Review Article CONSENSUS STATEMENT ON URETHRAL TRAUMA C. CHAPPLE et al.

In this continuation of the section on genitourinary trauma, the authors describe the consensus on urethral injury. This is an in-depth statement, describing all aspects of the condition, from anatomy to general recommendations.

Consensus statement on urethral trauma

C. CHAPPLE, G. BARBAGLI*, G. JORDAN, A.R. MUNDY, N. RODRIGUES-NETTO, V. PANSADORO and J.W. McANINCH
Department of Urology, The Royal Hallamshire Hospital,, Shefeld, UK, *Center for Urethral and Genitalia Reconstructive Surgery, Urology, Arrezo, Italy; Eastern Virginia Medical School, Urology, Norfolk, VA, USA; Institute of Urology and Nephrology, Urology, London, UK, Rua Martiniano De Carvalho, Urology, Sao Paulo, Brazil; Casa di Cura Pio XI, Urology, Rome, Italy, and Department of Urology, University of California School of Medicine, San Francisco, USA
Accepted for publication 24 February 2004

INTRODUCTION This document represents the deliberations of the WHO consultation on urethral trauma. The aim of this evidence-based review was to objectively assess the appropriate contemporary management of urethral trauma, and to provide recommendations, where appropriate, citing a subjective grading scale of Level 15 to reect the nature of the evidence cited in support of our recommendations on: Anatomy. Types and location of injury. Diagnosis. Management. The timing of surgery. Surgical technique. Outcome measures. General recommendations.

perineal membrane. The anatomy of the urethra varies along the urethra. The urethra is surrounded by a vascular organ (the corpus spongiosum) and comprising a thin urothelial lining lying on the vascularized spongy tissue. An appreciation of the anatomical characteristics of both the anterior and posterior urethra is an important prerequisite for both the accurate diagnosis and successful management of urethral injuries. Indeed, for convenience, injuries can be subdivided into those affecting either the anterior or posterior urethra, as both sites are exposed to different mechanisms of injury. Injuries to these regions should be further considered as subdivided into: Anterior urethra Urethral meatus/navicular fossa Pendulous/penile urethra Bulbar urethra Posterior urethra Membranous urethra Prostatic urethra/bladder neck.

A Medline review revealed 1129 cited references over the last 25 years; these have been reviewed by the committee and 297 used as the basis for this review (a full list and details of the analysis of these papers can be obtained from the authors on request). ANATOMY The male urethra is divided into anterior and posterior sections by the genitourinary

The anterior urethra consists of the bulbar and penile urethra and is 15 cm long, extending from the end of the membranous urethra to the external meatus. It is divided into two segments at the level of the penoscrotal junction; proximal to this is the bulbar urethra, which is the shorter of the two 11 9 5

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segments and lies in the midline between both penile crura. The distal segment is called the penile or pendulous urethra and lies closely juxtaposed to the two corpora cavernosa. The anterior urethra maintains a fairly constant luminal calibre until its terminal portion, at which point it widens to form the fossa navicularis, narrowing again at the external meatus. The posterior urethra consists of the prostatic and membranous urethra, the latter is enclosed in the urogenital diaphragm. It extends from the bladder neck to the distal sphincter mechanism for 3 cm. The bladder neck sphincter is functional from the internal meatus to the level of the verumontanum. In the male it is reliably competent, provided it is not surgically damaged or rendered functionally incompetent by rises in intrinsic detrusor pressure, e.g. related to overactive detrusor contractions. The distal sphincter mechanism is 2.5 cm long but it is only 34 mm thick and forms the whole thickness of the membranous urethra extending upward, through the apical prostatic capsule, to the verumontanum. The competence of this distal urethral mechanism entirely depends on the sphincter muscles within and surrounding this 34 mm thickness of the membranous and supramembranous urethra. There is no periurethral external sphincter mechanism either anteriorly or laterally. The traditional description of a complete urogenital diaphragm, enclosing a bulk of striated external sphincter muscle and encircling the membranous urethra, is inaccurate. A potential pubo-urethral space lies between the pubic bone and the urethra in the pelvic oor, exactly in the supposed position of the urogenital diaphragm [1]. This pubo-urethral space is particularly important as even in heavily scarred cases it is easy to develop surgically via a perineal approach after minimal mobilization of the bulbar urethra. The external approach to the membranous urethra and the apex of the prostate that it provides enables the distal extent of the distal sphincter mechanism to be accurately identied and preserved. TYPES AND LOCATION OF INJURY Injuries can occur from external blunt or penetrating trauma, or internal injury, either iatrogenic or as a consequence of the presence of foreign bodies within the urethral lumen. Urethral injuries range from a mild contusion with preservation of epithelial 11 9 6

