Straddle Injuries to the Bulbar Urethra: Management and Outcome
in 53 Patients
Mohammed Abd-alla Elgammal
Department of Urology, Assiut University Hospital, Assiut, Egypt
ABSTRACT
Objective:To describe our experience with blunt injuries to the bulbar urethra and their late sequelae to identify factors that may affect patient outcome.
Materials and Methods: A retrospective study was performed on 53 male patients who presented, between January 2001 DQG'HFHPEHUZLWKEOXQWWUDXPDWLFLQMXU\WRWKHEXOEDUXUHWKUD7KHGH¿QLWLYHGLDJQRVLVRIXUHWKUDOUXSWXUHZDVPDGH E\UHWURJUDGHXUHWKURJUDSK\ZKHUHXUHWKUDOUXSWXUHZDVFODVVL¿HGLQWRSDUWLDORUFRPSOHWH7KHPLQLPXPIROORZXSSHULRG ZDV\HDUV7KHLQLWLDOPDQDJHPHQWZDVHLWKHUVXSUDSXELFF\VWRVWRP\RUHQGRVFRSLFXUHWKUDOUHDOLJQPHQWRYHUDXUHWKUDO FDWKHWHUXVLQJDF\VWRVFRSHWRSDVVDJXLGHZLUHRYHUZKLFKWKHFDWKHWHUZDVLQVHUWHG6WULFWXUHIRUPDWLRQZDVPDQDJHG E\YLVXDOLQWHUQDOXUHWKURWRP\9,8IRUSDVVDEOHVWULFWXUHVDQGXUHWKURSODVW\VWULFWXUHH[FLVLRQDQGUHDQDVWRPRVLVIRU LPSDVVDEOHVWULFWXUHVRUUHFXUUHQFHDIWHU9,87KHIROORZXSSHULRGZDVWKUHH\HDUV7KHUHVXOWVZHUHDQDO\]HGE\6366 VRIWZDUHFKLVTXDUHDQG6WXGHQW¶VWWHVW
Results:6WULFWXUHIRUPDWLRQRFFXUUHGLQRISDWLHQWVZLWKFRPSOHWHXUHWKUDOUXSWXUHDQGLQRIZLWK
SDUWLDOUXSWXUHS6WULFWXUHVRFFXUUHGLQRISDWLHQWVWUHDWHGLQLWLDOO\ZLWKVXSUDSXELFF\VWRVWRP\DQG LQRIWUHDWHGZLWKSULPDU\XUHWKUDOUHDOLJQPHQWS7KHVXFFHVVUDWHDIWHU9,8ZDVRI SDWLHQWVDQGDIWHUXUHWKURSODVW\LWZDVRISDWLHQWVS
Conclusions:6XSUDSXELFF\VWRVWRP\LVEHWWHUWKDQXUHWKUDOUHDOLJQPHQWDQGFDWKHWHUL]DWLRQDVSULPDU\PDQDJHPHQWDIWHU
VWUDGGOHLQMXU\WRWKHEXOEDUXUHWKUD6WULFWXUHH[FLVLRQDQGUHDQDVWRPRVLVLVEHWWHUWKDQ9,8DVGHOD\HGPDQDJHPHQWIRU strictures that develop after straddle injury to the bulbar urethra.
Key words: urethra; trauma; rupture: management; reconstructive surgical procedures Int Braz J Urol. 2009; 35: 450-8
INTRODUCTION
%OXQWRUSHQHWUDWLQJWUDXPDPD\FDXVHDQ
terior urethral injuries. Blunt injuries are more com
PRQO\GLDJQRVHGDQGWKHEXOEDUXUHWKUDLVWKHPRVW IUHTXHQWO\LQMXUHGVHJPHQWEHFDXVHLWLV ¿[HGEHQHDWKWKHSXELFERQHXQOLNHWKHIUHHO\PR
bile pendulous urethra. Blunt injuries to the bulbar urethra are typically caused by straddle type injuries
HJPRWRUYHKLFOHDFFLGHQWVELF\FOHDFFLGHQWVIDOO LQJDVWULGHRQWRDIHQFHUDLOLQJRUVDGGOHRUNLFNV
WRWKHSHULQHXP7KHIRUFHFRQWDFWLQJWKHSHULQHXP FUXVKHVWKHEXOEDUXUHWKUDDJDLQVWWKHLQIHULRUSXELF UDPL OHDGLQJ WR FRQWXVLRQ RU XUHWKUDO ODFHUDWLRQ
(2).
0DQDJHPHQWRISDUWLDODQGFRPSOHWHGLVUXS
tions after blunt trauma to the bulbar urethra remains
FRQWURYHUVLDO7KHTXHVWLRQZKLFKLVKLJKO\GHEDWHGLQ
the literature is whether it is better to divert the urine
E\WUDQVXUHWKUDORUVXSUDSXELFFDWKHWHUL]DWLRQDIWHU LQMXU\WRWKHDQWHULRUXUHWKUD$QRWKHUTXHVWLRQLV
WKHEXOEDUXUHWKUDDUHEHVWWUHDWHGZLWKVXUJLFDOUHSDLU
or endoscopic urethrotomy.
