Introduction: We report the results of treatment of posterior urethral rupture (PUR) by primary realignment with some modifications of the technique.Materials and Methods: In this prospective study, 25 patients (mean age, 33.5 years; range, 18 to 70 years) in whom PUR had been proved underwent primary urethral realignment. All patients were evaluated postoperatively for urinary incontinence, erectile dysfunction, and urethral stricture. They were followed for a mean of 20 months (range, 9 to 27 months).Results: In 20 of 25 patients (80%), posterior urethral rupture was associated with pelvic fractures and in 2 (8%), bladder rupture also was present. None of the patients had urinary incontinence. Six patients (24%) had evidence of postoperative stricture that required urethral dilatation and/or direct vision internal urethrotomy in 2 or 3 procedures under local anesthesia. Erectile dysfunction (which all responded to sildenafil) was reported by 4 patients (16%) as a decreased quality of erection. Conclusion: We believe that primary realignment of PUR is a simple procedure associated with low morbidity. It is recommended for patients who are stable and have no other significant intra-abdominal and pelvic organ injuries.</p

Abdolaziz Khezri

Mehdi Salehipour

Parham Masoudi

Rashid Askari

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IntroductionOf patients with pelvic fractures, 4% to 14% alsohave posterior urethral rupture (PUR), which isassociated with considerable morbidities such asincontinence, erectile dysfunction, and urethralstricture.(1)Management of PUR continues to evolve. Someurologists advise initial placement of asuprapubic cystostomy followed by delayedurethroplasty 3 to 6 months later, while otherssuggest immediate realignment.(2) The definitionof primary realignment of urethral distractioninjury has changed over the years. The currentdefinition of primary realignment refers toimmediate stenting of urethral distraction with acatheter without pelvic dissection or suture.(3) Inthe present study, we review our experience withprimary realignment of PUR and report itsoutcome and complications. Materials and MethodsBetween March 2002 and August 2004, therewere 25 men (mean age, 33.5 ± 14.5 years; range,18 to 70 years) with PUR due to injury whounderwent primary realignment in our medicalcenter. Posterior urethral ruptures werediagnosed and confirmed by history, physicalexamination, and retrograde urethrography. Weprospectively selected those patients with novisceral injuries to undergo primary realignment.Surgical technique. A lower midlineabdominal incision is made. If the patient ishemodynamically stable with no othergenitourinary tract injuries, a vertical cystotomyincision is made under direct vision, and aurethral Foley catheter is gently passed in aretrograde fashion. If the catheter is easilyPrimary Realignment of Posterior Urethral RuptureMehdi Salehipour, Abdolaziz Khezri, Rashid Askari,* Parham MasoudiDepartment of Surgery, Division of Urology, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, IranABSTRACTIntroduction: We report the results of treatment of posterior urethral rupture (PUR)by primary realignment with some modifications of the technique.Materials and Methods: In this prospective study, 25 patients (mean age, 33.5years; range, 18 to 70 years) in whom PUR had been proved underwent primaryurethral realignment. All patients were evaluated postoperatively for urinaryincontinence, erectile dysfunction, and urethral stricture. They were followed for amean of 20 months (range, 9 to 27 months).Results: In 20 of 25 patients (80%), posterior urethral rupture was associated withpelvic fractures and in 2 (8%), bladder rupture was also present. None of the patientshad urinary incontinence. Six patients (24%) had evidence of postoperative stricturethat required urethral dilatation and/or direct vision internal urethrotomy in 2 or 3procedures under local anesthesia. Erectile dysfunction was reported by 4 patients(16%) as a decreased quality of erection, all of whom responded to sildenafil. Conclusion: We believe that primary realignment of PUR is a simple procedureassociated with low morbidity. It is recommended for patients who are stable and haveno other significant intra-abdominal and pelvic organ injuries. KEY WORDS: urethra, urethral distraction, urethroplasty, injuries, primary realignment 211Urology JournalUNRC/IUAVol. 