Management of pelvic fracture urethral injuries (PFUIs) is a permanent challenge. Here, we discuss 2 modifications aimed at improving results, based on our experience spanning over 30 years. “When?” relates to timing for reconstruction and “How?” to our vessel sparing approach.

PFUI: When?

Acute management of a PFUI with suprapubic cystostomy placement and a delayed reconstruction is a widely accepted strategy. However, the best time to proceed to this delayed reconstruction has not been established. Traditionally, an interim waiting time of “3 to 6 months” has been advocated to allow for “hematoma reabsorption and resolution of traumatic inflammation.” However, this recommendation has not yet been validated with objective data. While it may be true that many of these patients present complex and severe injuries requiring a lengthy recovery time, there is a subset of patients who can undergo reconstruction earlier. In our institution, we evaluate the patients at 4–6 weeks and proceed to reconstruction if 3 criteria are met: 1) that the pelvic fracture is stable, thus the orthopedic consultant authorizes us to place the patient in an extended lithotomy position; 2) that other associated injuries have been stabilized; and 3) that following digital rectal palpation, the perineum is considered soft, ruling out hematoma or post-traumatic inflammation.

To validate our approach, we analyzed the outcome of reconstruction by comparing early versus late surgery. To perform a clean comparison, we selected only those patients treated with suprapubic tube placement and delayed urethroplasty. Patients treated with catheter realignment or those who failed catheter realignment were excluded. Patients were split into 2 groups: those who underwent reconstruction within the first 6 weeks following injury (Group A) and those underwent reconstruction 12 or more weeks after the injury (Group B). Ten patients operated on between 6 and 12 weeks were also excluded from the comparison. No discernible difference was shown in the outcome of patients from the 2 groups (see table).¹

Comment: This suggests that in the selected cases of those patients who met the 3 criteria, a mandatory waiting time of 3 or more months is unnecessary. In these patients, early reconstruction at 4–6 weeks may be performed safely, minimizing the morbidity and disability of a suprapubic cystostomy.

PFUI: How?

Reconstruction of PFUI requires mobilization of the bulbar urethra to remove the scar tissue and reach the prostatic apex. To do this, the bulb must be separated from the perineal membrane, with division of the bulbar arteries. The distal urethral stump then becomes a flap, with retrograde irrigation from the glans and some perforating arteries. However, in some cases, penile arterial blood supply has been compromised by the pelvic fracture, resulting in penile arterial insufficiency. In such cases, ischemic necrotic failure of the urethral reconstruction has been reported. After Jordan and co-workers introduced the vessel sparing concept for surgery in the proximal bulbar urethra,² we modified the classic PFIU reconstruction technique to preserve the antegrade arterial blood supply.

Technique: After standard dissection of the bulb but prior to its mobilization from the perineal membrane, the bulbar arteries are located using a directional Doppler ultrasound stethoscope (fig. 1). A decision is then made to sacrifice the artery with the weakest Doppler signal to preserve the contralateral best artery. The bulb is then mobilized from one side only; the scar tissue is removed, and the apical prostatic urethra is exposed as usual (figs. 2 to 4). No dissection is performed at the bulb contralaterally, thus preserving the artery on that side. The end-to-end anastomosis is then completed with the standard technique. Preservation of bulbar arterial inflow coming from the spared bulbar artery is verified by directional Doppler auscultation at the end of the anastomosis.

Figure 1. Location of bulbar arteries with a Doppler ultrasound probe.

Figure 2. Bulbar urethra is retracted to right mobilizing bulb from left side; crura has been split and left bulbar artery divided, exposing scar to be removed.

Figure 3. No dissection is performed on right side to preserve right bulbar artery.

Figure 4. Here, right-sided approach has been taken to preserve left artery; bulb is retracted to left, scar has been removed and proximal urethra is ready for anastomosis. Note that bulb remains attached to perineum.

We reported our preliminary experience in 2015 with 26 cases.³ We now have 48 cases with a mean followup of 56 months and 1 stricture failure observed at 15 months, giving a 98% success rate. In all cases, it was possible to preserve 1 artery and perform a tension-free, wide mucosa-to-mucosa, end-to-end anastomosis. In some cases, when the urethra is in continuity without complete disruption, both bulbar arteries can be spared.

Comment: Preservation of the arterial blood supply to the bulb during PFUI reconstruction is feasible and can be achieved without compromising the results. Theoretically, a well irrigated reconstruction should heal better, and this technique may avoid ischemic failure of an otherwise well performed urethroplasty. Moreover, in the future, some of these patients may require an artificial sphincter implantation due to post-traumatic incontinence, and a well vascularized bulb may decrease the chances of cuff-related complications. With this small series, we cannot prove that vascular preservation improves the outcome of reconstruction, but our results are highly encouraging. We propose that these modifications should be considered by reconstructive urologists performing PFUI surgery.