Damage and trauma to the urethra

In wartime, up to 30% of the wounded have damage and injuries 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%), usually with pelvic fractures. About 70% of urethral injuries occur as a result of road accidents.

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

A distinction is made between closed (subcutaneous) and open injuries, as well as isolated and combined injuries of the urethra. Closed injuries are observed in 96% of victims and open injuries in only 4%.

ICD-10 code

S37.3. Injuries of urethra.

What causes damage and injury to the urethra?

Causes of damage and injury to the urethra

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

From an anatomical and practical point of view, the urethra is usually divided into two parts: the posterior (fixed urethra) and the anterior. The boundary between them is the urogenital diaphragm. Damage to these two sections can differ significantly in the mechanism of formation, clinical course and treatment tactics. It is for this reason that they are usually considered separately.

[ 1 ], [ 2 ]

Pathogenesis of damage and injuries of the urethra

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

In the vast majority of cases, urethral injuries occur with fractures of the pelvic bones (usually the pubic and ischial bones). In these cases, the membranous and prostatic parts of the urethra are especially often damaged. Rupture of the prostatic part of the urethra occurs extremely rarely. Damage to the urethra occurs due to tension of the ligamentous apparatus and the urogenital diaphragm or bone fragments.

Injuries to the posterior urethra

Damage to the posterior urethra is usually observed in pelvic bone fractures (3.5-19% of pelvic bone fractures), which are the main cause of damage to this part of the urethra. Most often, the urethra is damaged in fractures of the horizontal branches of the pubic bones, especially in the presence of diastasis of the coccygeal-iliac joint ("stable fracture").

The main causes of these injuries are traffic accidents (75%), falls from height, and crushing force. Displaced pelvic fractures usually result in stretching of the fixed portion of the urethra, which can cause the urethra to detach from the apex of the prostate.

In 10-17% of cases, a combined rupture of the bladder occurs, which can complicate diagnosis.

The forces that lead to a pelvic fracture are usually divided by the direction of impact into anteroposterior, lateral and vertical, of which the first two groups can lead to both a stable and an unstable fracture, and the third - to the formation of only unstable fractures ("fracture with displacement").

In a stable pelvic fracture, injury to the urethra may occur when an external force breaks all four rami of both pubic bones, creating a butterfly-shaped fragment that moves backward, causing the urethra to detach from the apex of the prostate, damaging the external urethral sphincter.

Unstable pelvic fractures include fractures of the anterior or lateral segments of the pelvic ring and the sacrosciatic joint. In this case, the posterior part of the urethra is damaged either directly by bone fragments or by displacement of any bone fragment to which the urethra is fixed or due to stretching of the urethra.

As shown by Siegel et al., when the damaging force acts in the anteroposterior direction (compared to the lateral direction), more severe damage to the pelvic bones and lower urinary tract occurs and the risk of retroperitoneal bleeding, shock and mortality increases.

Despite the widespread belief that pelvic injuries most often result in damage to the urethra above the urogenital diaphragm and below the apex of the prostate, some studies prove the exact opposite. According to Mouraviev and Santucci, of 10 male cadavers with pelvic injuries and urethral rupture, 7 had urethral damage below the urogenital diaphragm. The study also showed that with a complete rupture of the urethra, the mucosal defect is always larger (on average 3.5±0.5 cm) than the defect of the outer layer (on average 2.0±0.2 cm). In addition, the extent of the defect in the dorsal direction is greater than in the ventral direction. Due to the severity of damage to the urethra and pelvic bones, the authors distinguish two types of damage:

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

In rare cases, damage to the urethra is possible without a fracture of the pelvic bones. The cause of such damage may be blunt trauma to the perineum.

Damage to the posterior urethra is also possible during endoscopic and open vaginal surgeries. Ischemic damage to the urethra and bladder neck during prolonged labor has also been described.

In women, incomplete rupture of the urethra in the anterior wall is usually observed. Complete rupture of the anterior or posterior part of the urethra is extremely rare.

Extravasation or perforation of the urethra occurs in 2% during TURP.

Classification of urethral injuries

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

Depending on the localization of damage, there are injuries to the spongy (penile), penile and prostatic parts of the urethra.

Recently, in Europe, a classification of closed (blunt) injuries of the urethra has been used, based on retrograde urethrography data. In addition, they are also divided depending on the localization into injuries of the anterior and posterior sections of the urethra, due to some differences in their diagnosis and treatment.

Classification of blunt injuries of the posterior and anterior urethra

Stage	Description of pathological changes
L	Distension injury. Rupture of the urethra without extravasation according to retrograde urethrography
II	Concussion. Urethrorrhagia without extravasation according to retrograde urethrography
III	Partial rupture of the anterior or posterior urethra. Extravasation of contrast at the site of injury, but with contrast enhancement of the proximal urethra and bladder
IV	Complete rupture of the anterior urethra. Extravasation of contrast medium. The proximal urethra and bladder are not contrasted.
V	Complete rupture of the posterior urethra. Extravasation of contrast medium. The bladder is not contrasted.
VI	A partial or posterior urethral rupture with concomitant damage to the bladder neck and/or vagina has occurred.

