that might have an impact on the surgical result, such as the size and type of sutures, urethral stents, and use of antibiotics were standardized. The records of all patients with unsuccessful results during a follow-up of 2 to 20 years were analyzed. RESULTS Overall, the results were unsuccessful in 12 cases (8%). A negative result was related to incomplete excision of the scar tissue in 3 cases, inadequate fixation of the prostatic mucosa in 6 cases, and anastomotic tension in 2 cases; 1 patient was lost to follow-up. Previous repair, length of distraction defect, and urinary infection had no statistically significant influence on the result. CONCLUSIONS The essential operative details of posterior urethroplasty include complete excision of scar tissue involving the membrano-prostatic region, lateral fixation of pliable prostatic mucosa, and creation of a tension-free anastomosis. If a tension-free anastomosis cannot be achieved through the perineum, the perineo-abdominal progressive approach or the elaborated perineal technique should be used at the same setting. Previous repair, a long distraction defect, and urinary infection do not preclude successful posterior urethroplasty.

Changing Age Incidence and Pathological Types of Schistosoma-Associated Bladder Carcinoma

PURPOSE The changes in certain characteristic features of schistosoma-associated bladder carcinoma are determined. MATERIALS AND METHODS A retrospective study was done of patients with schistosoma-associated bladder carcinoma treated between 1962 and 1967, and between 1987 and 1992. RESULTS Mean patient age increased from 47 +/- 13.6 to 53 +/- 12.2 years and the male-to-female ratio changed from 7.8:1 to 4.9:1. Tumors showed a decreased incidence of nodular (58.7% versus 83.4%) and squamous (54% versus 65.8%) cell types, and an increased incidence of papillary (34.8% versus 4.3%) and transitional (42% versus 31%) cell types. All changes were statistically significant (p < 0.05) and paralleled by an increased incidence of low degree schistosomal infestation from 18.6 to 47.8% (p < 0.05). CONCLUSIONS The shift in age incidence and pathological findings towards those of nonschistosomal cases could conceivably be attributed to the increased incidence of low infestation in recent years. The change in male-to-female ratio is probably due to more exposure of women to schistosomal infestation than has occurred previously.

Predictors of Surgical Approach to Repair Pelvic Fracture Urethral Distraction Defects

PURPOSE We identified preoperative factors predictive of the appropriate surgical approach to anastomotic repair of pelvic fracture urethral distraction defects. MATERIALS AND METHODS We reviewed the medical records and imaging studies of 121 patients who had undergone anastomotic repair of a pelvic fracture urethral distraction defect. The review was focused on 10 preoperative clinicoradiological variables that may influence or predict the surgical repair. The patients were categorized as having undergone a simple perineal operation (78 patients, group 1), or an elaborated perineal or a combined perineo-abdominal procedure (43 patients, group 2). Univariate and multivariate analyses were used to identify preoperative parameters predictive of the type of anastomotic repair. In addition, ROC analysis was used to assess prediction results of the multivariate analysis. RESULTS On univariate analysis 5 parameters were significant predictors of the type of repair, while on multivariate analysis only 3 parameters remained strong and independent predictors including the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index was a proxy for all other parameters. At a cutoff index of 0.35 the appropriate surgical repair was predicted with 91% specificity and a 95% positive predictive value. When ROC analysis was performed the AUC was 0.979. CONCLUSIONS The type of anastomotic repair of pelvic fracture urethral distraction defect can be predicted by 3 preoperative factors, namely the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index has the highest predictive accuracy and is a proxy for all other factors. An index less than 0.35 indicates a simple perineal operation and an index greater than 0.35 indicates an elaborated perineal or a transpubic procedure.

Gapometry and anterior urethrometry in the repair of posterior urethral defects.

PURPOSE We determined the influence of bulbar urethral length on the anastomotic repair approach to bulboprostatic urethral distraction defects. MATERIALS AND METHODS We reviewed the medical records and radiographic studies of 120 patients 6 to 52 years old who had undergone anastomotic repair of bulboprostatic urethral gaps. Repair was accomplished by a simple perineal operation in 84 patients (group 1) and an elaborated perineal or a transpubic procedure in 36 (group 2). The length of the urethral gap and bulbar urethra was measured on preoperative urethrogram. Also, the length of the urethral gap as a fraction of bulbar urethral length (index of elastic lengthening) was calculated. RESULTS Mean length of the urethral gap was 1.5 cm in group 1 vs 4.2 cm in group 2 (p <0.001). Mean bulbar urethral length was 7.3 cm in group 1 vs 6.6 cm in group 2 (p >0.05). The mean index of elastic lengthening was 0.21 (range 0.06 to 0.34) in group 1 vs 0.64 (range 0.38 to 0.88) in group 2 (p <0.001). The difference in the mean length of the urethral gap between children and adults in the 2 groups was not statistically significant (2.4 vs 2.5 cm, p >0.05), while the difference in the mean length of the bulbar urethra was highly significant (5.6 vs 7.7 cm, p <0.001). CONCLUSIONS Bulboprostatic urethral gaps shorter than a third of bulbar urethral length are usually corrected by a simple perineal operation. For longer gaps an elaborated perineal or transpubic procedure is usually done. Also, the latter 2 procedures are more commonly performed in children than in adults because of the shorter bulbar urethra.

Desire to Void and Force of Micturition in Patients with Intestinal Neobladders

PURPOSE We attempted to determine how patients with an orthotopic bladder perceive the desire to void and the force achieved to evacuate the bladder. MATERIALS AND METHODS A total of 24 men who had undergone post-cystectomy bladder substitution (ileocecal in 12, sigmoid in 6 and ileal in 6) was evaluated subjectively an objectively by pressure-flow study 1 to 3 years postoperatively. RESULTS Desire to void was felt at the base of the penis or in the perineum by 20 men (83%). Abdominal pressure contributed to intra-reservoir pressure by 51 to 54% in ileocecal, 20 to 24% in sigmoid and 23 to 25% in ileal neobladders. CONCLUSIONS Patients perceive the desire to void when drops of urine leak into the proximal urethra from an overfilled neobladder. Urine is evacuated mainly by abdominal straining for ileal neobladders, mainly by contraction for sigmoid neobladders, and by approximately equal contributions of contradiction and straining for ileocecal neobladders.