Transperineal urethroplasty for urethral distraction defects caused by pelvic fracture: Outcome analysis in 36 patients

Pai-Yen Pan; Ta-Min Wang; Kuo-Jen Lin; Hsu-Han Wang; Sheng-Hsien Chu; Yang-Jen Chiang; Chih-Te Lin

doi:10.4103/UROS.UROS_78_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 33 | Issue : 1 | Page : 42-46

Transperineal urethroplasty for urethral distraction defects caused by pelvic fracture: Outcome analysis in 36 patients

Pai-Yen Pan, Ta-Min Wang, Kuo-Jen Lin, Hsu-Han Wang, Sheng-Hsien Chu, Yang-Jen Chiang, Chih-Te Lin
Department of Surgery, Division of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

Date of Submission	20-May-2021
Date of Decision	23-Sep-2021
Date of Acceptance	28-Sep-2021
Date of Web Publication	02-Mar-2022

Correspondence Address:
Dr. Ta-Min Wang
Department of Surgery, Division of Urology, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan 33305
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_78_21

Abstract

Purpose: We report the outcomes of transperineal urethroplasty in patients with pelvic fracture urethral distraction defects (PFUDDs) over the past 12 years. Materials and Methods: Patients who received transperineal anastomotic repair of PFUDDs from January 2007 to December 2019 were retrospectively analyzed, specifically focusing on demographic findings, pelvic fracture type, urethral distraction defect length (based on retrograde urethrography and cystography), previous treatments, and ancillary maneuvers during surgery. Simultaneously, differences in clinical factors between successful and failed cases were also analyzed. Results: A total of 36 patients were included, with a final success rate of 83%. The mean age was 40.4 years, whereas the mean urethral distraction defect length was 31.9 mm. Most patients (69%) presented with unstable pelvic fractures. Treatment before referral included endoscopic treatment and urethroplasty in 13 (36%) and 2 cases (6%), respectively. For difficult cases, ancillary procedures, which included corporeal splitting (61.1%) and inferior pubectomy (8.3%), were performed. The postoperative average peak flow rate was 14.9 mL/s in the success group. Age and urethral defect length differed significantly between the success and failure groups. Conclusions: Over the past 12 years, transperineal urethral reconstruction demonstrated a success rate of 83% in 36 patients with PFUDD. Age and urethral defect length were identified as the two main factors affecting surgical prognosis.

Keywords: Pelvic fracture, urethra, urethroplasty

How to cite this article:
Pan PY, Wang TM, Lin KJ, Wang HH, Chu SH, Chiang YJ, Lin CT. Transperineal urethroplasty for urethral distraction defects caused by pelvic fracture: Outcome analysis in 36 patients. Urol Sci 2022;33:42-6

How to cite this URL:
Pan PY, Wang TM, Lin KJ, Wang HH, Chu SH, Chiang YJ, Lin CT. Transperineal urethroplasty for urethral distraction defects caused by pelvic fracture: Outcome analysis in 36 patients. Urol Sci [serial online] 2022 [cited 2023 Sep 25];33:42-6. Available from: https://www.e-urol-sci.com/text.asp?2022/33/1/42/338935

Introduction

The management of unstable pelvic fractures caused by high-speed impact, resulting from events such as traffic accidents or falls from high places, is complicated. These fractures have been strongly associated with organ damage and fatalities. Urethral injury is one of those comorbidities; posterior urethral injury occurs in 10% of pelvic fractures.^[1] Although urethral injury is not fatal, it requires urethral reconstruction, which is quite challenging. Our treatment of posterior urethral distraction defects involves immediate suprapubic cystostomy and delayed urethral reconstruction. To assess the efficacy of this approach, we reviewed the records of 36 patients at our institution, focusing on the association between clinical parameters and long-term outcomes.