Because only a few small series have been
SXEOLVKHG UHJDUGLQJ VWUDGGOH LQMXU\ RI WKH EXOEDU XUHWKUDZHUHYLHZHGWKHXURORJLFDOWUDXPDGDWDEDVH DWRXUGHSDUWPHQWWREHWWHUGH¿QHWKHFOLQLFDORXWFRPH
of these injuries.
MATERIALS AND METHODS
A retrospective study was carried out on 53 male patients who presented to our trauma unit be tween January 2001 and December 2005 with blunt traumatic injury of the bulbar urethra. No attempts
ZHUHPDGHWRFDWKHWHUL]HWKHSDWLHQWVLQWKHHPHU JHQF\URRP%ORRGDWWKHPHDWXVZDVWKHVLQJOHPRVW LPSRUWDQWFOLQLFDOGLDJQRVWLFVLJQRIXUHWKUDOLQMXU\ 7KHGH¿QLWLYHGLDJQRVLVRIXUHWKUDOUXSWXUH ZDV PDGH E\ UHWURJUDGH XUHWKURJUDSK\ &RPSOHWH XUHWKUDOUXSWXUHZDVGLDJQRVHGRQWKHDSSHDUDQFHRI
extravasation of contrast medium in the area of the
EXOEDUXUHWKUDRXWVLGHWKHFRUSXVVSRQJLRVXPZLWK QRFRQWUDVWHQWHULQJWKHSURVWDWLFXUHWKUDRUEODGGHU 3DUWLDOXUHWKUDOUXSWXUHZDVGLDJQRVHGRQWKHDSSHDU
ance of contrast extravasation in the area of the bulbar
XUHWKUDZLWKLQWKHFRUSXVVSRQJLRVXPZLWKFRQWUDVW HQWHULQJWKHSURVWDWLFXUHWKUDRUEODGGHU
$OOSDWLHQWVUHFHLYHGEURDGVSHFWUXPDQWL
biotics at induction of anesthesia. Either suprapubic
F\VWRVWRP\RUHQGRVFRSLFXUHWKUDOUHDOLJQPHQWZDV XVHGDVSULPDU\PDQDJHPHQW,QFDVHVRIHQGRVFRSLF XUHWKUDOUHDOLJQPHQWDF\VWRVFRSHZDVXVHGWRE\SDVV WKHUXSWXUHGVHJPHQWE\LQWURGXFLQJDJXLGHZLUH WKURXJKLWVFKDQQHOWRWKHEODGGHUDQGWKHQDVLOL FRQHFDWKHWHU)ZDVSDVVHGRYHUWKHJXLGHZLUH 8QGHUÀXRURVFRSLFJXLGDQFHFRQWUDVWPHGLXPZDV
injected into the catheter to verify its position inside
WKHEODGGHU6XSUDSXELFFDWKHWHUVZHUHOHIWLQGZHOO LQJIRUWKUHHZHHNVWKHQVSLJRWHGDQGLISDWLHQWV
could urinate freely, they were removed. If patients
FRXOGQRWXULQDWHUHHYDOXDWLRQRIWKHXUHWKUDXVLQJ DVFHQGLQJXUHWKURJUDSK\ZDVGRQH8UHWKUDOFDWKHWHUV DIWHUHQGRVFRSLFUHDOLJQPHQWZHUHOHIWLQSODFHIRU WZRDQGWKUHHZHHNVLQSDUWLDODQGFRPSOHWHLQMXU\
respectively. In cases of complete urethral injury with perineal hematoma or extravasation, no attempt
DWXUHWKUDOUHDOLJQPHQWZDVPDGH$OOSDWLHQWVZHUH LQVWUXFWHG WR UHWXUQ IRU IROORZXS URXWLQHO\ HYHU\ WKUHHPRQWKVLQWKH¿UVW\HDUWKHQHYHU\VL[PRQWKV WKHUHDIWHU5HWURJUDGHXUHWKURJUDSK\ZDVSHUIRUPHG LIWKHSDWLHQWKDGGLI¿FXOW\XULQDWLQJPD[LPXPXULQH ÀRZUDWH4PD[ZDVOHVVWKDQP/PLQXWHRUWKH SRVWYRLGLQJUHVLGXDOXULQHYROXPH395ZDV! P/RQXOWUDVRXQG3DWLHQWVZLWKDSDVVDEOHVWULFWXUH ZHUHPDQDJHGE\YLVXDOLQWHUQDOXUHWKURWRP\9,8 DVDWULDORIOHVVLQYDVLYHWUHDWPHQW3DWLHQWVZLWKDQ LPSDVVDEOHVWULFWXUHRUIDLOHG9,8ZHUHPDQDJHGE\ RSHQXUHWKURSODVW\7UHDWPHQWVXFFHVVZDVGH¿QHG DVQRV\PSWRPVRILQIUDYHVLFDOREVWUXFWLRQ4PD[ SHUVLVWHQWO\!P/VHFRQG395SHUVLVWHQWO\ P/DQGJRRGXUHWKUDOFDOLEHURQDVFHQGLQJXUHWKURJ
raphy.
