Session IV - Pelvis

Urological Injuries among Patients with Pelvic Fractures: Management and Impact on Outcome

Sanjeev Agarwal, MD; Peter V. Giannoudis, MD; Malcolm R Smith, MD; St James' University Hospital, Leeds, United Kingdom

Introduction: Injuries to the urinary tract are a well-known complication among patients with pelvic trauma. A severe urological injury frequently results in an adverse long-term outcome and prolonged disability. We reviewed the results of management of urological injury and the impact on final outcome among patients with pelvic fractures.

Methods: Of 554 patients admitted to our center with a pelvic fracture, 39 with injury to the urinary tract were identified: 8 women and 31 men who comprised the study group. The mean age of the patients was 30.9 years (range, 15 to 71), and the mean ISS was 12.9 (range, 9 to 22). Two patients had a skin wound communicating with the fracture hematoma. Seven (18%) had an upper tract injury, 6 (15.4%) had an extraperitoneal bladder rupture, 9 (23.1%) had an intraperitoneal rupture, 3 (7.6%) had a bladder neck injury, and 14 (35.9%) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure, complications, and long-term result in terms of incontinence, stricture, and sexual dysfunction were assessed. All patients were assessed with orthopaedic, urological, and the Euroqol (EQ5D) generic health questionnaire and compared with an age- and sex-matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow-up period was 2.3 years.

Results:

Upper urinary tract injuries: All patients were managed nonoperatively and had a uniformly good outcome except for one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three patients had acetabular fractures (one anterior column and two both-column fractures), and four had pelvic ring injuries (2 AP, 2 LC). Six patients were operated on, with an average time delay between injury and surgery of 7.1 days. We considered the urological injury related to the general trauma rather than to the specific pelvic injury.

Lower tract injuries: Fourteen of 15 patients with a bladder rupture had a repair of the bladder within 24 hours of arrival at our center. One patient who had a small extraperitoneal tear was managed nonoperatively. Seven had LC injury, 6 had APC, and 2 had acetabular fractures (both-column). One of the acetabular fractures was managed with fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated on. Pelvic ring injuries were managed by internal or external fixation or both, as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with an AP2 fracture died after 3 weeks because of the severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was performed on the 4^th day. He developed fecal and urinary incontinence and loss of sexual function. Thirteen men with an average age of 37 years (range, 19 to 70) had urethral injury; 5 had APC, 5 had LC pelvic ring injuries, and 3 had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends, and three patients had delayed repair. One patient in this group had sexual dysfunction, and five developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear.

The control group had 7 acetabular fractures, 19 AP compressions, 17 lateral compression injuries, and 4 vertical shear injuries. Four were managed nonoperatively. None of these patients had an open fracture. The average time delay between injury and operation was 2.2 days. We found no significant difference between the study and the control groups in outcome when patients with upper tract and bladder injuries were compared, but the urethral injury group had a poorer result in all five parameters of the EQ5D.

Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described; they do not add significant morbidity compared with the control group. In contrast, urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilization and a delayed repair, if required, produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results.