UROLOGIC INJURY ASSOCIATED WITH PELVIC FRACTURES: MANAGEMENT AND IMPACT ON OUTCOME

Abstract

To evaluate the results of management of urological injury and the impact on final outcome in patients with pelvic fractures.

Out of 554 patients with pelvic fractures, 39 (7%)(8 female) were identified with urinary tract injuries. The mean age of the patients was 30.9 yrs (range 15–71) and the mean ISS was 12.9 (range 9–22). Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. Timing of urological intervention, complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to 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.

Upper urinary tract injuries: All were managed non-operatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy.

Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extraperitoneal tear was managed nonoperatively. Three patients reported failure of erection. 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 done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function.

Thirteen males had urethral injury. 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 delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture.

We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D.

Upper tract and bladder injuries do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function.