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Pelvic Fracture Urethral Injury

Pelvic Fracture Urethral Injuries

When the male pelvis is fractured or crushed, there can be in some cases an associated injury to the urethra under the prostate where the urethra is torn. This can be a partial urethral tear, or more often, a complete urethral tear where the 2 ends separate. These pelvic fracture urethral injuries (PFUI) are most commonly from motor vehicle accidents but also are related to other causes of pelvic crush injuries such as work-related falls or other trauma. Although the “current terminology” is for this urethral trauma to be called a pelvic fracture urethral injury (PFUI), this injury has also been called a “prostatomembranous urethral injury” or a “pelvic fracture urethral distraction defect” or PFUDD, but patients think of it as a torn urethra that they want fixed!

Medical illustration of urethral tear

Fortunately, these injuries can be effectively repaired. Our Center has had a 21-year history of successfully repairing torn urethras with a 99+% technical success rate, including patients who had one or more failed surgeries by other Reconstructive or General Urologists, and then came to us for successful re-do surgery. Detailed information about our approach, which includes specialized instrumentation developed by Dr. Gelman to facilitate a successful repair, can be found in his most recently published surgical text book chapters on the subject:

This section of our educational website was written for men who suffered a urethral injury or tear, and want to know the best way to have pelvic fracture urethral injuries effectively evaluated and then permanently fixed so they can then urinate normally again. In addition, as more surgeons with an interest in urethroplasty attempt these repairs, we are seeing more men with one or more failed repairs who are then mistakenly told they have no further options but to repeatedly insert catheters into their urethras to keep the area of injury open so that they can urinate.

Initial Evaluation and Management of pelvic fracture trauma associated urethral injuries

In general, patients who suffer pelvic bone fractures from trauma are transported by ambulance to the nearest Emergency Room, and are found to have blood at the tip of the urethra. Appropriate evaluation is with a urethral imaging X-ray study retrograde urethrogram (RUG). This confirms the diagnosis.

Retrograde urethrogram after a pelvic trauma showing a urethral tear

This is a retrograde urethrogram (RUG) obtained after pelvic trauma associated with a pelvic fracture urethral injury. There is contrast extravasation seen during injection. What that means is that when contrast fluid is injected through the urethra, the contrast does not remain contained within the urethra, but instead escapes through the area of the tear into the surrounding tissues.

Men who suffer urethral injuries with complete tears are unable to urinate, and often have suprapubic tubes placed on an emergency basis after the injury. A suprapubic tube is a catheter that enters the bladder directly through the lower midline abdomen (in between the penis and belly button). The urine in the bladder can then pass through the tube into a collection bag, allowing the bladder to drain.

Suprapubic tube. This tube is placed through a small hole in the skin between the penis and umbilicus (belly button) and directly enters the bladder. A small balloon that is inflated at the tip of the catheter inside the bladder keeps the catheter from sliding out.

Medical illustration of a suprapubic tube inserted in bladder

In some cases when there is a torn urethra, Urologists will then perform a surgery called Primary Realignment. The objective is to negotiate a catheter through penis and then through the area of injury and into the bladder. It is thought that perhaps as the healing is occurring and the blood surrounding the injury (hematoma) gets reabsorbed back into the body, the presence of the stenting catheter bridging the gap will allow the ends of the urethra to come together so that when the catheter is removed, the urethra will remain open, and if not, this “realignment” will facilitate subsequent surgery. This is a topic of some controversy among Urologists. At the Center for Reconstructive Urology, we do not consider this technique to be curative when there are compete urethral tears as the result of a pelvic fracture related injury to the urethra. What is not controversial is that if a primary realignment is done, and the catheter eventually comes out, the urethra should not be repeatedly catheterized to “keep it open” in an effort to avoid surgical repair. This will not be curative and will delay curative treatment. In this video, one of our patients who suffered a pelvic fracture membranous urethral injury describes his experience with being advised that he needed to catheterize himself to keep his urethra open, as though there was not a curative alternative.

Delayed Repair of Pelvic Fracture Urethral Injuries

When men with urethral tears are referred to us, generally with suprapubic tubes, we advise that they wait approximately 3 months with the suprapubic tube before we proceed with surgical repair, called posterior urethroplasty. In some cases, men need to wait longer when they have other injuries (such as other bone fractures) that need to first heal more before we are able to do urethral surgery. During this time, the urethral tear seals off, and the swollen tissues surrounding the torn urethra become more normal. Since this bladder drainage tube is what allows the bladder to empty as the urethra is stabilizing in preparation for surgery, it is important that this tube be of proper size and location.

