British Journal oJUrology (1995). 75. 65-67

The importance of accurate assessment and conservative management of the open bladder neck in patients with post- pelvic fracture membranous urethral distraction defects S . MAcDIARMID, D . R O S A R I O and C.R. CHAPPLE Department of Urology, The Royal Hallamshire Hospital, Shefield, UK

Objective To review the pre-operative assessment of bladder neck competence and assess the success of non-operative management of the bladder neck in patients with pelvic fracture membranous urethral distraction defects.

Patients and methods A series of four patients with long-standing post-pelvic fracture urethral distraction defects and open bladder necks demonstrated on pre- operative investigation are presented.

Results All four patients were managed by perineal

urethroplasty without surgery to the bladder neck. All patients were continent post-operatively despite the injury having ablated the distal sphincter mechanism.

Conclusion We believe that the majority of patients can be managed successfully by a non-operative approach to the bladder neck, sparing them the unnecessary operative morbidity of an abdomino-perineal repair, which should be reserved for those with obviously scarred or distorted bladder necks.

Keywords Pelvic fracture, urethroplasty, trauma

Introduction

Following a pelvic fracture membranous urethral distrac- tion defect (PFLTDD), continence relies upon an intact functioning bladder neck, since the distal sphincter mechanism is ablated by the injury. The diagnosis of bladder neck incompetence has traditionally been an indication for a combined abdomino-perineal repair with reconstruction of the bladder neck to achieve continence [l, 21. Though it is well documented that competence of the bladder neck can be assessed by pre-operative radiographic and endoscopic techniques, no specific guidelines exist on correct interpretation.

In this paper we review the pre-operative assessment of bladder neck competence and assess the success of non-operative management of the bladder neck in patients with PFUDD.

Patients and methods

Four male patients with long-standing PFUDD and open bladder necks on a pre-operative cystogram were referred to this unit. Patient ages ranged from 1 7 to 54 years (Table 1). Three patients had been managed initially by insertion of a suprapubic catheter and one by immediate open exploration of the urethra with realignment over a stenting urethral catheter. This patients stricture

Accepted for publication 26 September 1994

Table 1 Specific details on the four patients with open bladder necks as detailed by cystography; with a urethral distraction defect following a pelvic fracture injury

Timing of urethroplasty following initial injury

Patient Age (years) Nature of injury (months)

1 17 Road-traffic accident 9 2 54 Work related 18 3 18 Road-traffic accident 8 (previous

failed primary repair)

4 39 Road-traffic accident 13

recurred within 5 months, requiring suprapubic cystostomy .

Pre-operatively all four patients had a simultaneous retrograde urethrogram and antegrade cystogram to assess anatomy with particular reference to the length of the urethral defect, the normality of the anterior urethra and the apparent competence of the bladder neck. Radiographs were taken at low bladder volumes with the detrusor at rest. In addition, antegrade cystos- copy through the suprapubic tract was carried out to rule out bladder calculi and to further assess the bladder neck. The cystoscopy was combined with urethroscopy and was performed under general anaesthesia.

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66 S. MACDIARMID, D. ROSARIO and C.R. CHAPPLE

All patients underwent a transperineal end-to-end anastomotic urethroplasty, managing the bladder neck conservatively. The duration of time from injury to time of definitive urethroplasty ranged from 8 to 18 months (mean 12). Patients were routinely reassessed post- operatively at 3 and 12 months. The length of follow- up ranged from 3 to 15 months (mean 6).

Results

On pre-operative radiographic evaluation all four patients had a normal anterior urethra and a distraction defect 2-3 cm in length. In three patients the bladder neck was consistently open and in one it was beaked (Fig. 1). Antegrade cystoscopy was normal in all patients at low bladder volumes. With increasing filling of the bladder the bladder neck funnelled open but showed no obvious distortion or scarring.

Intra-operatively, adequate urethral lengthening necessary to achieve a tension-free bulbo-prostatic anas- tomosis was obtained by bulbar mobilization and by sharp separation of the crura performed entirely trans- perineally. Urinary diversion was obtained by insertion of a 14F Neoplex urethral catheter and a suprapubic tube.

Each patient had an unremarkable post-operative course and was discharged home within 14-21 days voiding spontaneously. The urethral catheter was not removed until a retrograde catheterogram and voiding urethrogram around the catheter showed no contrast extravasation. At 3 months all patients were voiding well with measured maximum urinary flow rates of

Fig. 1. Combined ascending and descending contrast study demon- strating a rupture of the membranous urethra with distraction of the ends. Note the open bladder neck.

22-28 mL/s. All were continent from the time of catheter removal and in all patients erectile function was pre- served. EndoscopicaIly their bladder necks were shut and their urethral anastomoses were well healed anti patent.

Discussion

Membranous urethral distraction defect is a relatively uncommon injury, occurring most often in association with disruption of the pelvic ring. The majority of membranous urethral distraction defects resulting from a pelvic fracture are short (

BLADDER NECK COMPETENCE AND PELVIC FRACTURE URETHRAL DEFECTS 67

urethral defect. However, the degree of filling will vary greatly between individual radiologists and the interpret- ation of bladder neck competence based on radiography wiB by necessity remain rather subjective.

Bearing this in mind, the foilowing algorithm for the interpretation of the cystogram is suggested: a bladder neck that is closed during cystography when an adequate amount of contrast has been instilled (2 100 mL) should be interpreted as competent. A consistently open bladder neck may or may not represent bladder neck incom- petence and further assessment by antegrade cystoscopy is necessary. Under these circumstances, if the bladder neck appears normal endoscopically and is not obviously scarred, distorted or gaping, it should be considered competent. If the bladder neck in these patients is managed conservatively, the majority of them are likely to be continent after transperineal urethroplasty alone, as was the case in the patients presented here. A bladder neck that is obviously scarred or gaping is most likely to be truly incompetent and we believe should be repaired via a combined abdominal approach at the time of urethroplasty. However, endoscopic evaluation of blad- der neck function can be difficult and all patients in whom doubt exists should be managed conservatively.

This small prospectively studied series of patients confirms previous observations based on a retrospective analysis of over 600 cases [ 5 ] . Patients who fail a conservative approach to bladder neck management can be salvaged by a second procedure, but they need to be informed of this pre-operatively.

References

1 Turner-Warwick R. Urethral stricture surgery. In: Turner- Warwick R ed., Current Operative Surgery: Urology. London: Balliere TindalI, 1988: 160-218

2 Turner-Warwick R. Complex traumatic posterior urethral strictures. J Urol 1977; 118: 564-74

3 Webster GD, Sihelnik S. The management of strictures of the membranous urethra. J Urol 1985: 1 3 4 469-73

4 Webster GD. Management of complex posterior urethral strictures. In Webster GD ed., Problems in Urology: Reconstructive Urology. Philadelphia: JB Lippincott, 1987:

5 Wong J, Chapple CR, Turner-Warwick R. Continence after pelvic fracture urethral injuries and restoration of bladder neck competence by sphincteroplasty. Presentation to the British Association of Urological Surgeons, Scarborough 1990, Abstract 83

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Authors S. MacDiarmid, FRCS-C. formerly Visiting Urological Fellow

now Assistant Professor in Urology, University of Arkansas. D. Rosario, FRCS (Eng), Urological Research Fellow. C.R. Chapple, BSc, MD, FRCS (Urol), Consultant Urological

Correspondence: Mr C.R. Chapple, Department of Urology, Royal Hallamshire Hospital, Glossop Road, SheEeld S10 2JF. UK.

Surgeon.

British Journal of Urology (1995). 75