2, No. 4, 211-215 Autumn 2005Printed in IRANReceived January 2005Accepted July 2005*Corresponding Author: Department of Urology,Faghihi Hospital, Zand Ave, Shiraz, Iran.Tel: ++98 711 233 0724, ++98 711 235 5397,Fax: ++98 711 233 0724E-mail: rashidaskari@yahoo.comPrimary Realignment of Posterior Urethral Rupturebrought into the bladder, its tip is sewn to the tipof a Nelaton catheter using a nonabsorbablesuture, and the latter catheter is brought outfrom the bladder and the anterior abdominal walland fixed to the abdominal wall. A suprapubictube is placed in the dome of the bladder and thebladder is closed in 2 layers using a standardtechnique (Figure 1A). If retrograde catheter placement fails, a 20-FNelaton catheter is gently passed from theurethral meatus to the urethral disrupted areaand the space of Retzius. A second 18-F Nelatoncatheter is also gently passed from the bladderneck and the prostatic urethra to the disruptedarea and the space of Retzius, in an antegradefashion. The ends of these catheters are tiedtogether, and the antegrade catheter ismanipulated through the anterior urethra bypulling the retrograde catheter back to theurethral meatus. Subsequently, the antegradecatheter is secured to a Foley catheter by anonabsorbable suture, which is then pulled backinto the bladder. The antegrade catheter isbrought out the anterior wall of the bladder andabdominal wall and fixed to the skin. The Foleycatheter balloon is filled with 20 mL fluid. Asuprapubic cystostomy tube is placed using astandard technique as previously described. Notraction is applied on the Foley catheter. The Foley catheter is left in place for 4 weeksand replaced by another one based on theguidance of the antegrade catheter. The Foleycatheter is retracted until the tip of theantegrade catheter are seen via the urethralmeatus. The suture is removed from tips of bothcatheters, and a new Foley catheter is sewn tothe tip of the antegrade catheter. The antegradecatheter is retracted through the bladder and theabdominal wall and removed by cutting thesutures (Figure 1B). The new Foley catheter isretracted gently while its balloon is filled with 20mL fluid (Figure 1C). The new Foley catheter isleft in place for another 4 weeks and removedwhen a retrograde urethrography around theFoley catheter shows no extravasation of contrastmedium. The suprapubic cystostomy is clamped,but left in place. If the patient voids normally andwithout difficulty, the cystostomy tube may beremoved 2 weeks later. Follow-up. After the removal of catheters, thepatients were followed at 3, 6, and 12postoperative months with physical examination,uroflowmetry studies, and, if needed, retrogradeurethrography and/or a voiding cystourethrography.Potency and continence were evaluatedsubjectively by interviews with the patients.Patients were considered potent if they were ableto have intercourse with vaginal penetration. Ifthe patients had decreased firmness of erectioncompared with the preinjury status, this wasconsidered decreased potency. Continence wasdefined as no requirement to use a pad to protectagainst urine loss. Eventually, the need foradditional urologic procedures was assessed. 212FIG. 1. Primary realignment of posterior urethral rupture, A. A 20-F Foley catheter is inserted, its tip is sewn to a Nelatoncatheter, and cystostomy is placed. B and C. After 4 weeks, the Foley catheter is exchanged with another one, and theNelaton catheter is retracted from the bladder and abdominal wall and removed. A Foley catheter is placed for another 4weeks. Salehipour et alResultsMean follow-up was 20.0 ± 5.6 months (range,9 to 27 months). Twenty patients (80%) had pelvicfractures, and 2 (8%) had both pelvic fracture andbladder rupture. They had no visceral injury. Allpatients underwent surgical operation within 12hours after injury. Twenty-one patients werefollowed for more than 12 months. The mostcommon mechanisms of injury in our patients, inorder of frequency, are shown in Table 1. On follow-up, 19 patients (76%) had nosymptoms or radiologic evidence of urethralstricture. All patients