RECONSTRUCTION OF URETHRAL INJURIES

ABSTRACTObjectives: To highlight the complexity of urethral injuries and to emphasise their prevention.Design: A retrospective study.Setting: Coast Province General Hospital, Mombasa, Kenya.Subjects: Twenty two male patients operated between 1997 and 2007.Results: Surgery for urethral injuries was done on 22 patients; 16 were of the posterior urethra, fivebulbar urethra and one proximal penile urethra. The posterior urethral injuries were due to: pelvicfracture in 14, penetrating stick in one, and one animal injury by a buffalo. The bulbar urethralinjuries were due to straddle injuries in four and one gunshot injury. The penile urethral injurywas by compression of the subject by a motor vehicle against a wall. Anastomotic urethroplastywas performed in 20 patients, of whom 16 had complete recovery. Surgery for all bulbar and thepenile urethral injuries was successful. Failure of repair with restenosis occurred in four patientswith posterior urethral injuries. Bouginage was done in one patient who subsequently requiredno further treatment. Eventual total obliteration occurred in three patients. Reoperation wasdone in two of these with complete recovery in one and failure in the other who had two furtherurethroplasties, optical urethrotomy and is currently on clean intermittent self catheterisation. Thefourth patient awaits reoperation. Sutureless membranous urethroplasty was done in two patientswith posterior urethral injuries in whom sutures could not be inserted into the proximal prostaticurethra. One developed stenosis a year later, had optical urethrotomy and commenced on cleanintermittent self catheterisation for a while, without further trouble. The other developed totalobliteration. At repeat surgery enhanced scarring with urethral shortening were found and theoperation was abandoned. The Mitrofanoff principle was applied with an appendicovesicostomy;one form of urinary diversion with a continent catheterisable conduit. On follow up, now nineyears, the diversion is continent, has no catheterisation difficulties, and no urinary calculi.Conclusion: Urethral injuries are difficult to manage. A two pronged approach is advanced;prevention and competent repair. Surgeons managing these injuries are encouraged to acquire theneeded reconstruction skills. Emphasis on prevention is paramount. Appropriate road, industrialand occupational safety measures should be enforced. Iatrogenic injuries can be avoided by duecare during catheterisation and urethral instrumentation