Management of posterior urethral disruption injuries

Abstract

Posterior urethral disruption is a traumatic injury to the male urethra, which most often results from pelvic fracture. After trauma, the distraction defect between the two ends of the urethra often scars and becomes fibrotic, blocking the urethra and bladder emptying. Increasing evidence suggests that many posterior urethral disruptions occur at the junction between the membranous urethra and the bulbar urethra, which is distal to the rhabdosphincter. In the acute setting, when a posterior urethral disruption is suspected, retrograde urethrography should be performed. Posterior urethral disruptions can be managed acutely by realignment of the urethra over a urethral catheter or by placement of a suprapubic catheter for bladder drainage only. Once fibrosis has stabilized, the patient can undergo posterior urethroplasty. In most cases, this procedure can be performed via a perineal approach in a single-stage surgery. The results of this single-stage perineal urethroplasty are excellent, and a patent urethra can be re-established in the majority of men who undergo surgery.

Key Points

• Posterior urethral disruption is almost always caused by pelvic fracture; the specific pelvic fractures that most-frequently cause urethral injuries are symphysis pubis diastasis and inferior pubic rami fracture

• Immediate management of posterior urethral disruption should consist of bladder drainage by placement of a suprapubic catheter; urethral realignment should be attempted only by clinicians familiar with the technique

• Most posterior urethral disruptions cause fibrosis that can be treated via a single-stage perineal anastomotic repair; the goals of this surgery are complete excision of fibrosis, healthy apposition of urethral mucosa, and tension-free anastomosis of the urethra

• Perineal posterior urethroplasty is successful in the vast majority of patients; when posterior urethroplasty fails and a stricture occurs, endoscopic salvage is often possible