Damage and trauma to the urethra

In wartime, up to 30% of the wounded have injuries and trauma to the urethra. The vast majority of them have open injuries. This type of injury is more common in men. The urethra in women is rarely damaged (no more than 6%) as a rule, with pelvic fractures. About 70% of the damage to the urethra occurs as a result of traffic accidents. 

25% as a result of a fall from height and 5% - as a result of other causes, including iatrogenic ones.

There are closed (subcutaneous) and open injuries, as well as isolated and combined injuries of the urethra. In 96% of the victims, closed lesions are observed and only 4% are open.

ICD-10 code

S37.3. Damage to the urethra.

What causes injury and injury to the urethra?

Causes of injuries and injuries of the urethra

Open injuries often occur with gunshot wounds, and closed ones - with a fracture of the pelvic bones and a fall on the perineum. Sometimes, this trauma can occur with the forced insertion of medical instruments (metal catheter, bougie, cystoscope, resectoscope) into the urethra, as well as when passing through the urethra, stones, damage to the penis, birth trauma, operations on the prostate, etc.

From the anatomical and practical point of view, the urethra can be divided into two parts: the posterior (fixed urethra) and the anterior. The border between them is the urogenital diaphragm. Damage to these two departments can differ significantly in the mechanism of education, clinical course and treatment tactics. It is for this reason that they are. Usually. Treated separately.

[1], [2]

Pathogenesis of injuries and injuries of the urethra

Mechanism of damage to the urethra. With the direct impact of traumatic force, the spongy part of the urethra is usually damaged.

In the vast majority of cases, urethra trauma occurs with fractures of the pelvic bones (usually bony and ischium bones). In these cases, the membranous and prostate parts of the urethra are especially damaged. The rupture of the prostatic part of the urethra occurs extremely rarely. Damage to the urethra occurs due to the tension of the ligamentous apparatus and the urogenital diaphragm or fragments of bones.

Injury of the posterior urethra

Injuries of the posterior urethra are usually observed in fractures of the pelvic bones (3.5-19% of pelvic fracture observations), which are the main cause of damage to this part of the urethra. More often the urethra is damaged by fractures of the horizontal branches of the pubic bones, especially in the presence of diastase of the coccygeal-iliac articulation ("stable fracture).

The main causes of these damages are traffic accidents (75%), falling from height and impact of pressing force. Fractures of the pelvic bones due to displacement usually lead to the stretching of the fixed section of the urethra, so that the urethra can come off the apex of the prostate.

In 10-17% of cases there is a bladder rupture that can complicate the diagnosis.

The forces leading to a pelvic fracture are divided into anteroposterior, lateral and vertical forces, the first two groups can lead to both stable and unstable fracture, and the third - to the formation of only unstable fractures ("fracture at offset ").

With a stable fracture of the pelvic bones, damage to the urethra can occur when, under the influence of an external force, all four branches of both pubic bones are broken, forming a fragment in the form of a butterfly that moves back and causes the urethra to come off the apex of the prostate; while the external sphincter of the urethra is damaged.

Unstable fracture of the pelvis includes fractures of the anterior or lateral segments of the pelvic ring and sacroiliac joint. In this case, the posterior part of the urethra is damaged either directly by bone fragments or by the movement of any bone fragment to which the urethra is fixed or because of the stretching of the urethra.

As shown by Siegel et al. With the action of the damaging force in the anteroposterior direction (in comparison with the lateral one) there are more severe damage to the pelvic bones, lower urinary tracts, and the risk of retro-peritoneal bleeding, shock and mortality increases.

Despite the widespread belief that with pelvic injuries most often the urethra is damaged above the urogenital diaphragm and below the tip of the prostate, studies by some authors prove diametrically opposite. According to Mouraviev and Santucci, out of 10 corpses of men with pelvic injuries and rupture of the urethra, 7 lesions were found in the urethra below the urogenital diaphragm. The study also showed that when the urethra is completely detached, the mucosal defect is always greater (on average 3.5 ± 0.5 cm) of the defect in the outer layer (on average 2.0 ± 0.2 cm). In addition, the length of the defect in the Dorsal direction is greater than in the ventral direction. In connection with the severity of the damage to the urethra and pelvic bones, the authors distinguish two varieties of her injuries:

• simple with a small dislocation of the symphysis, general preservation of the urethra and a relatively small distraction of the mucosa - up to 3.3 cm;
• complex, in which there is a significant dislocation of the symphysis. Complete divergence of the stump of the urethra often with an interposition of other tissues and a more pronounced distraction of the mucous membrane - up to 3.8 cm and more;

In rare cases, damage to the urethra can occur without breaking the pelvic bones. The cause of such damage can be a blunt perineal injury.

Damage to the posterior urethra is also possible with endoscopic and open vaginal operations. Ischemic damage to the urethra and neck of the bladder is also described in case of prolonged labor.

In women, incomplete separation of the urethra in the region of the anterior wall is usually observed. A complete separation of the anterior or posterior part of the urethra occurs extremely rarely.

Extrusion or perforation of the urethra occurs in 2% during the TUR of the prostate.

Classification of damage to the urethra

Urologists use the classification of urethral injury, depending on the integrity of the skin, dividing these injuries into closed and open injuries.

Localization of lesions distinguishes between damage to the spongy (penile), renal and prostatic parts of the urethra.

Recently, the classification of closed (stupid urethral injuries based on retrograde urethrography data is used in Europe, and they are also subdivided depending on the localization of the damage to the anterior and posterior parts of the urethra, due to some differences in their diagnosis and treatment.