Materials and Methods

Between 2007 and 2019, 36 patients were admitted to our institution with pelvic fracture-related urethral distraction defects (PFUDDs) involving the prostate and membranous urethra (IRB No.: 202100730B0, the IRB approves the waiver of the participants' consent.) A single surgeon (T.M.W.) performed transperineal posterior urethral reconstruction in all patients, after which their medical records were retrospectively reviewed. The mechanisms of injury were as follows: traffic accident in 19 patients (52.8%), crush injury by a heavy object at work (occupational accident) in 12 patients (33.3%), and falls from a high place in 5 patients (13.9%). Transarterial embolization was required in 18 patients (50%) because of retroperitoneal or intraperitoneal bleeding. Concomitant bladder ruptures were noted in two patients. Most patients sustained multiple associated injuries, including pneumothorax, spinal fracture, tibial fibular fracture, anus injury, diaphragm injury, femur fracture, rectum injury, scrotum injury, and spleen rupture. The mean number of associated injuries per patient was 1.19. At referral, all patients had undergone suprapubic cystostomy due to urethral obstruction. Prior urethroplasty had failed in two patients (8.3%), and prior internal urethrotomy under direct vision or urethral dilation failed in 13 cases (36.1%). All patients underwent retrograde urethrography with simultaneous cystography to assess the length of urethral disruption [Figure 1]a and [Figure 1]b. Elective transperineal open urethral reconstruction was performed in all patients approximately 3 months after they sustained the urethral injuries.

Figure 1: (a) Retrograde urethrography performed immediately after injury. (b) A combination of retrograde urethrography and cystography demonstrating a long distraction defect. Arrows indicate the distracted urethral ends. (c) Voiding cystourethrography after open urethroplasty revealing a patent urethra without extravasation

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Urethral Reconstruction Techniques

Patients were placed in the lithotomy position, after which the urethra was exposed through a midline perineal incision. The bulbar urethra was then circumferentially mobilized proximally toward the obliterated segment, transected at the obliteration site, and mobilized distally to the crura of the corporal body. A descending urethral sound was passed through the suprapubic cystostomy tract and the bladder neck into the proximal portion of the urethra. If the stricture segment was noted to be short, the tip of the sound could be palpated easily, and a simple urethral anastomosis was constructed. When a long urethral defect with dense fibrotic tissue precluded palpation of the tip of the sound, the scar tissue was incised until the tip of the sound was encountered. Thereafter, the membranous urethra was dissected until healthy mucosal edges were identified. At this time, if creating a tension-free anastomosis with the urethral suture was difficult, further maneuvers were performed. Afterward, the proximal corporeal bodies were separated in 22 patients (61.1%), and the distal urethra was placed between the separated bodies to shorten the distance to the anastomosis. If creating the anastomosis remained difficult with a high-lying proximal urethra, the surgeon performed inferior pubectomy by excising a wedge of pubic bone from the inferior surface of the pubis exposed by the corporal body separation. To achieve a tension-free anastomosis, three patients (8.3%) required this bone excision. Regardless of the method used, the urethral ends were prepared by spatulation to achieve a tension-free anastomosis with four to eight interrupted sutures [Figure 2]. To accomplish postoperative urine drainage, the surgeon used a 16-Fr suprapubic catheter and a 16-Fr urethral catheter.

Figure 2: Intraoperative image of proximal urethral end following complete excision of fibrotic tissue and proximal installation of eight anastomotic sutures

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The urethral catheter was removed 28 days after surgery. Afterward, voiding cystourethrography was performed routinely to confirm the patency of the urethra [Figure 1]c. The suprapubic catheter was then removed 1 week later if the patient could urinate smoothly. All patients were monitored postoperatively for 1 month with uroflowmetry and ultrasound examination of postvoiding residual urine. Cystourethroscopy was performed in all patients approximately 1 month after surgery. Subjective surgical success was defined as satisfactory catheter-free urination, whereas objective surgical success was defined as a urinary peak flow rate of ≥14.0 mL/s and the radiological or urethroscopic appearance of a normal patent urethra.

Statistical analysis was performed using the Statistical Package for the Social Sciences version 20.0 software (SPSS Inc., Chicago, IL, USA). Student's t-test and Chi-square test were used for statistical analysis. P < 0.05 indicated statistical significance.

Results

The patients' background information is summarized in [Table 1]. Age at surgery ranged from 16 to 82 years (mean, 40.4 years), and all patients were men. According to the Tile classification of pelvic fractures, 2 patients (5.6%) had Type A fractures, 13 (36.1%) had Type B fractures, and 12 (33.3%) had Type C fractures; meanwhile, in 9 (25%) cases, the fracture type was unclear. Type A and B pelvic fractures were unstable and were noted in most of our patients (69%). In accordance with the initial treatment for pelvic fracture-related posterior urethral injuries, all patients underwent suprapubic cystostomy. Before referral, 13 patients (36.1%) had undergone endoscopic treatment, and 2 (5.6%) had undergone urethroplasty. The remaining 21 patients (58.3%) had undergone no surgical treatment. The previous endoscopic treatment included internal urethrotomy and urethral dilation. The period from initial treatment to elective urethroplasty was approximately 3–6 months. Transperineal urethroplasty, performed in all patients, included excision of the urethral stricture and anastomosis of both ends of the normal urethra to reconstruct the continuity of the urethra. In difficult cases involving long defects, ancillary procedures, such as corporeal splitting and inferior pubectomy, were performed. No patients underwent augmented urethroplasty with substitute tissues, such as those of the foreskin or buccal mucosa.