The urethra can be damaged both from the lumen and from the outside. The main types of closed injuries of the urethra are considered to be:

• injury;
• incomplete rupture of the wall of the urethra;
• complete rupture of the wall of the urethra;
• interruption of the urethra;
• crushing.

In case of open injuries (wounds) of the urethra, a distinction is made

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

In addition, the urethral ruptures are divided into:

• simple - the ends of the torn urethra are located along the same axis and are separated by a small gap;
• complex - in the presence of significant diastasis between the ends of the torn urethra, which are displaced relative to each other.

The severity of pathological changes that develop after damage to the urethra depends on the nature of the damage and the intensity of urinary infiltration. If all layers of the canal are torn, blood and urine during urination enter the tissues surrounding the urethra. This causes urinary infiltration. Even sterile urine, entering the surrounding tissues, causes an inflammatory process, which often leads to extensive tissue necrosis. The intensity of infiltration largely depends on the size of the damage, the degree of tissue crushing and the protective reactions of the patient's body.

When the spongy part of the urethra is damaged, there is no urinary infiltration of the pelvic tissue even with significant tissue crushing.

When the urethra is torn away from the bladder, the internal sphincter moves upward. Urine is retained in the bladder and periodically, when it is full, it flows out and accumulates in the pelvic cavity, gradually infiltrating the perivesical and pelvic tissue.

In addition, when the pelvic bones are fractured, a large amount of blood accumulates in the pelvic cavity. The severity of these changes depends on the time of formation of the urohematoma.

With urinary infiltration, even after surgery, the wound may become complicated by suppuration with subsequent 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.

Depending on the localization, there are injuries to the spongy (penile), membranous and prostatic parts of the urethra.

Closed injuries of the urethra in 40-60% of cases are combined with fractures of the pelvic bones.

[ 3 ], [ 4 ], [ 5 ]

Complications of urethral injuries

There are early and late complications of urethral injuries. The most common early complications are urinary infiltration and infectious and inflammatory complications ( cystitis, urethritis, pyelonephritis, pelvic cellulitis, urosepsis, osteomyelitis of the pelvic bones). These complications often become the immediate cause of death, especially in the case of gunshot wounds.

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

Urinary infiltration

Urinary infiltration in the pelvic area with subsequent formation of pelvic tissue phlegmon most often developed 2-3 weeks after the injury. The clinical picture of urinary infiltration depends on the location of the injury. If the urethra is damaged above the urogenital diaphragm, urine infiltrates the deep space of the perineum, sometimes it rises to the iliac fossa and is directed to the spinal column, peeling off the subperitoneal tissue. Less often, urine passes into the superficial space of the perineum. Most often, urine seeps through thinning of the rectovesical septum and passes along the sides of the rectum into the fossa ischiorectalis. If the urethra is damaged below the urogenital diaphragm, urine penetrates into the tissue of the superficial space of the perineum, the area of the scrotum, penis, pubis, and lateral parts of the abdomen.

In case of urinary infiltration, the area of urinary infiltration is immediately opened in patients, urine is drained by creating a suprapubic fistula, and intensive antibacterial and detoxification therapy is prescribed.

Phlegmon of the pelvic tissue

With the development of pelvic cellular tissue phlegmon, the already serious condition of the victim quickly worsens, the body temperature rises sharply, the tongue becomes dry, thirsty, chills, diarrhea appear, the patient loses appetite. In case of open injuries, pus with a strong odor is released from the wound openings. If the patient is not operated on in a timely manner, his condition worsens: facial features become sharper, the patient is delirious, the skin becomes sallow, covered with cold sticky sweat, metastatic purulent foci appear in other organs, anuria occurs and the patient dies from urosepsis.

Cystitis, urethritis and pyelonephritis

It is observed in almost all victims. However, only in 20% of patients (usually with severe damage to the urethra and prolonged presence of drainage tubes in the urinary tract, as well as with urinary infiltration) pyelonephritis is complicated by renal failure of varying degrees.

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

Osteomyelitis of the pelvic bones

In case of damage to the urethra, osteomyelitis of the pelvic bones develops under the influence of urinary leaks, phlegmons and abscesses located near the bones. The development of osteomyelitis can also be facilitated by urine leakage into the prevesical space with a low-lying suprapubic fistula and poor drainage.

Stricture and obliteration of the urethra

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

As a result of cicatricial replacement of the walls of the urethra in the surrounding tissues after injury, when plastic surgery is postponed to a later time, strictures, obliterations and fistulas of the urethra occur. Such a complication is often observed after reconstructive operations on the urethra performed immediately after injury. Descending and ascending urethrography are used to diagnose these strictures. Urethrograms show images of narrowed or obliterated sections of the urethra, their size, nature and localization, as well as the condition of the section of the urethra located behind the stricture. Over time, due to difficult urination, the urethra expands above the site of cicatricial stenosis, the tone of the bladder and upper urinary tract decreases, inflammation of the mucous membrane of the canal, bladder develops, pyelonephritis occurs.

