Controversies in management of Pelvic Fracture Urethral Injuries

INTRODUCTION
Pelvic fracture associated urethral injury (PFUI) is sequelae of blunt pelvic trauma. The published rate of urethral injury varies from 5-25% in different series.1 This is associated with superior displacement of bladder and prostatic urethra. Management includes options from primary realignment to delayed anastomotic urethroplasty.2 Steps of surgery include simple perineal approach to elaborated perineal approach and combined transpubic approach. Though the treatment and approach is well accepted across the globe, controversies do exist. Through this section we would debate the literature regarding some controversial issues in management of PFUI.

AIMS AND OBJECTIVES
The aim of this article is to evaluate and elucidate upon the controversies that surround the PFUI repair in this era. Though the treatment of pelvic fracture urethral distraction defect has evolved the controversies with respect to early management or deferred progressive perineal approach and its various steps have persisted. The objective of this review is to analyze possible variable treatment pathways and the controversial aspects of treatment. An evidence based opinion is suggested for each contentious treatment option.

MATERIALS AND METHODS
A literature search was done for the definitive management of PFUI. All the controversial issues of the treatment and management were researched and then addressed sequentially. Starting from the initial management the following variable pathways and outcomes were reviewed:
1. Primary Realignment versus Delayed repair of Pelvic injury
2. Necessity of Inferior pubectomy
3. Predictability of Inferior wedge pubectomy
4. Spatulation of distal bulbar and proximal urethral ends.
5. Nomenclature of Bulbar Urethra
Each of the above possibilities, surgical steps of progressive perineal approach were analyzed with evidence based literature. Only data from high volume urethroplasty centers and peer reviewed articles which made significant contribution were considered.
This study and evaluation comes from a tertiary high volume center of reconstructive urology. More than 500 patients with simple to complex posterior urethral injury due to pelvic fracture have undergone surgery in our center in past five years (2009 -2014). Apart from our own center’s experience the literature was reviewed for evidence synthesis and framing an opinion

RESULTS

1. Primary Realignment Versus Delayed repair:
Issue of primary realignment after PFUI against delayed anastomotic urethroplasty is constantly debated. Modern techniques of endourology were introduced in 1980.The techniques involved using transurethral and transvesical approach in conjunction with fluoroscopy. This gave birth to the option of early primary realignment after PFUI. Proponents of this technique suggest it avoids delayed surgery in some patients.2 If there is a recurrence then the gap is small. As there is no manipulation of periprostatic tissues there is less risk of erectile dysfunction. Many studies have compared the success rates of realignment versus delayed repair.3-12
Webster et al in their comprehensive review of 538 patients suggest stricture developed in 97% of patients treated with initial suprapubic catheter against 53% who underwent mixed techniques of primary realignment 1.
This study analyzed impotence rates after both approaches. Primary realignment had impotence at 36% compared to 19% after delayed repair.
This study did not involve the advanced endourological and fluoroscopic guided procedures and hence suffered from more adverse results. The later generation data is more favorable.
According to Mundy et al endoscopic realignment may impede urethroplasty due to extension of inflammatory fibrotic process up and down the urethra on either side of injury13.
Morey AF in his editorial comment concluded that patients placed on endoscopic pathway after primary realignment often tend to stay there. Urethra is subjected to trauma due to subsequent self-catheterizations, emergent dilatations and other unfortunate complications 14. Also in a recent comparative study he also concluded high rate of adverse events in the primary realignment group such as time taken to achieve catheter free state, prolonged (>6 months) self catheterization, failure following urethroplasty, pelvic abscesses and incontinence in primary realignment patients.15
Wessels et al favor early urethral realignment via endourologic methods based on literature and their own experience. Though realignment leads to higher rates of stricture recurrence it spares significant number of patients with further need of subsequent surgery 13.

Table 1: Studies describing stricture rate after primary realignment

Primary realignment is an extension of initial trauma care and it might be one of the multiple factors responsible for less severe pelvic fracture urethral injuries after a prompt trauma rescue. The difference in the potency and the continence rates is not significant.

Table 2: Studies describing incontinence rates after primary realignment and urethroplasty.

Table 3: Studies describing potency rates after primary realignment and delayed urethroplasty.

2.Can we predict if inferior pubectomy is required?

