EAU Guidelines on Urethral Trauma
Authors:
L. Martínez-Pineiro 1; N. Djakovic 2; E. Plas 3; Y. Mor 4; R. A. Santucci 5; E. Serafetinidis 6; L. N. Turkeri 7; M. Hohenfellner 8
Authors‘ workplace:
Urology Unit, Infanta Sofia Hospital, Madrid, Spain
1; Rupprecht Karl University Heidelberg, Heidelberg, Germany
2; Hanusch Hospital, Vienna, Austria
3; Department of Urology, The Chaim-Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
4; Detroit Receiving Hospital and The Detroit Medical Center, Detroit, Michigan, USA
5; Department of Urology, Sismanoglio Hospital, Athens, Greece
6; Department of Urology, Marmara University Hospital, Marmara University School of Medicine, Istanbul, Turkey
7; Rupprecht Karl University Heidelberg, Heidelberg, Germany
8
Published in:
Urol List 2011; 9(1): 65-78
Category:
Guidelines
Overview
Context:
These guidelines were prepared on behalf of the European Association of Urology (EAU) to assist urologists in the management of traumatic urethral injuries.
Objective:
To determine the optimal evaluation and management of urethral injuries by review of the world’s literature on the subject. Evidence acquisition: A working group of experts on Urological Trauma was convened to review and summarize the literature concerning the diagnosis and treatment of genitourinary trauma, including urethral trauma. The Urological Trauma guidelines have been based on a review of the literature identified using on-line searches of MEDLINE and other source documents published before 2009. A critical assessment of the findings was made, not involving a formal appraisal of the data. There were few high-powered, randomized, controlled trials in this area and considerable available data was provided by retrospective studies. The Working Group recognizes this limitation.
Evidence synthesis:
The full text of these guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article comprises the abridged version of a section of the Urological Trauma guidelines. Conclusions: Updated and critically reviewed Guidelines on Urethral Trauma are presented. The aim of these guidelines is to provide support to the practicing urologist since urethral injuries carry substantial morbidity. The diversity of urethral injuries, associated injuries, the timing and availability of treatment options as well as their relative rarity contribute to the controversies in the management of urethral trauma.
Key words:
EAU Guidelines: urethral trauma: assessment, surgical management, delayed management
Sources
1. Koraitim MM. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997; 157: 641–645.
2. Nicolaisen GS,Melamud A, Williams RD et al. Rupture of the corpus cavernosum: surgical management. J Urol 1983;130: 917–919.
3. Gomez RG, Castanheira ACC, McAninch JW. Gunshot wounds to the male external genitalia. J Urol 1993; 150: 1147–1149.
4. Pontes JE, Pierce Jr JM. Anterior urethral injuries: four years of experience at the Detroit General Hospital. J Urol 1978; 120: 563–564.
5. Sevitt S. Fatal road accidents. Injuries, complications, and causes of death in 250 subjects. Br J Surg 1968;55:481–505.
6. Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996; 77: 876–880.
7. Chapple CR, Png D. Contemporary management of urethral trauma and the post-traumatic stricture. Curr Opin Urol 1999; 9: 253–260.
8. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999; 161: 1433–1441.
9. Goldman SM, Sandler CM, Corriere Jr JN et al. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol 1997; 157: 85–89.
10. Al-Rifaei M, Eid NI, Al-Rifaei A. Urethral injury secondary to pelvic fracture: anatomical and functional classification. Scand J Urol Nephrol 2001; 35: 205–211.
11. Armenakas NA, McAninch JW. Acute anterior urethral injuries: diagnosis and initial management. In: McAninch JW, editor. Traumatic and reconstructive urology. Philadelphia, PA: WB Saunders; 1996: 543–550.
12. Armenakas NA, McAninch JW. A uniform approach to urethroplasty. Probl Urol 1994; 8: 254–268.
13. Colapinto V. Trauma to the pelvis: urethral injury. Clin Ortho Rel Res 1980; 151: 46–55.
14. Koraitim MM, Reda SI. Role of magnetic resonance imaging in assessment of posterior urethral distraction defects. Urology 2007; 70: 403–406.
15. McAninch JW. Urethral injuries in female subjects following pelvic fractures (editorial comment). J Urol 1992; 147: 143.
16. Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992; 147: 139–143.
17. Hemal AK, Dorairajan LN, Gupta NP. Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management. J Urol 2000; 163: 282–287.
18. Venn SN, Mundy AR. Trauma and reconstruction. The immediate management of major trauma to the urinary tract. Eur Urol 1998; 33: 1–8.