Urinary fistulas

Fistulas of the urethra are most often formed after open injuries to its spongy part, especially if a suprapubic fistula was not applied in a timely manner. As a rule, fistulas are formed at the site of the entry or exit wound, at the sites of incisions made due to urinary leaks and hematomas, at the site of spontaneously opened leaks and hematomas, or at the site of spontaneously opened leaks and abscesses.

Diagnosis of urethral fistulas

Diagnosis of urethral fistulas is based on anamnesis and examination data and is not particularly difficult. With the help of ascending or descending urethrography, it is possible to determine the condition of the canal and the location of the fistula. In case of fistulas, on urethrograms, the shadow of the fistula tract appears to extend from the shadow of the urethra in the form of a narrow channel ending blindly. There are single and multiple fistula tracts.

In case of urethrorectal fistulas, the urethrogram determines the filling of the rectum. If the fistula tracts open on the skin of the penis, perineum or in other places accessible for examination, then it is always necessary to do urethrography in combination with fistulography.

Fistulas of the urethra are usually closed surgically. In case of purulent fistulas, the cicatricial tissues are completely excised together with the fistula, and the tissue defect is sutured over the catheter inserted into the urethra. A labial fistula is closed in various ways. In the simplest method, the fistula is excised with a border incision. A catheter is inserted into the bladder, on which the defect of the urethra is closed with interrupted sutures. The skin wound is sutured tightly. In other cases, the following plastic surgeries are used for small fistulas of the anterior section of the urethra.

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

Operation Aliota

The fistula is excised with a quadrangular incision. Two parallel incisions are made transversely from both corners of the defect in the skin of the posterior wall of the penis at a distance equal to the length of the defect. The resulting skin flap is pulled over the refreshed edges of the fistula and sutured to the edges of the defect with interrupted sutures. After the wound has healed, the catheter is removed.

Operation Albarran

The fistula is excised with a border incision, then additional transverse incisions are made above the upper and lower ends of the wound. The skin edges of the wound are mobilized, forming two rectangular flaps. The urethral defect is sutured with interrupted sutures. The skin wound is closed with separate sutures placed on the skin flaps. A catheter is inserted into the bladder for 5-7 days.

Guyon's Operation

A catheter is first inserted into the bladder. Two identical skin incisions are made above and below the fistula in a transverse direction parallel to each other and connected with a midline incision. The flaps are mobilized and their edges are refreshed. A quadrangular skin flap is cut out at the lower edge of the wound with the base towards the fistula tract. The flap is folded upward and the epidermal surface is used to cover the fistula opening in the wall of the urethra. The excess flap is placed under the skin of the upper edge of the wound and fixed. The wound surface of the flap is covered with lateral skin flaps and sutured. The wound remaining after the mobilization of the quadrangular flap is pulled together and sutured. A permanent catheter is left in place for 7-10 days.

Operation Holtzoff

During the operation, fistulas of the middle part of the urethra are closed with skin flaps cut from the scrotum. For this purpose, retreating from the circumference of the fistula in both directions by 0.5 cm, two parallel incisions are made with a transition to the scrotum. The fistula is excised at the upper end of the incisions. Retreating downwards by a distance equal to the length of the defect, a transverse incision is made between the longitudinal incisions. The edges of the wound are separated upward and downward, forming two skin flaps: internal and external. The internal flap is folded upward with the epidermis inward and is used to close the defect of the urethra. The external defect is pushed over the internal one so that their wound surfaces touch each other. The external flap is sutured to the skin of the penis with separate sutures, capturing the internal flap in the suture.

Combined injuries often result in urethrorectal fistulas, which are very difficult to treat. In surgical treatment of urethrorectal fistulas, it is not enough to separate the anastomosis and close the defect of the rectum and urethra. To avoid relapse, it is necessary to shift the fistula openings relative to each other. For this purpose, various plastic surgeries are used.

Jung's operation

The patient is placed on his back with the thighs spread and drawn to the abdomen. The urethra, the anterior and lateral walls of the rectum up to the fistula are exposed by a longitudinal incision surrounding the anus. The ostium is dissected and the rectum is mobilized. The callous edges of the fistula opening of the canal are excised and the fistula is sutured with catgut sutures. After this, the rectum is separated from the external sphincter, lowered downwards and resected above the fistula opening. The proximal section of the resected rectum is fixed to the anus. A rubber drain is brought to the site of the sutures on the fistula of the urethra. Urine is drained through the suprapubic vesical fistula.

A urethrorectal fistula can also be eliminated by disconnecting the anastomoses, closing the fistula openings, and then inserting a muscle flap between the rectum and the urethra. For this purpose, the bulbospongiosus muscle, the levator ani muscle, the delicate muscle of the thigh, or a flap from the gluteus maximus muscle can be used. The most convenient flap to use is the gluteus maximus muscle. In this operation, urine is drained through a suprapubic vesical fistula. An arcuate incision is made on the perineum, which is extended toward the ischiorectal fossa and carried out under the ischial tuberosity to the sacrococcygeal joint. The skin with subcutaneous tissue is separated and the gluteus maximus muscle is exposed.

