Injuries of the urethra in the male

Injuries of the urethra in the male

Injury, 7, 77-83 77 Injuries of the urethra in the male John Blandy Professor of Urology, The London Hospital, St Peter’s Hospital, London ANY inj...

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Injury, 7, 77-83

77

Injuries of the urethra

in the male

John Blandy Professor of Urology, The London Hospital, St Peter’s Hospital, London ANY injury to the urethra

will heal with a scar and, if the scar narrows its lumen, there will be a stricture. Scarring is worse if there is infection in a haematoma, loss of part of the lining of the urethra, or extravasation of hypertonic urine which kills tissue. The guiding principles in the early management of these injuries must therefore be to prevent infection, extravasation ofurine, and loss or displacement of the lining of the urethra. Although my personal experience of the acute management of urethral trauma is limited to about a dozen cases, my interest in the development of urethroplasty has given me the opportunity to deal with 78 examples where very severe strictures had followed trauma of various kinds. This group of 78 cases forms the largest single group in my series of 205 urethroplasties(TabZeZ). One can usefully subdivide trauma to the urethra into 4 categories (Table II): internal urethral injury, perineal, membranous, and combined urethrorectal or ‘ down-trousers ’ injury. Internal urethral

injury

Again, one may subdivide internal urethral injury into the acute laceration of the lining of the urethra, as may be caused by the rough introduction of the cystoscope (Fig. l), and the insidious onset of a pressure sore in the urethra. Contrary to many impressions, it would seem that the cystoscope is not the usual cause of mischief; the catheter is far more dangerous-and one must remember that nearly every badly injured patient, no matter where he is injured, will probably need to have a catheter passed at some time during his treatment. One sequel of prolonged catheterization, no matter how gently or expertly performed, can be a urethral stricture (Fig. 2). Perineal

injury

Direct injury to the bulbar urethra has, in our series, usually followed a kick on the perineum

and Consultant Surgeon,

(Fig. 3), generally

from a ‘ friend ’ in a roughhouse, or at football, but in one of my patients the injury was received from that ostensibly most placid of animals, a cow.

Tab/e 1. Aetiology urethroplasty

of stricture

in 205 cases needing

Circumcision and meatal lesions Trauma Inflammation (gonorrhoea, NSU etc.) Others (and unknown) Total

12 78 54 61

5.9% 38.0% 26.4% 29.7%

205

100.0%

Tab/e //. Types of trauma to the urethra in 78 cases needing urethroplasty Internal urethral injury: Cvstoscopv Millin prdstatectomy Transurethral resection Urethral stone Perineal injury Membranous rupture Combined urethral and rectal injury Total

Rupture

The third concerns namely resulting

5) 12 7 I 2)

26 17 30 5 78

of the membranous

type the the from

urethra

of injury is, no doubt, the one which accident surgeon most seriously; dislocated membranous urethra a fracture of the pelvis (Fig. 4).

Combined urethral trousers ‘) injury

and rectal (’ down-

Lastly there is a fourth category, which, thanks to increasing improvement in accident services, and the quality of care in resuscitation units,

Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

78

thighs, femora, pelvis and soft parts are all lacerated (Fig. 5). The injury to the urethra and the base of the bladder is but one part of a massive crushing injury, the associated tear of the rectum being its most dangerous feature. MANAGEMENT

Fig. 1. Internal urethral injury from clumsy use of the cystoscope. The perforation is usually in the bulbar urethra.

A

B

C

Fig. 2. If a catheter is too tight for the urethra, A, or if it is too big, and secretions get bottled up behind it, then there will be localized pressure necrosis in the urethral wall, B, and after the slough has separated it is replaced by scar, so narrowing the lumen of the urethra, C.

