Complex pelvic fracture urethral distraction defects revisited.

OBJECTIVE: This study aimed to establish some guidelines for the definition, diagnosis and treatment of complex pelvic fracture urethral distraction defects (PFUDD).

MATERIAL AND METHODS: A total of 40 patients with complex PFUDD was enrolled in this study. Urethral defects were associated with a paraurethral bladder base fistula (PBBF) (six patients), urethrorectal fistula (eight), urethrocutaneous fistula (nine), urinoma cavity (eight) or bladder neck incompetence (nine). In four patients the urethra had been wrongly reconstructed into a bladder base fistula (three) or urinoma cavity (one), elsewhere. Repair was performed by a perineal anastomotic urethroplasty in 15 patients and by a perineoabdominal transpubic procedure in 25.

RESULTS: Repair was successful in nine out of 15 (60%) patients who received a perineal repair and in 23 out of 25 (92%) who underwent a perineoabdominal transpubic procedure. Of the eight patients with unsuccessful outcomes five were successfully recorrected by transpubic urethroplasty.

CONCLUSIONS: A PFUDD may be considered as complex if it is associated with a PBBF, urethrorectal or urethrocutaneous fistula, urinoma cavity, or bladder neck incompetence. Complete excision of a PBBF usually requires a perineoretropubic approach. The initial trauma-related urethrorectal fistula usually opens into the prostatic urethra and its repair requires an abdominal approach, whereas an iatrogenic rectal fistula usually opens into the proximal bulbar urethra and can be resolved by a relatively simple perineal operation. Excision of a urinoma cavity or urethrocutaneous fistula can usually be accomplished from the perineum, while repair of a bladder neck incompetence requires an abdominal approach.