Koraitim M M
Department of Urology, College of Medicine, University of Alexandria, Egypt.
J Urol. 1999 May;161(5):1433-41.
The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined.
All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive.
The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001).
In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.
确定关于骨盆骨折尿道损伤尚未解决的争议，以及是否能得出任何结论以制定针对该损伤的治疗方案。
对过去50年英文文献中所有关于骨盆骨折尿道损伤的数据进行严格分析。仅当数据完整且具有结论性时，研究才符合条件。
尿道损伤的风险受耻骨支骨折数量以及骶髂关节受累情况的影响。根据创伤程度，膜部尿道首先被拉伸，然后在球膜部交界处部分或完全断裂。前列腺尿道和膀胱颈损伤仅发生于儿童。女性尿道损伤通常是前壁的部分撕裂，近端或远端尿道很少完全断裂。男性的诊断依赖于尿道造影，女性则依赖于高度怀疑和尿道镜检查。在三种传统治疗方法中，断裂尿道两端的一期缝合出现尿失禁和阳痿的并发症发生率最高（分别为21%和56%）。与耻骨上膀胱造瘘术和延迟修复相比，一期复位术导致阳痿的发生率翻倍，狭窄发生率减半（分别为36%对19%，53%对97%，p<0.0001）。
在男性中，手术和内镜手术并非相互竞争，而是在不同情况下针对不同损伤相互补充，包括尿道牵拉伤留置导尿管、部分破裂时内镜支架置入或耻骨上膀胱造瘘术、完全破裂且牵张缺损最小时内镜复位或耻骨上膀胱造瘘术，以及牵张缺损较大时手术复位。膀胱、膀胱颈或直肠的合并损伤需要立即进行探查修复，但不一定意味着要探查尿道损伤部位。在女性中，治疗方式取决于尿道损伤的程度，包括近端损伤时立即耻骨后复位或缝合，远端损伤时经阴道尿道推进。