After the healing occurs, the urethra will no longer be torn. However, there will be an area of scar in the area of the urethral tear, and the 2 ends will not be connected. The main purpose of the delayed evaluation is to precisely determine the exact length and length and location of the defect in preparation for surgery. The evaluation of patients with posterior urethral disruptions includes imaging during the simultaneous injection of contrast through the urethra from below (called a retrograde urethrogram), and through a scope inserted through the tract established by the suprapubic tube from above (called a cystourethrogram). It is our preference to perform this testing in the operating room.

The following slide show provides pictures and information describing how we evaluate patients before surgery when the time is right to proceed.

Imaging used to determine location of the torn urethra

Imaging used to determine location of the torn urethra

This is an example of the urethal imaging we obtain of a pelvic fracture urethral injury after the tear has healed, and we are ready to proceed with a surgery called posterior urethroplasty to re-connect the urethra back together. The urethral X-ray imaging represents 2 types of imaging done at the same time. One is called a retrograde urethrogram (RUG) and the other is called a cystourethrogram. The prostate, that is just below the bladder, can't be seen on X-rays, but the urethra is normal as it passes through the prostate. The typical pelvic fracture urethal injury is just below the prostate where the 2 ends of the urethra are separated.

Injecting contrast in order to locate torn urethra

Injecting contrast in order to locate torn urethra

This is the technique we use to image pelvic fracture urethral injuries. We gently inject contrast through the opening of the urethra (using a specific technique developed by Dr. Gelman). This test is called a retrograde urethrogram (RUG). At the same time, a flexible scope is advanced though the tract into the bladder that was established from the suprapubic tube. The scope is then advanced through where the bladder meets the prostate (called the bladder neck) into the urethra that is surrounded by the prostate. As the RUG is being performed to visualize the urethra below the injury, contrast is also being instilled into the urethra within the prostate through the tip of the scope, which then backfills the bladder and outlines the normal urethra and bladder above the injury.

Simultaneous retrograde urethrogram and cystourethrogram

Simultaneous retrograde urethrogram and cystourethrogram

This picture is from another patient with a pelvic fracture urethral injury who underwent urethral imaging in preparation for his successful posterior urethroplasty, a surgery to repair the torn urethra and re-connect the 2 ends. Notice the scope. It is very easy to insert this scope into the bladder when a patient has had a suprapubic tube for at least 1 month. The balloon keeping the suprapubic tube in place in the bladder is deflated, the tube easily slides out, then then the scope (same diameter as the tube) slides into the bladder where we can then see the inside of the bladder and advance the scope to the proper location in the prostate area. Also note that these injuries are not where the bladder meets the prostate, but below the prostate where there is some healthy urethra between the bladder and the torn injured area.

Examples of imaging with no view of prostatic urethra

Examples of imaging with no view of prostatic urethra

Notice that in these images (not performed at the Center for Recontsructive Urology) the bladder is filled with contrast, but there is no filling of the urethra below the bladder. The problem with that technique is that you do not see any of the urethra between the bladder and the injured area. Where the bladder meets the prostate (called the bladder neck), the urethra is normally pinched off except during normal urination. That is a good thing as this allows a man to be totally continent even when their other sphincter (in the area of the membranous urethra) is damaged from the pelvic fracture urethral injury. However, when this poor technique is used, and the urethra within the prostate is not seen, doctors often mistakenly think the defect starts at the bladder and that the gap is longer than it really is.

Small pigtail suprapubic tube

Small pigtail suprapubic tube

This man underwent placement of a small "pigtail" suprapubic tube when he was in the emergency room shortly after his injury. These small tubes are easily inserted by interventional radiologists and accomplish the goal of providing a way for the bladder to empty. However, these tubes are too small, are not well secured (they can "fall out") and are usually not in the ideal location. When patients come to us with these tubes, we replace them with size 16 tubes, which drain better than pigtail catheters, are more comfortable than these rigid tubes, are less likely to become encrusted with stone fragments (as shown on the picture on the right) and are very easily changed.