19. Jackson DH, Williams JL. Urethral injury: a retrospective study. Br J Urol 1974; 46: 665–676.
20. Glassberg KI, Tolete-Velcek F, Ashley R et al. Partial tears of prostatomembranous urethra in children. Urology 1979; 13: 500–504.
21. Cass AS, Godec CJ. Urethral injury due to external trauma. Urology 1978; 11: 607–611.
22. Husmann DA, Boone TB, Wilson WT. Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone. J Urol 1993; 150: 70–72.
23. Martınez-Pineiro JA, Carcamo P, Garcıa Matres MJ et al. Excision and anastomotic repair for urethral stricture disease: experience with 150 cases. Eur Urol 1997; 32: 433–441.
24. Gibson GR. Impotence following fractured pelvis and ruptured urethra. Br J Urol 1970; 42: 86–88.
25. King J. Impotence after fractures of the pelvis. J Bone Joint Surg Am 1975; 57: 1107–1109.
26. Dhabuwala CB, Hamid S, Katsikas DM et al. Impotence following delayed repair of prostatomembranous urethral disruption. J Urol 1990; 144: 677–678.
27. Corriere JN. 1-Stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year followup. J Urol 2001; 165: 404–407.
28. Turner-Warwick R. Prevention of complications resulting from pelvic fracture urethral injuries–and from their surgical management. Urol Clin North Am 1989; 16: 335–338.
29. Turner-Warwick R. Complex traumatic posterior urethral strictures. J Urol 1977; 118: 564–574.
30. Mundy AR. The role of delayed primary repair in the acute management of pelvic fracture injuries of the urethra. Br J Urol 1991; 68: 273–276.
31. Mouraviev VB, Coburn M, Santucci RA. The treatment of posterior urethral disruption associated with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty. J Urol 2005; 173: 873–876.
32. Onen A, Ozturk H, Kaya M et al. Long-term outcome of posterior urethral rupture in boys: a comparison of different surgical modalities. Urology 2005; 65: 1202–1207.
33. Antoci JP, Schiff Jr MJ. Bladder and urethral injuries in patients with pelvic fractures. J Urol 1982; 128: 25–26.
34. Berman AT, Tom L. Traumatic separation of the pubic symphysis with associated fatal rectal tear: a case report and analysis of mechanism of injury. J Trauma 1974; 14: 1060–1067.
35. Muhlbauer S, Bard RH. Early definitive urologic management of patient with crush pelvic trauma and deep perineal laceration. Urology 1980; 15: 56–59.
36. Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996; 156: 1288–1291.
37. Webster GD, Mathes GL, Selli C. Prostato mem branous urethral injuries: a review of the literature and a rational approach to their management. J Urol 1983; 130: 898–902.
38. Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, editor. Traumatic and reconstructive urology. Philadelphia, PA: WB Saunders; 1996: 347–355.
39. Coffield KS, Weems WL. Experience with management of posterior urethral injury associated with pelvic fracture. J Urol 1977; 117: 722–724.
40. Follis HW, Koch MO, McDougal WS. Immediate management of prostatomembranous urethral disruptions. J Urol 1992; 147: 1259–62.
41. Herschorn S, Thijssen A, Radomski SB. The value of immediate or early catheterization of the traumati zed posterior urethra. J Urol 1992; 148: 1428–1431.
42. Porter JR, Takayama TK, Defalco AJ. Traumatic posterior urethral injury and early realignment using magnetic urethral catheters. J Urol 1997; 158: 425–430.
43. Guille F, Cipolla B, Leveque JM et al. Early endoscopic realignment of complete traumatic rupture of the posterior urethra. Br J Urol 1991; 68: 178–180.
44. Gelbard MK, Heyman AM, Weintraub P. A technique for immediate realignment and catheterization of the disrupted prostatomembranous urethra. J Urol 1989; 142: 52–55.
45. Ragde H, McInnes GF. Transpubic repair of the severed prostatomembranous urethra. J Urol 1969; 101: 335–337.
46. Gibson GR. Urological management and complications of fractured pelvis and rupture urethra. J Urol 1974; 111: 353–355.
47. Crassweller PO, Farrow GA, Robson CJ et al. Traumatic rupture of the supramembranous urethra. J Urol 1977; 118: 770–771.
48. Malek RS, O’Dea MJ, Kelalis PP. Management of ruptured posterior urethra in childhood. J Urol 1977; 117: 105–109.
49. Cohen JK, Berg G, Carl GH et al. Primary endoscopic realignment following posterior urethral disruption. J Urol 1991; 146: 1548–1550.