Anastomotic urethroplasty for PFUI is carried by transperineal progression approach, which includes 4 steps. 1. Complete mobilization of bulbar urethra.2 Developing intercrural space to promote crural separation.3.Wedge resection of inferior pubic arch 4. Supracrural rerouting.
For most general urologists inferior pubectomy is challenging. Controversy exists regarding predicting the decision to perform pubectomy preoperatively.
Gap between the transected urethral ends can be calculated preoperatively using simultaneous antegrade and retrograde urethrograms. Koraitim et al devised index of elastic lengthening based on gapometery and bulbar urethrometery. They suggest that urethral gaps shorter than one third of the bulbar urethra can be repaired by simple perineal operation. For longer gaps with short bulbar urethra elaborated perineal approach using pubectomy or transpubic procedure is required 16.
In the study of Mundy et al in 38% patients the gap could not be calculated because posterior urethra could not be demonstrated radiologically. In 62% patients there was no association between measured defect length and scale of subsequent surgery. Mundy et al suggest it is not possible to predict in advance what exactly must be done to achieve tension free anastomosis. Surgeons preparing to repair an apparently short PFUI cannot assume that simple repair is all that may be necessary. It is suggested that surgeon willing to repair PFUI must be trained and be able to perform comfortably all 4 steps described above 18. There are not many studies aiming at predicting to perform pubectomy but occasionally closed bladder neck, very high bladder neck can better be delineated through an MRI study. Also MRI can help detect any bony fragment between the bladder neck and the pubis19.

Kulkarni et al published a study comparing the need for pubectomy and progressive abdomino perineal approach procedures in the different population subsets in Italy and India17. The differences in pathogenesis and early treatment of PFUDD greatly influenced the choice of surgical technique and the need for ancillary maneuvers during delayed posterior urethral reconstructions and its results.
There is a need to develop an three dimensional or cross sectional ‘gap’ parameter index which can be a lot more accurate and convincing than a two dimensional study.

Table 2

3. Is pubectomy really necessary in progressive perineal approach:
Webster and Ramon popularized elaborated perineal approach for reconstruction of PFUI in 19831.This template has been well accepted around the globe. However there remains a controversy regarding the requirement of pubectomy in different studies.
Morey et al concluded in their study that ancillary maneuvers such as corporal rerouting or inferior pubectomy are seldom required for successful posterior urethroplasty 20.In the review of Webster et al inferior pubectomy with rerouting was required in 15-40% of patients.21Both this studies highlight a population in the western world.
Kulkarni and Barbagli published the difference of choice of procedure for PFUI in developing and developed worlds. In Italy inferior Pubectomy was required in 18 % against Indian population where it was required in India 58 %, which increased to 75% in, redo cases.17
The requirement of Inferior pubectomy and subsequent steps in progressive Perineal approach is much higher in India and Asian countries as compared to the western world. This may be related to the dynamics of trauma and anthropometric differences in pelvis in different population. Also the fracture stabilization and early realignment as earlier noted tend to bring the two ends together hence mitigating the injury. Another factor, which is pertinent for research is the difference of bulbar urethral length in the two populations. In the western world, urethra is longer and hence can be stretched more to achieve a tension free anastomosis. Shorter urethra in the east may be inadequate to be stretched to optimal extent requiring pubectomy for the longer urethral gap.

4.Spatulation of Urethral ends?
Spatulation of urethral ends is favored in anastomotic urethroplasty. The distal and proximal ends of urethra can be spatulated on either side.
Webster et al spatulated distal urethra dorsally at 12 Clock position and proximal urethra at 6 Clock position (Posteriorly) to achieve anastomosis of at least 40 French 1,21.
Hosseini et al suggest dorsal anterior urethral spatulation in urethroplasty is more efficient than ventral anterior urethral spatulation 22.
Kulkarni et al spatulated anterior urethra dorsally at 12 Clock position and posterior urethra dorsally at 12-clock position.
Mundy in the Atlas of Urologic clinics of North America in 1997 preferred spatulating anterior urethra dorsally at 12 clock and posterior urethra also dorsally at 12 clock. However he would rotate the anterior urethra 180 degrees and anastomose to the posterior urethra23.
Turner Warwick spatulated anterior urethra ventrally at 6 clock and posterior urethra dorsally at 12 clock24.
There have been no studies to support if any particular technique is better than other.