The urethrorectal anastomosis is released and split. The fistula of the rectum and urethra is sutured. A muscle flap from the gluteus maximus is mobilized and fixed to the anterior wall of the rectum with interrupted catgut sutures, covering the fistula opening with it. A rubber drain is inserted into the wound and sutured.

Diagnosis of urethral injuries

[ 22 ], [ 23 ]

Clinical diagnostics of urethral injuries

Symptoms of urethral 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 excluded by catheterization of the bladder, which is performed in patients with multiple injuries anyway.

However, according to Lowe et al., urethrorrhagia, perineal hematoma, and high prostate are not detected during physical examination in 57% of cases. This can be explained by the fact that with 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 physical examination cannot be considered a reason to refuse further examination of the patient if there is a suspicion of such damage (unstable pelvic fracture, etc.)

The next step is to collect anamnesis. Pelvic fractures, any damage to the penis and perineum should always raise suspicions of possible damage to the urethra. In case of penetrating wounds, it is necessary to find out the parameters of the weapon used (caliber, projectile velocity). In conscious patients, it is necessary to collect data on the last urination (stream intensity, painful urination), and the following symptoms of urine extravasation after TUR of the prostate are noted:

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

Urethrorrhagia with damage to the posterior urethra is noted in 37-93%, and the anterior - 75% of observations. In this situation, any instrumental procedures should be excluded until a full examination is carried out.

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 very weakly correlates with the severity of the urethral injury Fallon et al. of 200 patients with pelvic trauma, 77 had microhematuria, of which only one had significant damage to the urethra

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

[ 24 ], [ 25 ]

Hematoma and swelling

In anterior urethral injuries, the location of the hematoma can help determine the level of damage. If the hematoma is located along the length of the penis, it is limited by Buck's fascia. If this fascia is torn, the Colis fascia becomes the limiting factor, and the hematoma can extend upward to the thoracoclavicular fascia and downward along the fascia lata. A butterfly-shaped swelling occurs in the perineum. In women with pelvic trauma, swelling of the labia may indicate damage to the urethra.

A high position of the prostate, revealed by a digital rectal examination, indicates a complete separation of the urethra.

However, in case of a pelvic bone fracture and the presence of a large hematoma, especially in young patients, it is not always possible to palpate the prostate. An abnormal position of the prostate is determined by digital rectal examination during tearing off the urethra in 34% of cases.

Instrumental diagnostics of damage and injuries of the urethra

Radiological examination. Retrograde urethrography is considered the "gold standard" for diagnosing urethral damage. A 12-14 CH Foley catheter is inserted into the scaphoid fossa, the balloon is filled with 2-3 ml, 20.0 ml of a water-soluble contrast agent is slowly injected, and an X-ray is taken with the body tilted at 30. This makes it possible to detect pelvic bone fractures, the presence of a foreign body, or a bone fragment in the projection of the urethra or bladder. If damage to the urethra is diagnosed, a cystostomy is usually installed, which is then used to perform cystography and descending urethrography. The latter is performed in a week if primary delayed urethroplasty is planned, or in 3 months if delayed urethroplasty is planned.

If retrograde urethrography fails to visualize the proximal urethra, MRI and endoscopy performed through a suprapubic fistula may be informative. Endoscopy can be combined with retrograde urethrography.

The classification of urethral injuries is based on retrograde urethrography data, although it is somewhat relative, since the presence of extravasation in the area of injury without visualization of the proximal sections does not indicate that the urethra is completely transected. In this case, it is possible to preserve a bridge-like section consisting of the wall of the urethra, which prevents the formation of a large diastasis between the ends.

Ultrasound is not considered a routine method for diagnosing urethral injuries, but it can be very useful for diagnosing pelvic hematoma or high bladder position when planning a cystostomy.

CT and MRI are not used in the initial examination of patients with damage to the urethra, since these studies do not have much information content. They are mainly used to diagnose concomitant injuries to the bladder, kidneys, and intra-abdominal organs.

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

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

Treatment of damage and injuries of the urethra

Posterior part of the urethra

It is important to distinguish between stenosis of the posterior urethra and its complete rupture, in which there is a certain area filled with scar tissue between the proximal and distal ends of the urethra (the walls of the urethra are completely absent in this area).

Partial rupture of the posterior urethra, in which case a cystostomy or urethral catheter is inserted, followed by a repeat retrograde urethrography 2 weeks later. Typically, such injuries heal without stricture formation or with the formation of a short stricture, which can be eliminated by optical urethrotomy or dilation. According to Glassberg et al., in children, suprapubic drainage of the bladder is preferable to transurethral catheterization.

One of the common causes of partial urethral injury is perforation of the prostatic capsule during TUR of the prostate. If perforation is suspected, the operation should be completed as soon as possible, but hemostasis must be ensured. Bleeding must be stopped, even if extravasation increases. More than 90% of such patients are cured by stopping the operation and placing a transurethral catheter into the bladder alone. If extravasation is extensive and infection of the perivesical tissue is suspected, suprapubic drainage of the bladder should be performed.