Classification of blunt injuries of the posterior and anterior parts of the urethra

Stage	Description of pathological changes
L	Damage resulting from stretching. Separation of the urethra without zkstravazatsii according to retrograde urethrography
II	Shake. Urethrorrhagia without extravasation according to retrograde urethrography
III	Partial rupture of anterior or posterior urethra. Extravasation of contrast at the site of injury, but with contrasting proximal urethra and bladder
IV	Full rupture of the anterior part of the urethra. Extravasation of contrast medium. The proximal part of the urethra and the bladder do not contrast
V	Full rupture of the posterior urethra. Extravasation of contrast medium. The bladder is not contrasted
VI	A partial rupture of the posterior urethra with concomitant damage to the neck of the bladder and / or vagina has been reported.

The urethra can be damaged both from the side of the lumen. And from the outside. The main types of closed injuries of the urethra are:

• injury;
• incomplete rupture of the wall of the urethra;
• complete rupture of the urethra wall;
• a break in the urethra;
• crushing.

With open injuries (injuries) of the urethra,

• injury;
• tangential and blind injuries without damage to all layers of the wall;
• tangential, blind and through wounds with damage to all layers of walls
• interruptions of the urethra;
• crushing.

In addition, interruptions of the urethra are divided into: on

• simple - the ends of the ruptured urethra are located along one axis and separated by a small gap;
• complex - if there is a significant diastase between the ends of the ruptured urethra displaced in relation to each other.

The severity of pathoanatomical changes developing after the damage to the urethra depends on the nature of the damage and intensity of urinary infiltration. If all layers of the canal are ruptured, blood and urine enter the tissues surrounding the urethra when urinating. This is the cause of urinary infiltration. Even sterile urine, getting into surrounding tissues, causes an inflammatory process, which often leads to extensive necrosis of tissues. The intensity of infiltration largely depends on the size of the damage, the degree of crushing of tissues and the protective reactions of the patient's body.

If the spongy part of the urethra is damaged, there is no urinary infiltration of the pelvic tissue even if the tissues are significantly crushed.

With the separation of the urethra from the bladder, the inner sphincter branches upward. Urine is kept in the bladder and periodically, when it overflows, it flows and accumulates in the pelvic cavity, gradually infiltrating the periububic and pelvic cellulose.

In addition, with a fracture of the pelvic bones in the cavity of the small pelvis accumulates a large amount of blood. The severity of these changes depends on the time of formation of urohematemata.

With urinary infiltration even after surgery, the wound can be complicated by suppuration followed by the formation of massive scars that narrow the lumen of the urethra.

Depending on the integrity of the skin, damage to the urethra is divided into closed and open.

Localization distinguishes between damage to the spongy (penile), membranous and prostatic part of the urethra.

Closed urethral damages in 40-60% of cases are combined with fractures of pelvic bones.

[3], [4], [5]

Complications of urethra trauma

Distinguish between early and late complications of urethra damage. The most frequent early complications are urinary infiltration and infectious-inflammatory complications ( cystitis, urethritis, pyelonephritis, phlegmon of pelvic fat, urosepsis, osteomyelitis of pelvic bones). This complication often becomes the direct cause of death, especially with gunshot wounds.

[6], [7], [8], [9]

Urinary infiltration

Urinary infiltration in the pelvic region followed by the formation of phlegmon of the pelvic fat often developed after 2-3 weeks after injury. The clinic of urinary infiltration depends on the location of the lesion. If the urethra is damaged in the urine by the urogenital diaphragm, the urine infiltrates the deep space of the perineum, sometimes it rises to the iliac fossa and is sent to the vertebral column, flaking off the subperitoneal tissue. Less often the urine passes into the surface of the perineum. Bowl of urine seeps through the thinning of the rectum-vesicular septum and passes along the sides of the rectum in the fossa ischiorectalis. If the urethra is damaged under the urogenital diaphragm, the urine penetrates the cell surface of the perineal surface, the area of the scrotum, the pubic penis, and the lateral parts of the abdomen.

With urinary infiltration, patients immediately open the urinary infiltration zone, withdraw urine by superficial fistula, prescribe intensive antibacterial and detoxification therapy.

Phlegmon of pelvic fat

With the development of phlegmon of the pelvic cellulose, the severely affected condition quickly deteriorates, body temperature rises sharply, dryness of the tongue appears, thirst, chills, diarrhea, and the patient loses appetite. With open lesions, pus with a pungent odor is released from the wound holes. If the patient does not undergo timely surgery, his condition worsens: facial features are sharpened, the patient raves, the skin becomes earthy in color, covered with cold sticky sweat, metastatic purulent foci appear in other organs, anuria sets in and the patient dies from urosepsis.

Cystitis, urethritis and pyelonephritis

Practically all victims are observed. However, only 20% of patients (usually with severe damage to the urethra and prolonged finding of drainage tubes in the urinary tract, as well as urinary infiltration), pyelonephritis is complicated by renal insufficiency of various stages.

[10], [11], [12], [13], [14]

Osteomyelitis of pelvic bones

If the urethra is damaged, osteomyelitis of the pelvic bones develops under the influence of urine swells, phlegmon and abscesses located near the bones. The development of osteomyelitis can also contribute to the flow of urine into the vestibular space with a low suprapubic fistula and poor drainage.

Striction and obliteration of the urethra

Among the late complications of the urethra, the stricture and obliteration of the urethra and urinary fistulas are most common.

As a result of cicatricial replacement of the urethra in the surrounding tissues after injury, when plastic surgery is postponed for a later time, there are strictures, obliteration and fistulas of the urethra Often such a complication is observed after recovery operations on the urethra performed immediately after the injury. To diagnose these strictures apply descending and ascending urethrography. On urethrograms, images of narrowed or obliterated sections of the urethra, their size, nature and localization, as well as the state of the urethra canal located behind the stricture are seen. Over time, due to difficulty urinating, the urethra widens above the cicatrical narrowing, the tone of the bladder and upper urinary tract decreases, inflammation of the mucosa of the canal, bladder, pyelonephritis joins.

