Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries
Simplification of classification and surgical expertise in the delayed treatment of traumatic...
Palminteri, Enzo; Fusco, Ferdinando
2011-09-01 00:00:00
Arab Journal of Urology (2011) 9, 197–198 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION EDITORIAL Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries The classifications indicated in Elbakry’s article are based on needs to be re-evaluated. The radiological and endoscopic clinical evaluations and investigations carried out at the time re-evaluation is aimed to define: of the pelvic trauma. Therefore, they might be useful in the choice of the initial management of the trauma, which cur- 1. The location and length of stenosis. rently provides the only immediate recourse to surgery for 2. The function of the bladder neck. the repair of the bladder or rectal injury. Attempting endo- 3. The conditions of the anterior urethra. 4. Any associated lesions (e.g. urethrorectal fistula, etc.). scopic re-canalisation is justified only in stabilised patients and in the presence of adequate instrumentation and expertise. Otherwise, the drainage of urine through the simple supra- This assessment helps to clarify with the patient: pubic cystostomy in critical patients is the manoeuvre that pro- tects it from further damage. These three steps summarise the (i) The appropriate therapeutic strategy: For example, in current guidelines for posterior urethral trauma, the philoso- case of non-obliterative stenosis combined with mainte- phy of which is to avoid inappropriate manoeuvres (e.g. nance of erectile function after injury, the patient might through clumsy attempts at urethral catheterisation or endo- opt for endoscopic attempts to stabilise the urethral scopic/surgical re-canalisation) and therefore reduce the risk patency. of causing damage to the residual sphincter or to the nervous (ii) The target of the urethroplasty: For example, in a patient structures of erection at the time of initial management of the with an incompetent bladder neck, the only target will trauma [1]. be urethral re-canalisation, which will be followed by We must consider that the initial management of trauma is inevitable incontinence, of which the patient must be often in peripheral non-specialised centres, where the first goal well informed. is to save the life of the patient. Often, these centres are not (iii) The degree of difficulty of the operation: A long and/or equipped to conduct urethrography adequately enough to high stenosis implies a more difficult operation, with allow proper classification of the lesion. increased risk of tension on the anastomotic repair or After some months, the patient arrives in the specialised an indication of other types of urethral repair. centre for the repair of the sequelae of the trauma, represented mainly by the posterior urethral stricture. It is often extremely In this sense, the studies of Koraitim [2,3] on gapometry try difficult to reconstruct the exact history of the initial trauma to provide a response before surgery to the difficulties that the management. Accordingly, it is also difficult to define the clas- surgeon will find at the time of the surgery, and to try to plan sification of the initial injury. In addition, we do not know the type of intervention. what manoeuvres, potentially harmful to the sphincter appara- Other authors have proposed the use of MRI to optimise tus, have been carried out beforehand. So at this point, the the preoperative evaluation of urethral lesions, and thus anatomical situation of the actual lesion has changed and facilitate the definition of their classification [4,5]. In reality, currently, a well-made combined retrograde and voiding cysto-urethrogram remains the best way to obtain sufficient 2090-598X 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.07.001 198 Editorial [2] Koraitim MM. Gapometry and anterior urethrometry in the repair information. However, often the intraoperative path of the of posterior urethral defects. J Urol 2008;179:1879–81. repair could prove to be more unpredictable than what has [3] Koraitim MM. Predictors of surgical approach to repair pelvic been estimated by the preoperative evaluation. fracture urethral distraction defects. J Urol 2009;182:1435–9. The current reconstructive techniques are characterised [4] Oh MM, Jin MH, Sung DJ, Yoon DK, Kim JJ, Moon du G. above all by the use of an elaborate progressive perineal ap- Magnetic resonance urethrography to assess obliterative posterior proach, which, progressing through additional steps (urethral urethral stricture: comparison to conventional retrograde ureth- mobilisation, corporal body separation, inferior pubectomy rography with voiding cystourethrography. J Urol 2010;183:603–7. and retrocrural urethral re-routing) allows bridging both short [5] El-Ghar MA, Osman Y, Elbaz E, Refiae H, El-Diasty T. MR and long or complex urethral defects, and therefore repairs urethrogram versus combined retrograde urethrogram and most of the stenoses [6]. sonourethrography in diagnosis of urethral stricture. Eur J Radiol 2010;74:193–8. Differently, it is possible to resort to the use of other surgi- [6] Webster GD, Ramon J. Repair of pelvic fracture posterior urethral cal options (e.g. combined abdomino-perineal approach, defects using an elaborated perineal approach: experience with 74 staged techniques, etc.) for the