Tomografía computarizada con reconstrucción 3D para el diagnóstico de lesiones traumáticas de uretra / Three-dimensional computed tomography reconstruction for the diagnosis of traumatic urethral injuries

RESUMEN La uretrografía retrógrada es la técnica de referencia (gold standard) utilizada clásicamente para hacer diagnóstico de lesiones de uretra. En este contexto se presenta un caso en el que se realizó tomografía computarizada con reconstrucción 3D con contraste intravenoso y endouretral, pudiendo reconstruir la uretra en toda su extensión en forma tridimensional. De esta manera se arribó al diagnóstico de certeza de la lesión de uretra. Como ventaja del método se menciona la posibilidad de diagnosticar ‒ con un solo estudio por imágenes‒ lesiones de todo el tracto urinario, órganos sólidos, huecos y lesión del anillo pélvico asociados al traumatismo, con una alta sensibilidad y especificidad sin necesidad de requerir otros estudios complementarios.

ABSTRACT Retrograde urethrography is the gold standard method for the diagnosis of urethral injuries. In this setting, we report the use of computed tomography with intravenous injection and urethral administration of contrast medium and 3D reconstruction of the entire urethra. The definitive diagnosis of urethral injury was made. The advantage of this method is the possibility of making the diagnosis of traumatic injuries of the entire urinary tract, solid organs, hollow viscera and of the pelvic ring within a single imaging test, with high sensitivity and specificity, with no need to perform other complementary tests.

Urethral leiomyoma: combined vaginal and abdominal approach - a case report / Mioma uretral: abordagem combinada vaginal e abdominal - um relato de caso

Abstract Introduction: leiomyomas are benign mesenchymal tumors of smooth muscle origin that can develop in various locations. Urethral leiomyomas are rare, with approximately only 120 cases reported in the literature. These tumors often occur in the third and fourth decades of life but are rare in menopausal patients. In general, treatment involves surgery, only three recurrence reports in the literature. Description: a case report on a 56-year-old woman; the patient had type II diabetes mellitus and chronic high blood pressure, was overweight (body mass index, 27.1 kg/m2), and a smoker. Besides this, the patient presented symptoms of urinary obstruction and had a large urethral leiomyoma. The tumor was completely removed with no associated urethral lesions using a complex, combined abdominalvaginal surgical approach. Discussion: the management and treatment on urethral leiomyomas is challenging and have not been established yet due to the rarity of these tumors.

Resumo Introdução: os leiomiomas são tumores mesenquimais benignos de origem muscular lisa, podendo manifestar-se em diversas localizações. Os leiomiomas uretrais são raros, tendo apenas aproximadamente 120 casos relatados na literatura. São mais comuns na terceira e quarta décadas de vida, sendo raros em pacientes menopausadas. Em geral, são tratados cirurgicamente, com apenas três relatos de recidivas na literatura. Descrição: relato de caso de uma paciente do sexo feminino, 56 anos, portadora de diabetes mellitus do tipo II, hipertensão arterial crônica, sobrepeso (IMC 27,1Kg/m2) e tabagismo. Além disso, com quadro de sintomas obstrutivos urinários e portadora de um grande leiomioma uretral, este que foi completamente removido, através de uma desafiadora abordagem cirúrgica combinada (abdominal e vaginal), sem lesões uretrais associadas. Discussão: os leiomiomas uretrais são tumores raros e seu manejo é desafiador e ainda não foi estabelecido.

Urethral injury in penile fracture: a narrative review

ABSTRACT Objective To present the evolution and the recent data on the etiology, diagnosis, management and outcomes of penile fracture (PF) with concomitant urethral injury. Materials and Methods We searched the Pubmed database between 1998 and 2019 using the following key words: "penile fracture", "fracture of penis", "trauma to penis", "rupture of corpora cavernosa", "urethral injury", "urethral rupture" and "urethral reconstruction". Results The incidence of urethral lesion in patients with PF varies by geographic region and etiology. Blood in the meatus, hematuria and voiding symptoms are highly indicative of urethral rupture. The diagnosis of PF is eminently clinical and complementary exams are not necessary. The treatment consists of urethral reconstruction and the most common complications found are urethral stenosis and urethrocutaneous fistula. Conclusion PF is an uncommon urological emergency, particularly in cases with urethral involvement. Urethral injury should be suspected in the presence of suggestive clinical signs, and diagnosis is usually clinical. Urgent urethral reconstruction is mandatory and produces satisfactory results with low levels of complications.