Urinary fistulas

Fistulas of the urethra are formed most often after open lesions of the spongy part of it, especially if the suprapubic fistula has not been applied in time. As a rule, fistulas are formed in the place of the entrance or exit wound hole, in the places of incisions, made for urinary swabs and bruises, in the place of spontaneous opening of the feces and bruising or in the place of spontaneous opening of the inclusions and abscesses.

Diagnosis of fistulas of the urethra

Diagnosis of fistulas of the urethra is based on the history of the examination, and does not present any special difficulties. With the help of an ascending or descending urethrography, it is possible to determine the condition of the canal, the location of the fistula. In fistulas on the urethrograms, the shadow of the urethra leaves the fistula in the form of a narrow canal that ends blindly. There are single and multiple fistulous passages.

With urethrorectal fistula on the urethrogram, the filling of the rectum is determined. If the fistula moves open on the skin of the penis, perineum, or in other places accessible to the study, it is always necessary to do urethrography in conjunction with fistulography.

Close the fistulas of the urethra, usually in an operative way. With festering fistulas, scar tissue is completely excised along with the fistula, and tissue defect is sutured over the catheter inserted into the urethra. Guboid fistula is closed in various ways. In the simplest way, the fistula is excised with a fringing incision. A catheter is inserted into the bladder, on which the defect of the urethra is closed by the nodal sutures. The wound of the skin is sewn tightly. In other cases with the small fistula of the anterior part of the urethra the following plastic operations are used.

[15], [16], [17], [18], [19], [20], [21]

Operation Aliot

A fourfold incision is excised fistula. From both angles of the defect in the transverse direction, two parallel cuts of the skin of the posterior wall of the penis are made at a distance equal to the length of the defect. The formed skin flap is stretched to the freshened edges of the fistula and nodular sutures are hemmed to the edges of the defect. After the wound is healed, the catheter is removed.

Operation Albarran

The fissure cuts the fistula, then additional cross sections are made above the upper and lower ends of the wound. Mobilize the skin edges of the wound, forming two rectangular flaps. The defect of the urethra is sutured with nodal sutures. The wound of the skin is covered with seams, superimposed on the skin flaps. A catheter is inserted into the bladder for 5-7 days.

Operation of Guyon

A catheter is inserted into the bladder. Over the fistula and underneath, two identical cuts of skin are parallel to each other in the transverse direction and connected by a median incision. The grafts are mobilized and their edges are refreshed. At the lower edge of the wound, a quadrangular cutaneous flap is cut out with a base to the fistula. The flap is wrapped up and the epidermal surface closes the fistula in the wall of the urethra. Excess flap is brought under the skin of the upper edge of the wound and fixed. The wound surface of the flap is closed with lateral cutaneous flaps and stitched. Remaining after mobilization of the quadrangular rag, the wound is tightened and sutured. Leave a permanent catheter for 7-10 days

Operation Holtsova

In the operation, fistulas of the middle part of the urethra are covered with skin flaps cut from the scrotum. For this purpose, retreating from the fistula circumference in both directions by 0.5 cm, two parallel incisions are performed with the transition to the scrotum. At the upper end of the incisions, a fistula is excised. Retreating down a distance equal to the length of the defect, a transverse section is made between the longitudinal cuts. The edges of the wound are cut up and down, forming two skin flaps: the inner and the outer. The inner flap is wrapped upward with the epidermis inward and closes the defect of the urethra. The outer defect is pushed onto the inner defect so that their wound surfaces touch each other. Separate sutures of the external flap are sewn to the skin of the penis, grasping the seam and the inner flap.

When combined injuries are often formed urethrorectal fistulae to treat which is very difficult. In the surgical treatment of urethrectectal fistulas, it is not enough to separate the anastomosis and close the defect of the rectum and urethra. To avoid recurrence, the fistulous apertures should be displaced relative to each other. To do this, resort to various plastic operations.

Young's operation

The patient is placed on his back with the hips extended and brought to the stomach. Longitudinal and surrounding anus with incision uncover the urethra, anterior and lateral walls of the rectum to the fistulous course. Soust is dissected and mobilized in the rectum. The callous edges of the fistulous opening of the canal are excised and the fistula is sutured with catgut sutures. After that, the rectum is removed from the external sphincter, lowered downwards and resected above the fistula opening. The proximal segment of the resected rectum is fixed to the anus. To the place of stitches on the fistula of the urethra is the rubber graduate. Urine is removed through the suprapubic urinary fistula.

Elimination of the urethrerectal fistula can also be done by severing the fistula, closing the fistula, and then bringing the muscle graft between the rectum and the urethra. For this purpose, you can use bulbous-spongy muscle, a muscle that lifts the anus. A tender muscle of the thigh or a flap of the gluteus muscle. It is most convenient to use a flap from the large gluteus muscle. With this operation, the urine is removed through the suprapubic urinary fistula. The crotch is made on the perineum, which is lengthened towards the ischium-rectum and is carried under the ischial tubercle to the sacrococcygeal articulation. Separate the skin with subcutaneous fat and expose the gluteus maximus muscle.

The urethrorectal anastomosis is released and cleaved. Fistula of the rectum and urethra is sutured. The muscular flap is mobilized from the gluteus majorus and the nodal catgut sutures are fixed to the anterior wall of the rectum, covering the fistulous opening. A rubber graduate is injected into the wound and sutured.

Diagnosis of urethra trauma

[22], [23]

Clinical diagnosis of urethra trauma

Symptoms of urethra damage:

• urethrorrhagia;
• painful urination or inability to urinate;
• hematuria;
• palpation - filled bladder:
• hematoma and swelling.

