Urethral Trauma Treatment & Management

Initial management decisions in patients with urethral trauma must be made in the context of their other injuries and overall stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. ^[15]   

Initial emergent treatment remains controversial, but mainstays of therapy include drainage of the urinary bladder, often with placement of a suprapubic catheter (SPT) and primary endoscopic realignment of the urethra if possible.

Immediate urethral repair is relatively contraindicated because life-threatening injuries must be corrected first. Urethral repair should be undertaken after the patient has stabilized, when hemorrhage is less of a concern. If open repair is planned, it is better to allow the pelvic hematoma to subside prior to the procedure.

Penetrating anterior urethral injuries should be explored; however, defects longer than 2 cm in the bulbar urethra and longer than 1.5 cm in the penile urethra should never be emergently repaired. They should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair. ^[16]

The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small incision. Ultrasound guidance can aid in the percutaneous approach. Some authors advocate immediate realignment through a number of different techniques, although much controversy exists on this topic. ^[17]

Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has resolved and the patient's orthopedic injuries have stabilized. It is often carried out via a perineal approach, and repair consists of mobilizing the urethra distally to allow a direct anastomosis after excision of the stricture.

To prevent tension on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal and abdominal approach with pubectomy provides maximum exposure of the prostatic apex. ^{[18, 19, 20, 21]}

Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury, using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.

Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma will have stabilized and hemorrhage is less of a concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern. ^{[22, 15]} Ultimate outcomes and benefits of this approach remain controversial, however. ^{[23, 24]}

Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries is often that of decreased urinary stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa) to achieve a tensionless anastomosis. ^{[25, 26]}

Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval. ^[27]

In all urethral injuries, the location of the injury should be localized with repeat urethrography, antegrade cystogram through the suprapubic tube, and cystoscopy, if needed. If an open perineal repair is performed, the patient should be positioned in an exaggerated lithotomy position with the legs well padded. Deep venous thrombosis prophylaxis with compression stockings is preferred. Access to the bladder via the indwelling suprapubic catheter is also useful.

If endoscopic realignment is contemplated, a more relaxed lithotomy position is better. A wide variety of endoscopes, graspers, and wires is needed. This procedure is often best performed using a C-arm for fluoroscopy because of the ease in obtaining oblique views.

Exploration for penile urethral injuries can be performed with the patient in the supine position, although lithotomy position may be helpful if dissection must be carried down into the scrotum. Flexible cystoscopy may also be of assistance during the procedure.

In open urethral reconstruction, careful dissection of the urethra is important. Anastomoses must be performed in a mucosa-to-mucosa fashion to ensure proper healing without further scarring. All anastomoses should be performed over a catheter for stenting purposes.

Excessive mobilization of the urethra must be avoided to prevent tethering of the penis. If a gap of more than 2 cm must be bridged, performing a flap procedure rather than placing the anastomosis under tension or tethering the penis, which causes curvature, is better. This should be performed as part of a delayed reconstruction and not in the acute setting.

Local flaps should be handled meticulously to avoid devascularization. Buccal mucosal grafts should be harvested from the inner cheek and carefully tubularized over a catheter. These may also be effectively used in an onlay fashion.

In endoscopic realignment, having 2 urologists working simultaneously with fluoroscopy is preferable. One should pass a scope transurethrally and the other should work via the suprapubic tract. Often, injuries thought to be a complete disruption are found to be partial disruptions, and the intact mucosa can be followed into the bladder. If the scopes can meet and pass wires to one another, then a catheter may be placed transurethrally over the wire.

In open repairs, the suprapubic catheter may be removed immediately, leaving the urethral catheter for drainage and stenting. The patient may be mobilized on the day following surgery and discharged when tolerating a diet. Antibiotics are maintained for 2 weeks, and the catheter is removed after 4 weeks. A similar pattern is followed for the endoscopic procedure except that the urethral catheter is left indwelling for 6 weeks. After either type of procedure, retrograde urethrography may be indicated to ensure extravasation is not occurring prior to catheter removal. This is particularly true for patients with poor wound healing such as those with diabetes.

In all instances of urethral injury, follow-up should include assessment of the patient's voiding history, continence status, and potency. Undoubtedly, follow-up should be lifelong, although in the trauma population this is often difficult to achieve. Repeat cystourethrography and cystoscopy should be used whenever changes occur following reconstruction.