5.Definition of Bulbar Urethra:
In the pathology of PFUI, the posterior urethra is displaced in upward direction. The principle of surgery is to mobilize the bulbar urethra and stretch it till the lower end of proximal urethra. This lower end is usually the membranous urethra. If the bulbar urethra is inadequately mobilized, there is tension on anastomosis and high chance of failure after primary repair.
As per the definition by ICUD guidelines that currently exist, penile urethra extends from the meatus to the distal edge of the Bulbospongiosus muscle 25. The bulbar urethra extends from the proximal penile urethra to the distal membranous urethra. This means bulbar urethra is the urethra behind Bulbospongiosus muscle.
Urethra after mobilization can be stretched to 1/3 its length. For tension free anastomosis the bulbar urethra has to be mobilized till penoscrotal junction 1,21. However due to lack of clarity in defining bulbar urethra, surgeons tend to mobilize urethra partially, which is major cause of failure of primary repair.
For all practical purposes we recommend to change the term of definition of bulbar urethra.
Bulbar urethra should be defined as urethra from penoscrotal junction until membranous urethra.

Discussion
1. Primary Realignment versus Delayed Repair
Most of the studies favoring early endoscopic realignment have rather small sample size, few were prospective and suffered from a bias of a successful endoscopic procedure for a less severe pelvic fracture. The only study with ‘sizeable’ sample is by Moriarev et al with 96 patients but authors were not very clear as to why they used endoscopic means initially even in the delayed urethroplasty group and were successful in up to 53% of that subset. It may well reflect on the different population of patients with less severe pelvic urethral injuries2. In a comparison of contemporary series of management of pelvic fracture urethral distraction between Indian and Italian cohort, Kulkarni et al17 depicted difference in initial trauma care which is more prompt in Italy. Not just trauma care but the modality of accidents the mean age of the population affected and the mechanism of trauma and associated non pelvic injuries all affect the outcomes of endoscopic realignment or open surgical repair.
The endoscopic alignment is performed usually after 1 to 14 days of the injury after stabilization of the patient and gaining suprapubic access. The availability of two urologist team is necessary.
There is no final word about primary realignment which requires urgent trauma care and two teams of urologists working in cohesion.
Though there is no convincing evidence favoring early primary realignment, the data apparently favor the same provided necessary infrastructure, skill and personnel are available.

2. Can we predict if inferior pubectomy is required
Although literature16,17 stays non corroborative the two dimensional arrangement of either urethral ends on retrograde and antegrade studies cannot be ignored and long gap as per gapometry indices by Koraitim or a high bladder neck or a bladder neck that does not open despite all the maneuvers needed may be a subject to evaluation with a cross sectional study such as MRI.

3. Is pubectomy really necessary in progressive perineal approach.
The incidence of pubectomy may vary across the globe owing to the differences in the modality of accident, the management initially and anthropoimetric measurements of pelvises in various races. Because of inaccuracy in the prediction of pubectomy it is mandatory that all reconstructive urologists be versed with this technique. No study with reasonable number of PFUI repairs has a null pubectomy rate hence underscoring the necessity of this maneuver. Centers which deal with high number of redo and referred cases usually encounter a higher incidence of pubectomy. Whether or not pubectomy is an ancillary procedure which relents proximal urethra more easily amenable to anastomosis or is overutilized can not be ascertained with zero error as the technique like any surgical addendum is a matter of surgical experience, protocol and patient factor. To surmise that it is useful only to Asian population is an unscientific opinion because the approach was invented in the Caucasian population and held fort for a long time before the recent studies suggested the redundancy.

4. Spatulation of Urethral end
The urethral ends at either sides need more elaborate tailoring in the form of spatulation for wider anastomosis. It is the adequacy of other perineal maneuvers that can provide a tension free arrangement of the two dissected urethral ends. What is certain is that spatulation is necessary and must be wide enough. Whether ventrally or dorsally does not seem to matter as the results of reconstructive centers across the world have similar long term results. This may be diluting the controversy but as long as uniformly adequate long and short term results are achieved the surgical pathway is only conjenctural.

5. Definition of bulbar Urethra
The definition of bulbar urethra needs rethought and review as the current definition conceptually sublets a surgeon to inadequately mobilize during the first step of perineo progressive urethroplasty. This is more a recommendation than a subject to controversy so as to have a more uniform surgical anatomical understanding.
CONCLUSIONS:
Pelvic fracture urethral injury is seen across the globe. Though the treatment and approach is well accepted across the globe, controversies do exist. There is no conclusive article addressing the controversial issues highlighted in this article.

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