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G GovtRoyapettahHospit
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Gu trauma- urethra
1. URETHRAL INJURIES Dept of Urology Govt Royapettah Hospital and Kilpauk Medical College Chennai 1
2. Moderators: Professors: Prof. Dr. G. Sivasankar, M.S., M.Ch., Prof. Dr.A. Senthilvel, M.S., M.Ch., Asst Professors: Dr. J.
Sivabalan, M.S., M.Ch., Dr. R. Bhargavi, M.S., M.Ch., Dr. S. Raju, M.S., M.Ch., Dr. K. Muthurathinam, M.S., M.Ch., Dr.
D.Tamilselvan, M.S., M.Ch., Dr. K. Senthilkumar, M.S., M.Ch. Dept Of Urology, KMC and GRH, Chennai 2
3. INTRODUCTION Urethral injury is a breach in the structural integrity of the urethra resulting from trauma Caused by Blunt
injury , Penetrating injury & Iatrogenic injury Leads to strictures , impotence & incontinence Dept Of Urology, KMC and GRH, Chennai
3
4. CLASSIFICATION SITE Posterior Urethral injury Prostatic,Membraneous urethra Anterior Urethral injury - Bulbar & Penile
urethra Dept Of Urology, KMC and GRH, Chennai 4
5. ETIOLOGY POSTERIOR URETHRAL INJURY Pelvic fracture- PFUDD 10% Pelvic fracture associated with urethral injury following
RTA / BLUNTTRAUMA Site of injury – PROSTO MEMBRANOUS All membranous urethral disruptions due to blunt trauma have
associated pelvic fracture IATROGENIC Catheter related Post surgery – Endoscopy, Radical Prostatectomy Dept Of Urology, KMC
and GRH, Chennai 5
6. ETIOLOGY ANTERIOR URETHRAL INJURY STRADDLE INJURY IATROGENIC- Catheter related , Post surgery – Endoscopy, Radical
Prostatectomy. PENETRATING INJURY SELF MUTILATION – Mentally ill Dept Of Urology, KMC and GRH, Chennai 6
7. PFUDD Mechanism - Shearing force avulses the apex of the prostate from the membranous urethra 90 % involve the posterior
urethra Bulbomembranous junction is more vulnerable to injury than the prostatomembranous junction Dept Of Urology, KMC and
GRH, Chennai 7
8. Pelvic Fracture - Classifications TILE’S CLASSIFICATION Based on - Stability of the pelvic ring - Integrity of the posterior sacroiliac
complex TYPE A – Stable A1 - Fractures of the pelvis not involving the ring A2 - Stable, minimally displaced fractures of the ring Dept Of
Urology, KMC and GRH, Chennai 8
9. TYPE B - Rotationally unstable, vertically stable ( S.I. joint not disrupted) B1- Open book B2- Lateral compression : Ipsilateral
B3- Lateral compression : Contralateral (Bucket- handle) Dept Of Urology, KMC and GRH, Chennai 9
10. Urethral injury mechanisms Dept Of Urology, KMC and GRH, Chennai 10
11. Urethral injury mechanisms Dept Of Urology, KMC and GRH, Chennai 11
12. TYPE C - Rotationally and vertically unstable ( Disruption of S.I. joint) C1 - Unilateral C2 - Bilateral C3 - Associated with an
acetabular fracture Dept Of Urology, KMC and GRH, Chennai 12
13. Urethral injury mechanisms Vertical shear fractures Injury due to traction distraction mechanism Dept Of Urology, KMC and
GRH, Chennai 13
14. Young & Burgess Classification Based on mechanism and direction of force of injury Three vectors of force and how this
disrupts the pelvic ring - Lateral Compression (LC) - Anterior posterior compression (APC) -Vertical shear (VC) Dept Of Urology, KMC
and GRH, Chennai 14
15. OPEN BOOK FRACTURE Caused by A.P. compression Diastasis of pubic symphysis May be associated with ipsilateral S.I.
joint disruption Dept Of Urology, KMC and GRH, Chennai 15
16. BUTTERFLY FRACTURE STRADDLE Fracture A.P. compression Fracture of bilateral superior and inferior pubic rami
Butterfly shaped intact pubic symphysis 16
17. MALGAIGNE’S FRACTURE Vertical shear fracture Ipsilateral fracture of both superior and inferior pubic rami Ipsilateral
fracture of S.I. joint 17
18. BUCKET HANDLE FRACTURE Fracture of anterior arch and contralateral posterior arch 18
19. STRADDLE INJURIES Most common cause - ANTERIOR URETHRAL INJURY Person falls astride over BLUNT OBJECT
Mechanism: Bulbar urethra crushed aganist inferior aspect of Pubis bone Eg 1. Handlebar of Bicycle 2.Top of Fence 3. rung of a