continuity, to a partial tear of the urethral epithelium or full urethral transection, possibly combined with disruption. Injuries to the urinary tract occur in 10% of patients presenting after blunt or penetrating trauma [2]; not surprisingly, these are usually in young men aged 1525 years. Of these injuries a few involve the urethra, with 65% being complete and 35% partial tears [3]. Urethral injuries alone are rarely lifethreatening except as a consequence of their close association with pelvic fractures and multiple-organ injuries. Signicantly many urethral injuries also occur iatrogenically, after urethral instrumentation or penile surgery, usually resulting in partial urethral tears. Injuries to the anterior urethra occur with a recognized frequency of a third of that of the posterior urethra; they usually result as a consequence of direct trauma to the urethra, which is relatively exposed. In some cases the injury is not immediately recognized and presents later as a stricture Causes of anterior urethral injuries Blunt trauma, fall astride/kicks in the perineum, go-kart injuries, skateboarding; Penetrating trauma gunshot/stab wounds; Sexual excess, penile fractures, urethral foreign bodies; Constriction bands, paraplegics; Iatrogenic injuries, urethral catheters/ penile surgery, endoscopic instrumentation; After catheterization for surgery trauma/ ischaemia. Injuries to the posterior urethra are usually associated with major and often lifethreatening trauma. In recent years there has been a relative increase in iatrogenic problems, particularly with the increased use of radical prostatectomy. Causes of posterior urethral injuries Penetrating injuries; Gunshot wounds; Stab wounds; Urethral injuries associated with pelvic fractures, e.g. road trafc accidents, falls from heights, industrial accidents; Iatrogenic injuries, e.g. complications of endoscopic surgery, particularly TURP, and radical prostatectomy. Whilst the nature of types of injury is selfevident from these lists certain aspects of

clinical presentation warrant emphasis and discussion. Injury to the urethral meatus and navicular fossa is usually iatrogenic, and indeed planned, in the context of meatal surgery for balanitis xerotica obliterans, which involves a meatoplasty. Often this surgery fails to correct the problem as it is not radical enough. There is often consequently a restenosis, combined with a blunderbuss appearance to the urethral meatus, leading to functional problems with spraying of urine. Blunt or penetrating trauma to the anterior urethra is usually associated with extensive bruising of soft tissues. It is often concomitant with rupture of the corpora cavernosa, as seen in injuries related to sexual intercourse. In such cases exploration is mandatory to enable a repair of the corpora cavernosa and corpus spongiosum. Exploration is also important in the context of a penetrating injury or to carry out debridement. However, usually the acute management is to initiate drainage and deal with the urethral injury at a later date. Iatrogenic injuries of the penile urethra are rare but do occur, especially after circumcision particularly in children. These are of two types, urethrocutaneous stulae and urethral distortion secondary to partial glans penis amputation. The cosmetic retrieval of patients with this type of injury is important [4]. Bulbar urethral injuries are commonly associated with attempted catheterization and can follow any instrumentation of the urethra. Fall-astride injuries are probably the commonest other method of injury. Posterior urethral injuries classically occur in association with pelvic fracture and are the result of shearing of the membranous urethra at some level between the apex of the prostate and the distal extent of the membranous urethra. The association of urethral injuries with pelvic fractures has been quoted as being 325% in most studies; 27% are also associated with other intraabdominal injuries. Any such injury must be expected to be associated with damage to the external sphincter, although surprisingly in some patients part or all of the sphincter may be preserved. The function of the bladder neck mechanism in many patients becomes of preeminent importance in preserving continence, particularly where the function of the distal urethral sphincter mechanism is destroyed The incidence of double injuries involving both the urethra and the bladder is reported to be 1020% in males, which may be