reported good urinarycontinence with no need for a pad. Six (24%) hadstrictures that were treated with urethraldilatation and/or direct vision internalurethrotomy. Of these, 3 patients required 3procedures, and 3 required 2 procedures. Nonerequired open urethroplasty. Twenty-one (84%) patients reported a normalerection, while 4 (16%) had decreased firmness oferection (all of which responded to sildenafil, 50mg to 100 mg, daily).The mean operative time for primaryrealignment was 50 ± 3 minutes (range, 45 to 60minutes). The estimated blood loss was 300 mLto 700 mL, and 3 patients received 500 mL bloodtransfusion.DiscussionThe PUR is one of the worst types ofgenitourinary trauma with 3 significantcomplications: erectile dysfunction, urethralstricture, and urinary incontinence. Managementof PUR remains controversial. In the presentstudy, we showed that primary realignment wasassociated with no urinary incontinence, a lowrate of erectile dysfunction, and a relatively lowrate of urinary tract strictures that were treatedsuccessfully. Some studies have shown that initialsuprapubic cystostomy and delayed urethroplasty,3 to 6 months later produces less complicationthan does primary realignment, while otherstudies have shown the opposite. In 1972, Morehouse and colleagues(4) reportedhigh impotence and incontinence rates inpatients treated with primary realignment.Webster and coworkers(5) have compared delayedurethroplasty and primary realignment in thetreatment of PUR and noted a significantadvantage with delayed urethroplasty. On theother hand, Follis and colleagues(6) havecompared the operative outcomes of completeprostatomembranous disruptions in 20 men withdelayed repair and 13 with immediaterealignment. They reported potency rates of 50%and 80%, respectively, and an increased need fora secondary operation when the repair wasdelayed. Elliott and Barrett(3) analyzed the long-term (10-year) results of treatment of PUR withprimary realignment in 57 men and showed thatprimary realignment resulted in low incidence oferectile dysfunction (21%, mostly mild),incontinence (3.7%), and stricture (34%, but withno requirement for intervention). The main disadvantages of delayedurethroplasty are urethral stricture (inapproximately 100% of patients(1)) and the needfor a second operation with its potentialcomplications such as impotence andincontinence. Conversely, primary realignmentreduces the requirement for secondary openurethroplasty, and in addition, the majority ofstrictures can be treated with urethral dilatationand/or direct vision internal urethrotomy as anoutpatient procedure. Compared with otherstudies,(3,6) the rate of urethral stricture in ourstudy was relatively low. We think that the lowurethral stricture rate is probably due to theminor modifications we made in our procedure.We connect the tip of the retrograde catheter tothe tip of the antegrade Nelaton catheter for 2reasons: first, because it can prevent unwanteddisconnection of the retrograde catheter that actsas a stent and is important to the healingprocesses; and second, because passage of theNelaton catheter after 4 weeks (when we changethe retrograde Foley catheter with another one,while the antegrade catheter is connected to it)213TABLE 1. Mechanisms of posterior urethral rupturein 25 patients Mechanisms of injury  Number of patients (%) Car accident  12 (48) Falling  5 (20) Crushing  4 (16) Motorcycle accident  3 (12) Tractor rollover 1 (4) Total 25 (100)  Primary Realignment of Posterior Urethral Rupturemay result in mild urethral dilatation.Urinary continence depends on intact internaland external urethral sphincters. In PUR, thebladder neck is separated from the urethra, andso it seems that continence is dependant on theexternal sphincter function. Duringurethroplasty, the possibility of damage to theexternal urethral sphincter is high. Consequently,the rate of incontinence is higher than that inprimary realignment. The reported rate ofurinary incontinence with delayed urethroplastyhas been 2% to 8%.(4-6) In 2 studies on primaryrealignment, urinary incontinence was present in0% and 3.7% of the patients, and none of thepatients in the latter study needed treatment.