UROLOGICAL INJURIES IN PATIENTS WITH PELVIC FRACTURES – MANAGEMENT AND IMPACT ON OUTCOME

Abstract

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures.

Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. 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. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure 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.

Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. 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 extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. 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 – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. 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. The only female patient with urethral injury had an open tilt fracture associated with urethral tear.

The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days.

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.

Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they 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. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results.