A new material to prevent urethral damage after implantation of artificial devices: an experimental study

ABSTRACT Objective To validate the application of the bacterial cellulose (BC) membrane as a protecting barrier to the urethra. Materials and Methods Forty female Wistar rats (four groups of 10): Group 1 (sham), the urethra was dissected as in previous groups and nothing applied around; Group 2, received a 0.7cm strip of the BC applied around the urethra just below the bladder neck; Group 3, received a silicon strip with the same dimensions as in group 2; Group 4, had a combination of 2 and 3 groups being the silicon strip applied over the cellulosic material. Half of the animals in each group were killed at 4 and 8 months. Bladder and urethra were fixed in formalin for histological analysis. Results Inflammatory infiltrates were more intense at 4 months at lymphonodes (80% Grade 2), statistically different in the group 2 compared with groups 1 (p=0.0044) and 3 (p=0.0154). At 8 months, all samples were classified as grade 1 indicating a less intense inflammatory reaction in all groups. In group 2, at 8 months, there was a reduction in epithelial thickness (30±1μm) when com-pared to groups 1 (p=0.0001) and 3 (p<0.0001). Angiogenesis was present in groups 2 and 4 and absent in group 3. In BC implant, at 4 and 8 months, it was significant when comparing groups 4 with 1 (p=0.0159). Conclusion BC membrane was well integrated to the urethral wall promoting tissue remodeling and strengthening based on morphometric and histological results and may be a future option to prevent urethral damage.

Does MRI help in the pre - operative evaluation of pelvic fracture urethral distraction defect? - a pilot study

ABSTRACT Objectives To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)? Materials and Methods In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome. Results Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome. Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20). Conclusions MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED. Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.

Lesiones de uretra posterior secundarias a fractura pélvica tratadas a través de abordaje perineal progresivo. Breve revisión de la literatura. / Pelvic fracture posterior urethral injury repaired by progressive perineal approach: A brief review of the literature

Objetivo: Revisar los resultados operatorios de nuestros pacientes con rotura traumática de uretra posterior, tratados a través del abordaje perineal progresivo y realizar una breve revisión de la literatura. Materiales y métodos: fueron analizadas las historias médicas de 7 pacientes en edades comprendidas entre 2 y 12 años, con lesiones uretrales asociadas con fracturas pélvicas, producidas entre marzo de 2005 y enero de 2017. Después del diagnóstico de la lesión, se realizó cistostomía derivativa en los 7 casos; en 2 de ellos con lesión rectal asociada se realizó, además, colostomía tipo Hartman en el momento de la derivación urinaria. La evaluación urológica preoperatoria para la uretroplastia definitiva incluyó uretrografía anterógrada y retrograda simultánea para determinar la separación entre los segmentos uretrales. Se decidió la reparación retardada de la uretra a través de abordaje perineal progresivo con un mínimo de 6 meses posterior al trauma. Resultados: El mecanismo de producción del trauma fue arrollamiento por vehículos a motor en 6 pacientes y aplastamiento por balancín petrolero en uno. La lesión uretral fue completa en todos. Tres presentaron complicaciones quirúrgicas; 2 estenosis uretrales que mejoraron con dilataciones y una fístula uretroperineal que cerró en forma espontánea sin consecuencias. Todos los pacientes se encuentran asintomáticos; ninguno ha requerido una nueva uretroplastia. Comentarios: Nuestros hallazgos con la implementación de este abordaje terapéutico coinciden con lo reportado en la literatura.

Objective: To evaluate the postoperative outcomes of our patients with posterior urethral traumatic rupture repaired by progressive perineal approach, and to conduct a brief review of the literature. Materials and methods: The clinical records of 7 patients aged between 2 to 12 years with urethral injuries due to pelvic fracture produced between March 2005 and January 2017, were reviewed. A suprapubic cystostomy for urinary drainage was constructed in the 7 patients immediately after diagnosis; two of them had concomitant rectum injuries thus a Hartmann's colostomy was also performed in them. The preliminary urologic appraisal for definite urethroplasty included a synchronous anterograde and retrograde cysto-urethrogram to determine separation of the urethral segments. The final selection of surgical procedure was delayed urethral repair by progressive perineal approach minimum 6 months after the trauma event. Results: The mechanism of injury was, blunt trauma after being struck by a moving vehicle in 6 patients and a crash injury caused by an oil rocker in one patient. The urethral disruption was complete in all patients. Three patients developed surgical complications: 2 urethral strictures which improved with dilatation and one urethral-perineal fistula with spontaneous closure and no associated complications. All patients remain asymptomatic; no patient has required a redo urethroplasty. Commentaries: Our findings through the implementation of this therapeutic approach are consistent with those reported in the literature. Conclusions: Progressive perineal access allows performing an anastomotic urethroplasty with good clinical outcomes in most patients.