Closed injuries of the urethra

The treatment tactics of partial damage to the anterior urethra can be reduced to the installation of a suprapubic stoma or a urethral catheter. Later, this also makes it possible to examine the urethra. The cystostomy is preserved for about 4 weeks, ensuring the restoration of the urethra. Before removing the cystostomy, functional cystourethrography is indicated.

Possible early complications include stricture and infection, up to and including abscess formation, periurethral diverticulum and, rarely, necrotizing fasciitis.

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

Delicate strictures that form after trauma can be dissected endoscopically. In case of coarse strictures up to 1 cm long, urethroplasty can be performed in the form of anastomosis.

In case of longer strictures, 3-6 months after the injury, flap urethroplasty is performed. As an exception, primary restoration of the urethra is performed in case of rupture of the cavernous body, when the damage to the urethra is usually partial.

[ 26 ], [ 27 ], [ 28 ]

Penetrating injuries of the urethra

In cases of anterior urethral injuries sustained from low-velocity firearms, bladed weapons, or animal bites, which are often accompanied by damage to the penis and testicles, primary surgical restoration is indicated (the formation of unexpressed strictures is noted in 15% of cases or less). The anastomosis is established without tension using waterproof sutures. Continuity of the urethra can also be restored without suturing by simply installing a urethral catheter; however, the likelihood of stricture formation increases (78%).

In case of complete rupture in the area of damage to the urethra, the spongy body is mobilized in the distal and proximal directions, the stump is refreshed and an end-to-end anastomosis is formed on a 14 Fr catheter. Small ruptures can be sutured with absorbable sutures. Perioperative prophylaxis is performed. After 10-14 days, cystourethrography is performed under conditions of a urethral catheter in situ, after which (in the absence of extravasation) the catheter is removed. If after mobilization the urethral defect is more than 1 cm, its primary restoration is impossible. Marsupialization of the ends of the urethra is performed with waterproof double-row sutures and a suprapubic urinary fistula is applied. Then, the reconstructive surgery is performed after 3 months.

In case of damage to the anterior urethra, the method of suprapubic drainage of the bladder without restoration of the damaged area can also be successfully used. Positive results are noted in 80% of cases.

In case of injuries to the anterior urethra from a firearm, especially with the loss of a large section of the urethra and extensive crushing of the surrounding tissues, suprapubic drainage of the bladder is indicated as the first stage of treatment.

Santucci et al. presented the results of one of the largest studies of the treatment of anterior urethral strictures using anastomotic urethroplasty. The study included 168 patients. The average length of strictures was 1.7 cm. The average follow-up after treatment was six months, during which stricture recurrence was observed in 8 patients (optical urethrotomy was performed in 5 patients, and end-to-end anastomosis was repeated in 3 patients). Complications were rare - prolonged scarring of a small area of the wound, scrotal hematoma, and ED (each of these complications occurred in 1-2% of cases). Pansadoro and Emiliozzi described the results of endoscopic treatment of anterior urethral strictures in 224 patients. Recurrent strictures were observed in 68% of cases. Repeated urethrotomies did not increase the effectiveness of treatment. Strictures no longer than 1 cm were found to have a more favorable prognosis.

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

• Type I - no treatment required:
• Types II and III may require conservative treatment (cystostomy or urethral catheter);
• Types IV and V primary or delayed endoscopic or open surgical treatment:
• Type VI - primary restoration is required.

Complete rupture of the urethra

Treatment methods for complete rupture of the urethra.

• Primary endoscopic restoration of urethral patency.
• 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 for anesthesia, endoscopic restoration of urethral patency is possible during the first 2 weeks. The advantages of the method are as follows.

• Leads to a decrease in the incidence of stricture development (10% versus 60%), allowing approximately a third of patients to avoid reoperation.
• Reconstruction of the urethra after scarring is easier to perform (endoscopic dissection or dilation).
• If urethroplasty is performed at a later date, it is technically simpler, since both ends of the urethra are on the “same 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 provide more encouraging data: erectile dysfunction - in 21% of cases (more often, not complete erectile dysfunction, but a decrease in erection was observed), stress urinary incontinence - in 3.7%. stricture - in 68% (of 36 patients with recurrent strictures of the urethra, only 13 underwent further serious manipulations). Hussman et al., when examining 81 patients, did not find a significant difference between early and delayed recovery. Similar results were also obtained by other authors.

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

Primary recovery methods:

• Simple passage of a catheter through a urethral defect
• Catheter insertion using a flexible endoscope and a two-dimensional fluoroscope.
• Reconstruction of the urethra using a coaxillary magnetic catheter and complementary linear matching probes.
• Evacuation of the pelvic hematoma and dissection of the prostate apex (with or without suturing of the anastomosis) on a urethral catheter. Tensioning the catheter or retaining sutures of the perineum to fix the prostate in the desired position do not always lead to elimination of the defect and, in addition, can lead to necrosis of the muscles of the internal sphincter of the bladder and, as a consequence, to urinary incontinence.