Table 1: Patient characteristics

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[Figure 1]b illustrates the preoperative length of the urethral distraction defect length as depicted by simultaneous retrograde urethrography and cystography. The length of the urethral defect ranged from 15 to 45 mm (mean, 31.9 mm). No major perioperative complications were noted except for scrotal hematoma in one patient (5.0%) and wound infection in another. The mean postoperative observation period was 26 months (range, 6–84 months). Urethral stricture recurred in 10 patients after obliteration of the anastomosis and these patients required reoperation; thus, the initial success rate was 72%. Of these 10 patients with recurrent stricture, four were able to undergo successful repeated urethroplasty, bringing the final success rate to 83.3%.

[Table 2] shows the relationship between each clinical factor and postoperative outcome. According to univariable analysis, only age and urethral defect length differed significantly between the patients in whom surgery was successful and those in whom surgery failed. Other factors, including body mass index, previous treatment, rates of transarterial embolization, and type of pelvic fracture, did not differ significantly. We have also attempted to perform multivariable logistic analysis to identify predictors for surgical outcomes. However, the results showed that only age was significantly associated with surgical outcomes. In patients who were able to urinate postoperatively, the mean peak flow rate was 14.92 mL/s. We observed only one case of urinary incontinence in which small pad protection was needed during daytime activity. Erectile dysfunction (ED), subjectively defined as the absence of early morning erection and inability to achieve an erection for sexual intercourse, was observed in eight patients (22.2%) 1 year after surgery.

Table 2: Association between clinical parameters and outcome

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Discussion

Almost all urologists consider the treatment of PFUDDs challenging.^[2] Most urologists have limited experience with open urethroplasty for posterior urethral distraction defects. Kitahara et al. reported that over a 5-year period, 93% of urologists in Japan surgically treated fewer than three patients with PFUDDs, and none had operated on more than 10 patients with PFUDDs.^[3] Experience is similarly lacking in Taiwan; few centers have extensive experience with open urethroplasty for pelvic fracture-related urethral injuries. Our institution is a transfer center for patients who have sustained trauma, and we were able to examine 36 patients with PFUDDs; thus, this report concerns the largest case series of open urethroplasty for pelvic fracture-related urethral injuries in Taiwan.

This study demonstrated a final success rate of 83.3% at a mean follow-up duration of 26 months, which was lower compared to the success rates reported by Flynn et al.(95%) and Morey and McAninch (85%).^[4],[5] Other investigators from different countries, such as Koraitim, Webster and Ramon, Kulkarni et al., and Cooperberg et al., reported similarly high success rates.^{[5],[6],[7],[8],[9]} Aside from technological advancements, various patient circumstances may have accounted for the differences in success rates. In comparison with surgery for simple cases, surgery for complex PFUDDs may have lower success rates. For instance, Kulkarni et al. reported a lower success rate (78.6%) after urethroplasty for PFUDD, partly because stricture recurred more frequently.^[10] Moreover, Joshi and Kulkarni reported that in developing countries, PFUDDs tended to be more complex, involving long urethral distraction defects, concomitant bladder neck injuries, or other associated injuries, thus lowering the overall success rates.^[11]

Studies have confirmed that complications reduce the success rate of urethroplasty for PFUDDs. Turner-Warwick has examined these factors and recommended that PFUDDs be considered complex when the following conditions are present: (1) urethral defect length exceeding 20 mm; (2) presence of false passages or fistulas; and (3) extensive bladder neck damage.^[12] Kulkarni et al. expanded this list to include previous failed urethroplasty and age of younger than 12 years.^[9] According to these criteria, all cases of surgical failure in our series were complex cases, mainly because the mean length of urethral defects was 37.6 mm (>20 mm) and surgery had to be repeated in half those cases.