In the absence of urethrorrhagia and / or hematuria, the probability of damage to the urethra is very low, and can be easily eliminated with the help of a bladder catheterization, which in one way or another is administered to patients with polytrauma.

Nevertheless, according to Lowe et al., In a physical examination, urethrorrhagia, hematoma perineum and high prostate status are not detected in 57% of the observations. This can be explained by the fact that with the rapid hospitalization of the patient these symptoms do not have time to develop. That is why the absence of obvious signs of damage to the urethra during a physical examination can not be considered a reason for refusing further examination of the patient if there is a suspicion of such damage (unstable fracture of the pelvis, etc.)

The next step is to collect an anamnesis. Fracture of the pelvis, any damage to the penis and perineum should always raise suspicions of possible damage to the urethra. With penetrating wounds it is necessary to find out the parameters of the weapon used (caliber, speed of the projectile). In patients who are conscious, it is necessary to collect data on the last urination (jet intensity, painful urination), and urinary extravasation after TUR of the prostate, the following symptoms are noted:

• anxiety;
• nausea and vomiting;
• abdominal pain, despite spinal anesthesia, pain is usually localized in the lower half of the abdomen or in the back. Localizes

Urethrorrhagia with lesions of the posterior urethra is noted in 37-93%. And the anterior one - 75% of observations. In this situation, it is necessary to exclude any instrumental procedures before conducting a full survey

Hematuria only at the first urination after trauma may indicate damage to the urethra. It should be remembered that the intensity of hematuria and urethrorrhagia is very weakly correlated with the severity of the trauma of the urethra Fallon et al. Of 200 patients with pelvic trauma in 77 found a microhematuria, only one of them showed significant damage to the urethra

Pain and the inability to urinate may also indicate possible damage to the urethra

[24], [25]

Hematoma and swelling

With injuries of the anterior part of the urethra, the location of the hematoma can help in determining the level of its damage. If the hematoma is located along the length of the penis, it is limited to Buk's fascia. With the rupture of this fascia, the fascia of Colitis becomes the limiting one, and the hematoma can spread up to the thoracoklavicular fascia, and downwards through fascia lata. In the area of the perineum, a swelling appears, resembling a butterfly in shape. In women with pelvic trauma, swelling of the labia may indicate damage to the urethra

The high standing of the prostate, revealed by digital rectal examination, indicates the complete separation of the urethra.

However, with a fracture of the pelvic bones and the presence of a large hematoma, especially in young patients, it is not always possible to perform palpation of the prostate. An abnormal position of the prostate is determined in digital rectal examination during the separation of the urethra in 34% of cases.

Instrumental diagnosis of injuries and injuries of the urethra

Radiological study. Retrograde urethrography is considered a "gold standard" for the diagnosis of damage to the urethra. The Foley catheter 12-14 SN is placed in the scaphoid fossa, the balloon is filled with 2-3 ml, 20.0 ml of water-soluble contrast medium is slowly injected, the x-ray is performed when the body is tilted 30. This makes it possible to detect fractures of the pelvic bones, the presence of a foreign body, a fragment in the projection of the urethra or bladder. If a urethra can be diagnosed, a cystostomy is usually established, with which further cystography and descending urethrography are performed. The latter is performed in weeks. If the planned delayed urethroplasty is planned, or after 3 months. If they plan a delayed urethroplasty.

If, with the help of retrograde urethrography, it is impossible to visualize the proximal part of the urethra, MRI and endoscopy performed through the suprapubic fistula can be informative . You can combine endoscopy with retrograde urethrography.

Retrograde urethrography is based on the classification of urethral injury, although it is to some extent relative in nature, since the presence of extravasation in the lesion area without visualizing the proximal divisions does not mean that. That the urethra is completely crossed. In this case, it is possible to preserve the bridge area consisting of the urethral wall, which prevents the formation of a large diastase between the ends.

Ultrasound is not considered a routine method for diagnosing urethral injury, but it can be very useful for diagnosing pelvic hematoma or high bladder location when it is planned to establish a cystostom.

CT and MRI are not used for initial examination of patients with urethra damage, since these studies are not very informative. They are mainly used to diagnose concomitant injuries of the bladder, kidneys, intraperitoneal organs.

Before the delayed reconstruction of the urethra due to severe damage to the urethra, MRI is used to clarify the anatomy of the pelvis, the direction and severity of the dislocation of the prostatic and membranous parts of the urethra, the extent of its defect and the nature of the associated lesions (penile legs, cavernous bodies).

Endoscopic examination. Endoscopic examination can be used in women after preliminary retrograde urethrography.

Treatment of injuries and injuries of the urethra

Posterior urethra

It is important to distinguish between the narrowing of the posterior urethra from its complete rupture, in which there is some area between the proximal and distal ends of the urethra filled with scar tissue (there are no walls of the urethra in this area).

A partial rupture of the posterior urethra, in this case, the establishment of a cystostomy or urethral catheter is shown, after which a second retrograde urethrography is performed 2 weeks later. Typically, such damage is cured without the formation of stricture or with the formation of unextended stricture, which can be eliminated by optical urethrotomy or dilatation. According to Glassberg et al., In children it is preferable to perform suprapubic drainage of the bladder rather than transurethral catheterization.

One of the common causes of partial damage to the urethra is the perforation of the prostatic capsule during the TUR of the prostate. If the perforation is suspected, the operation should be completed as soon as possible, however, hemostasis must be provided. Bleeding should be stopped, even if extravasation is increasing. More than 90% of such patients are cured by discontinuation of surgery and by transurethral placement of the catheter alone in the bladder. If extravasation is extensive and suspected of infection with peri-vesical fiber, suprapubic drainage of the bladder should be performed.