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intraperitoneal (1739%) or extraperitoneal (5678%) or rarely both [2]. As the forces involved in pelvic fractures have to be high, urethral injuries associated with pelvic fracture tend to be associated with multiple and life-threatening injuries. Attention to resuscitation is of primary importance in the early management of these patients. Urethral injuries in females are rare events as the female urethra is short and mobile, with no signicant attachments to the pubic bone, thereby rendering it relatively resistant to injury. These injuries are rare (the quoted incidence in females with pelvic fracture is 06.0%), difcult to manage and often cause problems with continence. They tend to result from lacerations by bony fragments from the fractured pelvis. They vary in severity, but in a recent series of 12 patients they were associated with rectal injury in four and vaginal injury in nine, and three went on to urinary diversion [5]. Prolonged obstructed labour can result in ischaemic injury to the urethra and bladder neck, and is relatively common in women in developing countries. Penetrating injuries to the perineum and iatrogenic injuries to the urethra as a result of endoscopic instrumentation or during vaginal surgery are rare in experienced hands. Urethral injuries in children tend to follow the same mechanism of injury as in adults. Straddle pelvic fractures are more common than in adults [6]. The tear is often in the prostatic urethra or at the bladder neck because of the rudimentary nature of the prostate, and is more likely to be a complete rupture (69% vs 42%). The more proximal the injury the greater the risk of incontinence, impotence and stricture formation in the long term. Iatrogenic injuries are more signicant because of the smaller urethra in the child. In the posterior urethra iatrogenic injuries are most common in elderly men and are mostly related to surgery involving the prostatic urethra. Predisposing factors to such injuries during TURP include a vascular prostate, prostatic tumours and an inexperienced surgeon. There is an increasing incidence of posterior urethral strictures with the increasing use of radical prostatectomy as a consequence of the development of anastomotic stenoses. Unfortunately, the term posterior urethral stricture is still widely used to include both simple sphincter-strictures, subprostatic

pelvic fracture urethral distraction defects (PFUDDs) and strictures after both transurethral and radical prostatectomy. This is confusing because they and the principles of their surgical resolution are entirely different. With radical prostatectomy there is surgical transection of the urethra at the proximal extent of the distal sphincter mechanism, with subsequent stricture formation at the site of anastomosis to the bladder neck. In contrast, in the case of PFUDDs there is a traumatic disruption of urethral continuity, usually with minimal loss of urethra but with displacement of the two ends, and indeed there is a some preservation of sphincter function in a signicant proportion of those with a PFUDD [7]. Simple continuity strictures of the membranous urethra (both iatrogenic and after localized inammation) and those occurring after prostatectomy are best referred to as sphincter stenosis because this emphasizes that although the function is generally impaired to a variable extent, the distal urethral sphincter mechanism has not been destroyed. The primary aim of the treatment of a sphincter stenosis must be to preserve the residual distal sphincteric function. The primary aim of the management of a PFUDD is not only to restore urethral continuity but also to preserve or functionally reconstruct the residual sphincter mechanism at the bladder neck. Most of these are difcult strictures to manage as they occur in the area of the distal sphincter mechanism, and the prime consideration must be to preserve the all-important residual intrinsic sphincteric function rather than to denitively resolve the stricture itself. They present particular problems because: They are located in the only sphincter mechanism that remains after prostatectomy and ablation of the bladder neck. The injury that created the distal sphincter stricture, and often its subsequent treatment, also damages its functional competence to a greater or lesser extent. They tend to re-stenose particularly rapidly, presumably accelerated by natural sphincteric function which acts to occlude their lumen. There is a wide variation in the extent of sphincter damage associated with sphincter stenosis. There are, of course, all gradations between these extremes, and these are

identied by observing the result of judiciously progressive recalibration, using simple expansion of the Otis instrument without its knife blade, followed by intermittent self-dilatation. There are potential disasters associated with treating a sphincter stenosis after prostatectomy by internal urethrotomy. If a patient is not immediately rendered incontinent as a result of transecting the 34-mm thickness of the intramural distal sphincter mechanism, secondary brosis may convert a supple mechanism into one that is rigid and relatively complex. After careful thought and discussion, a patient with a supple sphincter stenosis that is proving difcult to manage by dilatation may elect to accept the inherent risk of incontinence involved in a denitive repair procedure, particularly if the bladder neck is incompetent, with subsequent reconstruction and/or implantation of an articial urinary sphincter. The committee recommend that the term stricture applies to the anterior urethra where there is intrinsic corpus spongiosum brosis (spongiobrosis) whilst the urethra remains in continuity. In injuries of the posterior urethra we recommend the terms stenosis or PFUDD. Simple continuity strictures of the membranous urethra such as those occurring after prostatectomy are best referred to as sphincter stenoses because this emphasizes that although the function is generally impaired to a variable extent, the distal urethral sphincter mechanism has not been destroyed (Level 5 evidence)