6WDWLVWLFDODQDO\VLVZDVSHUIRUPHGRQFRPSXW HUVRIWZDUH6366IRU:LQGRZV6366,QF&KLFDJR ,/86$XVLQJWKHFKLVTXDUHDQG6WXGHQW¶VWWHVW
RESULTS
Patient Characteristics
7KHPHDQSDWLHQWDJHZDVUDQJHWR
years). The mechanism of injury was a fall astride in
RIWKHSDWLHQWVDGLUHFWNLFNWRWKHSHULQHDO UHJLRQLQDQGDPRWRUFDUDFFLGHQWLQ 7KHPDLQFRPSODLQWZDVEOHHGLQJSHUXUHWKUDLQ SDWLHQWVDQGLQDELOLW\WRXULQDWHLQ 3HULQHDO DQG VFURWDO KDHPDWRPD ZDV SUHVHQW LQ SDWLHQWVZKLOHSHULQHDOH[WUDYDVDWLRQRIXULQH ZDVSUHVHQWLQ3DUWLDOXUHWKUDOGLVUXSWLRQZDV IRXQG LQ SDWLHQWV DQG FRPSOHWH XUHWKUDO GLVUXSWLRQLQ7KHUHZHUHQRSDWLHQWVZLWK
urethral contusion alone.
Partial Urethral Disruption
Of the 31 patients with partial urethral rup
WXUHZHUHWUHDWHGSULPDULO\ZLWKVXSUDSXELF
cystostomy, and stricture formation occurred in 2
DIWHUFDWKHWHUUHPRYDO0HDQVWULFWXUHOHQJWKLQSD
tients treated primarily with suprapubic cystostomy was not statistically different from those treated pri
PDULO\ZLWKXUHWKUDOUHDOLJQPHQWFPUDQJHWR FPDQGFPUDQJHFPUHVSHFWLYHO\S $OOSDWLHQWVZKRGHYHORSHGVWULFWXUHDIWHU SDUWLDOGLVUXSWLRQZHUHWUHDWHGE\9,8UHVWULFWXUH GHYHORSHG LQ PRQWKV DIWHU9,8 DQG
all of these patients were treated successfully with
DQDVWRPRWLFXUHWKURSODVW\)LJXUH
Complete Urethral Disruption
Of the 22 patients with complete urethral
UXSWXUHZHUHWUHDWHGSULPDULO\ZLWKVX
prapubic cystostomy, stricture formation occurred in
SDWLHQWVZKLOHWKHVXSUDSXELFFDWKHWHUZDV VWLOOLQSODFHLQSDWLHQWVRUZLWKLQPRQWKV RIFDWKHWHUUHPRYDOLQSDWLHQWVSDWLHQWV ZHUHWUHDWHGSULPDULO\ZLWKXUHWKUDOUHDOLJQ
ment, and stricture formation occurred in all patients
PRQWKVPHDQ PRQWKVDIWHUFDWKHWHU
removal. The duration of stricture formation was not
VLJQL¿FDQWO\GLIIHUHQWEHWZHHQSDUWLDODQGFRPSOHWH XUHWKUDOUXSWXUHS 0HDQVWULFWXUHOHQJWKLQ
patients treated primarily with suprapubic cystostomy
ZDVVLJQL¿FDQWO\VKRUWHUWKDQLQWKRVHWUHDWHGSULPDU LO\ZLWKXUHWKUDOUHDOLJQPHQWFPUDQJHWR FPDQGFPUDQJHWRFPUHVSHFWLYHO\S 2IWKHSDWLHQWVZKRGHYHORSHGDVWULFWXUH
DIWHU FRPSOHWH GLVUXSWLRQ KDG D SDVV DEOHVWULFWXUHDQGZHUHWUHDWHGE\9,8UHVWULFWXUH GHYHORSHGLQDOOWKHVHSDWLHQWVPRQWKVDIWHUWKH SURFHGXUH$OOSDWLHQWVZLWKUHFXUUHQWVWULFWXUHDIWHU
VIU and 3 patients with impassable stricture after injury were treated with anastomotic urethroplasty,
DQGRQO\RQHRIWKHVHSDWLHQWVUHTXLUHGD UHSHDWXUHWKURSODVW\IRUUHFXUUHQWVWULFWXUH)LJXUH
The incidence of stricture formation after complete
XUHWKUDOGLVUXSWLRQZDVVLJQL¿FDQWO\KLJKHUWKDQDIWHU SDUWLDOGLVUXSWLRQ7DEOH
Primary Management
3DWLHQW FKDUDFWHULVWLFV ZHUH DQDO\]HG LQ UHODWLRQ WR SULPDU\ PDQDJHPHQW 7DEOH7KHUH ZHUH QR VLJQL¿FDQW GLIIHUHQFHV ZLWK UHJDUG WR SD
tients characteristics between those treated primarily with suprapubic cystostomy and those treated with
SULPDU\ XUHWKUDO FDWKHWHUL]DWLRQ 7DEOH ,Q WKH JURXSRISDWLHQWVSULPDULO\WUHDWHGZLWK
suprapubic cystostomy, stricture formation occurred
LQZKHUHDVLQWKHWUHDWHGZLWK SULPDU\XUHWKUDOFDWKHWHUL]DWLRQVWULFWXUHIRUPDWLRQ RFFXUUHG LQ 7KH LQFLGHQFH RI VWULFWXUH IRUPDWLRQDIWHUSULPDU\XUHWKUDOFDWKHWHUL]DWLRQZDV VLJQL¿FDQWO\KLJKHUWKDQDIWHUVXSUDSXELFF\VWRVWRP\ 7DEOH
Stricture Management
,QWKHJURXSRISDWLHQWVWUHDWHGZLWK9,8 KDG D VXFFHVVIXO RXWFRPH DIWHU \HDUV IROORZXS,QWKHJURXSRISDWLHQWVWUHDWHGZLWK DQDVWRPRWLFXUHWKURSODVW\KDGDVXFFHVV IXORXWFRPHDIWHU\HDUVIROORZXS7KHGLIIHUHQFH
between these treatment outcomes was statistically
VLJQL¿FDQW7DEOH
Table 1 – Stricture formation in relation to type of urethral injury and primary treatment.
