The reported success of EER is variable, with rates of clinically significant stricture formation ranging from 14% in a single institution series to 53% in a large multicenter review. Our primary aim was to analyze the success of EER after blunt PFAUI in a subset of consecutive patients who were treated from initial injury to potential urethral reconstruction at our Level 1 trauma hospital. A secondary aim was to assess incontinence and erectile dysfunction during followup clinic appointments.

Urethral catheterization was maintained for a minimum of 3 weeks for urethral lacerations and 6 weeks for complete disruption. Catheters were left longer if necessary as part of the polytrauma recovery. A pericatheter retrograde urethrogram or voiding cystourethrogram was performed at urethral catheter removal. Contrast was injected around the urethral catheter using a 5 or 8Fr feeding tube to obtain the pericatheter study. Patients were closely followed with uroflowmetry and post-void residual during the first month after initial urethral catheter removal. Additional followup included uroflowmetry, post-void residual and/or cystoscopic evaluation at 3, 12 and 24 months.

One patient was lost to followup after EER. Using an intent to treat analysis we classified this case as a treatment failure and calculated followup after EER as 0. Based on this approach the overall success rate of EER was 4 of 19 (21%) with a mean followup of 3.7 years (median 3.5, range 0 to 7.1). For the patients treated successfully with EER mean followup was 2.1 years (median 2.2, range 0.86 to 3.1). The findings identified at EER in patients treated successfully were complete prostatomembranous urethral disruption (2) and partial proximal bulbar laceration (2).

The figure depicts the treatment pathway for the 15 patients in whom EER failed (78.9%). Mean time to identification of stricture formation after initial urethral catheter removal was 79 days (median 72, range 0 to 288). After initial EER failure 8 patients underwent posterior urethroplasty. Six patients were initially treated with DVIU. However, treatment failed in 3 of these patients who subsequently required posterior urethroplasty.

As shown in the figure, after EER failure 11 patients underwent posterior urethroplasty with a mean subjective stricture length of 1.8 cm (range 1 to 3). Penile revascularization before posterior urethroplasty was not required for any patient. The mean operative time for posterior urethroplasty was 225 minutes (median 220, range 131 to 307). During posterior urethroplasty additional operative maneuvers beyond urethral mobilization were required in 3 patients. The corporal bodies were split in 1 patient after complete urethral disruption and in another with a 1 cm membranous urethral tear. The third patient required inferior pubectomy and corporal splitting for successful urethroplasty. Corporal rerouting was not performed in any patient. The mean operative time for the urethroplasty procedures requiring additional urethral lengthening maneuvers was 243 minutes (median 239). One case required a combined abdominoperineal approach for repair, while all others were performed via a peri-neal approach. Posterior urethroplasty was successful in all 11 patients. Mean followup after posterior urethroplasty was 3.0 years (range 0.6 to 5.9).

Of the 4 patients treated successfully with EER alone after PFAUI none reported erectile dysfunction or SUI. Of the remaining 14 patients in whom EER failed who returned for clinical care, 4 reported erectile dysfunction and none reported subjective SUI. All 4 patients with subjective erectile dysfunction sustained a complete posterior urethral disruption. All 4 of these patients had successful treatment of erectile function with phosphodiesterase type 5 inhibitors or intracavernous injections.

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 to 45%.¹³ 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.