Ladder Dept Of Urology, KMC and GRH, Chennai 19
20. CLINICAL FEATURES POSTERIOR URETHRAL INJURY TRAID OF URETHRAL INJURY – Pelvic frature 1. Blood at the meatus. 2.
Inability to urinate 3.Palpably full bladder Other- may have DRE- High-riding prostate. bony spicules Dept Of Urology, KMC and GRH,
Chennai 20
21. CLINICAL FEATURES ANTERIOR URETHRAL INJURY IFTHE INJURY WITHIN BUCK’S FACIA Edema / Discolouration of Penile sha!
IFTHE INJURY BEYOND BUCK’S FACIA Butterfly Hematoma Swelling , discolouration & enlargement of scrotum Dept Of Urology, KMC
and GRH, Chennai 21
22. CLINICAL FEATURES Butterfly Hematoma Dept Of Urology, KMC and GRH, Chennai 22
23. INVESTIGATION DYNAMIC AUG Assess traumatic urethral injuries Ideally should be done under Fluoroscopy Dept Of Urology,
KMC and GRH, Chennai 23
24. GOLDMAN’S MODIFICATION (1997) OF COLOPINTO AND MACALLUM’S CLASSIFICATION Dept Of Urology, KMC and GRH, Chennai
24
25. Type I Puboprostatic ligament is ruptured, and the prostate is allowed to move superiorly. Membranous urethra only severely
stretched No extravasation of contrast material is seen Dept Of Urology, KMC and GRH, Chennai 25
26. Type II Urethra is torn superior to the urogenital diaphragm Contrast extravasation is seen within the extraperitoneal pelvis
Dept Of Urology, KMC and GRH, Chennai 26
27. Type III Most common Extends through the urogenital diaphragm and includes the proximal bulbous urethra. Extravasation
can be found within the extraperitoneal pelvis and within the perineum. Dept Of Urology, KMC and GRH, Chennai 27
28. Type IV Injury involving the bladder neck that extends into the proximal urethra. Contrast-agent extravasation is seen in the
extraperitoneal pelvis around the proximal urethra Dept Of Urology, KMC and GRH, Chennai 28
29. TypeV Pure Anterior Urethral injury Dept Of Urology, KMC and GRH, Chennai 29
30. POSTERIOR URETHRALTRAUMA - Rx Emergency - SPC , Endoscopic alignment ( Immediate) 7 days - Endoscopic realignment
(Delayed) May avoid urethroplasty 3 months - Anastomotic urethroplasty ( Late) Dept Of Urology, KMC and GRH, Chennai 30
31. Indications for early intervention Rectal tear Associated bladder neck injury Degloving perineal injury Penetrating
injuries SPC + Open surgical repair at 4-6months – GOLD STANDARD Dept Of Urology, KMC and GRH, Chennai 31
32. Immediate urethral realignment Injury explored at time of presentation Evacuation of pelvic hematoma Realignment of
urethra over a stenting catheter Flexible endoscopic catheter placement RAIL-ROADING technique - obsolete Disadvantages :
Incontinence Bleeding Impotency Dept Of Urology, KMC and GRH, Chennai 32
33. Primary repair -Technique 1.Open rail-roading 2.Endoscopic realignment 3.Blind realignment procedures -davis inter-locking
sounds -magnetic tip catheters Dept Of Urology, KMC and GRH, Chennai 33
34. Open ‘railroading’/realignment Prevesical space is explored and the haematoma and debris are evacuated Cystotomy made
and foley catheter passed antegradely. Retrogradely another catheter is passed and tied to the previous one. Catheter is brought
in and bulb inflated Disadvantage: 1.Tamponade e"ect of haematoma lost and bleeding may occur 2.Planes not well defined and high
chance of injury to neurovascular structures leading to impotence and incontinence Dept Of Urology, KMC and GRH, Chennai 34
35. Endoscopic realignment Step 1: antegrade flexible cystoscope Step 2: ategrade and retrograde flexible cystoscope Step 3:
fluoroscopic guidance Dept Of Urology, KMC and GRH, Chennai 35
36. Delayed Primary Repair SPC at time of injury 7-10 days later A!er stabilisation of patient GC Endoscopic realignment
over a stenting catheter Dept Of Urology, KMC and GRH, Chennai 36
37. Late endoscopic management ( secondary repair ) Non-obliterative memb. Urethralstrictures/partial tear → OIU / Dilatation
Obliterative memb. urethral defects → OIU ‘Cut for Light’ technique Dept Of Urology, KMC and GRH, Chennai 37
38. PFUDD- LATE MANAGEMENT Repair determined by the type and extent of associated injuries. Desirable to proceed within 4 to
6 months a!er trauma Primary anastomosis – Gold standard Dept Of Urology, KMC and GRH, Chennai 38
39. Late surgical repair of PFUDD Gold standard Two common approaches Perineal ( WEBSTER) - upto 8 cm. Abdomino-perineal (
WATERHOUSE) ->8 cm Procedure selection depends upon - Nature of defect - Length of defect - Presence of complicating factors
Dept Of Urology, KMC and GRH, Chennai 39