The vascular and neurogenic factors associated with erectile dysfunction in patients after pelvic fractures

ABSTRACT Erectile dysfunction (ED) is a common complication of pelvic fractures. To identify the vascular and neurogenic factors associated with ED, 120 patients admitted with ED after traumatic pelvic fracture between January 2009 and June 2013 were enrolled in this study. All patients answered the International Index of Erectile Function (IIEF-5) questionnaire. Nocturnal penile tumescence (NPT) testing confirmed the occurrence of ED in 96 (80%) patients on whom penile duplex ultrasound and neurophysiological testing were further performed. Of these ED patients 29 (30%) were demonstrated only with vascular abnormality, 41 (42.7%) were detected only with neural abnormality, 26 (27.1%) revealed mixed abnormalities. Of the 55 patients (29+26) with vascular problems, 7 patients (12.7%) with abnormal arterial response to intracavernous injection of Bimix (15mg papaverine and 1mg phentolamine), 31 (56.4%) with corporal veno-occlusive dysfunction and 17 (30.9%) had both problems. Of the 67 (41+26) patients with abnormal neurophysiological outcomes, 51 (76.1%) with abnormal bulbocavernosus reflex (BCR), 20 (29.9%) with pathological pudendal nerve evoked potentials (PDEPs) and 25 (37.3%) with abnormal posterior tibial somatosensory nerve evoked potentials (PTSSEPs). Our observation indicated that neurogenic factors are important for the generation of ED in patients with pelvic fracture; venous impotence is more common than arteriogenic ED.

Fratura de pênis com trauma uretra / Penile fracture with urethral trauma

We reported a case of a twenty-nine-year-old male who presented a penile fracture associated with urethral injury caused by a sexual intercourse. An ideal anamnesis and a special physical examination were determinant to correct diagnostics. Ultrasonography and uretrocistography must be performed for confirmation. The treatment is based on the presence of associated urethral injury. The surgical repair of cavernous body and urethra can produce good results, with a favorable prognosis and minimal rate of complications.

Pelvic fracture urethral injuries revisited: a systematic review

We attempted to determine the unresolved controversies about pelvic fracture urethral injuries and to present a treatment plan for this lesion. A systematic review was conducted on all contemporary pelvic fracture urethral injury articles published in the last 60 years. Studies were eligible only if data were complete and conclusive. Pelvic fractures associated with urethral injuries are usually caused by vehicular accidents or falls from heights. The risk of urethral injury is influenced by the number of broken pubic rami and the involvement or non-involvement of the posterior pelvic arch. Urethral rupture is assumed always to be preceded by stretching of the membranous urethra cephalad and usually to occur at the bulbomembranous junction. In children, the urethra and bladder neck may be directly torn by the sharp edge of bone fragments. Retrograde urethrography remains the cornerstone for the diagnostic appraisal of posterior urethral injury. Of the three conventional treatment methods primary suturing has the greatest complication rates of incontinence and impotence [21% and 56%, respectively] and primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy alone [36% vs. 19% and 53% vs. 97%, respectively, p< 0.0001]. Inflexible policies of one procedure or another are inappropriate for the treatment of pelvic fracture urethral injuries. The key to a good result lies in avoiding under-management of serious injuries as well as over-management of minor injuries. Partial rupture may be managed by either endoscopic urethral stenting in the first place or by suprapubic cystostomy. Complete rupture with minimal urethral distraction may be treated by either endoscopic realignment or suprapubic cystostomy. Complete rupture with marked urethral separation may be explored for primary realignment. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair

Monti’s procedure as an alternative technique in complex urethral distraction defect

