Primary Repair of Pediatric Posttraumatic Complete Bladder Neck Horizontal Transection: Our Experience.

Complete transverse transection just below the bladder neck is extremely rare. We present two such cases with associated pelvic fracture following trauma. Both underwent early primary vesicourethral anastomosis with no postoperative complications and are continent in the follow-up.

Management of complex and redo cases of pelvic fracture urethral injuries.

OBJECTIVES: Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. METHODS: Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995-2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. RESULTS: Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. CONCLUSION: The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

Paediatric Post-Traumatic Bladder Neck Distraction Injury: Case Series.

The bladder neck distraction is a rare posterior urethral injury in paediatric age group. It mostly occurs secondary to road traffic accidents. We report three cases of paediatric bladder neck distraction injury. Three paediatric patients aged between 4 to 7 years (mean 5 year), who presented with post traumatic bladder neck distraction injury but no other major injury, they were treated with early urethro-vesical anastomosis. Postoperatively all patients were continent and with good urine flow rates. In paediatric bladder neck distraction injury, immediate urethro-vesical anastomosis gives good results.

Complex posterior urethral injury.

OBJECTIVE: To assess treatment strategies for seven different scenarios for treating complex pelvic fracture urethral injury (PFUI), categorised as repeat surgery for PFUI, ischaemic bulbar urethral necrosis (BUN), repair in boys and girls aged ⩽12 years, in patients with a recto-urethral fistula, or bladder neck incontinence, or with a double block at the bulbomembranous urethra and bladder neck/prostate region. PATIENTS AND METHODS: We retrospectively reviewed the success rates and surgical procedures of these seven complex scenarios in the repair of PFUI at our institution from 2000 to 2013. RESULTS: In all, >550 PFUI procedures were performed at our centre, and 308 of these patients were classified as having a complex PFUI, with 225 patients available for follow-up. The overall success rates were 81% and 77% for primary and repeat procedures respectively. The overall success rate of those with BUN was 76%, using various methods of novel surgical techniques. Boys aged ⩽12 years with PFUI required a transpubic/abdominal approach 31% of the time, compared to 9% in adults. Young girls with PFUI also required a transpubic/abdominal urethroplasty, with a success rate of 66%. In patients with a recto-urethral fistula the success rate was 90% with attention to proper surgical principles, including a three-stage procedure and appropriate interposition. The treatment of bladder neck incontinence associated with the tear-drop deformity gave a continence rate of 66%. Children with a double block at the bulbomembranous urethra and at the bladder neck-prostate junction were all continent after a one-stage transpubic/abdominal procedure. CONCLUSION: An understanding of complex pelvic fractures and their appropriate management can provide successful outcomes.

Emergency primary repair of grade V bladder neck injury complicating pelvic fracture.

We report a case of a grade V bladder injury complicating an open-book pelvic fracture following a road traffic accident. The bladder neck injury was primarily repaired in the emergency setting of a poor-resourced area with successful outcome. The dangers of urinary extravasation are still to be considered of importance and we advocate and encourage immediate/emergency open intervention although it remains controversial to say the least in a lesser resourced healthcare set up.