DIAGNOSIS OF URETHRAL INJURY Anterior urethral injuries can present with blood at the meatus, inability to pass water, or the rapid development of a perineal urinoma or haematoma forming down a sleeve of Bucks fascia. Extension of penile bruising beyond the shaft is caused by the rupture of Bucks fascia, allowing Colles fascia to act as the limiting tissue. This results in bruising in the perineum. Urethral injury must be suspected in any patient with a fracture of the pelvis. The risk of urethral injury increases with: blood at the urethral meatus; difculty/inability to void; 11 9 7

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palpable bladder from distension; characteristic buttery pattern of bruising of the perineum; high-riding prostate, although this might be difcult to appreciate in the presence of a pelvic haematoma, at rectal examination; fractures involving displacement of the pubic rami relative to the rest of the pelvis; pelvic haematoma. Although this classic triad of blood at the external urethral meatus, inability to pass urine and a distended bladder is fairly indicative of urethral injuries, the absence of this triad does not exclude the diagnosis A DRE helps to exclude a dislocated prostate but swelling and oedema may mask the presence of a normally positioned prostate. The DRE is more important as a tool to screen for rectal injuries that can be associated with 5% of pelvic fractures [8]. Blood on the examination nger is highly suggestive of such an injury. Urethrography is the investigation of choice if a urethral injury is suspected [9]. The patient is placed in a 2535 oblique position. The examination should be carried out with water-soluble contrast medium. Radiography and where possible uoroscopy is undertaken as 2030 mL of full strength (60%) ionic contrast medium is injected into the urethra. If real-time uoroscopic imaging is not available, a series of plain X-rays using 10 mL of contrast medium each time, in the emergency room, can be as informative. If the patient develops retention and a urethral injury cannot be excluded, a suprapubic catheter is inserted and a simultaneous cystogram and voiding urethrogram taken at a later date. Alternatively, an endoscopic examination by a trained and experienced urologist using a cysto-urethroscope can be used as a preliminary procedure. Simultaneous suprapubic cystography and ascending urethrograms (the so-called upand-downogram) are the investigation of choice in assessing the site, severity and length of urethral injuries. This is usually done within a week of injury if delayed primary repair is contemplated or at 3 months if a delayed or late repair is considered. Colapinto and McCallum [10] classied posterior urethral injuries based on the 11 9 8

TABLE 1 Classication of urethral injuries according to [11] Class I II III IV IVa V Denition Posterior urethra stretched but intact Tear of the prostatomembranous urethra above the urogenital diaphragm Partial or complete tear of both anterior and posterior urethra with disruption of the urogenital diaphragm Bladder injury extending into the urethra Injury of the bladder base with periurethral extravasation simulating posterior urethral injury Partial or complete pure anterior urethral injury

FIG. 1. Suspect Urethral Trauma Imaging (endoscopy/urethrography) No Injury Anterior Urethra Drain Bladder suprapubic catheter urethral catheter If surgery is necessary for other reasons Conservative Management re-evaluate with imaging at 6-12 weeks Immediate <8 days No stricture Stricture Delayed Primary 814 days Delayed >2 months Surgery Injury Posterior Urethra

radiographic appearances into three types, depending on the integrity of the membranous urethra and extension of the disruption into the bulbar and membranous urethra. Recently, a new classication was proposed providing an anatomical classication and a means of comparing treatment strategies and outcomes (Table 1) [11]. Ultrasonography is not a routine investigation in the initial assessment of urethral injuries but can be useful in determining the position of pelvic haematoma and the high-riding bladder, when a suprapubic catheter is indicated. With improvements in the quality of ultrasonography there is current interest in its use for assessing urethral injuries and their follow-up. The obvious advantage is its non-invasiveness and ability to visualize periurethral spongiobrosis. Its role is still under assessment and is not yet an accepted form of investigation for urethral strictures in most urology units. MRI may be useful for the

further evaluation of complex posterior urethral distraction defects. In the longer-term management of patients endoscopy of the urethra and of the bladder neck via a suprapubic tract can be very useful as a precursor to surgical repair. Happily in most patients the integrity of the bladder neck mechanism is not difcult to assess, but depends on careful endoscopy via the suprapubic route, and careful assessment of a suprapubic cystogram to determine whether there is a defect of the bladder neck. The appearance of the bladder neck does not correlate absolutely with subsequent function [12]. A clinical history and examination are important in the initial assessment of patients. The diagnosis of any urethral injuries requires a high index of suspicion, particularly in the trauma patient, and should be excluded before a urinary catheter is inserted. Imaging

