Pelvic bone fractures from motor vehicle trauma or crush injuries can be associated with urewthral disruption or tear. Often the urethra is completely transected or torn,usually at prostate-membranous junction and ends are separated. The main presentation is blood at urethral meatus with inability to pass urine. Urethral catheterization drains only pelvic hematoma with only blood and no urine.
Treatment is emergency comprise of hemodynamic stabilization followed by suprapubic catheterization. It is necessary to place suprapubic catheter and keep it till formal repair of urethra is done.
Formal or secondary repair should be delayed for 3 to 4 months post injury for hematoma to get resolved, fibrosis to take place and tissue to become supple. After 3 months patient is assessed by retrograde urethrogram (RGU) and micturating urethrogram(MCU). By this we can measure the distraction defect and can also assess the bladder neck. Other option is to do flexible cystoscopy through suprapubic tract along with RGU.
Bladder neck competency is really important for post surgery urinary continence.
Those patients who suffer traumatic urethral injuries often have associated vascular and nerve damage to urethra and penis leading to erectile dysfunction in 30 to 35% of patients. We evaluate the vascular status of the patient by doing penile Doppler ultrasound study. Most patients, even with some arterial compromise, have enough blood flow to have their urethra repaired without any effect on healing. In case of severe impairment a revascularization procedure prior to urethral reconstruction so that the urethra will then have adequate blood supply at the time of surgical repair.
Posterior Urethroplasty
Patients with PFUDD and injury at least 4 months old are admitted to the center one day prior to surgery. Patients are started on intravenous antibiotics to prevent post surgical infections.
Posterior urethroplasty or progressive perineal urethroplasty is performed either in general anesthesia or spinal anesthesia. Posterior urethroplasty is performed in lithotomy position. Incision in made in perineal region under the scrotum, urethra is identified and dissected from surrounding tissue. Urethra is transected at the point of obliteration. Proximal urethra is identified by placing a sound through suprapubic tract and scar is cut over the sound. The objective of surgery to excise the scar until the healthy normal urethra is encountered and proximal and distal healthy urethra is anastomosed after placing the urinary catheter. Surgical wound is closed and patient is shifted to recovery.
Posterior urethral reconstruction is a difficult and complex surgery and should be done by urethral surgeon who is trained and frequently performing these surgeries. These injuries are amenable to repair with high success rate if performed properly.
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