Among the consecutive patients with blunt PFAUI treated at our Level 1 trauma center from 2004 to 2010 the success rate of EER alone was 21% (4 of 19). The severity of PFAUI did not correlate with successful EER outcomes as 2 of 12 patients with evidence of complete urethral disruption had successful EER. Subjective SUI was not reported among the 18 patients who returned after EER, while subjective erectile dysfunction was only reported in 4 of those in whom EER failed. As noted in previous series symphysis pubis diastasis and pubic ramus fracture are associated with PFAUI.3
However, our limited numbers preclude statistical analysis of the correlation of fracture patterns to EER success.
PFAUI is an uncommon yet debilitating injury resulting from significant blunt trauma to the pelvis. The mechanism of this injury involves signifi-cant shearing forces at the prostatomembranous junction, resulting in avulsion of the urethra from the fixed urogenital diaphragm.8
In the last 80 years debate has been ongoing in the urological and trauma literature regarding the safest method of treating these potentially catastrophic injuries, with the goal of treatment to produce unobstructed voiding while maintaining the highest rates of continence and potency. This debate has changed from immediate open surgical repair, to rudimentary forms of urethral realignment, to suprapubic drainage with delayed urethral stricture repair. In the last 30 years practice patterns have returned to favor early urethral realignment via endourological methods.1,9–11
Modern techniques of early endoscopic realignment were introduced in the late 1980s. These techniques evolved into a combination of transurethral and transvesical endourological procedures in conjunction with fluoroscopy.8
This technique is postulated to avoid further damage to erectile function since there is no manipulation of the periprostatic tissues and, thus, no additional trauma to the neurovascular bundles.8
Recent data on primary realignment are mixed with regard to subsequent urethral stricture development. Webster et al performed a comprehensive literature review encompassing 538 cases of urethral injuries associated with pelvic fracture dating from 1953 to 1995.12
Of the 508 patients treated with initial suprapubic cystostomy, stricture requiring repair developed in 97% vs 53% of the 326 patients who underwent mixed techniques of primary realignment. Other single institution series report rates of urethral stricture after primary realignment ranging from 14%7
These published series combined with our 79% failure rate indicate that primary realignment after PFAUI is not often successful. Continued followup of these patients after initial catheter removal after primary realignment is critical as delayed urethroplasty will often be required. While some may advocate initiation of intermittent self-catheterization if primary realignment is unsuccessful, we do not support this palliative stricture management strategy as posterior urethroplasty has durable results to allow volitional voiding.14
In a comprehensive literature review published in 1983 Webster et al reported that the rate of impotence was double in the primary realignment group vs the suprapubic cystostomy group (36% vs 19%).12
A common criticism of this comparison is that the technique of primary realignment was not uniform, as the cohort was from multiple centers (15) and time periods (1961 to 1983). In addition, there was no standardization of realignment technique or subsequent followup duration in many of the studies. As previously stated it is also unfair to compare rates of impotence in patients after initial suprapubic cystostomy to rates in those who underwent primary realignment due to differential misclassification because those treated with primary realignment were likely less severely injured.
EER is thought to be less traumatic than other means of primary realignment after PFAUI.8
A report of 29 patients with blunt trauma and posterior urethral injury used EER as the sole method of primary relignment.15
The authors reported a subjective 86% potency rate after EER, which is much higher than in older reports using mixed means of primary realignment. These improved findings with EER alone compare more closely to our series. Assuming the patient lost to followup after EER in our cohort was impotent, our subjective potency rate was 14 of 19 (74%).
While cases of PFAUI are relatively rare, these findings have influenced our clinical practice in several ways. Despite limited numbers, we did not find that patients with complete urethral disruption had higher rates of failure after EER, as 2 of the 4 successes with EER alone had endoscopic evidence of complete disruption. Subjective assessment during cystoscopy was the only mechanism for diagnosis and endoscopic visibility could have impaired our visual assessment. However, we do not counsel patients on the eventual need for urethroplasty or internal urethrotomy based on the initial endoscopic assessment of injury severity. Instead, the high failure rate after EER (78% in our series) has reinforced the necessity for close followup after initial catheter removal. Setting appropriate expectations of outcomes and educating patients regarding the need for close followup due to the risks of obstructive voiding and complete retention are of paramount impor tance. As such, we schedule close followup with uroflowmetry and post-void residual in the first month after EER catheter removal. If EER fails then we will recommend 1 internal urethrotomy for short strictures (less than 1 to 2 cm) that are not obliterative. However, we do not repeat internal urethrotomy if the initial attempt is unsuccessful (success defined as no use of self-catheterization). Using this approach 50% of patients (3 of 6) who underwent internal urethrotomy were successfully treated with a single internal urethrotomy. We do not advocate self-catheterization unless the patient has severe medical comorbidities preventing open surgical repair. The injured cohort is often young (median age 38 years in our analysis). When faced with a decision of lifelong intermittent self-catheterization vs definitive repair, most patients will opt for the latter option. As such, if EER and possibly internal urethrotomy fail, we recommend posterior urethroplasty as it has been shown to be a durable treatment option for posterior urethral strictures.14
In our selective series of patients with blunt PFAUI and failed EER, all 11 patients were treated successfully (ie no need for self-catheterization).
All but 1 of the patients in our cohort undergoing posterior urethroplasty was treated via a perineal approach. Of the 11 patients 3 required urethral mobilization to perform the urethroplasty. While we do not have a case matched cohort of patients who underwent initial SPT with delayed urethroplasty at our institution, this rate of additional urethral lengthening maneuvers is consistent with the findings of Cooperberg et al in a series of 134 patients who underwent posterior urethroplasty.14
In this series 30% of patients required corporal splitting, 22% required partial pubectomy and 4% required a combined abdominoperineal approach.
We did not evaluate our EER cohort with validated questionnaires to assess incontinence and potency. Instead, patients were questioned about continence and erectile function during followup visits. This lack of validated outcome measures is a limitation of our study. Data provided by the International Index of Erectile Function and the International Consultation on Incontinence Questionnaire have since been added to our clinical practice to provide improved quantitative outcome assessment. Our study is also limited by the small cohort size, reflecting the rarity of this injury pattern even at a Level 1 trauma center. Despite these limitations our study highlights the importance of close monitoring as the majority of patients undergoing EER after PFAUI will ultimately require complex posterior urethral reconstruction. Our series has shown that posterior urethroplasty after failed EER is durable.