Pelvic Fracture Urethral Injury and post operative Incontinence. Role of MRI in evaluation . By Sanjay Kulkarni and Pankaj Joshi

• 16 Oct 2021 09:21:58 AM
• |Reconstructive Urology

Anatomy:

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.

Treatment:

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 Horiguchi’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 Akio’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:

Indications:

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.

What’s important is the way in which. MRI should be done.

Principle:

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 .

References:

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. 

Comments(4)

• 

  PANKAJ JOSHI

  17 Oct 2021 09:07:36 AM

  Uploading the Pictures of MRI technique 

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• 

  Venugopal P

  17 Oct 2021 09:48:01 AM

  Dear all,

  We should thank Kulkarni’s Team for highlighting the Need of MRI in decision making of Surgery for Pelvic Fracture Urethral Injury. In this write up Pankaj has provided us with some references that we should read in enhancing our knowledge. Among this the article on ‘Injury in Pelvic Fracture Urethral Injury Is Membrano-Bulbar: Fact or Myth’ is a must as regards this injury. In that article, they have come out with a statement that the ‘Injury is Membrano-Bulbar and not Prostate-Membranous as thought conventionally’. This statement of theirs need to be drilled into our understanding.

  I am providing this article for your reading.

  With warm regards,

  Venu

   

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• 

  PANKAJ JOSHI

  17 Oct 2021 10:11:29 AM

  Uploading the Pictures of MRI technique 

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• 

  PANKAJ JOSHI

  17 Oct 2021 03:04:28 PM

  Uploading the Pictures of MRI technique 

  View Document