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techniques conrm the diagnosis (Level 5 evidence) If a urethral injury cannot be excluded, blind catheterization should not be used (Level 5 evidence). In patients referred with a urethral catheter already in place, who are suspected of having a urethral injury, then either a peri-catheter urethrogram and/or a voiding urethrogram/ urethroscopy should be used (Level 3/4 evidence). Simultaneous suprapubic cystography and an ascending urethrogram (the up-anddownogram) is the investigation of choice in assessing the site, severity and length of urethral injuries (Level 3 evidence). The committee would endorse the Goldman classication, which was proposed as a predictor of continence, but in view of its complexity would recommend a simpler classication to be: Anterior urethra 1 Partial disruption 2 Complete disruption Posterior urethra 3 Posterior urethra stretched but intact 4 Partial disruption 5 Complete disruption 6 Complex (involves bladder neck/rectum) (Level 5 evidence). Ultrasonography is not a routine investigation in the initial assessment of urethral injuries but can be useful in determining the position of pelvic haematoma and the high riding bladder. MRI may be useful for the further evaluation of complex posterior urethral distraction defects. Endoscopy of the urethra and of the bladder neck via a suprapubic tract can be useful as a precursor to surgical repair of posterior urethral distraction defects. The endoscopic and radiographic appearances of the bladder neck do not correlate absolutely with subsequent function (Level 3 evidence). Timing of surgical intervention; the committee would recommend that the following terminology is used: Immediate treatment; <48 h after injury

Delayed primary treatment; 214 days Deferred treatment; 3 months (Level 3 evidence). The management of urethral injuries remains controversial because of the wide variety of injury patterns, associated injuries, and treatment options available. In addition, the relative rarity of the injuries limits the experience of most urologists worldwide. The initial management of all urethral injuries is resuscitation of the patient as a result of associated injuries which can be lifethreatening. This is especially so for posterior urethral injuries because of their close association with pelvic fractures and other intra-abdominal and orthopaedic injuries. The next step in acute management is to obtain drainage of the bladder. Extravasated blood or urine from the urethral tear produces an inammatory reaction that can progress to the formation of an abscess. Extension of the infection depends on the fascial planes violated and can involve the abdomen, chest, perineum and medial thighs. Potential sequelae of these infections include urethrocutaneous stulae, periurethral diverticulae and, rarely, necrotizing fasciitis (Fourniers gangrene). Early diagnosis and prompt urinary diversion coupled with the appropriate administration of antibiotics decreases the incidence of these complications. This will prevent further extravasation into surrounding tissues and allow an assessment of the urine output. Suprapubic cystostomy is a simple procedure that can be used to divert the urine away from the site of injury. Moreover, it is familiar to all urologists and to many other surgical specialities, and avoids urethral manipulation. If the bladder is not easily palpable suprapubically, transabdominal ultrasonography should be used to guide the catheter placement. In exceptional circumstances open cystotomy may be necessary. The cystostomy tube is maintained for 4 weeks to allow urethral healing. Voiding cysto-urethrography is used and the tube then clamped as appropriate; if normal voiding can be re-established then the tube can be safely removed. Denitive management of the urethral injury can only commence after the patient has been stabilized and his associated injuries attended to. Urethral injury, as it is not life-threatening,

will assume lower priority in the initial management. However, after stabilization, the morbidity of urethral injuries tends to take a higher prole and can be a prolonged process. Long-term results of re-stricture and restenoses rates, incontinence and impotence predominate in this phase. ANTERIOR URETHRA If the integrity of the urethra is in question, with severe contusion and haematoma formation, delayed primary repair may be necessary after suprapubic cystostomy and subsequent urethroscopy to assess the situation. A stenting urethral catheter may be useful in some cases. In our experience, if there has been a signicant urethral injury, because of the injury to and loss of corpus spongiosum, many of these strictures require formal urethral reconstruction. In most cases there is a partial rupture of the urethra and it is prudent to allow the injury to resolve, to determine whether there is a residual stricture after healing occurs at >3 months. Immediate urethral repair can be attempted if the injury is complete, anterior, penetrating or open provided the patient is stable and the haematoma minimal. Immediate repair of the acutely traumatized anterior urethra can be technically difcult. It should be restricted to only those patients with penetrating urethral injuries who are haemodynamically stable with no signicant injuries to nongenital organs, for whom a simple urethral closure is enough. The urethral injury is repaired with a ne suture material, with attention being directed to over-closure of the corpus spongiosum and overlying tissues to minimize subsequent stula formation. More extensive partial disruptions and selected complete disruptions, which can be managed by primary excision and re-anastomosis, can be similarly explored. Longer defects require urethral replacement with grafts or aps and should be avoided in the acute trauma setting, as contamination or decreased blood supply can compromise such a repair. If, at the time of initial exploration, the urethra is found to be so extensively disrupted that primary anastomosis is not possible, then debridement should be used, with marsupialization of the urethra preparatory to a two-stage urethral repair, with proximal diversion. A delayed elective procedure is usually carried out at least 3 months after injury. 11 9 9

