Journal Reading

The management of the acute

setting of pelvic fracture
urethral injury (realignment vs
suprapubic cystostomy alone)
Jonathan N. Warner, Richard A. Santucci

Detroit Medical Center, Detroit, MI, USA

dr. Hendra
 HISTORICAL OVERVIEW

1990
Young 1929 First realignment 1934
1953 Johanson
Open Surgical Repair Minimally invasive,
Perineal approach vs Traction added to radiological, endoscopic
STDU > realignment
retropubic approach catheter techniques for
realignment
Goals
• Realign urethra whilst minimising the risk
of ED, incotinence, urethral stricture
• Early endoscopic realignment (EER) vs
early open primary realignment (EPR) vs
STDU
Erectile Dysfunction
• Main concern: EPR damage neurovascular
bundle
• Damage to neurovascular bundle (open
retropubic)
• Dhabuwala et al: injury induced not the
treatment
• Kotkin and Koch: EPR and simple catheter 
no differences
• Rates are the same (EER, EPR, STDU)
Incontinence
• After PFUI, rare, if persist initial injury
responsible
• Several review articles ≠ open suture
realignment  incr.risk
• 1 study: 21% rate after open suture
realignment, 4% STDU, 5% EPR
• This study: EER : EPR : STDU = 5,8% : 4,7%
: 5%
Stricture
• STDU  89%, EER and EPR = 43,8% and
48,9 %
• EPR more rapid spontaneous voiding
• Early urological evolution + EPR 
decrease rates of complex strictures
• If persist  dilatation + direct visual
internal urethrotomy alone
Other complications
• Pelvic abscess : 1/43 (3%)
• Perineal abscess (1/6 and 1/4)
• Urethral fistula (1/14)
• Septicemia (15% delayed realignment,
time placement 10 days)
Primary endoscopic realignment
Other technique
• Magnetic catheters
• Passing wire
• Antegrade catheter
Timing of catheter placement
• Attempting place the catheter as soon as
it is feasible
• If unsuccessful, leave suprapubic tube, try
again after 2-3 days
• Delayed placement  successful as late
as 10-19 days after injury
When to remove catheter
• Not the duration, values range 3-8 weeks
• Pericatheter retrograde urethrogram,
after at least 3 weeks for partial
disruption and 6 weeks for complete
disruption
• With extravasation  left catheter, test
again every week until there is no
extravasation
STDU
• Initially placed via a cystostomy during an
open laparotomy or a trocar into a distended
bladder, or a needle passed itu the bladder,
then a wire passed through the neddle and
serial dilatations over a wire until suprapubic
catheter can be passed
• 3-6 months period of healing, before
urethroplasty
• Long term success rates 90-98%
Conclusion
• EPR or EER initial approach immediate
treatment of PFUI
• EER > Other techniques of realignment
• Success in EPR in experienced hands
• STDU might be needed in unstable
patient, in complex injuries and when
attempts at early alignment fail