Stricture Formation
-ve +ve p Value
Type of urethral injury 3DUWLDOUXSWXUH
21
10 < 0.001
&RPSOHWHUXSWXUH 3
3ULPDU\PDQDJHPHQW 8UHWKUDOFDWKHWHUL]DWLRQ < 0.001
6XSUDSXELFF\VWRVWRP\ 20
11
-ve = no stricture formation occurred; +ve = stricture formation occurred)
Table 2 – Patient characteristics in relation to primary treatment.
Urethral Catheterization Suprapubic Cystostomy p Value
0HDQDJH\HDUV 33
Mean follow up (months)
Fall astride (N. of patients) 13 21 0.51
Direct trauma (N. of patients) 7
Motor car (N. of patients) 1 2
COMMENTS
0DQDJHPHQWRISDUWLDOXUHWKUDOODFHUDWLRQV
typically entails suprapubic urinary diversion or
SULPDU\UHDOLJQPHQWXUHWKUDOFDWKHWHUL]DWLRQIRUWR ZHHNV,QFRPSOHWHODFHUDWLRQVXVXDOO\KHDOUDSLGO\ DQGZLWKDORZVWULFWXUHUDWH:KHQVWULFWXUHVGRRFFXU WKH\DUHW\SLFDOO\VKRUWRUÀLPV\DQGFDQEHPDQDJHG
effectively by VIU (5). In the present study, stricture
IRUPDWLRQ GHYHORSHG LQ RI SDWLHQWV PDQDJHG SULPDULO\ZLWKVXSUDSXELFF\VWRVWRP\DQGLQRI SDWLHQWVZKRZHUHPDQDJHGSULPDULO\ZLWKXUHWKUDO UHDOLJQPHQW
(DUO\ UHSRUWV E\ 3RQWHV DQG 3LHUFH VWDWHG
that excellent results could be obtained with urinary
GLYHUVLRQUDWKHUWKDQUHDOLJQPHQWEXW+XVPDQQ HWDOUHSRUWHGWKDWXUHWKUDOUHDOLJQPHQWDIWHUVXUJLFDO
repair of the urethra achieved a better outcome (3). However, the type of trauma in the study by Husmann
HWDOZDVSHQHWUDWLQJZKHUHDVLQWKHSUHVHQWVWXG\
all patients had blunt trauma.
In the recent review of straddle injuries to
WKHEXOEDUXUHWKUDE\3DUNDQG0F$QLQFKRI SDWLHQWVSUHVHQWHGPRQWKVWR\HDUVDIWHU WKHDFXWHLQMXU\ZLWKREVWUXFWLYHYRLGLQJV\PSWRPVRU IUDQNXULQDU\UHWHQWLRQ,QWKHSUHVHQWVWXG\VWULF WXUHIRUPDWLRQGHYHORSHGDIWHUPRQWKVPHDQ PRQWKVLQSDWLHQWVZLWKSDUWLDOXUHWKUDOGLVUXSWLRQ DQGDIWHUPRQWKVPHDQ PRQWKVLQSDWLHQWV ZLWKFRPSOHWHGLVUXSWLRQS 7KHGLIIHUHQFH
between the present study and the series reported by
3DUNDQG0F$QLQFKLVWKDWZHFDOFXODWHGWKHWLPHWR
stricture formation only in patients who presented acutely after urethral injury and excluded patients who presented late after trauma without previous urinary
GLYHUVLRQRUXUHWKUDOUHDOLJQPHQW
([WUDSRODWLQJIURPWKHH[SHULHQFHZLWKSRV
terior urethral avulsion injuries, it could be expected
WKDWHDUO\HQGRVFRSLFUHDOLJQPHQWRYHUD)ROH\FDWK
eter in anterior urethral injury should produce fewer
VWULFWXUHVWKDQVXSUDSXELFF\VWRVWRP\DORQH7KH6DQ )UDQFLVFR*HQHUDO+RVSLWDOJURXSUHFHQWO\UHSRUWHG LWVH[SHULHQFHZLWKVWUDGGOHLQMXULHVWRWKHEXOEDU XUHWKUD 7KH SULPDU\ UHDOLJQPHQW JURXS PRUH
commonly required urethroplasty than the suprapubic
GLYHUVLRQJURXSYHUVXVDQGPRUHRYHU FRPSOH[ÀDSRUJUDIWXUHWKURSODVW\ZDVPRUHRIWHQ
required. In the current study, stricture formation de
YHORSHGLQRISDWLHQWVPDQDJHGSULPDULO\ZLWK VXSUDSXELFF\VWRVWRP\DQGLQRISDWLHQWVZKR ZHUHPDQDJHGSULPDULO\ZLWKXUHWKUDOUHDOLJQPHQW
Also, the strictures that developed after suprapubic
F\VWRVWRP\ZHUHRQDYHUDJHVLJQL¿FDQWO\VKRUWHU
than the strictures that developed after urethral re
DOLJQPHQW
It is possible that with early suprapubic cystostomy for total or partial urethral disruption the
H[WHQWRIWKHDFXWHDQGFKURQLFLQÀDPPDWRU\FDVFDGH
would be limited and the severity of stricture forma
WLRQPD\EHPLWLJDWHG0RUHRYHUWKHSUHVHQFHRID
catheter in the area of urethral injury may cause a
IRUHLJQ ERG\ UHDFWLRQ H[DFHUEDWLQJ WKH DFXWH DQG FKURQLFLQÀDPPDWRU\FDVFDGH$OVRLUULJDWLRQ DQG PDQLSXODWLRQ GXULQJ HQGRVFRSLF UHDOLJQPHQW
may cause additional injury to the ruptured urethra.