The most basic components of posterior urethral reconstruction surgery are complete excision of the periurethral scar tissue and distal mobilization of the corpus spongiosum from the corporal cavernosa to ensure tension-free anastomosis. Nevertheless, complex PFUDDs necessitate thoughtful adjustment of surgical techniques to achieve acceptable results. Webster et al. described auxiliary procedures to facilitate elaborate end-to-end primary anastomosis for PFUDDs, especially those with long defects.^[1],[7] These auxiliary procedures could help repair defects up to 5 cm long without the need for abdominal approach. In all our cases, the transperineal approach, as described by Webster et al., was used. Moreover, these auxiliary procedures (corporeal splitting and inferior pubectomy) were used in 22 patients (61.1%) in our series.

Joshi and Kulkarni reported that more than 60% of their patients required inferior pubectomy, regardless of whether the urethroplasty was primary or repeated.^[11] They ascribed this need to the complexity of PFUDDs in developing countries. Moreover, they suggested that, in most cases of failed urethroplasty, the patients referred to their institution were not successfully managed at the initial hospital, inasmuch as inferior pubectomy was not performed during the initial surgery. In Johnsen et al.'s review article examining 436 cases of posterior urethroplasty, 95% were completed through the perineal approach, whereas only 5% were completed through the abdominoperineal approach.^[13] Most authors have suggested that the abdominoperineal approach is best for patients with long urethral defects, a history of abscess or fistula, or those who have previously undergone rectal surgery.^[13],[14] According to recent studies, augmented urethroplasties with buccal mucosa grafts are most often used for anterior urethral strictures and less often used for posterior urethral reconstruction. However, in one rare case involving complicated long urethral defect with complete necrosis of the bulbar urethra, staged urethral reconstruction with a buccal mucosa graft or pedicle preputial flap was deemed necessary.^[8] For this ischemic condition of the bulbar urethra, either vascularized flaps must be used as a urethral tube substitution or buccal mucosa graft-augmented urethroplasty must be performed. Of course, it is best for the surgical approach to be planned and staged for such serious situations.

For simple cases of posterior urethral injury, most urologists will understandably use endoscopic methods in an attempt to realign the urethra. Although endoscopic realignment is usually successful in establishing temporary urethral continuity, persistent fibrotic changes around the periurethral area may hinder long-term success. In a series of 396 patients who underwent endoscopic treatment for posttraumatic urethral obliteration, El-Abd reported that 93% required two or more endoscopic urethrotomies.^[15] Pal et al. also reported poor stricture-free rates after the first, second, and third urethrotomies (29.66%, 22.64%, and 13.33%, respectively).^[16] In a review article, Barratt et al. demonstrated that after primary endoscopic realignment or delayed endoscopic treatment for pelvic fracture-related urethral injury, stricture recurrence rates were similarly high (60% and 80%, respectively).^[17] They concluded that delayed open urethroplasty produced the best overall outcomes and should be the treatment of choice for pelvic fracture-related urethral injury.

Postoperative urinary incontinence and ED have been identified as the two main considerations for patients undergoing urethroplasty. Only one of our patients, who had urinary incontinence, needed small pad protection during daytime activities. Other authors have reported a low incidence (approximately 5%–10%) of urine incontinence after open urethroplasty.^[5],[18] At the time of pelvic fracture-related urethral injury, the external sphincter is usually destroyed. Therefore, the continence mechanism after the posterior urethral reconstruction depends on the bladder neck and prostatic urethra.^[19] Affected patients rarely experience urinary incontinence after surgery because the mechanism of inhibiting urinary incontinence is rebuilt through the intact bladder neck and prostatic urethra.

We subjectively defined ED as the absence of early morning erection and inability to achieve an erection for sexual intercourse. In our series, eight patients (22.2%) had ED 1 year after surgery. Wide variations in ED incidence (ranging from 18% to 72%) after surgery for pelvic fracture-related urethral injury have been reported in the literature.^[20],[21] Such variations have been attributed to differences in the definition of ED, heterogeneous severity of urethral injuries, methods used for assessing ED, and duration from injury to ED assessment.^[22] After analyzing the effects of anastomotic urethroplasty for PFUDD on erectile function, Hosseini et al. concluded that urethroplasty itself did not significantly affect erectile function.^[23] In fact, the long-term prognosis regarding ED in patients with pelvic fracture-related urethral injury depends more on the severity of the initial injury than on the urethroplasty itself.

