Editing Penis and Urethra Surgery (section)

== Pelvic Fracture Urethral Injuries ==

* '''See [[AUA: Male Urethral Stricture (2016)|AUA Urethral Stricture Guideline Notes]]'''

=== Pathogenesis ===
*PFUIs are the result of blunt pelvic trauma and accompany ≈10% of pelvic fracture injuries
** Although total disruption of the urethra is possible with a straddle injury, '''straddle injuries most commonly involve only the bulbar urethra'''
** '''Distraction injuries are unique to the membranous urethra'''
*** '''The most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra'''

=== Diagnosis and Evaluation ===
* Important to define the precise anatomy of the pelvic fracture injury before treatment is undertaken
* '''<span style="color:#ff0000">Imaging'''
**'''<span style="color:#ff0000">Cystogram''' 
***'''<span style="color:#ff0000">Provides information on (3):'''
***#'''<span style="color:#ff0000">Rostral displacement of the proximal urethra'''
***#'''<span style="color:#ff0000">Bladder outline'''
***#'''<span style="color:#ff0000">Bladder neck competency'''
***#*'''<span style="color:#ff0000">Contrast in the prostatic urethra suggests an incompetent, open bladder neck'''
***#*'''<span style="color:#ff0000">Lack of contrast in the prostatic urethra suggests a competent, closed bladder neck'''
***#**'''<span style="color:#ff0000">The appearance of the bladder neck on contrast studies or on antegrade endoscopy does not accurately predict the ultimate function of the bladder neck after urethral reconstruction'''
***#***'''Although a lack of contrast material in the posterior urethra gives some information about the integrity of the bladder neck, contrast material may opacify the prostatic urethra when the bladder neck is more than adequately competent for continence'''
***#***In the past, great reliance was placed on whether the bladder neck was closed or open on cystography.
***#***If truly incompetent, open bladder neck, consider continent stoma instead of urethroplasty
***#***'''Can obtain videourodynamics to determine bladder neck competency'''

=== Management ===
*'''Repair'''
** In most cases, PFUIs are not long, and the resultant obliteration is amenable to a technically straightforward mobilization of the corpus spongiosum with a primary anastomotic technique.
*** '''Aggressive mobilization of the corpus spongiosum is performed with caution, because it is thought to have possible ill effects on retrograde blood supply, which in the pelvic fracture patient may be tenuous.'''
**** Meticulous detachment of the investment of Buck fascia from the corpus spongiosum increases the compliance of the corpus and limits the need for aggressive mobilization.
** Anastomosis of the proximal anterior urethra can be done to any segment of the posterior urethra (apical, prostatic, or below)
** Most PFUIs can be managed by the exaggerated lithotomy position for the perineal approach.
*** '''The boots are positioned to avoid stretch injuries of the common peroneal nerves.'''
**** '''The common peroneal [also called fibular] nerve is a nerve in the lower leg that provides sensation over the posterolateral part of the leg and the knee joint.'''
**** It divides at the knee into two terminal branches: the superficial fibular nerve and deep fibular nerve, which innervate the muscles of the lateral and anterior compartments of the leg respectively.
**** '''When the common peroneal nerve is damaged or compressed, foot drop can be the end result.'''
** Summary of Steps:
*** After the patient is correctly positioned, the perineal approach to reconstruction begins with an incision and dissection anterior to the transverse perinei musculature (anterior perineal triangle). We use a λ-shaped incision that is carried sharply down to the midline fusion of the ischiocavernosus musculature, then beneath the scrotum, to expose the uninvested portion of the corpus spongiosum. We then place a self-retaining ring retractor. The fusion of the ischiocavernosus musculature is divided, and the musculature is cleanly dissected from the corpus spongiosum and bulbospongiosum. The corpus spongiosum is detached from the triangular ligament and corpora cavernosa, the bulbospongiosum is detached from the perineal body, and the dissection is carried farther down to the infrapubic space. Posterior detachment of the bulbospongiosum is carried anteriorly, and the dissection is eventually carried through the area of fibrosis. We divide the triangular ligament and vigorously develop the intracrural space down to the pubis. If the dorsal vein is encountered, it is ligated and divided. '''If a tension-free anastomosis is thought to be impossible, we mobilize the corpus spongiosum.''' The proximal urethrotomy is spatulated; 10 to 12 anastomotic sutures are placed. The anastomotic sutures are placed in their respective locations. Before seating the anastomosis, we introduce a soft silicone (Silastic) ribbed urethral stenting catheter through the anastomosis under direct vision. Next, we reattach the corpus spongiosum to the corpora cavernosa and the bulbospongiosum to the perineal body. We place a small suction drain deep to the closure
** '''In cases in which the proximal urethra is significantly distracted in a rostral direction, the surgeon must be prepared to perform:'''
**# '''Mobilize corpus spongiosum'''
**# '''Development of the intracrural space and detachment of the bulbospongiosus from the perineal body'''
**# '''Sequesterectomy (removal of sequestrum (scar) associated with defect)'''
**# '''Corporeal rerouting (re-route the urethra under one side of the corpus cavernosum)'''
**# '''Infrapubectomy'''
**#* Potential long-term sequelae of pubectomy:
**#** Shortening of the penis
**#** Destabilization of erection
**#** Destabilization of the pelvis, resulting in a chronic pain syndrome with exercise
** It is important to try to avoid the creation of chordee during the repair of a distraction injury.
* '''Postoperative management'''
** '''Urine is diverted via the suprapubic cystostomy, and the small soft silicone (Silastic) urethral catheter is plugged and serves as a stent only.'''
** After the reconstruction, patients are initially kept at bed rest for 24-48 hours and then ambulated and discharged with the suprapubic catheter and stenting urethral catheter in place.
** Patients are discharged on a regimen of oxybutynin and a suppressive antibiotic only if the pre-operative urine culture was positive. The drains are removed as drainage allows.
** '''A voiding trial with contrast material is performed between 3-4 weeks post-operatively.'''
*** The trial involves removing the urethral catheter, filling the patient’s bladder with contrast material, and instructing him to void.
*** The voiding film is examined to ensure that there is no extravasation and that the anastomosis appears widely patent.
*** A urine culture specimen is also obtained, and the suprapubic catheter is plugged.
*** The patient is allowed to void through the urethra for 5-7 days, and the suprapubic catheter is then removed.
** ≈6 months postoperatively and again 1 year later, patients are evaluated with flexible endoscopy.
** With the use of the techniques discussed or similar techniques, curative rates for reconstruction of posterior PFUIs are in the high 90% range.
*** '''In general, failures are indicative of ischemia of the proximal corpus spongiosum with ensuing stenosis of the mobilized corpus spongiosum.'''
**** '''Duplex ultrasound has been used to predict the patients at risk for this ischemic atrophy phenomenon.'''
***** Patients with an intact pudendal artery on one side often were potent and were reliably cured with reconstruction.
***** Patients with only reconstituted vessels, either unilateral or bilateral, never were potent but were reliably reconstructed. We found that these patients were optimal candidates for penile arterial revascularization to improve potency.
***** '''Patients do well with reconstruction if they have at least one side that is reconstituted, and the only patients at risk for ischemic stenosis are patients with bilateral complete obstruction of the internal pudendal vessels. In such patients, we perform penile arterial revascularization to augment the vascularity and, with that accomplished, proceed to urethral reconstruction'''
** '''In many cases of pelvic fracture urethral distraction defects, erectile dysfunction is a consequence of the injury, although erectile dysfunction clearly results from the reconstructive surgery in some patients.'''