+RZHYHUSULPDU\UHDOLJQPHQWE\PLQLPDOO\LQYD
sive methods has become a common contemporary
PDQDJHPHQWRSWLRQIRUSRVWHULRUXUHWKUDOGLVUXSWLRQ SDUWLFXODUO\DWKLJKYROXPHWUDXPDFHQWHUVLQFDVHRI
posterior urethral disruptions and the stricture rates
DUHGHFUHDVHGYHUVXV7KLVIDFWLVWUXH ZLWKUHJDUGWRSRVWHULRUXUHWKUDOGLVUXSWLRQZKHUHWKH
Table 3 – Outcomes after urethroplasty and visual internal urethrotomy (VIU).
Success Failure p Value
Urethroplasty 1
< 0.001
VIU
PDLQSUREOHPVDUHXUHWKUDOGLVWUDFWLRQDQGPLVDOLJQ
ment but in the case of anterior urethral ruptures the
XUHWKUDLVPDLQWDLQHGLQDOLJQPHQWDVLWHQFORVHGLQVLGH WKHFRUSXVVSRQJLRVXPDQGVWULFWXUHVWKDWGHYHORS ODWHURQDUHGXHWRVXEVHTXHQWVSRQJLR¿EURVLV
Endoscopic procedures, such as dilation or
9,8DUHVHOGRPFXUDWLYH7KHUHVXOWLQJVWULFWXUHV
are usually narrower, shorter, and can be repaired by
DSHULQHDODSSURDFK7KHJROGVWDQGDUGWUHDWPHQWLV VWULFWXUHH[FLVLRQZLWKSULPDU\UHDQDVWRPRVLV6HY HUDOPHGLFDOFHQWHUVUHSRUWVXFFHVVUDWHVH[FHHGLQJ ,QWKHFXUUHQWVWXG\WKHVXFFHVVUDWHDIWHU 9,8ZDVFRPSDUHGWRDIWHUH[FLVLRQDQG UHDQDVWRPRVLV7KHORZHUVXFFHVVUDWHRI9,8IRUXUH
thral strictures after straddle injury may be explained
E\H[FHVVLYHSHULXUHWKUDO¿EURVLVUHVXOWLQJIURPWKH EOXQWIRUFHDFWLQJDVDKDPPHUFUXVKLQJWKHXUHWKUD DJDLQVWWKHDQYLORIWKHSXELV
The limitations of this study are that it is not
WUXO\UDQGRPL]HGDQGORQJHUIROORZXSLVUHTXLUHG
CONCLUSION
6XSUDSXELF F\VWRVWRP\ LV DVVRFLDWHG ZLWK D ORZHU VWULFWXUH UDWH WKDQ XUHWKUDO FDWKHWHUL]DWLRQ DVSULPDU\PDQDJHPHQWDIWHUVWUDGGOHLQMXU\WRWKH EXOEDUXUHWKUD6WULFWXUHH[FLVLRQDQGUHDQDVWRPRVLV
is associated with a lower recurrence rate than VIU
DVGHOD\HGPDQDJHPHQWIRUVWULFWXUHVDIWHUVWUDGGOH
injury to the bulbar urethra.
CONFLICT OF INTEREST
None declared.
