Pelvic fracture urethral injuries in context


What used to be known as pelvic fracture urethral distraction defects (PFUDD) are now, by consensus, known as pelvic fracture urethral injuries (PFUI). These are rare injuries and the paper by Fu et al. [1] is important because it includes a large group of patients from a single centre with an adequately long follow-up.

There are some points that the reader should note. In China, as in many other parts of the world, agricultural injuries and road traffic accidents involving bicycles are more common than in Europe and North America where motor vehicle accidents predominate. The emergency treatment of these injuries in such circumstances clearly also has an impact on outcome because it is extremely variable, in both its timing and its quality, as is the nature of further treatment given before referral to a specialist for urethroplasty.

The description provided by Fu et al. of the procedures is standard, bearing in mind that however dramatic the injury, the end result is usually a stenosis or obliteration of <2 cm in length. These authors leave a drain at the end of the operation, which is sensible after crural separation and pubectomy when there is a dead space. Their inpatient stay of a week was somewhat longer than our own, which is usually < 48 h. They remove the catheters at 3 weeks and then arrange urethrography, which is not standard but there is no consensus on the nature and duration of follow-up. Likewise, there is no consensus as to what constitutes ‘success’. Clinical symptoms, flow-rate studies, endoscopy and urethrography have all been used, but the most common definition of success is when the patient is free of the need for further intervention, and this is the criterion Fu et al. have used.

Fu et al. excluded all patients with pre-existing complications and all those with more complicated PFUI requiring adbomino-perineal repairs and so the results in their patient cohort should be good.

Given that the most common time of ‘stricture’ recurrence in their series was at 6 months to 1 year, it is surprising that success in this paper is linked with uroflowmetry at 4 weeks. In fact recurrent stenosis, in our experience, occurs most frequently during the first 48 h after removal of the postoperative catheter because, in most instances, it is caused by ischaemia that is either attributable to severe vascular damage at the time of injury or to tension at the anastomosis at the time of surgery, or a combination of the two. Delayed stenosis is relatively uncommon by comparison. Fu et al. note that re-operation carries a substantial failure rate – 40% in their experience – again perhaps higher than usual, but indicating that ischaemia and tension at the anastomosis are notable problems.

We have never seen the complications of rectal trauma or of creating a false passage as a result of surgery, although false passages do occur as a result of previous urethral dilatation which should be detected on preoperative imaging.

Incontinence is a difficult point because it is common to find impaired function of the urethral sphincter mechanism, either from the injury or from the surgery. Nonetheless most patients retain some degree of urethral sphincter function postoperatively, but there is usually a degree of stress incontinence with a full bladder which tends to settle in time. Incontinence otherwise, particularly that attributable to an overactive bladder, is very unusual in our experience.

Importantly, the authors note that erectile dysfunction is the consequence of the injury not of the subsequent surgery. Why erectile dysfunction occurs is not clear but it is probably neurological rather than vascular in origin, although psychological factors and the threat (or promise!) of litigation are also factors in some patients.

The authors' conclusion seems to be a little trite. Preoperative evaluation is obviously important,but the posterior urethra cannot be displayed by preoperative imaging in as many as 30% of patients, and so the length of the damaged segment or defect cannot be accurately assessed, nor can some instances of false passage be diagnosed. A urethrogram can identify an unusually long or complicated stricture; it will not, however, prevent most of the complications listed here except, perhaps, by warning of the presence of an unusually long stricture.

‘Careful intra-operative manipulation’, as Fu et al. describe it, is clearly important, especially to avoid tension at the anastomosis, which is the most common cause of a recurrent stenosis. It will also reduce the incidence of rectal injury or false passage but these should not, in our view, ever occur. Nevertheless, careful surgery does not reduce the degree of sphincter weakness incontinence or erectile dysfunction.

Conflict of Interest

None declared.