A

Internal urethral injury The management of these lesions depends upon whether the laceration is noted at the time of catheterization or endoscopy. If noted, and if the urine is diverted by means of an indwelling catheter for as long as is necessary to allow the corpus spongiosum to heal up, then one seldom ends up with a stricture. More dangerous is the consequence of prolonged pressure, as from an indwelling catheter, upon the lining of the urethra. This behaves just as a pressure sore at any other site in the body: first an area of the wall of the urethra sloughs, then the slough separates, and the defect is healed by scarring. In consequence of this scarring, there is a narrowing in the urethral lumen. Fortunately most of these strictures can be stretched by gentle repeated dilatation, and few of them result in such a tight or rigid scar that urethroplasty is required. But if urethroplasty is

B

Fig. 3.

Perineal injury of the urethra is a mixed crush and tear between the boot (or similar object) and the pubis, A. The danger is, B, in extravasation of urine out of Ihe hole in the urethra into the perineum. appears to be getting more common. This-the ‘ down-trousers crush injury ‘-is a massive combined tearing and crushing lesion, in which the

considered (and it should be considered for the young man who needs his urethra dilating more often than every two or three months), then the

Blandy:

Injuries

of the Urethra

79

operation of choice is the anterior LeadbetterOrandi (Leadbetter and Leadbetter, 1962; Orandi, 1968) patch procedure (Fig. 6), which can be done in one stage and has superseded the two-stage operations of Johanson (1953) and Swinney (1954).

perineum, and a hole of variable size in the urethra itself. The chief danger here is that urine may be extravasated into the fascial compartment of the scrotum and perineum. If this urine is hypertonic, it will lead to necrosis of the overlying skin and the subcutaneous tissues, and, if also infected, then extravasation will probably be followed by gangrene. The object of treatment is to prevent extravasation of urine. Hence the first step is to see if a soft, blunt-ended, narrow catheter (such as a plastic Jacques’ or Gibbon’s catheter) can be gently insinuated past the area of urethral damage and up into the bladder. If it goes into the bladder and the urine comes out freely, then

B

Fig. 4. Dislocation of the prostate with shearing off of the prostatic urethra in fractures of the pelvis. The pubis is forced backwards, A, tearing off the prostate from the membranous urethra, B, which is held in the pelvic diaphragm. When the pubis is reduced, C, there is a more or less wide gap between prostate and membranous urethra in which urine and blood will collect.

‘,

\

‘\

I;y s’

kv Fig. 5. Very severe crushing and rolling injury not only lacerates the urethra but the base of the bladder and the rectum. Perineal injury The second type of injury leads to an untidy laceration of the corpus spongiosum, with extravasation of blood into the soft tissues of the

nothing more needs to be done. There is no point at all in using a ‘ fenestrated ’ catheter: urine will leak out of the fenestra just as easily as exudate leaks in, and the prime object of the exercise is to prevent extravasation of urine. If the catheter has entered the bladder easily, it should be left there for 8 or 9 days-long enough for any hole in the wall of the urethra to be sealed up. There will probably be a stricture after this, but it will usually be a very easy one to treat by regular and gentle bouginage, and eventually the patient may only need to attend once a year, as much to reassure his surgeon as to have any real stricture stretched. Unfortunately, in most of these cases one cannot introduce a catheter past the stricture because the urethra is so bruised and swollen, if not lacerated, that the catheter cannot find its way up the proximal lumen. In this case I believe that the patient should have a suprapubic cystostomy

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Injury:

performed. My own preference is for a short, high, vertical midline incision, so that I can see the peritoneum and make certain I have wiped it off the bladder before entering the bladder and inserting a 20 Ch Foley catheter. Others have confidence in blind stab or Supracath cystostomies, but I do not trust them.

