Use of the perineal and perineal-abdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: long-term outcome.

PURPOSE

The results of 2 surgical approaches to restore urethral continuity in children with pelvic fracture urethral obliterative strictures were retrospectively reviewed.

MATERIALS AND METHODS

From 1980 to 1995, 30 boys 3.8 to 15.4 years old (median age 8.4) with urethral distraction injuries associated with pelvic fracture were treated with delayed 1-stage anastomotic repair. Surgical access was perineal in 15 cases and perineal-abdominal (transpubic) in 15. There were also associated injuries in 13 patients, including bladder neck laceration in 3. Overall postoperative followup ranged from 2 to 17 years (median 8.5).

RESULTS

The stricture-free rate of 1-stage anastomotic repair with perineal and perineal-transpubic access was 84 and 100%, respectively. Four recurrent strictures were treated successfully with additional perineal-transpubic anastomotic urethroplasty in 3 patients and internal urethrotomy in 1. Urinary incontinence developed in 1 boy in the perineal group and in 3 in the transpubic group. Retrospectively associated bladder neck injury was related to the original trauma in 3 of the 4 incontinent boys. The remaining child had overflow incontinence due to an acontractile detrusor. On review 3 of the 4 incontinent patients had severe, unstable type IV pelvic fractures.

CONCLUSIONS

Children with urethral distraction injuries associated with pelvic fracture require perineal-transpubic exposure when urethral obliterations of 3 cm. or greater develop or local complications are present in the affected area, making it impossible to create a tension-free, spatulated epithelium-to-epithelium anastomosis to restore urethral continuity via the perineal route. This study also supports previous reports that suggest a relationship of urinary incontinence and associated bladder neck injury with severe pelvic fracture rather than with delayed urethral repair.