50. Melekos MD, Pantazakos A, Daouaher H et al. Primary endourologic re-establishment of urethral continuity after disruption of prostatomembranous urethra. Urology 1992; 39: 135–138.
51. el-Abd SA. Endoscopic treatment of posttrauma tic urethral obliteration: experience in 396 patients. J Urol 1995; 153: 67–71.
52. Gheiler EL, Frontera JR. Immediate primary rea lignment of prostatomembranous urethral disruptions using endourologic techniques. Urology 1997; 49: 596–599.
53. Londergan TA, Gundersen LH, van Every MJ. Early fluoroscopic realignment for traumatic urethral injuries. Urology 1997; 49: 101–103.
54. Elliott DS, Barrett DM. Long-term follow-up and evaluation of primary realignment of posterior urethral disruptions. J Urol 1997; 157: 814–816.
55. Rehman J, Samadi D, Ricciardi Jr R et al. Early endoscopic realignment as primary therapy for complete posterior urethral disruptions. J Endourol 1998; 12: 283–289.
56. Sahin H, Bircan MK, Akay AF et al. Endoscopic treatment of complete posterior urethral obliteration. Acta Urol Belg 1998; 66: 21–24.
57. Tahan H, Randrianantenaina A, Michel F. Treatment of complete rupture of the posterior urethra by endoscopic treatment. Prog Urol 1999; 9: 489–495 [article in French].
58. Jepson BR, Boullier JA, Moore RG et al. Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up. Urology 1999; 53: 1205–1210.
59. Asci R, Sarikaya S, Buyukalpelli R et al. Voiding and sexual dysfunctions after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment. Scand J Urol Nephrol 1999; 33: 228–233. Urol List 2011; 9(1): 65–78 77 GUIDELINES
60. Ying-Hao S, Chuan-Liang X, Xu G et al. Urethroscopic realignment of ruptured bulbar urethra. J Urol 2000; 164: 1543–1545.
61. Weems WL. Management of genitourinary injuries in patients with pelvic fractures. Ann Surg 1979; 189: 717–723.
62. Mark SD, Webster GD. Reconstruction of the failed repair of posterior urethral rupture. In: McAninch JW, editor. Traumatic and reconstructive urology. Philadelphia, PA: WB Saunders; 1996: 439–451.
63. Chapple C, Barbagli G, Jordan G et al. Consensus statement on urethral trauma. BJU Int 2004; 93: 1195–1202.
64. Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol 1991; 145: 744–748.
65. Webster GD, Ramon J, Kreder KJ. Salvage posterior urethroplasty after failed initial repair of pelvic fracture membranous urethral defects. J Urol 1990; 144: 1370–1372.
66. MacDiarmid S, Rosario D, Chapple CR. The importance of accurate assessment and conservative management of the open bladder neck in patients with post-pelvic fracture membranous urethral distraction defects. Br J Urol 1995; 75: 65–67.
67. Mundy AR. Urethroplasty for posterior urethral stric tures. Br J Urol 1996; 78: 243–247.
68. Jordan GH. Management of membranous urethral distraction injuries via the perineal approach. In: McAninch JW, editor. Traumatic and reconstructive urology. Philadelphia, PA: WB Saunders; 1996: 393–409.
69. Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol 2002; 167: 1715–1719.
70. Zinman LM. The management of traumatic posterior urethral distraction defects (editorial). J Urol 1997; 157: 511–512.
71. Corriere Jr JN, Rudy DC, Benson GS. Voiding and erectile function after delayed one-stage repair of posterior urethral disruption in 50 men with fractured pelvis. J Trauma 1994; 37: 587–590.
72. Flynn BJ, Delvecchio FC, Webster GD. Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol 2003; 170: 1877–1880.
73. Webster GD. Impotence following delayed repair of prostatomembranous urethral disruption (editorial comment). J Urol 1990; 144: 678.
74. Fiala R, Zatura F, Vrtal R. Personal experience with treatment of posttraumatic urethral distraction defects. Acta Chir Orthop Traumatol Cech 2001; 68: 99–104 [article in Czech].
75. Koraitim MM. The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol 1995; 153: 63–66.
76. Podesta ML. Use of the perineal and perinealabdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: long-term outcome. J Urol 1998; 160: 160–164.
77. Hafez AT, El-Assmy A, Sarhan O et al. Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: the long-term outcome. BJU Int 2005; 95: 403–406.
78. Wadhwa SN, Chahal R, Hemal AK et al. Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty. J Urol 1998; 159: 1898–1902.