Simple or endoscopic reconstruction of the posterior urethra

The method is quite effective when feasible and is favorable and minimally invasive in terms of complications. It can be performed both immediately after injury and within a few weeks thereafter. Moundouni et al. performed early restoration of the posterior urethra in 29 patients (23 with complete and 6 with incomplete urethral rupture) within 1-8 days after injury. During further observation (mean 68 months), 4 patients underwent perineal urethroplasty, 12 transurethral manipulations. Impotence was not observed in 25 of the 29 patients. Intracavernous injections of prostaglandin E were used to achieve erection in 4 patients. Urinary incontinence was not observed in any of the patients.

Similar results were also reported by Ying-Nao, Melekos, Jepson, Tahan, and Cohen in their studies with a small number of patients. Porter et al. reported 11 unprecedented cases of primary urethral reconstruction within 1 to 24 hours after injury using coaxillary magnetic catheters. During follow-up (mean 6.1 months), 5 patients developed strictures, requiring an average of 1.4 interventions per patient to eliminate them. No urinary incontinence was observed. Rehman et al. suggest using a C-Arm fluoroscope, which provides a two-dimensional image during the procedure, to improve the efficiency of posterior urethral reconstruction.

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

In primary recovery, the general statistics for complications are as follows:

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

Urgent open urethroplasty

Many authors believe that such tactics are not indicated because in the acute phase, poor visualization and differentiation of anatomical structures make their mobilization and comparison 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, the frequency of urinary incontinence and erectile dysfunction is high (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 position of the prostate, concomitant damage to the rectum and bladder neck, as well as ongoing bleeding are detected.

Delayed primary urethroplasty

It is known that the choice of treatment time for injuries of the posterior urethra depends significantly on the choice of methods and time for treating pelvic bone fractures. The widespread introduction of new methods for treating pelvic bone fractures using external and internal fixation has created the opportunity to review the treatment tactics for injuries of the posterior urethra.

After 10-14 days of bladder drainage using a cystostomy installed immediately after the injury, it is possible to perform delayed primary urethroplasty, since during this time the hematoma is absorbed. Urethroplasty is performed by endoscopic, abdominal or perineal access. Primary urethroplasty provides an 80% favorable outcome without the formation of strictures. This method is also considered the best option for the treatment of urethral injuries in women, which makes it possible to maintain the normal length of the urethra and urinary continence.

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

Delayed urethroplasty

In case of delayed treatment of damage to the subprostatic urethra, a short defect (diastasis) usually forms between the posterior and anterior sections of the urethra. In such cases, it is possible to restore the integrity of the urethra using a perineal approach, which is performed in the lithotomy position of the patient. All fibrous tissue located between the spongy section of the urethra and the apex of the prostate is removed, the stumps of the urethra are refreshed and its integrity is restored using an end-to-end anastomosis. If the length of the defect is 2-2.5 cm, it is possible to mobilize the urethra in the proximal direction for 4-5 cm. This makes it possible to close 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 position of the prostate, the next maneuver consists of separating the anterior part of the urethra by 8 cm, separating the proximal parts of the cavernous bodies from each other, lower pubectomy, and supracrural displacement of the urethra. Morey used this method in 37% of cases for performing posterior urethroplasty. Webster et al., using the described method, provided an end-to-end anastomosis without tension in conditions of a defect of up to 7 cm.

Koraitim conducted 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 - in 5%, impotence - in 36%. Subsequently, 42% of successfully operated patients underwent additional manipulations to eliminate recurrent strictures. Imperative need for urethroplasty arose in 33% of cases. Primary restoration of the urethra (n=37) in 49% of cases ended in its stricture, in 21% - urinary incontinence and in 56% - impotence. For comparison, it should be noted that the establishment of a suprapubic fistula before delayed restoration (n=508) ended in stricture in 97%, urinary incontinence - in 4% and impotence in 19% of cases.

After delayed urethroplasty, the rate of stricture recurrence is 10% lower, and that of impotence caused by the intervention is 2.5-5%.

Corriere analyzed the results of 63 cases of anterior urethroplasty, 58 of which were performed using perineal and 5 using combined peritoneal-perineal approaches. The average follow-up period was one year. The following complications were observed:

• rectal injury - in 2 cases;
• recurrence of stricture requiring repeated surgical intervention - in 3 cases;
• strictures that were overcome by dilation or optical excision - in 20 cases.

During the first year, 42 patients had normal urination. Five patients had neurogenic bladder dysfunction and performed periodic self-catheterization, five patients had urge urinary incontinence, and five had moderate stress incontinence. Thirty-one patients with normal erectile function before surgery did not experience any deterioration in erection in the postoperative period. The remaining 29 patients had erectile dysfunction before and immediately after surgery. However, nine of them had restored erection within a year.

Koraitim also examined children with post-traumatic strictures of the membranous urethra. Strictures most often occurred as a result of pelvic fractures of the Malgaigne type (35% of observations) and the so-called dislocation (26% of observations), diastasis of the sacroiliac joint or without it. According to the study, the best results were obtained after perineal and transsymphysial urethroplasty with end-to-end anastomosis in 93 to 91% of observations, respectively.