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POSTERIOR URETHRA Immediate open repair of posterior urethral injuries is usually associated with a higher incidence of strictures, re-stenosis, incontinence and impotence. Difculty in identifying structures and planes as a result of haematoma formation and oedema also hamper adequate mobilization and subsequent surgical apposition. Webster et al. [3] reviewed published reports, which at the time included 301 patients in 15 reported series, and concluded that urethral realignment was associated with re-stricture in 69%, impotence in 44% and incontinence in 20% of patients. More recently, Elliott and Barrett [13] reported on a series of 57 patients who underwent primary endoscopic urethral realignment with a mean follow-up of 10.5 years; 21% had some degree of erectile dysfunction, 3.7% had mild stress incontinence, 68% had post-alignment strictures, and 13 of these required a total of 20 procedures under general anaesthesia, which included four urethroplasties. The earlier series [3] reviewed included several techniques, which may explain the poor results compared with those reported by Elliott and Barrett, where there was no open intervention. Porter et al. reported a series of 13 patients where they established urethral realignment in 11 of the cases using magnetic urethral catheters within 11 days of injury [14]. Of the 10 patients available for followup, ve developed strictures which were managed by optical urethrotomy. Whilst there were no apparent complications associated with this technique, there were few patients assessed, with a follow-up of <1 year. The results of the various techniques were reviewed by Koraitim [15], in a personal series of 100 patients, combined with a review of 771 patients from previous reports. Immediate and early realignment (326 patients) was associated with a 53% stricture rate, a 5% incontinence rate and a 36% impotence rate; primary suturing (37 patients) was associated with rates of 49%, 21% and 56%, respectively, compared with inserting a suprapubic catheter before a delayed repair (508 patients), associated with rates of 97%, 4% and 19%. One series reviewed a few delayed primary repairs (17 patients) with a minimum 1 year follow-up; at 6 months three required resection of the stricture (one urethrotomy, two dilatation) and ve were potent. On the basis of this limited experience it must be concluded that whilst delayed repair was 1200

feasible it is not to be recommended except in experienced hands, and may be associated with a higher rate of morbidity than a delayed procedure [15]. Endoscopic alignment using guidewires and urethral catheters has been attempted with some success. This has been recommended both for complete ruptures of the posterior urethra and in the anterior urethra. Whilst this will reduce the gap, particularly in the posterior urethra, except in experienced hands the potential for considerable morbidity exists and long-term stricture-free rates are disappointing; urethral repair remains the treatment of choice. Immediate surgery is suggested in the following circumstances: For debridement purposes; With open wounds; Fractured penis corpora cavernosa injured; Where there are associated injuries; Fractures and their management (bleeding, genitourinary injury). Urethrotomy for trauma does not work unless combined with intermittent self-dilatation and has a very limited role in denitive treatment. Delayed primary repair is not advised except in experienced hands as it may be associated with greater morbidity. Anastomotic urethroplasty possible in most cases of traumatic urethral disruption even in re-operative cases, and substitution urethroplasty is rarely indicated. Permanent stents are contraindicated in the management of the injured urethra at any time (Level 3 evidence).