Fig. 6. Leadbetter’s strictures.

patch

for

anterior

urethral

Once the suprapubic cystostomy has been established, the only concern of the surgeon is to make sure that perineal extravasation of blood or urine does not warrant drainage. If in any doubt, a drain should be put in, but at this drainage operation one should not meddle with the mangled urethra. If the patient follows the usual course, his urethral injury will heal up leaving, at worst, a short, narrow stricture which can be treated by intermittent dilatation, or, if this proves painful or difficult, or has to be done too often, he can have a one-stage urethroplasty. This will be by the insertion of a Leadbetter-Orandi patch or by excision, mobilization and end-to-end anastomosis of the urethra as described by Marion (1935), though I do not not think this is as reliable as a one-stage patch. An alternative way of coping with the acute problem has been advised by some European surgeons who explore the injured urethra as an emergency, and then go on to carry out the first part of a two-stage urethroplasty. I cannot see the wisdom of this, for I believe that many of

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these patients will not need any urethroplasty at all if managed on the more conservative lines I have outlined above. Rupture of the membranous urethra It is in respect of the membranous type of injury that there exists today most controversy. In practice, my own experience of such acute cases is too small to permit any attempt at an authoritative dictum, and my own views are almost certainly unduly swayed by the disastrously damaged urethrae which are referred months or years later for urethroplasty. Moreover, the type of patient that I see does not usually fit into the preconceived categories of the textbooks, and rather than be doctrinaire about the issue, I prefer to consider the various clinical problems which present themselves. These, it seems to me, fall into three main groups: those who are far too shocked for any immediate attempt at a reconstructive operation on the ruptured membranous urethra; those who, while probably having an injury to the bladder or urethra, also have an urgent indication for laparotomy because there is evidence of internal bleeding and a suspicion of injury to other viscera such as gut or liver; and those who have either recovered from their shocked state, or else are in a satisfactory general condition from the beginning. When the patient is grossly hypovolaemic Here the immediate aim of treatment is to prevent leakage of urine from the bladder into the pelvic haematoma. Fortunately, in this injury the bladder generally goes into acute retention, and there is no need for haste in dealing with the urinary tract. Far more important in priorities is the replacement of blood loss and the care of other associated injuries. Minimal interference is the watchword. If circumstances permit, a wise precaution is to obtain an excretion urogram-but it is not essential. A cystogram may introduce infection, and will not help in deciding what to do. The picture is that of a shocked patient who has not passed water, with blood at the external meatus and a fractured pelvis. Under conditions of perfect asepsis, a narrow, soft, blunt catheter is introduced. If it goes up past the site of laceration of the urethra and into the bladder, well and good; it should be left indwelling for a week or so, and then removed. Later urethrography will display the residual stricture, which can be dilated from time to time in the usual way.

81

Blandy: Injuries of the Urethra

All too often the catheter does not go into the bladder, and urine does not come out. If the patient’s general condition is poor, then a suprapubic cystostomy should be performed. A few days later, when he has recovered, a combined cystogram and urethrogram may be done to determine the nature and extent of the displacement of the prostate. If the membranous urethra is (as it usually is) hopelessly dislocated, then a formal anastomosis of the urethra (described below) should be carried out. There is no urgency about this second reconstructive operation (one should allow time for the pelvic haematoma to become solid), but it should not be put off so long that the haematoma has turned into dense scar tissue. When laparotomy reasons

is indicated

for

other

There are a large number of patients in whom, although thegeneralcondition is poor, laparotomy is obligatory because there is evidence of internal bleeding and one has no way of knowing just which viscera have been injured. At this formal laparotomy, as is well known, one must examine the whole bowel, not neglecting the duodenum and the pancreas, and examine the liver and spleen carefully. From time to time, however, the bladder is the source of the intraperitoneal bleeding. Recently I removed from the subphrenic spaces a litre of blood which had come from a laceration in the vault of the bladder. It is usually all too obvious when the bladder is the culprit: for there is a large hole in it and a large pelvic haematoma. It is sensible to make a proper cystostomy, either widening the original laceration or entering the bladder through a separate incision. At this stage one should take care not to aggravate the hypovolaemia by unnecessary loss of blood from the cut edge of the bladder. Proceeding piecemeal, underrunning and suture-ligating all small vessels in the edge of the bladder, takes an extra few minutes but may save as much as one unit of blood. The point of making a separate cystostomy is that there are frequently several tears in the bladder, as Moy and Gibson have shown, and there may well be an associated dislocation of the membranous urethra (Moy, 1970; Gibson, 1974). Having mended the various holes in the bladder mucosa with 4/O chromic catgut, a 20 Ch Foley catheter is passed into the bladder up the urethra. The cystostomy incision is then repaired and the peritoneum closed over it. The retropubic space should be drained and the abdomen closed with catgut.

