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Urethral Injuries From Pelvic Fracture

Urethral injuries occur in up to 10 percent of pelvic fractures and are mainly due to high-speed motor vehicle accidents and industrial accidents.

How are urethral strictures that result from a pelvic fracture different?

Urethral injuries that occur from a pelvic fracture are not really strictures, but rather distraction injuries – where the urethra is torn off at the junction of the prostate and the membranous urethra or at the junction of the bulbar urethra and the membranous urethra. Typically, the gap between the torn ends of the urethra is roughly 2 cm.

Typically, the urethra is not repaired at the time of the pelvis fracture – as more life threatening injuries exist. To divert the urine, a tube is typically placed through the lower abdominal skin and straight into the bladder (known as a suprapubic tube). Once the patient has healed from his pelvic fracture, the urethra is reconstructed. This usually occurs at 3 or more months after the accident.

How are posterior urethral strictures evaluated?

Although newer imaging methods including ultrasound and magnetic resonance imaging (MRI) are sometimes used for evaluation, the simultaneous cystogram ( bladder X-ray) and retrograde urethrogram (dye injected into the penile urethra) remain the gold standard for evaluating posterior urethral strictures.

Aside from radiographic study, visualization of the stricture from above and below is important. This is performed with an in-office Cystoscopy (telescope) through the penile urethra and through the bladder.

How are posterior urethral strictures repaired?

One-stage open urethroplasty, where the scarred segment is excised and the two ends of the urethra are sewn together is the gold standard for posterior urethral stricture repair. Long-term success rates approach 90 to 95 percent.

Grafts are very rarely used due to the poor blood supply.

Minimally invasive surgical techniques (via a telescope) results are generally very poor, and should be considered only a temporary measure and never a cure.

How are the two ends of the urethra brought together?

Once the scarred tissue is removed, the two ends of the urethra can be brought together based on the natural elasticity of the urethra. By freeing up the urethra from its underlying attachments, the urethra is very elastic and can stretch up to 70% in length.

Diagram of a urethral injection from pelvic fracture. Courtesy Dr. A. Mundy
Photo Courtesy Dr. A. Mundy

Occasionally, the distance between the ends of the urethra is very far apart – and the elastic urethra will not make up the gap. In these cases, a small piece of the pubic bone is removed. Removing some of the pubic bone gives the urethra a straight shot to the prostate and thus shortens the distance.

Diagram of a urethral injection from pelvic fracture. Courtesy Dr. A. Mundy
Photo Courtesy Dr. A. Mundy