Pelvic fracture urethral injuries revisited: A systematic review

Purpose: We attempted to determine the unresolved controversies about pelvic fracture urethral injuries and to present a treatment plan for this lesion. Materials and methods: 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. Results: 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). Conclusions: 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.