Partial Inferior Pubectomy in the Delayed Repair of Pelvic Fracture Urethral Injury: Adopting a Bone-nibbling Technique

Background: The use of wedge inferior pubectomy can be challenging to many urethral surgeons. Our objective was to introduce a bone-nibbling technique to accomplish a partial inferior pubectomy (PIP) in a resource-poor setting, and to report the medium- to longterm outcome of using the technique. Methods: Five patients were recruited (mean age: 38.8 years) who presented, over a 30-month period, with posterior urethral fibrosis from a pelvic fracture urethral injury (PFUI). One had failed a previous attempt at posterior urethral reconstruction elsewhere. The length of urethral defect was from 2 to 4 cm. We describe a bone-nibbling technique used to carry out PIP for the delayed repair of PFUI in these patients. The outcomes in the medium to long term of surgical procedures done with this technique are presented. Results: Immediate postoperative complications in all were essentially a Clavien–Dindo grade I. Peak flow rate assessed 12 weeks’ post operation was between 20 mL/s and 23 mL/s (mean: 21 mL/s). The longest duration of follow-up was 34 months, and all patients were voiding satisfactorily. Conclusions: A satisfactory and durable outcome can be obtained from nibbling at the bone from the inferior margin of the pubic bone to achieve PIP. This is of interest to lower urinary tract reconstructive surgeons who have concerns with chiseling-out wedge of the inferior pubis. Keywords: Bone nibbling, Partial inferior pubectomy, PFUI, Posterior urethra, Urethral anastomosis

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Delayed Anastomotic Urethroplasty in Children and Adolescence with Pelvic Fracture Urethral Injury (PFUI): Experiences in Two Centers of Reconstructive Urethral Surgery in Indonesia

Indonesian Medical and Life Science Journal ◽

10.53536/melisa.v1i2.17 ◽

2021 ◽

Vol 1 (2) ◽

pp. 58-65

Author(s):

Paksi Satyagraha ◽

Kuncoro Adi ◽

I Made Udiyana Indradiputra ◽

Ahmad Agil ◽

Besut Daryanto

Keyword(s):

Success Rate ◽

Pelvic Fracture ◽

Average Length ◽

Operation Time ◽

Urethral Injury ◽

Urethral Reconstruction ◽

Tension Free ◽

Children And Adolescence ◽

Urethral Surgery ◽

Anastomotic Urethroplasty

Introduction: Incidence of pediatric pelvic fracture urethral injury (PFUI) is rare. This study reviews the experience of anastomotic urethroplasty surgery in children and adolescence PFUI in the last 3 years in two center of reconstructive urethral surgery in Indonesia. Method: This study retrospectively reviewed PFUI cases in Hasan Sadikin Hospital and Saiful Anwar Hospital from 2013-2016. The data cases were analysed base on aetiology of the trauma, urethral gap, and previous operations. The operation time and intra operative additional procedure to achieve tension free anastomotic was also noted. Result: A total 31 children and adolescence patients with PFUI were recorded in two institutions. Twenty patients were in Hasan Sadikin Hospital while 11 patients were in Saiful Anwar Hospital. The trauma mechanisms for PFUI were 28 (90.3%) cases due to motorcycle accidents and 3 (9.7%) cases due to high falls accidents. All patients underwent delayed urethral reconstruction in median 6 months (3-72). The median operation time was 150±101 minutes for children and 160±50.5 minutes for adolescence. The average length of the urethral gap in children cases was 2.8±1.2 cm, meanwhile 4±1.9 cm for adolescence cases. In order to achieve the tension free of anastomotic urethroplasty, 5 (16.1%) of PFUI patients underwent crural separation, 16 (51.6%) patients underwent inferior pubectomy and 3 (9.7%) patients for supracrural re-routing. Posterior pubectomy with omental wrap via transpubic approach was performed in one patient. The success rate for children cases was 83.3% and 88% for adolescence cases. Thus, the overall success rate after anastomotic urethroplasty for pediatric PFUI was 83.9%. Conclusions: In short-term follow up, delayed repair urethral reconstructive surgery by transperineal and transpubic anastomotic urethroplasty in children and adolescence with PFUI achieved a significant good result and showed promising outcome.

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The value of digital rectal examination in assessing for pelvic fracture–associated urethral injury

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0b013e3182a68668 ◽

2013 ◽

Vol 75 (5) ◽

pp. 913-915 ◽

Cited By ~ 3

Author(s):

Michael H. Johnson ◽

Andrew Chang ◽

Steven B. Brandes

Keyword(s):

Pelvic Fracture ◽

Digital Rectal Examination ◽

Urethral Injury ◽

Rectal Examination

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Redo pelvic fracture urethral injury repair: The case for tadalafil

10.5152/tud.2021.21065 ◽

2021 ◽

Vol 47 (4) ◽

pp. 319-324

Author(s):

Pankaj M. Joshi ◽

◽

Devang Desai ◽

Seichi Fuziwara ◽

Sheliyan Raveenthiran ◽

...

Keyword(s):

Pelvic Fracture ◽

Urethral Injury ◽

Injury Repair

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Traumatic Urethral Injury without Pelvic Fracture in an Adult Female

The Scientific World JOURNAL ◽

10.1100/tsw.2010.29 ◽

2010 ◽

Vol 10 ◽

pp. 308-310 ◽

Cited By ~ 4

Author(s):

Nathan A. Bockholt ◽

Kenneth G. Nepple ◽

Charles R. Powell ◽

Karl J. Kreder

Keyword(s):

Adult Female ◽

Pelvic Fracture ◽

Acetabular Fracture ◽

Bladder Neck ◽

Motor Vehicle ◽

Urethral Catheter ◽

Urethral Injury ◽

Rare Occurrence ◽

Urethral Meatus ◽

Vehicle Collision

A 23-year-old female was involved in a motor vehicle collision with multiple injuries, including a right acetabular fracture, but no pelvic fracture. Urology consultation was obtained due to difficulty placing a urethral catheter. Examination revealed a longitudinal urethral tear with vaginal laceration extending 2 cm from the urethral meatus proximally toward the bladder neck. The longitudinal urethral tear was repaired primarily. Traumatic female urethral injury in the absence of a pelvic fracture is an exceedingly rare occurrence.

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Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis

Current Urology ◽

10.1159/000499282 ◽

2019 ◽

Vol 13 (3) ◽

pp. 113-124 ◽

Cited By ~ 1

Author(s):

Alexander Light ◽

Tanya Gupta ◽

Maria Dadabhoy ◽

Allen Daniel ◽

Madura Nandakumar ◽

...

Keyword(s):

Systematic Review ◽

Urinary Incontinence ◽

Case Studies ◽

Pelvic Fracture ◽

Meta Analysis ◽

Urethral Injury ◽

Retrospective Case ◽

Eligibility Criteria ◽

High Quality Research ◽

Suprapubic Cystostomy

Objective: Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU. Methods: PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9). Results: From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82). Conclusion: For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

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