Closed urethra damage

The therapeutic tactics of partial injuries of the anterior part of the urethra can be reduced to the establishment of the suprapubic stoma or urethral catheter. Later this also makes it possible to perform an examination of the urethra. The cystostoma is retained for about 4 weeks. Providing restoration of the urethra. Before removal of the cystostomy, a functional cystourethrography is indicated.

Possible early complications are stricture and infection, up to an educated abscess, periurethral diverticulum and rarely necrotic fasciitis.

Closed injuries of the anterior part of the urethra are accompanied by concussion of the spongy body, which makes it difficult to differentiate the viable segments of the urethra on the site of injury, for this reason, urgent urethroplasty is not shown in such observations.

Gentle strictures, formed after injuries, can be dissected endoscopically. With rough strictures up to 1 cm in length, urethroplasty can be performed as an anastomosis.

With strictures greater than 3-6 months after the injury, a patchwork urethroplasty is performed. As an exception, the primary recovery of the urethra occurs when the cavernous body ruptures, when the damage to the urethra is usually partial.

[26], [27], [28]

Penetrating wounds of the urethra

In cases of injuries of the anterior part of the urethra obtained from low-speed firearms, from cold weapons or the bite of animals, which are often accompanied by lesions of the penis and testicles, primary operative recovery is shown (15% of observations or less are observed in the expression of strict strictures). Anastomosis is established without tension by watertight seams. Continuity of the urethra can also be restored without stitching with just the establishment of a urethral catheter, but the likelihood of a stricture is increased (78%).

With complete separation in the area of the urethra injury, the spongy body is mobilized in the distal and proximal directions, the stump is refreshed and an end-to-end anastomosis is formed on the catheter 14 Fr. Small gaps can be sutured with absorbable sutures. Conduct perioperative prophylaxis. After 10-14 days, cystourethrography is performed in situ in the urethral catheter, after which (in the absence of extravasation), the catheter is removed. If, after mobilization, the defect of the urethra is more than 1 cm, it is impossible to perform primary restoration of the urethra. Marsupilization of the ends of the urethra by watertight two-row sutures and superficial urinary fistula is applied. Further, the reconstructive operation is performed after 3 months

If the anterior section of the urethra is damaged, the method of suprapubic drainage of the bladder can be successfully used without restoring the damaged area. A positive result is noted in 80% of observations.

If the anterior section of the urethra is damaged from the firearm, especially when a large area of the urethra is lost and extensive crushing of the surrounding tissues, suprapubic drainage of the bladder is shown as the first stage of treatment.

Santucci et al. Presented the results of one of the largest studies of treatment of strictures of the anterior urethra by urethroplasty in the form of anastomosis. 168 patients were included in the study. The average length of the strictures was 1.7 cm. The follow-up after treatment was an average of six months, during which a stricture recurrence was observed in 8 patients (5 patients received optical urethrotomy, 3 repeated urethroplasty as end-to-end anastomosis). In rare cases, complications were noted - prolonged scarring of a small wound site, scrotum hematoma and ED (each of these complications occurred in 1-2% of cases). Pansadoro and Emiliozzi described the results of endoscopic treatment of the strictures of the anterior urethra in 224 patients. Repeated strictures were observed in 68% of cases. Repeated urethrotomy did not improve the effectiveness of treatment. Prognostically more favorable were strictures with a length of not more than 1 cm.

Thus, differentiated treatment of urethral injuries, depending on their type, can be reduced to the following:

• I type - treatment is not required:
• II and III types it is possible to conduct conservative treatment (cystostomy or urethral catheter);
• IV and V types of primary or delayed endoscopic or open surgical treatment:
• VI type - Primary restoration is necessary.

Complete rupture of urethra

Methods for treating complete rupture of the urethra.

• Primary endoscopic recovery of the urethra.
• Urgent open urethroplasty.
• Delayed primary urethroplasty.
• Delayed urethroplasty.
• Delayed endoscopic incision.

[29], [30], [31], [32], [33]

Primary recovery

If the patient's hemodynamic parameters are stable, the lithotomy position is possible and there are no contraindications to anesthesia, during the first 2 weeks, an endoscopic recovery of the urethra canal is possible. The advantages of the method are as follows

• It leads to a decrease in the incidence of stricture (10% vs. 60%), which allows about a third of patients to avoid repeated surgery.
• Restoration of the urethra after scarring is easier to perform (endoscopic dissection or dilatation).
• If urethroplasty is performed at a later date, it is technically simpler, since both ends of the urethra are on the "one line".

Disadvantages: erectile dysfunction is observed in 40-44% of patients (with delayed recovery - in 11%). Urinary incontinence - in 9-20% (with delayed recovery - in 2%).

Some authors give more comforting data: erectile dysfunction - in 21% of cases (more often than not complete erectile dysfunction, and decreased erection), stress urinary incontinence - in 3.7%. Stricture in 68% (of the 36 patients with recurrent urethral stricture strictures only 13 underwent further serious manipulation). Nussman et al. In the examination, 81 patients did not find a significant difference between early and delayed recovery Similar results were also obtained by other authors.

Diametrically opposite data are presented by Muraviev et al. The study included 96 patients with severe pelvic trauma and urethral injury. With delayed recovery of the urethra, the risk of complications is higher than in the early urethra: stricture - in 100% (with early recovery - in 49%), impotence - 42.1% (with early recovery - 33.6%), urinary incontinence - in 24.9% (with early recovery in - 17.7%) of observations.

Methods of primary recovery:

• Simple catheter placement through urethra defect
• Conduction of a catheter with a flexible endoscope and a two-dimensional fluoroscope.
• Restoration of the urethra using a coaxillary magnetic catheter and intercomplementary probes "linear comparison".
• Evacuation of pelvic hematoma and dissection of the apex of the prostate (with or without suturing anastamosis) on the urethral catheter. Tension of the catheter or crotch-retaining seams to fix the prostate in the desired position does not always lead to the elimination of the defect and, in addition, can lead to necrosis of the muscles of the internal sphincter of the bladder and, consequently, to urinary incontinence.

