Editing Lower Urinary Tract Trauma (section)

=== Management ===
* '''<span style="color:#ff0000">Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment</span>'''.
*'''<span style="color:#ff0000">Blind catheter passage prior to retrograde urethrogram should be avoided</span>, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring.[https://pubmed.ncbi.nlm.nih.gov/33053308/ §]'''
**If retrograde urethrogram demonstrates partial urethral disruption (contrast passes proximal to site of injury), then a a single attempt with a well-lubricated catheter may be attempted by an experienced team member

==== <span style="color:#ff0000">Male</span> ====

===== <span style="color:#ff0000">Posterior injuries</span> =====
* '''<span style="color:#ff0000">Pelvic fracture urethral injury: immediate suprapubic tube (percutaneous or open) with delayed repair</span>'''
** '''<span style="color:#ff0000">Immediate</span>'''
***
***'''<span style="color:#ff0000">Suprapubic tube</span>'''
****'''<span style="color:#ff0000">Remains the gold standard for urinary drainage</span>'''
**** Technique
*****If the bladder is displaced due to pelvic hematoma, bladder localization techniques such as aspiration with an 18 G spinal needle or imaging with ultrasound or fluoroscopy may facilitate percutaneous SPT insertion.
***** 14 Fr or larger Foley catheter is preferred
**** '''<span style="color:#ff0000">May be placed in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture</span>'''
***** No evidence to indicate that SPT insertion increases the risk of orthopedic hardware infection.
*** '''<span style="color:#ff0000">Primary realignment</span>'''
**** '''<span style="color:#ff0000">Refers to advancing a urinary catheter across the ruptured urethra</span>'''
**** May require two urologists to navigate the urethra simultaneously from above and below with multiple flexible or rigid cystoscopes, video monitors, and fluoroscopy.
**** May be associated with less severe urethral strictures compared to patients undergoing suprapubic tube alone; however, has been associated with a longer clinical course due to multiple procedures required for recurrent obstruction over an extended timeline.
**** '''Even if primary alignment successful,''' patients with pelvic fracture associated urethral injury are at high risk for developing urethral stricture, and '''suprapubic tube drainage should be maintained while awaiting resolution of PFUI.'''
*** '''Primary realignment vs. suprapubic tube'''
****'''The Emergency Department setting is inappropriate for primary realignment of most PFUI.'''
**** '''Prolonged attempts at endoscopic realignment in patients with PFUI should be avoided.'''
***'''Immediate sutured repair of posterior urethral injury'''
****'''Associated with unacceptably high rates of erectile dysfunction and urinary incontinence'''
** '''<span style="color:#ff0000">Delayed reconstruction</span>'''
*** '''<span style="color:#ff0000">Most PFUI patients will develop obliterative strictures which are amenable to open posterior urethroplasty</span>'''
***'''<span style="color:#ff0000">Posterior urethroplasty can be undertaken safely at 3 months</span>, provided that the patient is ambulatory and associated injuries are stabilized'''
**** In posterior urethral disruption, the rupture defect between the two severed ends fills with scar tissue, resulting in a complete lack of urethral continuity.
***** This separation is not a stricture; it is a true urethral rupture defect filled with fibrosis.
**** The scar tissue at the urethral disruption site is stable enough at 3 months to allow repair
*** '''<span style="color:#ff0000">Prior to repair, a cystogram and retrograde urethrogram should be obtained</span> to delineate the characteristics of the urethral rupture defect'''
*** '''<span style="color:#ff0000">Surgical management</span>'''
**** '''<span style="color:#ff0000">Approach</span>'''
***** '''<span style="color:#ff0000">Open perineal anastomotic posterior urethroplasty</span>'''
****** '''Posterior urethral reconstruction including excision of the fibrotic segment with distal urethral mobilization and primary anastomosis is associated with the best long-term outcomes after urethral disruption'''
******* '''<span style="color:#ff0000">Preferred treatment for most urethral distraction injuries</span>''' because it definitively cures the patient without the need for multiple procedures.
****** It is important to '''limit the lithotomy time to ≤5 hours to prevent lower extremity complications''' when any complex urethral reconstruction is undertaken
***** '''Endoscopic''' (e.g. direct-vision internal urethrotomy)
****** Best reserved for selected short urethral stenoses, such as partial distraction injuries for which early catheterization achieved urethral continuity.
******* '''AUA urethral stricture guidelines recommend urethroplasty over endoscopic management of strictures related to PFUI'''.
**** '''<span style="color:#ff0000">Complications of posterior urethral injury and it's repair (3):</span>'''
****# '''<span style="color:#ff0000">Urethral stricture</span>'''
****# '''<span style="color:#ff0000">Erectile dysfunction</span>'''
****# '''<span style="color:#ff0000">Incontinence</span>'''
***** '''Patients should be followed for at least 1 year following urethral injury to monitor for development of complications'''
****** Surveillance strategies for stricture recommended for the first year after injury include uroflowmetry, retrograde urethrogram, cystoscopy, or some combination of methods.
****** Stricture can be treated with urethroplasty or direct vision internal urethrotomy
***** '''After posterior urethroplasty, 5-15% of patients have recurrent stenosis at the anastomosis'''
***** Impotence and incontinence are generally considered to be caused by the pelvic fracture itself rather than contemporary interventions for PFUI.
***** '''Incontinence''' '''rates after reconstruction''' are low (<4%)

===== <span style="color:#ff0000">Anterior injuries</span> =====
*'''<span style="color:#ff0000">Contusions and incomplete injuries: urethral catheter diversion alone</span>'''
*'''<span style="color:#ff0000">Straddle injury to the anterior urethra: suprapubic tube (or primary realignment, in less severe cases) with delayed repair</span>'''
**'''<span style="color:#ff0000">With straddle injury, immediate operative intervention with to repair or debride the injured urethra is contraindicated due to the indistinct nature of the injury border.</span>'''
** '''<span style="color:#ff0000">Stricture formation after straddle injury is very high and thus all patients require follow-up surveillance using uroflowmetry, retrograde urethrogram and/or cystoscopy.</span>'''
** '''<span style="color:#ff0000">Delayed anastomotic urethroplasty is the procedure of choice in the totally obliterated bulbar urethra after a straddle injury</span>'''
*'''<span style="color:#ff0000">Penetrating trauma: prompt surgical repairs should be performed in patients with uncomplicated penetrating trauma of the anterior urethra</span>'''
**'''Spatulated primary repair of uncomplicated injuries in the acute setting offers superior outcomes to delayed reconstruction'''.
*** '''This is in contrast to PFUI or straddle urethral injuries where delayed reconstruction is recommended.'''
** Surgical repair should not be undertaken if the patient is unstable, the surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or loss

==== <span style="color:#ff0000">Female</span> ====
*'''<span style="color:#ff0000">Urethral disruption related to pelvic fracture: immediate primary repair, or at least urethral realignment over a catheter</span>'''
** '''Avoids subsequent urethrovaginal fistulae or urethral obliteration'''
** '''Delayed reconstruction is problematic in females''' because the urethra is too short (≈4 cm) to be amenable for mobilization during an anastomotic repair when it becomes embedded in scar