When the patient is in good condition

If the patient’s general condition is good, or if he has rallied after a few days with a suprapubic cystostomy, then the dislocated prostate should be explored and repaired (Del Villar et al., 1972; Cass and Ireland, 1973). A Pfannensteil incision gives perfectly good access. One proceeds as in a Millin prostatectomy, entering the retropubic space by blunt dissection in the usual way. Here one finds a considerable clot of blood. When it is evacuated the torn end of the urethra, usually in shreds, supported by the fascial covering of the levator ani-the pelvic diaphragmbecomes visible. The proximal urethra is usually awry, bent upwards or to the side, and totally separated from the distal end. The surgical performance of ‘ railroading ’ catheters as depicted in every textbook is, in practice, unnecessary if one has gone straight down upon the prostate through the retropubic space. A catheter is fed up the urethra, appearing in the tangled mess at the bottom of the wound which represents the torn urethra, whence it is brought up, gently fed into the proximal urethra, and inflated. The difficulty is making sure that the prostate stays down on the pelvic floor. First one should ensure that the displacement of the fractured pelvic ring has been reduced. Then stout 2/O catgut sutures can be inserted between the capsule of the prostate and the upper layer of pelvic fascia, to approximate the prostate down to the pelvic diaphragm. This is preferable to putting traction on the Foley catheter-which may destroy the internal vesical sphincter-and less dirty than putting nylon sutures through the perineum. The wound is closed in the usual way in layers with catgut and a retropubic drain. An alternative method of dealing with these injuries has recently come into vogue (Mitchell, 1973). It is said that most of the lacerations are incomplete, and that it is the first attempt with the catheter which tears the last remaining bridge of the urethra, making the tear complete. I have never understood how one can know whether a tear which is complete today was incomplete yesterday, and every patient I have explored personally has had an obviously complete tear, with a grossly displaced and rotated prostate. The proponents of this alternative method advise merely performing a suprapubic cystostomy, and waiting until the urethra heals itself. It is claimed that in time the urethra heals with tortuosity, but no stricture. This is quite contrary to my own experience: the few cases I have seen managed in this way have had both a tortuous urethra and a strictured one.

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Injury:

There is nothing unique to the posterior urethra which makes it immune from the ordinary laws of surgical healing, and no reason why restoration of anatomy, removal of haematoma and extravasated urine, and aseptic splinting will cause strictures which would not otherwise occur. But neglecting to reduce the dislocated prostate has one important consequence, namely that it makes subsequent urethroplasty exceedingly difficult. Although the usual patient does get a stricture, it is a soft one which is easy to dilate, and after a year or so it reaches the stage when he is attending perhaps every 9-12 months for a bougie to be passed. Regular gentle dilatation of an easy stricture is not a great hardship for the patient. If dilatation of the stricture is not so easy, but the prostate has been replaced and the stricture is therefore a short one, then urethroplasty is relatively easy. One can in fact perform a modification of the Leadbetter-Orandi patch operation and permanently enlarge the stricture with a small patch of skin on a pedicle of dartos. This is a dne-stage modification of the scrotal flap urethroplasty which used to be done in two stages (Blandy and Singh, 1975) (Fig. 7).

Fig. 7. Modified strictures

where

Leadbetter the prostate

patch for membranous is not dislocated.