Simple or endoscopic restoration of the posterior urethra

The method, when feasible, is quite effective and, with respect to complications, is favorable and minimally invasive. It can be carried out both immediately after the injury, and within a few weeks after it. Moundouni et al. Early restoration of the posterior urethra was performed in 29 patients (23 with full and 6 with incomplete urethral rupture) within 1-8 days after trauma. At the further observation (on the average 68 months) 4 patients have undergone urethroplasty by perineal access. 12 transurethral manipulations. In 25 patients out of 29 there was no impotence. 4, intracavernosal injections of prostaglandin E were used to achieve an erection. None of the patients had incontinence.

Similar results are reported also by Ying-Nao. Melekos. Jepson. Tahan and Cohen in their studies with a few patients. Porter et al. Report 11 unprecedented observations of primary recovery of the urethra for 1 to 24 hours after trauma with co-axillary magnetic catheters. At follow-up (mean 6.1 months), 5 patients developed strictures to eliminate which an average of 1.4 interventions were required per patient. Urinary incontinence was not observed. Rehman et al. With the aim of improving the efficiency of restoring the posterior urethra, suggest the use of the C-Arm fluoroscope, which provides a two-dimensional image during the procedure.

Simultaneously with the endoscopic restoration, suprapubic drainage is also established, with the help of which antegrade (also retrograde, on the sides of the urethral catheter) urethrography is performed 3-6 weeks after the trauma. If there is no extravasation of contrast medium, the catheter is removed. The method is also used in operations for combined injuries, if the patient's condition is stable.

At primary restoration the generalizing statistics of complications is those:

• erectile dysfunction - 35%;
• urinary incontinence - 5%;
• relapse stricture - 60% of observations.

Urgent open urethroplasty

Many authors believe that such tactics are not shown, because in the acute phase, due to poor visualization and differentiation of anatomical structures, their mobilization and comparison are difficult. Due to the presence of hematoma and edema, it is impossible to accurately determine the degree of damage to the urethra. With this technique, incontinence and erectile dysfunction rates are high (at 21 and 56%, respectively) in the postoperative period. Webster et al. Believe that the method should be reserved only for such rare cases when the so-called high standing of the prostate, accompanying damage to the rectum and the neck of the bladder, as well as the continuing bleeding are revealed.

Delayed primary urethroplasty

It is known that the choice of the timing of treatment of injuries of the posterior urethra can significantly depend on the choice of methods and timing of treatment of fractures of the pelvic bones. The widespread introduction of new methods for treating pelvic fractures through external and internal fixation has created an opportunity to review the therapeutic tactics of damage to the posterior urethra.

10-14 days after the bladder drainage with the help of a cystostomy installed immediately after the trauma, it is possible to produce delayed primary urethroplasty, as during this time the hematoma resolves. Urethroplasty is performed endoscopically. Abdominal or perineal access. Primary urethroplasty provides 80% of a favorable outcome without the formation of strictures. This method is also considered the best option for the treatment of urethra damage in women, which makes it possible to maintain the normal length of the urethra and urine retention.

[34], [35], [36], [37], [38], [39]

Delayed urethroplasty

With delayed treatment of the lesion of the subprostatic urinary tract, a short defect (diastasis) is usually formed between the posterior and anterior parts of the urethra. In such cases it is possible to restore the integrity of the urethra by the perineal access, which is carried out in the patient's lithotomy position. Remove all fibrous tissues located between the spongy section of the moccuspension channel and the apex of the prostate, refresh the urethral stump and restore its integrity with the end-to-end anastomosis. If the length of the defect is 2-2.5 cm, the urethra can be mobilized in the proximal direction for 4-5 cm. This makes it possible to cover the defect due to the elasticity of the urethra.

If the defect between the prostatic and spongy parts of the urethra exceeds 2-3 cm due to the high standing of the prostate, the next maneuver consists in the separation of the anterior section of the urethra by 8 cm in length, dilating each other from the proximal parts of the cavernous bodies. Lower pulectomy and a supracrural movement of the urethra. Moray for the use of posterior urethroplasty used this method in 37% of cases. Webster et al., Using the described method, provided end-to-end anastomosis without tension under defect conditions up to 7 cm.

Koraitim made a comparative analysis of his own 100 observations with published data of 771 observations of other authors and obtained the following results: with immediate restoration of the urethra (n = 326) stricture recurs in 53% of cases, urinary incontinence - 5%, impotence - 36%. In the future 42% of safely operated patients underwent additional manipulations to eliminate repeated strictures. An imperative need for urethroplasty occurred in 33% of cases. Primary recovery of the urethra (n = 37) in 49% of cases resulted in her stricture, in 21% - with urinary incontinence and in 56% with impotence. For comparison, we note that the establishment of the suprapubic fistula before the delayed recovery (n = 508) resulted in a stricture in 97%, incontinence in 4% and impotence in 19% of cases.

After delayed urethroplasty, the severity of recurrence of stricture is lower by 10%, and impotence due to intervention - by 2.5-5%.

Sorriere analyzed the results of 63 observations of anterior urethroplasty, 58 of which were performed by the perineal, and 5 by the combined peritoneal-perineal access. The period of observation of patients averaged a year. The following complications were observed:

• damage to the rectum - in 2 cases;
• relapse stricture, requiring repeated surgical intervention - in 3 cases;
• strictures, which were overcome by dilatation or optical excision, in 20 cases.

During the first year in 42 patients, urination was normal. Five patients noted neurogenic dysfunction of the bladder and performed periodic self-catheterization, 5 patients had urinary incontinence, and 5 had moderate stress incontinence. In 31 patients with a normal erectile function, there was no deterioration of the erection before surgery in the postoperative period. In the remaining 29 patients, erectile dysfunction was before and immediately after surgery. However, in 9 of them within a year the erection was restored.