REFERENCES
5LFKWHU(50RUH\$)8UHWKUDOWUDXPD,Q:HVVHOOV +%0F$QLQFK-:HG8URORJLFDOHPHUJHQFLHV 7RWRZD1-+XPDQD3UHVVSS $UPHQDNDV1$0F$QLQFK-:$FXWHDQWHULRUXUH
WKUDOLQMXULHVGLDJQRVLVDQGLQLWLDOPDQDJHPHQW,Q 0F$QLQFK-:-RUGDQ*+&DUUROO35HG7UDXPDWLF DQGUHFRQVWUXFWLYHXURORJ\3KLODGHOSKLD:%6DXQ GHUVSS
+XVPDQQ'$%RRQH7%:LOVRQ:70DQDJHPHQWRI ORZYHORFLW\JXQVKRWZRXQGVWRWKHDQWHULRUXUHWKUD the role of primary repair versus urinary diversion DORQH-8URO
3RQWHV-(3LHUFH-0-U$QWHULRUXUHWKUDOLQMXULHVIRXU years of experience at the Detroit General Hospital. J 8URO
%UDQGHV6,QLWLDOPDQDJHPHQWRIDQWHULRUDQGSRVWH ULRUXUHWKUDOLQMXULHV8URO&OLQ1RUWK$P
3DUN60F$QLQFK-:6WUDGGOHLQMXULHVWRWKHEXOEDU XUHWKUDPDQDJHPHQWDQGRXWFRPHVLQSDWLHQWV-8URO
(OOLRWW '6 %DUUHWW '0 /RQJWHUP IROORZXS DQG HYDOXDWLRQRISULPDU\UHDOLJQPHQWRISRVWHULRUXUHWKUDO GLVUXSWLRQV-8URO
.RUDLWLP000DU]RXN0($WWD0$2UDEL665LVN factors and mechanism of urethral injury in pelvic IUDFWXUHV%U-8URO
-RUGDQ*+9LUDVRUR5(OWDKDZ\($5HFRQVWUXFWLRQ DQGPDQDJHPHQWRISRVWHULRUXUHWKUDODQGVWUDGGOH LQMXULHVRIWKHXUHWKUD8URO&OLQ1RUWK$P
Accepted after revision: April 15, 2009
Correspondence address:
'U0RKDPPHG$EGDOOD(OJDPPDO /HFWXUHURI8URORJ\
Assiut University Hospital
$VVLXW(J\SW )D[
EDITORIAL COMMENT
7KHPDLQVKRUWFRPLQJRIWKLVUHWURVSHFWLYH QRQUDQGRPL]HGVWXG\LVWKDWLWGRHVQRWSURYLGHLQIRU
mation about the factor(s) that determined the choice
RILQLWLDOPDQDJHPHQWE\VXSUDSXELFF\VWRVWRP\RU XUHWKUDOFDWKHWHUL]DWLRQ7KHUHIRUHXQLGHQWL¿HGVHOHF
tion biases may explain the results.
1RQHWKHOHVVWKH¿QGLQJVVXSSRUWDQXPEHU RI FRQFOXVLRQV WKDW DSSHDU ORJLFDO DQG H[SOLFDEOH
(1) complete urethral rupture compared with partial
UXSWXUHOHDGVWRDKLJKHUUDWHRIVWULFWXUHIRUPDWLRQ SUREDEO\EHFDXVHWKHUHKDVEHHQPRUHGDPDJHWRWKH SHULXUHWKUDOWLVVXHVXUHWKUDOUHDOLJQPHQWDQG FDWKHWHUL]DWLRQ OHDG WR D KLJKHU VWULFWXUH UDWH WKDQ
suprapubic cystostomy, possibly because cystoscopy
FDXVHVPRUHGDPDJHWRWKHXUHWKUDDQGLQIHFWLRQRU LQÀDPPDWLRQ FDXVHG E\ WKH WUDQVXUHWKUDO FDWKHWHU OHDGVWRPRUHVHYHUH¿EURVLVXUHWKUDOVWULFWXUH
formation after blunt external trauma usually occurs
ZLWKLQPRQWKVPHDQWRPRQWKVDIWHUWKHLQMXU\
similar to recurrences after VIU, where the majority
DOVRRFFXUZLWKLQPRQWKV9,8KDVDORZHU
success rate than urethroplasty, no doubt because it
GRHVQRWUHPRYH¿EURWLFWLVVXHVDQGPD\OHDGWRHYHQ PRUHVSRQJLR¿EURVLV
In the Results section the authors state that,
LQWKHJURXSRISDWLHQWVWUHDWHGZLWK9,8RQO\ KDGDVXFFHVVIXORXWFRPHDIWHU\HDUVIRO ORZXS+RZHYHULVDVVKRZQLQ7DEOH 7KLVHDUO\VWULFWXUHUHFXUUHQFHUDWHRIDIWHU9,8 LVH[FHSWLRQDOO\KLJKFRPSDUHGZLWKWKHUHFXUUHQFH
rates reported in the literature. Importantly, the recur
UHQFHUDWHZDVORZHUIRU9,8SHUIRUPHGIRU
strictures after partial urethral rupture, compared with
FRPSOHWH UXSWXUH LQGLFDWLQJ WKDW9,8 IRU
stricture formation after complete urethral rupture is virtually futile.
