Pelvic Fracture Urethral Injury and post operative Incontinence. Role of MRI in evaluation . By Sanjay Kulkarni and Pankaj Joshi
PFUI involves a traumatic bulbo membranous injury .Membranous urethra with prostate gets disrupted from bulbar urethra.
Very rarely the injury is Membrano Prostatic or Intra prostatic or bladder neck prostate.
Irrespective of the site of injury, anastomotic urethroplasty is the procedure of choice.
What maintains Continence?
Prof. Mundy et al published his series of PFUI. The group performed Urodynamics .Bladder neck provides continence.Additional continence comes from the membranous urethra in 985% of patients.
Webster et el published a sesries of patients where the bladder neck seemed open on SPC scopy and MCU but after anastomotic urethroplasty,the patients were continent.
All this suggests a vital role of membranous urethra in preserving continence.
What is the significance?
Membranous urethra is intact in a PFUI .Our anastomosis is bulbo membranous .
For those where this does not work ,bladder neck supports continence.
Truly ,incontinence is only if there is bladder neck injury with membranous injury .
Such patients who are suspected to have a bladder neck injury should be repaired immediately .For all other patients we can insert a SPC and delayed anastomotic urethroplasty after 3 months
Tips and tricks:
There are various options of spatulation suggested by Webster,Mundy ,Turner Warwick.
In ouir large series of 1307 patients ,the incontinence rate was negligible.
The reason is we do not spatulate posterior urethra as this is the membranous urethra.
No excision of scar or dissection between 5 and 7 Clock position posteriorly to preserve the nerves .
Akio Horiguchiâ€™s Paper:
Akio et al are a recognized Reconstructive Unit in Japan. Both Akio and us published importance of performing MRI in the same year .
In Akioâ€™s series , about 32% patients after anastomotic Urethroplasty have incontinence.
We do not support this finding
Akio et al has published the role of membranous Urethral length in predicting the post op continence. This is more significant after radical prostatectomy .There are multiple studies which suggest that longer the membranous urethra ,more the chance of continence preservation after a radical prostatectomy .
This may hold true for PFUI, but we hardly see post op incontinence.
Extrapolating the same data to females, even after anastomotic urethroplasty for female PFUI ,we rarely see incontinence.
Our Technique of MRI:
MRI is indicated in complex scenarios, recto Urethral fistula.
But ,those in academic units can use MRI to predict the need for Pubectomy and get orientation to the anatomy.
Whatâ€™s important is the way in which. MRI should be done.
In MRI Water acts as natural contrast .SO fill the bladder with saline.
Inject Lignocaine jelly in anterior urethra .Tie gauze piece around glans and perform T2 Sagittal imaging only which tales 3 minutes for a 3 T MRI.
You will get images which will mimic RGU MCU as well as show a 3 D Orientation.
Please see the attached images to understand and predict if Pubectomy will be needed or not .
Its just not important to perform MRI. Its important to optimize the way we perform MRI and use the images for our surgical craft .
Joshi PM, Kulkarni SB. Management of pelvic fracture urethral injuries in the developing world. World J Urol. 2020 Dec;38(12):3027-3034.
Joshi PM, Desai DJ, Shah D, Joshi D, Kulkarni SB. Injury in Pelvic Fracture Urethral Injury Is Membranobulbar: Fact or Myth. Urology. 2017 Apr;102:e9-e10.
Horiguchi A, Edo H, Shinchi M, Ojima K, Hirano Y, Ito K, Azuma R, Shinmoto H. Membranous urethral length on magnetic resonance imaging as a novel predictor of urinary continence after delayed anastomotic urethroplasty for pelvic fracture urethral injury. World J Urol. 2021 Sep 21. doi: 10.1007/s00345-021-03840-0.
Joshi PM, Desai DJ, Shah D, Joshi DP, Kulkarni SB. Magnetic resonance imaging procedure for pelvic fracture urethral injuries and recto urethral fistulas: A simplified protocol. Turk J Urol. 2021 Jan;47(1):35-42.
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