Korraitim also examined children with posttraumatic strictures of the membranous urethra. Strictures were more frequent as a result of fractures of the pelvis by the type Malgaigne (35% of observations) and the so-called separation (26% of observations), diastasis of the sacroiliac joint OR 6e. According to the study, the best results were obtained after perineal and transsymphysical urethroplasty with end-to-end anastomosis in 93% in 91% of cases, respectively.

Authors of the study do not advise to apply trans-scrap two-stage urethroplasty and transurethral urethrotomy, as in the first case the outcome is unsatisfactory, and in the second one it is possible to lose the possibility of further urethroplasty in connection with the limitation of mobility of the anterior part of the urethra. Onfez et al. In a study that included 35 children who underwent urethroplasty in the form of an anastomosis of the posterior or bulbous parts of the urethra, a favorable outcome was noted in 31 patients (89%). Of the remaining 4 patients, two successfully performed optical urethrotomy, and two remaining repeated urethroplasty in the form of anastomosis.

Urethroplasty of the posterior urethra, if technically feasible, is always preferable to patchwork urethroplasty, since in the latter variant the probability of repeated constriction of the urethra is greater (for a 10-year follow-up period of 31 versus 12%). Regarding operative access: in comparison with perineal, puukectomy access is more traumatic, takes longer, provokes greater blood loss and prolonged postoperative pain. Thus, puukectomy should probably be used in rare cases, and an experienced urologist should only operate.

The given data convincingly prove that the gold standard of treatment should be considered a delayed recovery of the urethra after 3 months after the trauma by one-step crotch access.

Examining the condition of the neck of the bladder and the proximal urethra before urethroplasty. Iselin and Webster found a relationship between the degree of severity of the opening of the neck of the bladder and post-operative urinary incontinence. Cystography and / or suprapubic cystoscopy were used to assess the condition of the bladder neck.

Patients who developed incontinence after reconstructive surgery, on average, had a larger internal ring (1.68 cm on average) than patients who had no such problem after surgery (an average of 0.9 cm). Based on the foregoing, the authors of the study suggest that in patients with a high risk of postoperative urinary incontinence, in addition to urethroplasty, reconstruct the neck of the bladder, which provides urine retention (artificial sphincter installation, collagen implantation around the urethra).

McDiarmid et al. Operated 4 patients with obvious signs of failure of the neck of the bladder before surgery and performed only urethroplasty in the form of an anastomosis without neck reconstruction, with no case of postoperative urinary incontinence noted. The authors concluded that the use of combined peritoneal-perineal access with restoration of the neck of the bladder should be performed only in patients with obvious damage and mixing of the neck of the bladder, with the presence of complications (skin-urethral fistula, residual inflammatory process, diverticulum of the urethra, etc.), as well as with the accompanying stricture of the anterior part of the urethra.

As already noted, after ruptures of the back of the urethra, erectile dysfunction occurs in 20-60% of cases. Contributing factors include age, length of the defect and the type of fracture of the pelvis. Bilateral fracture of the branches of pubic bones is the most frequent cause of impotence.

This is due to bilateral damage to the cavernous nerves at the level of the prostomotombranous segment of the urethra (directly behind the pubic symphysis). More than 80% of the cases of erectile dysfunction are to a certain extent related to the violation of blood supply as a result of damage to the branches a. Pudenda. Another reason for erectile dysfunction is also considered the detachment of cavernous bodies from the branches of the bones. In this case, surgery does not increase the frequency of recovery of erectile function

Investigating the problem of erectile dysfunction associated with damage to the back of the urethra. Dhabuvvala came to the conclusion that it is more related to the injury itself than to the reconstructive operation. Moreover, erectile dysfunction can develop not only with joint damage of the pelvis and urethra, but also with pelvic fractures without damage to the urethra, and its cause is damage to the cavernous nerves.

Given the objective relationship between injuries of the posterior urethra due to fractures of the pelvis, and impotence, Shenfeld, Armenakas et al. Suggest before urethroplasty to find out the reason for the latter. For this, it is recommended to perform a pelvic MRI scan, a night-time tumescence test and a duplex scanning of the penis vessels with a pharmacological test, supplementing it with angiography if necessary.

The most common abnormalities detected with MRI are prostate dislocation (86.7%) and damage to cavernous bodies (80%). After reconstructive operation of the urethra, some authors observed even cases of restoration of the erection. The remaining patients had effective intra-cavernous injections of vasoactive drugs. A successful revascularization of the penis is also described.

Summarizing questions related to urethroplasty, Mundy noted that impotence associated with this manipulation is in fact a more common problem than presented in various reports, and the most painful aspect in this area. It can be concluded that the issue is still open and requires further in-depth study.

In case of failure of urethroplasty according to the type of anastomosis end-to-end, a repeated urethroplasty is shown - again in the form of an anastomosis end-to-end or scrappy, which is carried out as perineal or pulectomy. And combined peritoneal-perineal access, which depends on the extent of stricture and on the presence of concomitant complications. With the correct operational tactics, you can achieve up to 87% of the positive result. The optical urethrotomy is also successfully used, which can be supplemented with several probe dilatations of the urethra with 6-week intervals.

The following are considered conditions that prevent the conduct of primary urethroplasty.