Laterally placed suprapubic tube

Laterally placed suprapubic tube

When men with pelvic fracture urethral injuries are taken to the operating room for the initial placement of the suprapubic tube, perhaps with exploration at the same time for other injuries through a midline incision, the tube is often placed off to the side. The problem with the tube exiting in this location is that at the time of surgery to repair the urethra, certain instruments are used that enter from the channel that forms between the skin and the bladder. This will be better explained in the following section. For these instruments to be used, the established channel needs to be in the middle.

Low tube compared to suprapubic tube in proper position

Low tube compared to suprapubic tube in proper position

The picture on the left is of a suprapubic tube that is of appropriate size and in the middle. However, it is right over the bone and too low. In the picture on the right, you can see the tube reposition to the ideal proper location. The picture on the right demonstrates the position and size of the tube that is most appropriate. At our Center for Reconstructive Urology we use a very specific method to place tubes of size 16 French (which is around 16 mm circumference) in the ideal location without making an incision any larger than the size of the tube. Although one risk of this procedure is bowel injury, to date, we have placed over 1,500 suprapubic tubes without this complication or other complications.

Those patients who suffer traumatic urethral injuries often have associated vascular and nerve damage affecting the penis and urethra, and over half suffer erectile dysfunction as a result of the injury. We evaluate the vascular status prior to urethral reconstruction using an ultrasound test called a Penile Duplex. Most patients, even with some arterial compromise, have enough blood flow to have their urethras repaired without concern about proper healing. This test confirms adequate blood supply to the urethra. Occasionally, we document severe impairment, and in these cases, perform a revascularization procedure prior to urethral reconstruction so that the urethra will then have adequate blood supply at the time of repair. This is very rarely required.

In summary, when a man suffers a urethral tear, the initial management is placement of a bladder drainage tube called a suprapubic tube and patience is required as the tissues heal for at least 3 months. Then, before posterior urethoplasty surgery to repair the urethra, what is needed is:

The suprapubic tube to be at least size 16 and in the middle and at least 1 inch above the bone and for the tube to be in this location for at least 1 month prior to surgery.
All bone fracture damage to the pelvic has healed well enough that the legs can be positioned in stirrups as this position (called lithotomy) is used during surgery. In some cases, more than 3 months of physical therapy is needed before the orthopedic pelvic injuries are healed well enough for the urethral surgery to be scheduled.
Imaging has been performed from above and below at the same time in a very precise way to confirm that the injury is in the typical location and amenable to a surgery where the scar is removed and the severed ends of the urethra can then be re-connected.
The erectile function has been tested by a penile ultrasound (called a penile duplex) which is especially beneficial when there is erectile dysfunction caused by the pelvic fracture injury.

Posterior Urethroplasty

Our patients have the urine tested during the week prior to surgery and appropriate antibiotics are started prior to surgery based on urine culture results. In some cases, patients are admitted to the hospital the day prior to surgery to receive intravenous (IV) culture specific antibiotics. This is done because when patients have suprapubic tubes, the urine is generally contaminated with bacteria, and we want to take every precaution to prevent a wound infection and an associated breakdown of the repair. Although some may consider this “overkill”, we have seen patients who were not managed according to our protocol and suffered this devastating complication, and we have performed hundreds of perineal proximal reconstructive surgeries over the past 20 years without ever having an infection related failure.

The following slide show describes our approach to surgery.

Surgery table for exaggerated lithotomy positioning

Surgery table for exaggerated lithotomy positioning

The surgery is done with the patient in a position with the legs in stirrups. This is called the exaggerated lithotomy position. We use a custom designed table made specifically for lithotomy positioning by a company named Skytron (called the modified Skytron custom 6000 table) and this table has a pelvic tilt mechanism that cradles the pelvis and facilitates safe positioning. In addition, Dr. Gelman's stirrups were custom modified to his specifications to allow additional extension so that the knees and hips would not be excessively flexed. We are not aware of any other Center that has our identical unique setup.

Positioning prior to urethral stricture surgery

Positioning prior to urethral stricture surgery

The legs are very nicely padded to prevent pressure points. There is no pressure on the calves. One risk of surgery performed in the lithotomy position is nerve injuries to the legs or a vascular injury to the calves that is called compartment syndrome. We have seen patients who reported leaving the hospital with walkers or wheelchairs after surgery at centers without our modified custom equipment or who have developed compartment syndrome and required emergency surgery yet still had disability. To date, we have never had a patient who developed compartment syndrome or left the hospital needing assistance with walking.