PURPOSE: Pelvic fracture urethral distraction defect is usually managed by the end to end anastomotic urethroplasty. Surgical repair of those patients with post-traumatic complex posterior urethral defects, who have undergone failed previous surgical treatments, remains one of the most challenging problems in urology. Appendix urinary diversion could be used in such cases. However, the appendix tissue is not always usable. We report our experience on management of patients with long urethral defect with history of one or more failed urethroplasties by Monti channel urinary diversion. MATERIALS AND METHODS: From 2001 to 2007, we evaluated data from 8 male patients aged 28 to 76 years (mean age 42.5) in whom the Monti technique was performed. All cases had history of posterior urethral defect with one or more failed procedures for urethral reconstruction including urethroplasty. A 2 to 2.5 cm segment of ileum, which had a suitable blood supply, was cut. After the re-anastomosis of the ileum, we closed the opened ileum transversely surrounding a 14-16 Fr urethral catheter using running Vicryl sutures. The newly built tube was used as an appendix during diversion. RESULTS: All patients performed catheterization through the conduit without difficulty and stomal stenosis. Mild stomal incontinence occurred in one patient in the supine position who became continent after adjustment of the catheterization intervals. There was no dehiscence, necrosis or perforation of the tube. CONCLUSION: Based on our data, Monti’s procedure seems to be a valuable technique in patients with very long complicated urethral defect who cannot be managed with routine urethroplastic techniques.

Optical urethrotomy in strictures following fracture pelvis

Management of posterior urethral injuries with pelvic fracture remains a major controversy and has always been a challenge to urologists. Objective of this study was to see the outcome of optical internal urethrotomy in treatment of urethral strictures following fracture pelvis. This prospective study was conducted at the Urology Department, Lady Reading Hospital, Peshawar from January 2007 to July 2008. A total of 45 male patients [20-60 years of age] and having urethral strictures following fracture pelvis were treated with internal optical urethrotomy. Follow-up ranged from 3 months to 1 year. Fracture pelvis resulting from the road traffic accident, was the cause of urethral stricture. The good and fair results of internal optical urethrotomy were 68.56% patients who were treated with single internal optical urethrotomy. Internal optical urethrotomy was repeated in 22.86% of patients. Clean intermittent self urethral dilatation was applied as adjuvant treatment to prevent recurrence of stricture for variable period ranging from 1 to 3 months. Internal optical urethrotomy is safe and effective procedure for short yet inaccessible strictures from the perineum

Straddle injuries to the bulbar urethra: management and outcome in 53 patients

Objective: To describe our experience with blunt injuries to the bulbar urethra and their late sequelae to identify factors that may affect patient outcome. Materials and Methods: A retrospective study was performed on 53 male patients who presented, between January 2001 and December 2005, with blunt traumatic injury to the bulbar urethra. The definitive diagnosis of urethral rupture was made by retrograde urethrography, where urethral rupture was classified into partial or complete. The minimum follow-up period was 3 years. The initial management was either suprapubic cystostomy or endoscopic urethral realignment over a urethral catheter using a cystoscope to pass a guide-wire over which the catheter was inserted. Stricture formation was managed by visual internal urethrotomy (VIU) for passable strictures and urethroplasty (stricture excision and re-anastomosis) for impassable strictures or recurrence after VIU. The follow-up period was three years. The results were analyzed by SPSS software (chi-square and Student's-t-test). Results: Stricture formation occurred in 19 of 22 patients (86 percent) with complete urethral rupture and in 10 of 31 (32 percent) with partial rupture (p < 0.001). Strictures occurred in 11 of 31 (35 percent) patients treated initially with suprapubic cystostomy and in 18 of 22 (82 percent) treated with primary urethral realignment (p < 0.001). The success rate after VIU was 15 percent (4 of 26 patients) and after urethroplasty it was 96 percent (24 of 25 patients) (p < 0.001). Conclusions: Suprapubic cystostomy is better than urethral realignment and catheterization as primary management after straddle injury to the bulbar urethra. Stricture excision and re-anastomosis is better than VIU as delayed management for strictures that develop after straddle injury to the bulbar urethra.