• The distraction defect is 7-8 cm and more. In this case, you can use a patchwork of the skin from the perineoscrotal area or from the penis;
• Fistula. It is possible to use combined abdominal and perineal access to ensure adequate elimination of the fistula;
• Combined stricture of the anterior part of the urethra. In case of spongiofibrosis of the anterior part of the urethra, the cessation of blood flow through the bulbar arteries as a consequence of mobilization can lead to disruption of its nutrition.
• Urinary incontinence. If the external sphincter of the urethra is damaged due to destruction, urinary retention is performed by the sphincter of the neck of the bladder. However, simultaneous damage to the neck of the bladder with a high probability may lead to the development of urinary incontinence. In this case it is necessary to operate with combined abdominal-perineal access. Since often the cause of urinary incontinence is the circular fixation of the neck of the bladder by scar tissue, in such cases mobilization of the cervix can lead to the elimination of incontinence symptoms. The intervention should be supplemented by removal of residual hematomas and movement to the urethral wall of the urethra by flap from the large omentum on the pedicle in order to prevent fibrosis and provide mobility of the neck.

[40], [41], [42], [43]

Patchwork urethroplasty

Operations of urethroplasty with the use of flaps from the radial artery, appendix, and the wall of the bladder are described. Most often for this purpose, use grafts taken from the skin and mucous membranes of the cheeks. The skin flap is mainly taken from the scrotum and penis, it can be used both freely and on the nutritive stem. The main drawback of this plastic material is considered the continuation of hair growth, the appearance of hyperkeratosis in the moist environment and the formation of diverticula of the urethra.

Currently, the "gold standard" of plastic material for patchwork urethroplasty is considered a flap of the mucous cheek. This is due to the following properties:

• adaptation to wet conditions;
• absence of hair;
• easy access;
• resistance to infections;
• the presence of a thick mucous membrane that facilitates its formation and prevents the formation of diverticula even in the case of ventral urethroplasty;
• The presence of a thin, self-supporting plate that promotes rapid adhesion.

A flap taken from the buccal mucosa for the purpose of performing urethroplasty can be used by dorsal, ventral and tubular placement methods, in one- and two-stage manipulations. The best results were obtained with a one-stage dorsal urethroplasty of the anterior part of the urethra (efficacy 96.2% with an average follow-up period of 38 months).

Delayed endoscopic optical dissection (incision)

Before the intervention, it is necessary to clarify the extent of the stricture or obliterated area of the urethra, the position of the prostate and the condition of the neck of the bladder. For this purpose, it is usually sufficient to conduct an on-counter cystourethrography and a digital rectal examination. The procedure is indicated in the presence of a short urethral defect, a competent neck of the bladder and a minimum distance between the prostate and the onion bulb of the urethra.

The curved metal probe is passed through the cystostomy into the blindly terminating proximal section of the urethra, and then under visual control it is inserted into the urethra by a urethrot and dissection is performed.

In order to translate the perineal membrane, the suprapubic passage of the cystoscope is performed, after which the urethra is cut in the direction of light (sitting-to-light). At present, the sitting-to-thе-light technique has become more effective with the use of the C-arm fluoroscope for stereotactical direction. At the end of the manipulation for 1-3 weeks, a urethral catheter and suprapubic drainage are installed, which is removed after an additional 2 weeks.

EI-Ab presented data from a survey of 352 patients with injuries of the posterior urethra without an accompanying upward shift of the bladder. All patients had a cystostomy. In 284 patients strictures were formed, which were eliminated by delayed optical excision. The remaining 68 patients developed complete obliteration, which was used to eliminate endoscopic resection, creating conditions for the further implementation of urethrotomy (a similar approach is also described by Liberman and Barry). This method is used to facilitate the conduct of distant urethralgia.

As a result, it was possible to ensure the patency of the urethra in 51.8% of cases, the remaining patients underwent open urethroplasty. The appearance of impotence due to such interference was not noted. Chiou et al., Despite the listed complications, with complete obliteration of the posterior urethra, aggressive endoscopic tactics using the method of serial optical urethrotomy often allows to completely eliminate strictures within 2 years, not resorting to urethroplasty.

Marshall represents a method of endoscopic treatment of a fully obliterated segment of the urethra of the posterior part of the urethra with a length of no more than 3 cm using a balloon catheter and a conductor. The balloon-catheter is carried into the urethra antegrade along the trocar epicystostome. When inflated, the balloon expands, which leads to splitting of scar tissue, which can later be excised with the help of optical urethrotomy.

The method allows to achieve good results without the development of serious complications. Dogra and Nabi presented an interesting method for treating complete obliteration of the posterior urethra in an outpatient setting with a guided urethrotomy using a YAG laser. To stabilize the patency of the urethra sometimes had to use optical urethrotomy at a later date. A favorable outcome without complications was noted in 61 of 65 patients. Repeated obliteration developed in 2 patients.

The establishment of intraurethral stents with strictures and obliteration of the posterior urethra is not recommended. Since fibrous tissue can germinate into the lumen of the urethra through the wall of the stent. Leading to repeated obliteration.

In contrast, Milroy et al. Described 8 observations of endourethral application of endovascular stents. After 4-6 months after their installation, epithelization of the inner surface of the stent was observed instead of obliteration. A short period of observation of patients does not allow us to draw conclusions from the remote results of this method.

Summarizing the foregoing, it should be noted that the numerous methods of treating the injuries of the posterior urethra do not indicate their inconsistency at all. Despite the fact that there are no universal methods of treatment of injuries of the posterior urethra, it is safe to say that in men open surgical and endoscopic methods complement each other. The choice of method depends both on the nature of the trauma and the characteristics of the clinical course, and on the personal experience of the urologist, instrumental equipment, etc. In each specific case, the choice of the most appropriate method of treatment should be based on a correct analytical evaluation of all these circumstances.

The largest specialist in the reconstruction of the urethra of the Thurner-Waigwick emphasizes the special role of the urologist's individuality in this area. He notes that at present the rapid development of urology led to the fact that, in contrast to optical urethrotomy and dilatation of the urethra, reconstruction of the latter is considered not a general professional intervention.

[44], [45], [46], [47]