79. Cooperberg MR, McAninch JW, Alsikafi NF et al. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol 2007; 178: 2006–2010.
80. Pierce Jr JM. Management of dismemberment of the prostaticmembranous urethra and ensuing stricture disease. J Urol 1972; 107: 259–264.
81. Sachse H. Zur behandlung der Harnrohren striktur: Die transuretrale schlitzung unter Sicht mit scharfem Schinitt. Fortschr Med 1974; 92: 12–15 [article in German].
82. Blandy JP. Urethral stricture. Postgrad Med J 1980; 56: 383–418.
83. Dogra PN, Nabi G. Core-through urethrotomy using the neodymium: YAG laser for obliterative urethral strictures after traumatic urethral disruption and/or distraction defects: long-term outcome. J Urol 2002; 167(2 Pt 1): 543–546.
84. deVries CR, Anderson RU. Endoscopic urethroplasty: an improved technique. J Urol 1990;143:1225–6.
85. Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: longterm follow-up. J Urol 1996; 156: 73–75.
86. Gupta NP, Gill IS. Core-through optical internal urethrotomy in management of impassable traumatic posterior urethral strictures. J Urol 1986; 136: 1018–1021.
87. Yasuda T, Yamanishi T, Isaka S et al. Endoscopic re-establishment of membranous urethral disruption. J Urol 1991; 145: 977–979.
88. Williams G. Stents in the lower urinary tract. Am Urol Assoc Update Ser 1993; 12: 26.
89. Milroy EJ, Chapple CR, Eldin A et al. A new treatment for urethral strictures–a permanently implanted urethral stent. J Urol 1989; 141: 1120–1122.
90. Baert L, Verhamme L, Van Poppel H et al. Long-term consequences of urethral stents. J Urol 1993; 150: 853–855.
91. Jordan GH, Schlossberg SM. Surgery of the penis and urethra. In: Walsh PC, Retik AB, Vaughan Jr ED, Wein AJ, editors. Campbell’s Urology. 8th ed. Philadephia, PA: WB Saunders; 2002: 3886–3952.
92. Fenton AS, Morey AF, Aviles R et al. Anterior urethral stricture: etiology and characteristics. Urology 2005; 65: 1055–108.
93. Hammarsten J, Lindqvist K. Suprapubic catheter following transurethral resection of the prostate: a way to decrease the number of urethral strictures and improve the outcome of operations. J Urol 1992; 147: 648–651.
94. Kashfi L, Messer K, Barden R et al. Incidence and prevention of iatrogenic urethral injuries. J Urol 2008; 179: 2254–2257.
95. Hammarsten J, Lindqvist K, Sunzel H. Urethral strictures following transurethral resection of the prostate. The role of the catheter. Br J Urol 1989; 63: 397–400.
96. Elliott SP, Meng MV, Elkin EP et al. CaPSURE investigators. Incidence of urethral stricture after primary treatment for prostate cancer: data from CaPSURE. J Urol 2007; 178: 529–534.
97. Msezane LP, Reynolds WS, Gofrit ON et al. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol 2008; 22: 97–104.
98. Polat O, Gul O, Aksoy Y et al. Iatrogenic injuries to ureter, bladder and urethra during abdominal and pelvic operations. Int Urol Nephrol 1997; 29: 13–18.
99. Gokalp A, Yildirim I, Aydur E et al. How to manage acute urethral false passage due to intermittent catheterization in spinal cord injured patients who refused insertion of an indwelling catheter. J Urol 2003; 169: 203–206.
100. Maheshwari PN, Shah HN. Immediate endoscopic management of complete iatrogenic anterior urethral injuries: a case series with long-term results. BMC Urol 2005; 5: 13.
101. Eisenberg ML, Elliott SP, McAninch JW. Pre servation of lower urinary tract function in posterior urethral stenosis: selection of appropriate patients for urethral stents. J Urol 2007; 178: 2456–2460.
102. Elliot DS, Boone TB. Combined stent and artificial urinary sphincter for management of severe recurrent bladder neck contracture and stress incontinence after prostatectomy: a long-term evaluation. J Urol 2001; 165: 413–415.
103. Elliott SP, McAninch JW, Chi T et al. Management of severe urethral complications of prostate cancer therapy. J Urol 2006; 176 (6 Pt 1): 2508–2513.
104. Chrouser KL, Leibovich BC, Sweat SD et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol 2005; 173: 1953–1957.
105. Marguet C, Raj GV, Brashears JH et al. Rectourethral fistula after combination radiotherapy for prostate cancer. Urology 2007; 69: 898–901.
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