Although the urethral injury is seldom the main problem of these often severally and severely traumatized patients, consequences of the urethral trauma such as urethral strictures, erectile dysfunction, and (in some cases) urinary incontinence may be problems with lifelong ramifications for these patients.
In this connection, primary urological treatment should be directed at preventing early complications and minimizing the risk of the aforementioned potential problems. A satisfactory outcome is dependent on a correct diagnosis, along with thorough and well-planned urological therapy.
Meanwhile, the controversy surrounding immediate vs delayed treatment of urethral injuries is still unresolved. The perfect treatment plan still remains to be developed; the value of the different approaches including recent evolution of innovative endourological techniques to achieve urethral continuity needs to be determined.
The following treatment strategies are available for acute management:
1. Primary open suturing of the disrupted urethra
2. Endoscopic or surgical realignment by insertion of a transurethral »railroad« catheter
3. Suprapubic cystostomy and delayed repair
4. Acute surgical intervention is indicated for the following:
™ Concomitant rectal tear ™ Bladder neck laceration
™ Serious, life-threatening bleeding, mainly from the inferior or superior gluteal arteries
A large gap between the bladder neck and the disrupted urethra, also known as »pie in the sky bladder,« is a relative indication for open surgical exploration (□ Fig. 14.2).
Nevertheless, immediate surgical exploration does not necessarily indicate exploration of the urethral injury site. Exploration of the urethral injury also involves release of the tamponade effect of the hematoma in the small pelvis and may compromise control of the venous bleeding.
Attempts to suture both ends of the urethra are challenging - dissection of the periurethral and prostatic tissues can cause additional damage to the neurovascular bundles and the intrinsic urethral sphincter structures. Due to the increased risk of iatrogenic impotency and incontinence, primary anastomotic repair is no longer recommended. Reconstructive procedures should be limited to open surgical placement of the transurethral catheter and suprapu-bic drainage of the bladder.
Therefore, for primary therapy of posterior urethral injury, we recommend urinary diversion using a suprapubic catheter and/or by endoscopically inserting a transurethral catheter. Several researchers have described a number of different railroading techniques to manipulate the catheter across the urethral gap into the bladder. It may be useful to railroad the prostate to the urethra by using a suprapubic sound or an endoscope. Sometimes it is also useful to drain the pelvic hematoma via the endoscope.
Additional traction obtained by applying additional weight to the transurethral catheter has been shown to produce pressure damage to the bladder neck and subsequently increase the risk of urinary incontinence. In addition, the traction may pull the prostatic gland into an abnormal position, causing misalignment or malrotation. For these reasons, traction has been abandoned, as has »vest sutures,« which are introduced through the prostatic apex and brought out through the perineum.
The purpose of the realignment is to reduce the number of secondary urethral strictures, and to decrease the stricture length in comparison to both suprapubic cystostomy and delayed repair. Although the ultimate value of this procedure is still under discussion, there is clear evidence that realignment can significantly decrease the incidence of strictures (Koraitim 1985, 53% vs 97%). On the other hand, this procedure may be associated with an increased risk of erectile dysfunction. (Koraitim 1996, 36% vs 19%). In another study (McAnninch 1997), the incidence of erectile dysfunction was reported at up to 55% after immediate realignment.
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