The authors of the study do not recommend using transscrotal two-stage urethroplasty and transurethral urethrotomy, since in the first case the outcome is unsatisfactory, and in the second case the possibility of further urethroplasty may be lost due to limited mobility of the anterior urethra. Hafez et al. in a study that included 35 children who underwent urethroplasty in the form of anastomosis of the posterior or bulbous parts of the urethra, noted a favorable outcome in 31 patients (89%). Of the remaining 4 patients, two successfully underwent optical urethrotomy, and the remaining 2 underwent repeated urethroplasty in the form of anastomosis.

Posterior urethral urethroplasty, if technically feasible, is always preferable to flap urethroplasty, since the latter has a higher risk of recurrent urethral stenosis (31% versus 12% over a 10-year follow-up). Regarding surgical access: compared to perineal, pubectomic access is more traumatic, takes longer, causes greater blood loss, and prolonged postoperative pain. Thus, pubectomic access should probably be used in rare cases, and only an experienced urologist should perform the operation.

The presented data convincingly prove that the gold standard of treatment should be considered delayed restoration of the urethra 3 months after injury using a one-stage perineal approach.

In examining the bladder neck and proximal urethra before urethroplasty, Iselin and Webster found a relationship between the degree of bladder neck opening and postoperative urinary incontinence. Cystography and/or suprapubic cystoscopy were used to evaluate the bladder neck.

Patients who developed incontinence after reconstructive surgery had, on average, a larger internal ring (1.68 cm on average) than patients who did not have such a problem after surgery (0.9 cm on average). Based on the above, the authors of the study suggest that in addition to urethroplasty, bladder neck reconstruction should be performed in patients with a high risk of postoperative urinary incontinence, ensuring urinary continence (installation of an artificial sphincter, collagen implantation around the urethra).

McDiarmid et al. operated on 4 patients with obvious signs of bladder neck insufficiency before surgery and performed only urethroplasty in the form of anastomosis without reconstruction of the neck, and not a single case of postoperative urinary incontinence was noted. The authors concluded that the use of a combined peritoneal-perineal approach with restoration of the bladder neck should be performed only in patients with obvious damage and displacement of the bladder neck, with complications (cutaneous urethral fistula, residual inflammatory process, diverticulum of the urethra, etc.), as well as with concomitant stricture of the anterior urethra.

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

This is due to bilateral damage to the cavernous nerves at the level of the prostate-membranous segment of the urethra (immediately behind the pubic symphysis). In more than 80% of cases, erectile dysfunction is to some extent associated with impaired blood supply as a result of damage to the branches of a. pudenda. Another cause of erectile dysfunction is also considered to be the detachment of the cavernous bodies from the branches of the pubic bones. However, surgical intervention does not increase the frequency of restoration of erectile function

While studying the problem of erectile dysfunction associated with damage to the posterior urethra, Dhabuvvala came to the conclusion that it is more related to the injury itself than to the reconstructive surgery. At the same time, erectile dysfunction can develop not only with combined damage to 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 connection between posterior urethral injuries caused by pelvic fractures and impotence, Shenfeld, Armenakas, and co-authors suggest that the cause of impotence be determined before urethroplasty. For this purpose, they recommend performing MRI of the pelvis, a night tumescence test, and duplex scanning of the penile vessels with a pharmacotest, supplemented by angiography if necessary.

The most frequent abnormalities detected by MRI are prostate dislocation (86.7%) and damage to the cavernous bodies (80%). After reconstructive surgery of the urethra, some authors even observed cases of erectile restoration. In other patients, intracavernous injections of vasoactive drugs were effective. Successful revascularization of the penis has also been described.

Summarizing the issues related to urethroplasty, Mundy noted that impotence related to this manipulation is in fact a more common problem than is 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 research.

If end-to-end anastomosis urethroplasty fails, repeat urethroplasty is indicated - again in the form of end-to-end anastomosis or flap, which is performed by either perineal or pubectomic or combined peritoneal-perineal approaches, depending on the length of the stricture and the presence of concomitant complications. With the correct surgical tactics, up to 87% of positive results can be achieved. Optical urethrotomy is also successfully used, which can be supplemented with several probe dilations of the urethra at 6-week intervals.

The following conditions are considered to be obstacles to performing primary urethroplasty.

• Distraction defect of 7-8 cm or more. In this case, flap interposition of skin from the perineoscrotal area or from the penis can be used;
• Fistula. It is possible to use a combined abdominal-perineal approach to ensure adequate elimination of the fistula;
• Combined stricture of the anterior urethra. In spongiofibrosis of the anterior urethra, the cessation of blood flow through the bulbar arteries as a consequence of mobilization can lead to a disruption of its nutrition.
• Urinary incontinence. If the external sphincter of the urethra is damaged due to destruction, urine retention is performed by the sphincter of the bladder neck. However, simultaneous damage to the bladder neck is very likely to lead to the development of urinary incontinence. In this case, it is necessary to operate using a combined abdomino-perineal approach. Since urinary incontinence is often caused by circular fixation of the bladder neck with scar tissue, in such cases, mobilization of the neck can lead to the elimination of incontinence symptoms. The intervention should be supplemented by the removal of residual hematomas and the displacement of a flap from the greater omentum on a pedicle to the palmar wall of the urethra in order to prevent fibrosis and ensure neck mobility.