If the prostate has not been replaced and is riding high up in the distorted pelvis, separated from the distal urethra by a considerable gap, then bridging the gap becomes very difficult. In many cases one can suture the apex of the scrotal flap to the proximal urethra from below, but the urethroplasty is too difficult to be safely performed in a single stage. It may need to be revised from time to time between the first and second stages, and one must subject the patient to a protracted series of examinations under anaesthesia before one knows that it is safe to go on to a secondstage closure. In worse cases one simply cannot

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identify the proximal urethra and it is only possible to bridge the gap by carving away the scar tissue, opening the bladder and bringing the scrotal flap up as a skin tube anchored to a suprapubic catheter (Fig. 8). Although this works quite well, it is a major procedure and can be avoided if the prostate is brought down and stuck to the floor of the pelvis soon after injury.

Fig. 8. Tubed scrotal flap pull-through technique cases where the prostate has not been repositioned.

for

Combined urethral and rectal injury In the fourth and most severe category of urethral injury, where there is also a lesion of the wall of the rectum and gross crushing of the surrounding thigh and pelvic soft tissues, it is not possible to lay down any hard-and-fast rules for dealing with the patient, since each case will be different from the next. But one must emphasize that it is extremely unwise to attempt primary suture of the crushed tissues of the perineum. The first duty of the surgeon, after restoring blood loss, is to carry out a diverting colostomy, to prevent gross faecal and clostridial contamination of the devitalized tissues of the perineum. Wound excision must be scrupulous and radical. The urine also needs to be diverted, and initially a suprapubic cystostomy should be performed as soon as possible, preferably at the time of the colostomy. Unfortunately these patients may have an injury to the trigone as well as the urethra and the suprapubic cystostomy alone may not keep them dry, and it may even require an ileal conduit in order to achieve adequate urinary diversion. Delayed suture of the rectum, the perineum and eventually the urethra can all be done after adequate urine and faecal diversion has been achieved (Blandy and Singh, 1972).

CONCLUSION Today one should try to manage injuries of the urethra in such a way as not to make subsequent

Blandy: Injuries of the Urethra

urethroplasty more difficult. The principles which underlie urethral surgery are no different from the principles which should underlie the surgery of all trauma-to remove haematoma and dead tissue, to restore anatomical continuity, and to divert urine and faeces away from the healing tissues. Displacement of the parts, organizing haematoma, sepsis, and extravasation of urine will all promote scarring and make subsequent urethroplasty difficult.

REFERENCES

J. P. and SINGH M. (1972) Fistulae involving the adult male urethra. Br. J. Ural. 44, 632. BLANDYJ. P. and SINGH M. (1975) The technique and results of one-stage island patch urethroplasty. Br.

BLANDY

J. Ural. 47, 83.

CASSA. S. and IRELANDG. W. (1973) Bladder trauma associated with pelvic fractures in severely injured patients. J. Trauma 13, 205.

83

VILLAR R. G., IRELANDG. W. and CASS A. S. (1972) Management of bladder and urethral injury in conjunction with the immediate surgical treatment of the acute severe trauma patient. J. Ural.

DEL

108, 581.

GIBSON G. R. (1974) Urological management and complications of fractured pelvis and ruptured urethra. J. C&o/. 111, 353. JOHANSON B. (1953) Reconstruction of the male urethra in strictures. Acta Chir. Scund. Suppl. 176. LEADBETTER G. W. jun. and LEADBETTER W. F. (1962) Urethral strictures in male children. J. Ural. 87,409. MARION J. B. C. G. (1935) Traite’ d’Urologie, 3rd ed., vol. 2. Paris, Masson, p. 1110. MITCHELLJ. P. (1973) Current concepts: trauma to the urinary tract. N. Engl. J. Med. 288, 90. MOY H. H. (1970) Lower urinary tract injuries. Br. J. Ural. 42, 739. ORANDI A. (1968) One-stage urethroplasty. Br. J. Ural. 40, 717. SWINNEYJ. (1954) Urethroplasty in the treatment of strictures. Proc. R. Sot. Med. 47, 395.

Requesfs.for reprints should be addressed to: Professor J. Blandy, The London Hospital, Turner Street, London, El.