Based on this review it is evident that late primary urethral repairs, particularly in cases of posterior urethral injury at >3 months after trauma using a one-stage perineal approach, remains the recommended approach. This technique has the advantage that most associated injuries, as well as damaged skin and tissues and haematoma, have resolved by then. Problematical to this approach is the length of time the patient has to have a suprapubic catheter before denitive treatment. The most common end result of a subprostatic urethral injury managed by delayed repair is the development of a relatively short membrano/ bulbar urethral gap. Usually, such a simple short-gap defect can be resolved by a relatively technically straightforward perineal-approach anastomotic repair, provided it is not associated with extensive haematoma brosis and provided the bladder neck mechanism is occlusive and competent. The patient is placed supine and the urethra explored through a circumferential subcoronal incision (with penile injuries) and via a midline perineal incision if there is a bulbar/posterior urethral injury. Once the site of injury is identied any necessary debridement is completed, and the urethra mobilized proximally and distally. In the case of a PFUDD after dividing the bulbar urethra immediately below the subprostatic haematoma brosis, mobilization of a normal bulbar urethra to the base of the penis generally achieves 45 cm of elastic lengthening; this is usually sufcient to achieve a tension-free 2-cm spatulated overlap anastomosis with the apical prostatic urethra, after bridging a gap of 2.02.5 cm without re-routing. When the prostatobulbar gap is >23 cm (as a result of a high dislocation of the prostate or when the available elongation of the mobilized bulbar urethra has been foreshortened by damage from previous surgical procedure) it may be necessary to re-route the mobilized bulbar urethra transpubically, over the penile crus on one side, to enable it to be anastomosed to a highlying prostate. It is rarely necessary to remove the whole of the pubis simply to gain adequate access for a bulboprostatic anastomosis from above; a partial resection of its posterior margin with a Capeners gouge is usually sufcient. The rare coincidence of pubic osteomyelitis, is virtually the only indication for a total pubectomy approach. In

SURGICAL TECHNIQUE The principles of urethral repair include: Epithelial apposition; Establishment of a good blood supply to the anastomosis; Healthy tissues which can hold sutures; Robust surgical technique; Ensuring bladder neck competence (when dealing with a posterior urethral defect involving the distal sphincter mechanism).

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most instances (>90%) a perineal approach (particularly if the bladder neck is functioning adequately) provides sufcient access with no need to proceed to abdominal surgery. Urethral repairs using a one-stage perineal anastomotic urethroplasty give excellent results. A delayed repair has a re-stenosis rate of 12% at 10 years [16] and the risk of complications such as impotence or incontinence occurring as a consequence of the surgery in experienced hands is low [1719]. A series of 30 children treated by either transperineal (15) or transpubic urethroplasty (15) was reported by Podesta [20]; it is evident that similar results are obtained to those in adults, the higher incidence of abdominal surgery simply reecting the greater propensity to damage of the bladder neck in children . Both urethral ends are spatulated and an overlapped anastomosis completed over a 12/14 F catheter; a suprapubic catheter is also essential to guard the urethral repair. Immobilizing the repair site and preventing subsequent anastomotic stenosis can be done by suturing the mucosa and urethral wall laterally to the corpus cavernosum. Perioperative prophylactic antibiotics, good hypotensive anaesthesia and a tight compression dressing using netted elastic pants are also key elements in preventing infections and haematoma formation. At 10 days to 2 weeks a cystourethrogram is taken with the urethral catheter in situ, and provided that there is no leakage at the anastomotic site the urethral catheter can be removed. If there is leakage then the catheter is left longer and the X-ray study repeated a week later.

by mobilizing it meticulously, by removing the dense haematoma brosis, anchoring it to the pubis anteriorly and laterally; naturally, the reliability of this procedure depends on preventing secondary brotic reimmobilization by occluding the consequent paraprostatic dead-space cavity with a supple omental ap, which preserves the functional mobility of the liberated sphincter mechanism. The erectile mechanism may be damaged by pelvic fracture injuries that do not result in urethral injury; the incidence is higher when the urethra is ruptured and much higher when the prostate is grossly dislocated. The investigation of impotence by intracorporal papaverine injections has shown that erectile failure after pelvic fracture is more often the result of damage to its neural (89%) than its vascular mechanism [17]. Because of the posterolateral proximity of the nervi erigentes to the subprostatic urethra, which are somewhat tethered within the brotic perineal body, it is probable that most subprostatic dislocations are associated with some degree of injury to the neural mechanisms of potency, irrespective of whether they result in an overt impairment of erection or not. Any local operation, immediate or deferred, in the area of a secondary haematoma brosis behind the apex of the prostate must carry some risk of critically extending any primary local neuropathy associated with the original injury, particularly if it involves dissecting or separating the tissue planes behind the apex of the prostate. A strictly anterior approach to surgical repairs in this area is therefore advocated. The consequences of any injury to the urethra depend upon both the nature of the injury and the result of any repair of urethral injury. This may be inuenced by both the technique and timing of surgical repair (Level 3 evidence).

endoscopy; the last two are the most sensitive (Level 2 evidence). GENERAL RECOMMENDATIONS The management of urethral injuries remains controversial because of several factors: the variety of injury patterns; associated injuries; treatment options; relative rarity of the injuries; limited experience of most urologists.