(3,6)We had no cases of incontinence. Thus, is seemsthat primary realignment can be done with noserious impact on the patient's continence. Wespeculate that this is due to less manipulation ofthe external sphincter during primaryrealignment and repair of bladder neck andprostatic urethra with a good exposure. Inaddition, we used no traction on the urethralFoley catheter, which prevents ischemic damageto the internal urethral sphincter, which is veryimportant in maintaining continence.(7)Causes of erectile dysfunction following PURare not understood. Dhabuwala and associateshave noted that impotence is caused by theoriginal injury and is not due to the urethralrepair.(8) In a report by Tunc and colleagues,(9)erectile dysfunction was attributed to delayedurethral reconstruction in 16.2% of patients. It islikely that injury to the autonomic plexus inpatients with pelvic fractures, or injury to thenervi erigentes in the neurovascular bundlesdorsolateral to the prostatomemberanous urethracontributes to erectile dysfunction.(6) In ourstudy, no patient developed permanent erectiledysfunction, and 4 patients with decreasedfirmness of erection responded to sildenafil andgradually improved significantly. We suppose thatminimal manipulation of pelvic viscera and a lowincidence of hematomas contributed to the lowrate of erectile dysfunction in our study. Thecomplication rates of primary realignment in ourstudy and some other studies are shown in Table 2.ConclusionWe believe that primary realignment of PUR isa simple procedure associated with low morbidity.This technique is useful for patients who arestable with no other significant intra-abdominalor pelvic organ injuries. AcknowledgementWe gratefully acknowledge Ms. MersedehFeradoni for her drawings in this article. Wewould also like to thank the Office of ResearchDevelopment of Nemazee Hospital and Dr.Hooman Yarmohammadi for his editorialassistance.References1. McAninch JW, Santucci RA. Genitourinary trauma, In:Walsh PC, Retik AB, Vaughan ED Jr, et al, editors.Campbell's urology. 8th ed. Philadelphia: WB Saunders;2002. p. 3707-44. 214TABLE 2. Results of primary realignment versus delayed urethroplasty of posterior urethral rupture indifferent studiesStudy Technique Number of patients Stricture No.        (%) Incontinence No.           (%) Erectile dysfunction No.                  (%) Elliott and Barrett(3) PR 57 18 (34) 2 (3.7) 12 (21) Webster and colleagues(5) PR 19 18 (95) 1 (5.2) 10 (53) Follis and colleagues(6) PR/DU 20/13 3/11 (15/85) 0/1 (0/8) 4/5 (20/39) Tunc and colleagues(9) DU 77 77 (100) 7 (9.1) 7/58 (16.2) Patterson and colleagues(10) PR 29 11(38) 1 (3.4) 4 (14) Husmann and colleagues(11) DU 17 16 (94) 2 (12) 8 (47) The present study PR 25 6 (24) 0 (0) 4 (16) Salehipour et al2. Koraitim MM. Pelvic fracture urethral injuries: theunresolved controversy. J Urol. 1999;161:1433-41. 3. Elliott DS, Barrett DM. Long-term follow-up andevaluation of primary realignment of posterior urethraldisruptions. J Urol. 1997;157:814-6. 4. Morehouse DD, Belitsky P, Mackinnon K. Rupture of theposterior urethra. J Urol. 1972;107:255-8.  5. Webster GD, Mathes GL, Selli C. Prostatomembranousurethral injuries: a review of the literature and a rationalapproach to their management. J Urol. 1983;130:898-902.6. Follis HW, Koch MO, McDougal WS. Immediatemanagement of prostatomembranous urethraldisruptions. J Urol. 1992;147:1259-62.  7. McAninch JW. Traumatic injuries to the urethra. JTrauma. 1981;21:291-7.  8. Dhabuwala CB, Hamid S, Katsikas DM, Pierce JM Jr.Impotence following delayed repair ofprostatomembranous urethral disruption. J Urol.1990;144:677-8.9. Tunc HM, Tefekli AH, Kaplancan T, Esen T. Delayedrepair of post-traumatic posterior urethral distractioninjuries: long-term results. Urology. 2000;55:837-41. 10. Patterson DE, Barrett DM, Myers RP, DeWeerd JH, HallBB, Benson RC Jr. Primary realignment of posteriorurethral injuries. J Urol. 1983;129:513-6.11. Husmann DA, Wilson WT, Boone TB, Allen TD.Prostatomembranous urethral disruptions: managementby suprapubic cystostomy and delayed urethroplasty. JUrol. 1990;144:76-8.215

Primary Realignment of Posterior Urethral Rupture

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Primary Realignment of Posterior Urethral Rupture

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