A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury

Benjamin J McCormick; Sorena Keihani; Judith Hagedorn; J Patrick Selph; Bradley D Figler; Niels V Johnsen; Rodrigo Donalisio da Silva; Joshua A Broghammer; Shubham Gupta; Brandi Miller; Frank N Burks; Jairam Eswara; E Charles Osterberg 3rd; Kenneth J Carney; Bradley A Erickson; Matthew B Gretzer; Paul H Chung; Catherine R Harris; Gregory P Murphy; Paul Rusilko; Anand Shridharani; Cooper Benson; Amjad Alwaal; Sarah D Blaschko; Benjamin N Breyer; Gregory M Amend; Maxim McKibben; Sean P Elliott; Ian W Schwartz; Jay Simhan; Alex J Vanni; Rachel A Moses; Jeremy B Myers

doi:10.1097/TA.0000000000003774

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury

J Trauma Acute Care Surg. 2023 Feb 1;94(2):344-349. doi: 10.1097/TA.0000000000003774. Epub 2022 Sep 19.

Affiliation

¹ From the Division of Urology (B.J.M., S.K.), University of Utah, Salt Lake City, Utah; Department of Urology (J.H.), University of Washington, St. Louis, Michigan; Department of Urology (J.H.), Harborview Medical Center, Seattle, Washington; Department of Urology (J.P.S.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Urology (B.D.F.), University of North Carolina, Chapel Hill, North Carolina; Department of Urology (N.V.J.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology (R.D.d.S.), Denver Health Medical Center, University of Colorado, Denver, Colorado; Department of Urology (J.A.B.), University of Kansas Medical Center, Kansas City, Kansas; Department of Urology (S.G.), University Hospitals, Case Western Reserve University, Cleveland, Ohio; Department of Urology (B.M.), Detroit Medical Center, Detroit, Michigan; Department of Urology (F.N.B.), Beaumont Medical Center, Royal Oak, Michigan; Department of Urology (J.E.), St. Elizabeth's Medical Center (previously Brigham and Women's Medical Center, Boston, Massachusetts), Brighton, Massachusetts; Department of Urology (E.C.O.), University of Texas Dell Medical School, Austin, Texas; Department of Urology (K.J.C.), Emory University School of Medicine (Grady Hospital), Atlanta, Georgia; Department of Urology (B.A.E.), University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Urology (M.B.G.), University of Arizona Medical Center, Tucson, Arizona; Department of Urology (P.H.C.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Santa Clara Valley Medical Center (C.R.H.), Santa Clara, California; Department of Urology (G.P.M.), Washington University School of Medicine, St. Louis, Missouri; Department of Urology (P.R.), University of Pittsburgh Medical Center, Pittsburg, Pennsylvania; Department of Urology (A.S.), University of Tennessee College of Medicine, Chattanooga, Tennessee; Department of Urology (C.B.), Tulane School of Medicine, New Orleans, Louisiana; Division of Urology (A.A.), Rutgers New Jersey Medical School, New Brunswick, New Jersey; Alameda Health System (S.D.B.), Oakland, California; Department of Urology (B.N.B.), University of California, San Francisco, California; Department of Urology (G.M.A.), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Urology (M.M.), Atrium Health, Carolinas Medical Center, Charlotte, North Carolina; Department of Urology (S.P.E.), University of Minnesota, Minneapolis, Minnesota; Department of Urology (I.W.S.), Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota; Einstein Healthcare Network (J.S.), Philadelphia, Pennsylvania; Department of Urology (A.J.V.), Lahey Hospital and Medical Center, Burlington, Massachusetts; Department of Urology (R.A.M.), Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; and Division of Urology (J.B.M.), University of Utah, Salt Lake City, Utah.

PMID: 36121280
DOI: 10.1097/TA.0000000000003774

Abstract

Background: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI.

Methods: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction.

Results: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784).

Conclusion: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter.

Level of evidence: Therapeutic/Care Management; Level III.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Cystostomy
Fractures, Bone* / complications
Fractures, Bone* / surgery
Humans
Pelvic Bones* / injuries
Prospective Studies
Urethra / injuries
Urethra / surgery
Urethral Diseases* / complications
Urethral Obstruction* / complications