Controversies in the management of pelvic fracture urethral distraction defects

Özet

Pelvic fracture associated urethral injury (PFUI) is a sequel of blunt pelvic trauma. The published rate ofurethral injury varies from 5-25% in different series. Management includes options from primary realignment to delayed anastomotic urethroplasty. Anastomotic urethroplasty include an elaborated progressiveperineal approach and combined transpubic approach. Though the treatment and approach is well acceptedacross the globe, controversies do exist. Through this section we would debate the literature regarding somecontroversial issues in management of PFUI. The aim of this article was to evaluate and elucidate upon thecontroversies that surround the PFUI repair in this era.The following controversial and pertinent issues with respect to the repair of such injuries were reviewed:1. Primary realignment versus delayed repair of PFUI,2. Necessity of inferior pubectomy,3. Predictability of inferior wedge pubectomy,4. Spatulation of distal bulbar and proximal urethral ends,5. Nomenclature of bulbar urethra.This study and evaluation comes from a tertiary high-volume center of reconstructive urology. Apart fromour own center’s experience the literature was reviewed for evidence synthesis and framing an opinion. Eachof the above principles and surgical steps regarding management of pelvic fracture urethral injury was dealtwith sequentially and evidence based literature reviewed. Only data from high volume urethroplasty centersand peer reviewed articles which made significant contribution were considered. The data was analyzedand conclusion drawn. On evidence collection there was sparse and scattered evidence in favour of earlyrealignment even after technical advancement. Delayed anastomotic urethroplasty with progressive perinealapproach is recommended. Inferior wedge pubectomy cannot be predicted based upon current conventionalimaging.The injury and urethral distraction has a wide spectrum and with the fallibility of imaging, inferior pubectomy is a necessary steps under relevant settings to gain access to the posterior urethra. There are multitudeof ways to spatulate urethra at either end although literature does not provide a superior way. Spatulation ofdistal urethra dorsally and leaving the proximal sphincter active urethra unspatulated is be the best scientifically. There is a need to reclassify the bulbar urethra to the penoscrotal junction to avoid under mobilization of bulbar urethra during the repair. There is no conclusive article addressing the controversial issueshighlighted in this article. Adequate mobilization of bulbar urethra should be done till penoscrotal junction.Inferior pubectomy as a technique cannot be predicted and its utility cannot be underestimated. The spatulation of urethra can be done in multiple ways. Current anatomical definition of bulbar urethra is erroneous toimply urethra only in the bulb but with respect to surgery it should be extended till the penoscrotal junction.