The committee makes the following general recommendations: Surgery should be conducted wherever possible by experienced surgeons with a consistent referral population. The surgeon should be familiar with and skilled in all techniques, as surgical technique and outcome depends upon expertise. There is limited experience of patients undergoing acute urethral repair and therefore deferred surgery in a specialized unit is recommended. Realignment and immediate or delayed primary repair shorten the stricture/stenosis but are potentially associated with increased morbidity, including erectile dysfunction, incontinence and re-stenosis requiring reoperation. CONFLICT OF INTEREST None declared.

REFERENCES 1 Turner-Warwick R. The sphincter mechanisms. The avoidance of postprostatectomy incontinence. In Webber W, Jonas D eds. Die PostOperative Harninkontinenz Des Mannes Internationales Symposium. Stuttgart: Thieme, 1981: 1733 Carlin BI, Resnick MI. Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury. Semin Urol 1995; 13: 924 Webster GD, Mathes GL, Selli C. Prostatomembranous urethral injuries. A review of the literature and a rational approach to their management. J Urol 1983; 130: 898902 Baskin LS, Canning DA, Snyder HM, Duckett JW. Surgical repair of urethral 1201

CONSEQUENCES OF INJURY The most common result of blunt injury of the anterior and posterior urethra is a stricture. In the presence of infection or penetrating injuries, stulae and tissue loss may result. In the anterior urethra damage to the corpora cavernosa associated with penile fracture may lead to erectile dysfunction. With posterior urethral injuries the bladder neck may be damaged directly as a consequence of a pelvic fracture injury or by the circumferential tethering of an uninjured mechanism by the natural shrinkage/replacement of an extensive pelvic oor haematoma by brosis. In such (in practice) rare cases, it is usually possible to restore its functional competence

OUTCOME MEASURES There is a limited evidence base which has assessed the accuracy, comparability and appropriateness of different outcome measures. The committee suggests that the aim of therapy is to restore asymptomatic storage and voiding function. Commonly used outcome measures include symptoms, ow rates, urethrography and

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circumcision injuries. J Urol 1997; 158: 226971 5 Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int 1999; 83: 62630 6 Koraitim MM. Post-traumatic posterior urethral strictures in children a 20 yr experience. J Urol 1997; 157: 6415 7 Andrich DE, Mundy AR. The nature of urethral injury in cases of pelvic fracture urethral trauma. J Urol 2001; 165: 1492 5 8 Palmer JK, Benson GS, Corriere JN. Diagnosis and initial management of urological injuries associated with 200 consecutive pelvic fractures. J Urol 1983; 130: 7124 9 Sandler CM, Goldman SM, Kawashima A. Lower urinary tract trauma. World J Urol 1998; 16: 6975 10 Colapinto V, MacCallum RM. Injury to the male posterior urethrain fractured pelvis, a new classication. J Urol 1977; 18: 575 11 Goldman SM, Sandler CM, Corriere JN,

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McGuire EJ. Blunt urethral trauma a unied, anatomical mechanical classication. J Urol 1997; 157: 859 MacDiarmid S, Rosario D, Chapple CR. The importance of accurate assessment and conservative management of the open bladder neck in patients with pelvic fracture membranous urethral distraction defects. Br J Urol, 1995; 75: 657 Elliot DS, Barrett DM. Long-term follow-up and evaluation of primary realignment of posterior urethral disruptions. J Urol 1997; 157: 8146 Porter JR, Takayama TK, Defalco AJ. Traumatic posterior urethral injury and early realignment using magnetic urethral catheters. J Urol 1997; 158: 42530 Koraitim MM. Pelvic fracture urethral injuries. Evaluation of various methods of management J Urol 1996; 156: 128891 Mundy AR. The role of delayed primary repair in the acute management of pelvic fracture injuries of the urethra. Br J Urol 1991; 68: 2736 Mundy AR. Urethroplasty for posterior

urethral strictures. Br J Urol, 1996; 78: 2437 18 Mark SD, Keane TE, Vandemark RM, Webster GD. Impotence following pelvic fracture urethral injury: incidence, aetiology and management. Br J Urol 1995; 75: 624 19 Morey AF, McAninch JW. Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 1997; 157: 50651 20 Podesta ML. Use of the perineal and perineal-abdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: long-term outcome. J Urol 1998; 160: 1064 Correspondence: C.R. Chapple, Department of Urology, The Royal Hallamshire Hospital, Glossop Road, Shefeld, S10 2JF, UK. e-mail: c.r.chapple@shef.ac.uk Abbreviation: PFUDD, pelvic fracture urethral distraction defects.

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