repair of the more complex ste- cases. J Urol 1991;145:744–8. noses [7,8]. [7] Pratap A, Agrawal CS, Pandit RK, Sapkota G, Anchal N. Factors So, overall, experienced surgeons rely on their ability and contributing to a successful outcome of combined abdominal competence in dealing with the intervention, rather than on transpubic perineal urethroplasty for complex posterior urethral the preoperative classification of the lesion [9]. However, an at- disruptions. J Urol 2006;176:2514–7. tempt to simplify the classification of delayed lesions in non- [8] Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP. Urethral complex (e.g. non-obliterative stenoses) and complex urethral reconstruction for traumatic posterior urethral disruption. out- injuries (e.g. long defects, or associated with incompetent blad- come of a 25-year experience. J Urol 2007;178:2006–10. [9] Andrich DE, O’Malley KJ, Summerton DJ, Greenwell TJ, der neck or urethrorectal fistulae, etc.) could be useful in pro- Mundy AR. The type of urethroplasty for a pelvic fracture viding the clearest idea about what can be expected at the time urethral distraction defect cannot be predicted preoperatively. of surgery, and to inform the patient adequately. J Urol 2003;170:464–7. Finally, there is controversy about the terminology. The term ‘posterior urethral distraction defects’ might not be accu- Enzo Palminteri rate, because all distractions are injuries but not all injuries are Centre of Urethral and Genital Reconstruction, Via Fra necessarily distractions. Thus, perhaps the use of the term Guittone 2, 52100 Arezzo, Italy ‘traumatic posterior urethral injuries’ might help to provide a E-mail address: enzo.palminteri@inwind.it uniform nomenclature. References Ferdinando Fusco Department of Urology, University Federico II, Naples, Italy [1] Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto V, Pansadoros V, et al.. Consensus statement on urethral trauma. Available online 2 August 2011 BJU Int 2004;93:1195–202.
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Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries
Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries
Abstract
Arab Journal of Urology (2011) 9, 197–198 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION EDITORIAL Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries The classifications indicated in Elbakry’s article are based on needs to be re-evaluated. The radiological and endoscopic clinical evaluations and investigations...
Arab Journal of Urology (2011) 9, 197–198 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION EDITORIAL Simplification of classification and surgical expertise in the delayed treatment of traumatic posterior urethral injuries The classifications indicated in Elbakry’s article are based on needs to be re-evaluated. The radiological and endoscopic clinical evaluations and investigations carried out at the time re-evaluation is aimed to define: of the pelvic trauma. Therefore, they might be useful in the choice of the initial management of the trauma, which cur- 1. The location and length of stenosis. rently provides the only immediate recourse to surgery for 2. The function of the bladder neck. the repair of the bladder or rectal injury. Attempting endo- 3. The conditions of the anterior urethra. 4. Any associated lesions (e.g. urethrorectal fistula, etc.). scopic re-canalisation is justified only in stabilised patients and in the presence of adequate instrumentation and expertise. Otherwise, the drainage of urine through the simple supra- This assessment helps to clarify with the patient: pubic cystostomy in critical patients is the manoeuvre that pro- tects it from further damage. These three steps summarise the (i) The appropriate therapeutic strategy: For example, in current guidelines for posterior urethral trauma, the philoso- case of non-obliterative stenosis combined with mainte- phy of which is to avoid inappropriate manoeuvres (e.g. nance of erectile function after injury, the patient might through clumsy attempts at urethral catheterisation or endo- opt for endoscopic attempts to stabilise the urethral scopic/surgical re-canalisation) and therefore reduce the risk patency. of causing damage to the residual sphincter or to the nervous (ii) The target of the urethroplasty: For example, in a patient structures of erection at the time of initial management of the with an incompetent bladder neck, the only target will trauma [1]. be urethral re-canalisation, which will be followed by We must consider that the initial management of trauma is inevitable incontinence, of which the patient must be often in peripheral non-specialised centres, where the first goal well informed. is to save the life of the patient. Often, these centres are not (iii) The degree of difficulty of the operation: A long and/or equipped to conduct urethrography adequately enough to high stenosis implies a more difficult operation, with allow proper classification of the lesion. increased risk of tension on the anastomotic repair or After some months, the patient arrives in the specialised an indication of other types of urethral repair. centre for the repair of the sequelae of the trauma, represented mainly by the posterior urethral stricture. It is often extremely In this sense, the studies of Koraitim [2,3] on gapometry try difficult to reconstruct the exact history of the initial trauma to provide a response before