Dr. Christiaan F. HeynsChristiaan F. Heyns Department of Urology University of Stellenbosch & Tygerberg Hospital Tygerberg, South Africa E-mail: [email protected]
EDITORIAL COMMENT
This is a retrospective analysis of a cohort
RISDWLHQWVPDQDJHGIRUDFXWHSUHVHQWDWLRQRIEXOEDU XUHWKUDOVWUDGGOHLQMXU\DWDVLQJOHLQVWLWXWLRQEHWZHHQ DQG7KHRXWFRPHVDQDO\]HGZHUHDUDWHRI GHYHORSPHQWRIVWULFWXUHDIWHULQLWLDOPDQDJHPHQWZLWK VXSUDSXELFF\VWRVWRP\WXEH637RUHQGRVFRSLFUH DOLJQPHQWDQGEVXFFHVVUDWHVDIWHUYLVXDOLQWHUQDOXUH
throtomy (VIU) or primary anastomotic urethroplasty. All patients had partial or complete disruption of the
XUHWKUDDQGZHUHURXJKO\HTXDOO\GLVWULEXWHGEHWZHHQ WKHWZRGLIIHUHQWDFXWHPDQDJHPHQWSURWRFROV :KHUHDVRWKHUDXWKRUVKDYHGLVFXVVHGVXFFHVV ZLWK 637 YV HQGRVFRSLF UHDOLJQPHQW LQ SRVWHULRU XUHWKUDOGLVUXSWLRQLQMXULHVOLWWOHLVNQRZQDERXWKRZ
these treatments fare relative to each other in acute
PDQDJHPHQWRIVWUDGGOHLQMXULHVWRWKHEXOEDUXUHWKUD &RQWUDU\WRWKH¿QGLQJVLQWKHSRVWHULRUXUHWKUDWKH
authors report that whether the injuries to the bulbar urethra were partial or complete disruptions, patients
PDQDJHGZLWK637KDGDORZHULQFLGHQFHRIVWULFWXUH IRUPDWLRQWKDQWKRVHXQGHUJRLQJHQGRVFRSLFUHDOLJQ
ment. The authors present possible reasons for these
FRXQWHULQWXLWLYH¿QGLQJ&HUWDLQO\WKHSDWKRSK\VL RORJ\RIVWULFWXUHIRUPDWLRQLQFUXVKLQMXULHVWRWKH
bulbar urethra is quite different from that of shear
LQMXULHVWRWKHSRVWHULRUPHPEUDQRXVXUHWKUD3HUKDSV WKLVDFFRXQWVIRUWKHGLIIHUHQFHLQ¿QGLQJV2IQRWH WKHUHVXOWVVKRXOGEHHYDOXDWHGZLWKVRPHVNHSWLFLVP DVWKLVLVDQRQUDQGRPL]HGVWXG\DQGE\GH¿QLWLRQ
EDITORIAL COMMENT
7KHSULPDU\UHVSRQVLELOLWLHVRIWKHXURORJLVW ZKHQHQFRXQWHULQJDSDWLHQWZLWKDQDFXWHDQWHULRU XUHWKUDOLQMXU\DUHWRGLDJQRVHWKHH[WHQWRIWKHLQ
jury and 2) to divert the urine away from the injury if
DSSURSULDWHZKHWKHULWLVZLWKXUHWKUDOFDWKHWHUL]DWLRQ
or suprapubic diversion (1). Many times, the initial evaluation includes cystourethroscopy, which serves
WRERWKYLVXDOL]HWKHLQMXU\DQGWRWKHQDLGLQXUHWKUDO FDWKHWHUL]DWLRQXVXDOO\RYHUDF\VWRVFRSLFDOO\SODFHG ZLUH&RQYHQWLRQDOZLVGRPZRXOGVD\WKDWKDYLQJD FDWKHWHUDFURVVDXUHWKUDOLQMXU\ZRXOGDXJPHQWDS SURSULDWHXUHWKUDOKHDOLQJDQGVXEVHTXHQWO\GHFUHDVH
urethral stricture rates. This is why, for example, a catheter is nearly universally placed after radical retropubic prostatectomy or urethral reconstructive
VXUJHU\+RZHYHUWKHVXSHULRULW\RIVXSUDSXELFWXEH SODFHPHQWRYHUXUHWKUDOFDWKHWHUL]DWLRQUHSRUWHGE\ $EGDOOD(OJDPPDOLQWKLVPDQXVFULSWFKDOOHQJHVWKDW
notion.
$VGLVFXVVHGLQWKHPDQXVFULSWWKLV¿QGLQJ KDVEHHQUHSRUWHGEHIRUH3DUNHWDODQDO\]HGDVH ULHVRIDQWHULRUXUHWKUDOLQMXULHVIURP6DQ)UDQFLVFR
General Hospital, and found that while strictures any information about the selection criteria in acute
PDQDJHPHQW8UHWKUDOUHDOLJQPHQWPD\KDYHEHHQ
attempted in patients who were older, had more co morbidities or had more severe injuries.
