RECONSTRUCTION OF URETHRAL INJURIES

Abstract

ABSTRACT
Objectives: To highlight the complexity of urethral injuries and to emphasise their prevention.
Design: A retrospective study.
Setting: Coast Province General Hospital, Mombasa, Kenya.
Subjects: Twenty two male patients operated between 1997 and 2007.
Results: Surgery for urethral injuries was done on 22 patients; 16 were of the posterior urethra, five
bulbar urethra and one proximal penile urethra. The posterior urethral injuries were due to: pelvic
fracture in 14, penetrating stick in one, and one animal injury by a buffalo. The bulbar urethral
injuries were due to straddle injuries in four and one gunshot injury. The penile urethral injury
was by compression of the subject by a motor vehicle against a wall. Anastomotic urethroplasty
was performed in 20 patients, of whom 16 had complete recovery. Surgery for all bulbar and the
penile urethral injuries was successful. Failure of repair with restenosis occurred in four patients
with posterior urethral injuries. Bouginage was done in one patient who subsequently required
no further treatment. Eventual total obliteration occurred in three patients. Reoperation was
done in two of these with complete recovery in one and failure in the other who had two further
urethroplasties, optical urethrotomy and is currently on clean intermittent self catheterisation. The
fourth patient awaits reoperation. Sutureless membranous urethroplasty was done in two patients
with posterior urethral injuries in whom sutures could not be inserted into the proximal prostatic
urethra. One developed stenosis a year later, had optical urethrotomy and commenced on clean
intermittent self catheterisation for a while, without further trouble. The other developed total
obliteration. At repeat surgery enhanced scarring with urethral shortening were found and the
operation was abandoned. The Mitrofanoff principle was applied with an appendicovesicostomy;
one form of urinary diversion with a continent catheterisable conduit. On follow up, now nine
years, the diversion is continent, has no catheterisation difficulties, and no urinary calculi.
Conclusion: Urethral injuries are difficult to manage. A two pronged approach is advanced;
prevention and competent repair. Surgeons managing these injuries are encouraged to acquire the
needed reconstruction skills. Emphasis on prevention is paramount. Appropriate road, industrial
and occupational safety measures should be enforced. Iatrogenic injuries can be avoided by due
care during catheterisation and urethral instrumentation.