Incision for urethroplasty and mobilization of the urethra

Incision for urethroplasty and mobilization of the urethra

During posterior urethroplasty to repair a pelvic fracture urethral injury, the incision is made under the scrotum and the urethra is detached from surrounding structures, which is called urethral mobilization. The area of injury is pointed out. At this level, the urethra is divided-transected, and what is generally seen is white dense scar tissue the has to then be carefully removed so that the healthy end towards the bladder can be seen. This is difficult surgery that can't be accomplished with a high success rate without specialized equipment and surgeon expertise.

Solid metal sound next to Gelman hollow urethroplasty sound

Solid metal sound next to Gelman hollow urethroplasty sound

What often guides the dissection through the area of scar towards the healthy end towards the bladder during urethoplasty surgery is the placement of a "U"shaped metal instrument called a sound through the hole that is a channel between the skin and the bladder where the suprapubic tube is located. This solid sound is blindly guided by feel through the bladder neck (the area where the bladder is connected to the prostate) and then the tip can be felt in the area of injury which guides the dissection. The problem is that sometimes the tip of the instrument can't be felt. As an advancement in surgical technique for posterior urethroplasty, Dr. Gelman developed a new urethroplasty sound that now prevents that invasive maneuver from ever being needed.

Flexible cystoscope being advanced through Gelman sound

Flexible cystoscope being advanced through Gelman sound

The Gelman sound is a hollow instrument to allow a flexible scope to be advanced through the sound so that the tip of the sound can be guided to the proper location under direct vision. Although major textbooks continue to mention the use of only solid sounds during surgery and the occasional need for a major incision in the bladder to facilitate identification of the urethra in the area of the prostate (called a temporary vesicostomy), with the use of the Gelman sound, we have not needed to perform a temporary vesicostomy for the past 18 years.

Posterior urthroplasty surgery with excision and primary anastomosis

Posterior urthroplasty surgery with excision and primary anastomosis

The picture on the left outlines the area of injury to the membranous urethra and the defect between the healthy ends of the urethra. Once the scar tissue is removed with the dissection guided by the Gelman sound, the ends are re-connected with fine sutures placed under optical magnification. The goal of posterior urethroplasty is to permanently fix the urethra by removing the scar between the severed ends of the urethra and precisely sewing the urethra back together.

Our patients are maintained with urethral catheters and suprapubic tubes for 3 weeks after surgery, and then return for an imaging test called a voiding cystourethrogram. In general, at that time, both tubes are then removed, and our patients resume normal urination without need for further intervention.

Retrograde urethrogram prior to surgery to repair pelvic fracture urethral injury
Retrograde urethrogram after surgery to repair pelvic fracture urethral injury

The image on the left was taken of one of our patients prior to surgery to repair his pelvic fracture urethral injury by a posterior urethroplasty. The image on the right was the post-operative imaging called a voiding cystourethrogram. This image after surgery was obtained by easily filling the bladder with contrast and then taking a film during urination. The image shows a wide open urethra and a “water tight” repair.

Our Outcomes with Posterior Urethroplasty

Posterior urethral reconstruction is a very difficult surgery. However, these injuries are amenable to repair with a very high success rate when properly performed and with custom specialized instruments. The outcomes are highly surgeon dependent. To date our technical success rate has been 99+% with up to 20-year follow-up. To clarify, we define success as a wide-open urethra that stays open when the catheter is removed after surgery without the need for catheters to ever then be inserted to “calibrate” or maintain the opening or “stabilize” the urethra. If any dilation or internal incision (called a urethrotomy) is needed to open back up the urethra after a repair, this means that the surgery failed. While it is true that recurrence of stricture is always a possibility, it should be a very uncommon occurrence. The most common cause of failure is inexperience of a surgeon who is not exclusively specialized in male urethral-genital reconstructive surgery. Patients who come to us for re-do surgery after 1 or more failed surgeries elsewhere can still be successfully fixed with a surgery that is generally even more complex than a first surgery. In general, it is our expectation that just about everyone who has a pelvic fracture urethral injury can undergo a successful repair and resume normal urination without the need for tubes or dilations or other intervention. There are exceptions, but these are very rare.

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