)ROORZLQJVWULFWXUHIRUPDWLRQWKHDXWKRUV
evaluate the success rates for urethroplasty and VIU. The success rates for primary anastomotic
XUHWKURSODVW\TXRWHGDWDUHLQDJUHHPHQWZLWK WKHSXEOLVKHGOLWHUDWXUH,WLVLQWHUHVWLQJWRQRWHWKH ORZVXFFHVVUDWHGIRU9,8IRUVWULFWXUHVWKDW DUHOHVVWKDQFPLQOHQJWK7KHSXEOLVKHGVXFFHVV
rates of VIU for bulbar urethral strictures are in the
UDQJHRI7KHORZHUUDWHVVHHQLQWKHFXUUHQW VWXG\DWWHVWVWRWKHJUHDWGHJUHHRIVSRQJLR¿EURVLV WKDWRFFXUVLQWKHVHWWLQJRIFUXVKLQMXU\,WZRXOGEH LQWHUHVWLQJWRNQRZZKHWKHUWKHLQLWLDOPDQDJHPHQW 637RUUHDOLJQPHQWDIIHFWVWKHVXFFHVVUDWHVRIVXE
sequent stricture treatments (VIU or urethroplasty). However, such a subset analysis is not possible in this series due to small numbers.
7KHDXWKRUVKRXOGEHFRQJUDWXODWHGIRUWKHLU
contribution to the published literature on urethral straddle injuries. Further studies should attempt to
DGGUHVVVLPLODUTXHVWLRQVLQDUDQGRPL]HGVHWWLQJ
Dr. Bahaa Malaeb & Dr. Sean P. Elliott
Department of Urology Surgery University of Minnesota Minneapolis, Minnesota, USA E-mail: [email protected]
UHTXLULQJLQWHUYHQWLRQZHUHKLJKUHJDUGOHVVRILQLWLDO PDQDJHPHQWIRUVXSUDSXELFGLYHUVLRQY IRUXUHWKUDOFDWKHWHUL]DWLRQS WKHJURXSWKDW
initially had suprapubic diversion without urethral
PDQLSXODWLRQ ZHUH OHVV OLNHO\ WR UHTXLUH FRPSOH[
reconstruction (2). The authors in the current study
UHSRUWVLPLODU¿QGLQJV3DWLHQWVZLWKFRPSOHWHDQWHULRU XUHWKUDOGLVUXSWLRQPDQDJHGZLWKDXUHWKUDOFDWKHWHU KDGDVWULFWXUHUDWHYHUVXVDVWULFWXUHUDWH ZLWKVXSUDSXELFPDQDJHPHQW,QSDUWLDOGLVUXSWLRQV
the results were even more dramatic, with strictures
GHYHORSLQJLQRIPHQPDQDJHGZLWKXUHWKUDO FDWKHWHUL]DWLRQYHUVXVRQO\LQPHQZLWKVXSUD
pubic tubes.
:KDWLVWKHPHFKDQLVPIRUWKHGLIIHUHQFHV
found in this study? If the reported outcomes are to
EH EHOLHYHG D PXOWLIDFWRULDO H[SODQDWLRQ LV PRVW SODXVLEOH$VVXJJHVWHGLQWKHPDQXVFULSWLWLVSRV
sible that the initial cystoscopic exam with subsequent
XUHWKUDOFDWKHWHUL]DWLRQFRXOGSURSDJDWHWKHRULJLQDO LQMXU\7KHFDWKHWHUEHLQJDIRUHLJQERG\FRXOGDOVR ZRUVHQWKHSHULXUHWKUDOLQÀDPPDWRU\UHDFWLRQDQG
catheter is in place, it serves to stent open the bladder
QHFNZKLFKFDQDOORZIRUOHDNDJHRIXULQHDURXQG WKH FDWKHWHU IXUWKHU XULQDU\ H[WUDYDVDWLRQ WKURXJK WKHXUHWKUDOLQMXU\DQGDJDLQDZRUVHSHULXUHWKUDO LQÀDPPDWRU\UHDFWLRQ
6R VKRXOG DOO DQWHULRU XUHWKUDO LQMXULHV EH PDQDJHGZLWKVXSUDSXELFWXEHDORQH"8QIRUWXQDWHO\ ZLWKRXW D FRQWUROOHG UDQGRPL]HG VWXG\ WKLV TXHV
tion cannot be completely answered. However, the
¿QGLQJVIURPWKLVVWXG\VKRXOGPDNHDOOXURORJLVWV
question the need for heroic attempts at endoscopic
UHDOLJQPHQWRIDQDQWHULRUXUHWKUDOLQMXU\DVRXWFRPHV
in terms of future stricture rates are at least similar and
DWZRUVWPXFKKLJKHUZKHQSODFLQJDXUHWKUDOFDWKHWHU WKDQZKHQVLPSO\SODFLQJDVXSUDSXELFWXEH
REFERENCES
&KDSSOH&%DUEDJOL*-RUGDQ*0XQG\$55R GULJXHV1HWWR 1 3DQVDGRUR 9 HW DO &RQVHQVXV VWDWHPHQW RQ XUHWKUDO WUDXPD %-8 ,QW
3DUN60F$QLQFK-:6WUDGGOHLQMXULHVWRWKHEXOEDU XUHWKUDPDQDJHPHQWDQGRXWFRPHVLQSDWLHQWV-8URO
7DOMD0.RUSHOD$-lUYL.&RPSDULVRQRIXUHWKUDO UHDFWLRQ WR IXOO VLOLFRQH K\GURJHQFRDWHG DQG VLOL FRQLVHGODWH[FDWKHWHUV%U-8URO
Dr. Bradley A. Erickson & Dr. Christopher M. Gonzalez