40. Principles of open repair Reconstruction a!er min. 4 months a!er the event Exact delineation of the defect Status of
bladder neck Status of erectile function Complete excision of all scar tissue Tension free & water-tight anastomosis Asepsis
Dept Of Urology, KMC and GRH, Chennai 40
41. PFUDD - OPPOSING URETHEROGRAM Dept Of Urology, KMC and GRH, Chennai 41
42. Dept Of Urology, KMC and GRH, Chennai 42
43. Predictors for repair of PFUDD repair Urethrometry index – Urethral gap length / Length of bulbar urethra < 0.35 = simple
perineal operation- End to End Anastomosis > 0.35 = Webster / Waterhouse Urethral gap length Prostatic displacement Dept Of
Urology, KMC and GRH, Chennai 43
44. Progressive Perineal Urethroplasty (Webster’s procedure) EXAGGERATED LITHOTOMY POSITION Dept Of Urology, KMC and GRH,
Chennai 44
45. PPU= WEBSTER ( Cardinal steps) 1. Bulbar urethra mobilisation 2. Corporal/crural separation 3. Inferior pubectomy 4. Corporal
rerouting Dept Of Urology, KMC and GRH, Chennai 45
46. Dept Of Urology, KMC and GRH, Chennai 46
47. InvertedY incision and exposure of Midline fusion of Bulbospongiosus muscle Dept Of Urology, KMC and GRH, Chennai 47
48. Division of fusion of Bulbospongiosus muscle Dept Of Urology, KMC and GRH, Chennai 48
49. Exposure of full length of bulb Dept Of Urology, KMC and GRH, Chennai 49
50. Incision of fibrosed urethra- freeing of bulb Dept Of Urology, KMC and GRH, Chennai 50
51. Opening of the anterior urethra Dept Of Urology, KMC and GRH, Chennai 51
52. Incision of fibrotic defect and antegrade passage of Haygrove sta" 52
53. Incision and seperation of triangular ligament 53
54. PFUDD Step 1- Bulbar urethral mobilization Dept Of Urology, KMC and GRH, Chennai 54
55. Crural separation 55
56. Inferior pubectomy 56
57. Supracrural Re-routing 57
58. End to end anastomosis 58
59. Perineo-Abdominal Progression- Approach (PAPA) INDICATIONS: Long distraction defects > 8cms To allow a tension free
anastomosis in long distraction defects To aid in excision of fistulas and cavities Dept Of Urology, KMC and GRH, Chennai 59
60. Perineo-Abdominal Progression- Approach (PAPA) 1. Bulbar urethra mobilisation 2. Corporal separation 3. Inferior pubectomy
4. Supracrural rerouting 5. Total pubectomy 6. Omental wrapping Midline infraumblical incision Dept Of Urology, KMC and GRH,
Chennai 60
61. Waterhouse procedure Dept Of Urology, KMC and GRH, Chennai 61
62. Waterhouse procedure Dept Of Urology, KMC and GRH, Chennai 62
63. PFUDD Omental wrapping Dept Of Urology, KMC and GRH, Chennai 63
64. Post-operative Management Silicon catheter – plugged- only used as a stent Urine diverted by SPC Bed rest – 24 to 48
hours 3 rd day – drain removed Discharged with SPC and urocath 21- 28 days – pericatheteric study If study normal – SPC
clamping for 5-7 days & urethral voiding SPC removal Flexible endoscopy a!er 6 months and 1 year Dept Of Urology, KMC and
GRH, Chennai 64
65. Postoperative Complications Incontinence Anastomotic stenosis Impotence Nerve injury - superficial peroneal nerve
neuropraxia Dept Of Urology, KMC and GRH, Chennai 65
66. ANTERIOR URETHRAL INJURY - MANAGEMENT Mc Aninch classified Contusion Treated with Incomplete Distruption
Catheterization complete Distruption Primary surgical repair Gunshot injuries Penetrating injuries Initial Suprapubic Urinary
diversion + Delayed reconstruction Dept Of Urology, KMC and GRH, Chennai 66
67. Anastomotic urethroplasty –GOLD STANDARD Procedure of choice in obliterated bulbar urethra a!er straddle injury DEFECT
1.5 to 2 cm long - Scar completely excised. The proximal and distal urethra can be mobilized for a tension-free, end-to-end
Anastomosis. High succes rare - 95% Dept Of Urology, KMC and GRH, Chennai 67
68. Female urethral injuries Less commonly associated with pelvic fractures ( < 1 %) -short ,mobile -no significant attachment to
pelvis Injury is most commonly due to sharp bone spikes Associted with rectal & vaginal injury Urethroscopy is the investigation
of choice Managed by primary repair over a catheter and suturing of vagina SPC diversion and delayed management high
incidence of fistula. Dept Of Urology, KMC and GRH, Chennai 68
69. Injuries in children Bladder neck injuries & Prostatic urethral and are more common due to rudimentary nature of prostate.
Mechanism of injury is same, High incidence of incontinence and impotence Dept Of Urology, KMC and GRH, Chennai 69
70. THANKYOU Dept Of Urology, KMC and GRH, Chennai 70

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