surgery to the difficulties that the management. Accordingly, it is also difficult to define the clas- surgeon will find at the time of the surgery, and to try to plan sification of the initial injury. In addition, we do not know the type of intervention. what manoeuvres, potentially harmful to the sphincter appara- Other authors have proposed the use of MRI to optimise tus, have been carried out beforehand. So at this point, the the preoperative evaluation of urethral lesions, and thus anatomical situation of the actual lesion has changed and facilitate the definition of their classification [4,5]. In reality, currently, a well-made combined retrograde and voiding cysto-urethrogram remains the best way to obtain sufficient 2090-598X 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.07.001 198 Editorial [2] Koraitim MM. Gapometry and anterior urethrometry in the repair information. However, often the intraoperative path of the of posterior urethral defects. J Urol 2008;179:1879–81. repair could prove to be more unpredictable than what has [3] Koraitim MM. Predictors of surgical approach to repair pelvic been estimated by the preoperative evaluation. fracture urethral distraction defects. J Urol 2009;182:1435–9. The current reconstructive techniques are characterised [4] Oh MM, Jin MH, Sung DJ, Yoon DK, Kim JJ, Moon du G. above all by the use of an elaborate progressive perineal ap- Magnetic resonance urethrography to assess obliterative posterior proach, which, progressing through additional steps (urethral urethral stricture: comparison to conventional retrograde ureth- mobilisation, corporal body separation, inferior pubectomy rography with voiding cystourethrography. J Urol 2010;183:603–7. and retrocrural urethral re-routing) allows bridging both short [5] El-Ghar MA, Osman Y, Elbaz E, Refiae H, El-Diasty T. MR and long or complex urethral defects, and therefore repairs urethrogram versus combined retrograde urethrogram and most of the stenoses [6]. sonourethrography in diagnosis of urethral stricture. Eur J Radiol 2010;74:193–8. Differently, it is possible to resort to the use of other surgi- [6] Webster GD, Ramon J. Repair of pelvic fracture posterior urethral cal options (e.g. combined abdomino-perineal approach, defects using an elaborated perineal approach: experience with 74 staged techniques, etc.) for the repair of the more complex ste- cases. J Urol 1991;145:744–8. noses [7,8]. [7] Pratap A, Agrawal CS, Pandit RK, Sapkota G, Anchal N. Factors So, overall, experienced surgeons rely on their ability and contributing to a successful outcome of combined abdominal competence in dealing with the intervention, rather than on transpubic perineal urethroplasty for complex posterior urethral the preoperative classification of the lesion [9]. However, an at- disruptions. J Urol 2006;176:2514–7. tempt to simplify the classification of delayed lesions in non- [8] Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP. Urethral complex (e.g. non-obliterative stenoses) and complex urethral reconstruction for traumatic posterior urethral disruption. out- injuries (e.g. long defects, or associated with incompetent blad- come of a 25-year experience. J Urol 2007;178:2006–10. [9] Andrich DE, O’Malley KJ, Summerton DJ, Greenwell TJ, der neck or urethrorectal fistulae, etc.) could be useful in pro- Mundy AR. The type of urethroplasty for a pelvic fracture viding the clearest idea about what can be expected at the time urethral distraction defect cannot be predicted preoperatively. of surgery, and to inform the patient adequately. J Urol 2003;170:464–7. Finally, there is controversy about the terminology. The term ‘posterior urethral distraction defects’ might not be accu- Enzo Palminteri rate, because all distractions are injuries but not all injuries are Centre of Urethral and Genital Reconstruction, Via Fra necessarily distractions. Thus, perhaps the use of the term Guittone 2, 52100 Arezzo, Italy ‘traumatic posterior urethral injuries’ might help to provide a E-mail address: enzo.palminteri@inwind.it uniform nomenclature. References Ferdinando Fusco Department of Urology, University Federico II, Naples, Italy [1] Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto V, Pansadoros V, et al.. Consensus statement on urethral trauma. Available online 2 August 2011 BJU Int 2004;93:1195–202.
Journal
Arab Journal of Urology
– Taylor & Francis
Published: Sep 1, 2011
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References
Consensus statement on urethral trauma
Gapometry and anterior urethrometry in the repair of posterior urethral defects
Predictors of surgical approach to repair pelvic fracture urethral distraction defects
Magnetic resonance urethrography to assess obliterative posterior urethral stricture: comparison to conventional retrograde urethrography with voiding cystourethrography
MR urethrogram versus combined retrograde urethrogram and sonourethrography in diagnosis of urethral stricture
Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases
Factors contributing to a successful outcome of combined abdominal transpubic perineal urethroplasty for complex posterior urethral disruptions
Urethral reconstruction for traumatic posterior urethral disruption. outcome of a 25-year experience
The type of urethroplasty for a pelvic fracture urethral distraction defect cannot be predicted preoperatively
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