Podestá M L, Medel R, Castera R, Ruarte A
Department of Surgery, Hospital de Ninos Ricardo Gutierrez, Buenos Aires, Argentina.
J Urol. 1997 Apr;157(4):1444-8.
We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children.
From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3).
In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries.
As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapublic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.
我们回顾性分析了儿童骨盆骨折致尿道断裂的3种初始治疗方法的结果。
1980年至1994年，对35例2至15岁（平均年龄8.1岁）的前列腺膜部尿道断裂男孩进行了治疗，其中17例还伴有其他损伤。立即治疗包括19例患者行耻骨上膀胱造瘘及延迟尿道成形术（第1组），10例患者行尿道导管对合无牵引并同时行耻骨上膀胱造瘘（第2组），6例患者行一期耻骨后吻合性尿道成形术（第3组）。
第1组和第2组所有患者均发生严重尿道闭锁。第3组4例患者（66%）在吻合口修复部位出现狭窄。延迟尿道成形术后，第1组16例患者（84%）和第2组所有10例患者均能控制排尿。然而，第3组只有3例患者（50%）实现了控尿。回顾性分析发现，6例尿失禁男孩中有5例伴有膀胱颈损伤。除3名儿童外，所有儿童治疗前后均观察到勃起功能。不稳定骨盆环骨折（IV型）占所有骨盆骨折的28%，且合并损伤发生率高。
如前所述，尿道对合不利于避免尿道闭锁。因此，我们建议在这些病例中，耻骨上膀胱造瘘是唯一的初始治疗方式。尿失禁似乎更可能与合并的膀胱颈破裂和骨盆骨折的严重程度有关，而不是与初始治疗或延迟尿道修复有关。因此，当存在合并膀胱颈损伤时，我们主张立即进行手术修复。
