Editing AUA: Urethral Stricture Disease (2023) (section)

===Pelvic fracture urethral injury (PFUI)===
*'''<span style="color:#ff0000">Acute management of PFUI</span>'''
**'''<span style="color:#ff0000">Options (2)</span>'''
**#'''<span style="color:#ff0000">Endoscopic primary catheter realignment</span>'''
**#'''<span style="color:#ff0000">Insertion of a SP tube</span>'''
**'''<span style="color:#ff0000">The resulting distraction defect, stenosis or obliteration should be managed with delayed perineal anastomotic urethroplasty</span>'''
*'''<span style="color:#ff0000">Preoperative evaluation</span>'''
**'''<span style="color:#ff0000">RUG, VCUG, and/or retrograde urethroscopy</span>'''
***'''<span style="color:#ff0000">VCUG may include a static cystogram to determine</span>'''
***#'''<span style="color:#ff0000">Competency of the bladder neck mechanism</span>'''
***#'''<span style="color:#ff0000">Level of the bladder neck in relation to the symphysis pubis</span>'''
***Other adjunctive studies may include antegrade cystoscopy, with or without fluoroscopy, and pelvic CT or MRI to assess the proximal extent of the injury, degree of malalignment of the urethra, and length of the defect.
*'''<span style="color:#ff0000">Delayed urethroplasty, instead of delayed endoscopic procedures, should be performed after urethral obstruction/obliteration due to PFUI</span>'''
**Repeated endoscopic maneuvers including intermittent catheterization should be avoided because they are not successful in the majority of PFUI, increase patient morbidity, and may delay the time to anastomotic reconstruction.
**Technique
***Anastomotic reconstruction is performed through a perineal approach. 
***Excision of the scar tissue and wide spatulation of the anastomosis is required.
***'''Several methods to gain urethral length and reduce tension can be employed when necessary including (4):'''
***#'''Mobilization of the bulbar urethra'''
***#'''Crural separation'''
***#'''Inferior pubectomy'''
***#'''Supracrural rerouting'''
***#*In most cases the latter two maneuvers are not required. In rare cases, trans abdominal or transpubic techniques may be required.
*Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.
**Reconstruction should occur when patient factors allow the surgery to be performed, usually within 3 to 6 months after the trauma.
**Patient positioning in the lithotomy (standard, high, or exaggerated) may be limited until orthopedic and lower extremity soft tissues injuries have resolved.