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

Flap urethroplasty

Urethroplasty operations using flaps from the radial artery, appendix, and bladder wall are described. Most often, flaps taken from the skin and mucous membrane of the cheek are used for this purpose. The skin flap is mainly taken from the scrotum and penis, it can be used both freely and on a pedicle. The main disadvantage of this plastic material is considered to be the continuation of hair growth, the appearance of hyperkeratosis in a humid environment, and the formation of urethral diverticula.

Currently, the "gold standard" of plastic material for flap urethroplasty is considered to be a flap from the buccal mucosa. This is due to the following properties:

• adaptation to humid conditions;
• lack of hair;
• easy access;
• resistance to infections;
• the presence of a thick mucous membrane, which facilitates its formation and prevents the formation of diverticula even when used for ventral urethroplasty;
• the presence of a thin proper plate, which promotes rapid fusion.

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

Delayed endoscopic optical incision

Before performing the intervention, it is necessary to clarify the length of the stricture or obliterated section of the urethra, the position of the prostate, and the condition of the bladder neck. For this purpose, it is usually sufficient to perform a counter cystourethrography and a digital rectal examination. The procedure is indicated in the presence of a short urethral defect, a competent bladder neck, and a minimal distance between the prostate and the bulbous part of the urethra.

A curved metal probe is inserted through a cystostomy into the blind-ending proximal urethra, after which, under visual control, a urethrotome is inserted into the urethra and an incision is made.

In order to transilluminate the perineal membrane, a suprapubic passage of the cystoscope is performed, after which the urethra is dissected towards the light (sitting-to-the-light). Currently, the sitting-to-the-light technique has become more effective with the use of a C-arm fluoroscope for stereotactile guidance. At the end of the manipulation, a urethral catheter and suprapubic drainage are installed for 1-3 weeks, which are removed after an additional 2 weeks.

EI-Abd presented data from a study of 352 patients with posterior urethral injuries without associated upward displacement of the bladder. All patients underwent cystostomy. In 284 patients, strictures developed, which were eliminated by delayed optical excision. In the remaining 68 patients, complete obliteration developed, which was eliminated by endoscopic resection, creating conditions for further urethrotomy (a similar approach is also described by Liberman and Barry). This method is used to facilitate remote urethrolasty.

As a result, it was possible to ensure patency of the urethra in 51.8% of cases, the remaining patients underwent open urethroplasty. No impotence was observed as a result of such intervention. Development of a false course of the urethra, stress incontinence or damage to the rectum is possible. According to Chiou et al., despite the listed complications, with complete obliteration of the posterior urethra, aggressive endoscopic tactics using serial optical urethrotomy often allow complete elimination of strictures within 2 years without resorting to urethroplasty.

Marshall presents a method for endoscopic treatment of a completely obliterated segment of the posterior urethra no more than 3 cm in length using a balloon catheter and guidewire. The balloon catheter is advanced into the urethra antegradely through a trocar epicystostomy. When inflated, the balloon expands, which leads to the breakdown of scar tissue, which can then be excised using optical urethrotomy.

The method allows achieving good results without the development of serious complications. Dogra and Nabi presented an interesting method for the treatment of complete obliteration of the posterior urethra in an outpatient setting using guidewire-guided urethrotomy with the use of a YAG laser. To stabilize the urethra, it was sometimes necessary 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 placement of intraurethral stents for strictures and obliterations of the posterior urethra is not recommended, since fibrous tissue can grow into the lumen of the urethra through the stent wall, leading to repeated obliteration.

In contrast to this opinion, Milroy et al. described 8 observations of endourethral use of endovascular stents. 4-6 months after their installation, instead of obliteration, epithelialization of the inner surface of the stent was observed. The short period of observation of patients does not allow conclusions to be made about the long-term results of this method.

To summarize the above, it should be noted that the multitude of methods for treating injuries to the posterior urethra does not at all indicate their inconsistency. Despite the fact that there are no universal methods for treating injuries to the posterior urethra, it can be said with confidence that in men, open surgical and endoscopic methods of treatment complement each other. The choice of method depends on the nature of the injury and the characteristics of the clinical course, as well as on the personal experience of the urologist, instrumental equipment, etc. In each specific case, the choice of the most appropriate treatment method should be based on a correct analytical assessment of all these circumstances.

The leading specialist in urethral reconstruction, Turner-Wagwick, emphasizes the special role of the urologist's individuality in this field. He notes that the current rapid development of urology has led to the fact that, unlike optical urethrotomy and dilatation of the urethra, reconstruction of the latter is not considered a general professional intervention.

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