The main limitation of our study was the small number of cases, which, in turn, limited the level of evidence. However, our population of patients with posterior urethral reconstruction is the largest in Taiwan to date. We hope to provide clinicians with meaningful local information and continue to promote open urethroplasty for pelvic fracture-related urethral injuries.

Conclusions

Transperineal urethral reconstruction in 36 patients with PFUDD demonstrated an overall success rate of 83.3%. Age and urethral defect length were identified as the two main factors affecting surgical prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Webster GD, Guralnick ML. Reconstruction of posterior urethral disruption. Urol Clin North Am 2002;29:429-41.
2.	Koraitim MM. Pelvic fracture urethral injuries: The unresolved controversy. J Urol 1999;161:1433-41.
3.	Kitahara S, Sato R, Yasuda K, Arai G, Nakai H, Okada H. Surgical treatment of urethral distraction defect associated with pelvic fracture: A nationwide survey in Japan. Int J Urol 2008;15:621-4.
4.	Flynn BJ, Delvecchio FC, Webster GD. Perineal repair of pelvic fracture urethral distraction defects: Experience in 120 patients during the last 10 years. J Urol 2003;170:1877-80.
5.	Morey AF, McAninch JW. Reconstruction of posterior urethral disruption injuries: Outcome analysis in 82 patients. J Urol 1997;157:506-10.
6.	Koraitim MM. On the art of anastomotic posterior urethroplasty: A 27-year experience. J Urol 2005;173:135-9.
7.	Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: Experience with 74 cases. J Urol 1991;145:744-8.
8.	Kulkarni SB, Joshi PM, Hunter C, Surana S, Shahrour W, Alhajeri F. Complex posterior urethral injury. Arab J Urol 2015;13:43-52.
9.	Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP. Urethral reconstruction for traumatic posterior urethral disruption: Outcomes of a 25-year experience. J Urol 2007;178:2006-10.
10.	Kulkarni SB, Barbagli G, Kulkarni JS, Romano G, Lazzeri M. Posterior urethral stricture after pelvic fracture urethral distraction defects in developing and developed countries, and choice of surgical technique. J Urol 2010;183:1049-54.
11.	Joshi PM, Kulkarni SB. Management of pelvic fracture urethral injuries in the developing world. World J Urol 2020;38:3027-34.
12.	Turner-Warwick R. Complex traumatic posterior urethral strictures. J Urol 1977;118:564-74.
13.	Johnsen NV, Moses RA, Elliott SP, Vanni AJ, Baradaran N, Greear G, et al. Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury. World J Urol 2020;38:1073-9.
14.	Pratap A, Agrawal CS, Tiwari A, Bhattarai BK, Pandit RK, Anchal N. Complex posterior urethral disruptions: Management by combined abdominal transpubic perineal urethroplasty. J Urol 2006;175:1751-4.
15.	El-Abd SA. Endoscopic treatment of posttraumatic urethral obliteration: Experience in 396 patients. J Urol 1995;153:67-71.
16.	Pal DK, Kumar S, Ghosh B. Direct visual internal urethrotomy: Is it a durable treatment option? Urol Ann 2017;9:18-22. [PUBMED] [Full text]
17.	Barratt RC, Bernard J, Mundy AR, Greenwell TJ. Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes. Transl Androl Urol 2018;7 Suppl 1:S29-62.
18.	Hafez AT, El-Assmy A, Sarhan O, El-Hefnawy AS, Ghoneim MA. Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: The long-term outcome. BJU Int 2005;95:403-6.
19.	Koraitim MM, Atta MA, Fattah GA, Ismail HR. Mechanism of continence after repair of post-traumatic posterior urethral strictures. Urology 2003;61:287-90.
20.	Koraitim MM. Predictors of erectile dysfunction post pelvic fracture urethral injuries: A multivariate analysis. Urology 2013;81:1081-5.
21.	Anger JT, Sherman ND, Dielubanza E, Webster GD, Hegarty PK. Erectile function after posterior urethroplasty for pelvic fracture-urethral distraction defect injuries. BJU Int 2009;104:1126-9.
22.	Chung PH, Gehring C, Firoozabadi R, Voelzke BB. Risk stratification for erectile dysfunction after pelvic fracture urethral injuries. Urology 2018;115:174-8.
23.	Hosseini J, Soleimanzadeh Ardebili F, Fadavi B, Haghighatkhah H. Effects of anastomotic posterior urethroplasty (simple or complex) on erectile function: A prospective study. Urol J 2018;15:33-7.