Fracture penis with complete urethral disruption during intercourse

We present a rare case of fracture penis with complete urethral disruption in a 38 years old male. This resulted in an erect penis during sexual intercourse. He presented with diffuse and tense swelling of the penis along with acute urinary retention and distended urinary bladder. Emergency exploration revealed complete urethral disruption with tears in both corpus cavernosa. Evacuation of haematoma, repair of corpora and primary urethral repair was performed. Post-operative recovery was smooth and the patient developed satisfactory erectile and voiding function

Supracrural rerouting as a technique urology for resolution of posterior urethral disruption defects

Selection of an acceptable method for the treatment of posterior urethral disruption defects would be highly desirable. We determined the efficacy and success rate of some techniques including supracrural rerouting for removing of these defects among our patients. Records of 200 consecutive men treated with anastomotic urethroplasty for traumatic posterior urethral strictures were reviewed at our teaching hospital. Prior treatment, surgical approach, and ancillary techniques required during reconstruction were evaluated. Success rate due to posterior urethral reconstruction was achieved in 78.0% of cases. Supracrural urethral rerouting was performed in 11 patients [5.5%], of whom 7 sustained recurrent stricture requiring intervention. The highest success rate of defect resolving was reported by urethral mobilization [92.4%]. Supracrural rerouting is not an acceptable technique and can result in postoperative complications such as recurrent stricture in most of the patients with posterior urethral disruption defects

Congenital penile urethral aplasia in a 4-day-old bull calf

A 4-day-old Holstein bull calf with considerable oedema of the belly [water belly] was referred to the Veterinary Teaching Hospital of the School of Veterinary Medicine, Shiraz University. The owner did not observe any urination since birth. Rupture of the urethra was suspected. Perineal urethrotomy was performed. Subsequently, catheterization of urethra revealed the obstruction near the external urethral orifice. Urethrotomy showed a three cm long rupture of urethra proximal to the penile orifice. Surgical exploration showed the penile urethral aplasia which confirmed by histopathological findings. Permanent perineal urethrostomy was the surgical treatment of choice. Fluid and antibiotic therapy were administrated postoperatively. Postoperative follow-up showed a healthy calf without any signs of water belly

Trauma urológico / Urologic trauma

Os traumas geniturinários representam 10% de todos os traumas em nosso Serviço de Emergência (HC-FMUSP). O rim é, em geral, o órgão mais frequentemente envolvido, sendo os traumas de ureter e bexiga mais raros e associados a traumas de alta energia e a outras lesões severas concomitantes...

The genitourinary trauma represents 10% of all traumas in our Emergency Service (HC-FMUSP). The kidney is the organ most frequently affected. The ureteral and bladder traumas are rare and are associated wit traumas of high energy and with other severe injuries...

Fracture of the penis with urethral rupture.

We report a rare case of penile fracture with incomplete urethral rupture in a 25 years old male who sustained the injury during sexual intercourse. He presented with a tense haematoma on the ventral aspect of the penile shaft, associated with urethral bleeding. Per urethral catheterization was possible though it was painful. Exploration and repair of the penile fracture and urethra were performed within 16 hrs. The patient made an uneventful recovery with good erectile and voiding function. This case illustrates the value of early surgical repair of the fracture in order to prevent complications. The true incidence of penile fracture is not known even in the Western countries because it is under reported or hidden for social embracement and even it is reported to physicians it remains undiagnosed or mismanaged. Very rarely it is associated with urethral rupture.

Bladder flap posterior urethroplasty 9faseeh's technique]

Posterior urethral distraction defects are common nowadays because of increased incidence of road traffic accidents [RTA] and FALL. Approximately 90% are associated with pelvic fracture. Initial suprapubic cystostomy followed by delayed single stage end-to-end perineal urethroplasty, in most of these cases, is current mode of treatment. We feel the most important factor in determination of outcome is the length of distraction defect of the posterior urethra. In many cases, the gap between the two stumps exceeds 05 cms. This, coupled with the distorted anatomy of pelvis, can render end-to-end anastomoses impossible, despite all the claims made in literature. We have used an attached bladder flap to overcome this difficult situation. The results of the procedure evaluated by Uroflowmetry [UFM] micturating cystourethrogram and urethroscopy are very encouraging. We report this new technique for further evaluation

Limited experience in the early management of fractured penis

To review the effect of early surgical exploration and repair, of penile fractures, on the overall prognosis of these injuries and the maintenance of erectile function. This was a retrospective study in which we reviewed a total of 16 patients with penile fracture who presented over a period of 36 months. Associated urethral injuries were found in 3 out of the 16 patients [18.75%]. All patients were treated by early surgical repair within 24 hours from the time of injury.They were discharged in good condition and were followed up, both clinically and pharmacocavernosographically, in the outpatient department with excellent results. We recommend early surgical exploration and repair of these injuries because of the excellent results, shorter hospitalization, less morbidity and earlier return to full sexual activity