Primary Repair of Pediatric Posttraumatic Complete Bladder Neck Horizontal Transection: Our Experience.

Complete transverse transection just below the bladder neck is extremely rare. We present two such cases with associated pelvic fracture following trauma. Both underwent early primary vesicourethral anastomosis with no postoperative complications and are continent in the follow-up. Copyright:

INTRODUCTION

Pelvic fracture urethral injury (PFUI) is mostly seen at the prostatomembranous-bulbar urethra junction. Complete separation of urethra from bladder neck is extremely rare.[123] We describe our experience of managing two such patients who had a successful outcome after primary surgical reconstruction.

CASE REPORTS

Case 1

A 7-year-old male child presented with a history of fall from bus with blunt trauma of the abdomen and pelvis. He was initially managed elsewhere where he was catheterized and then referred. His vitals were stable, but there was lower abdominal tenderness and gross hematuria with urine output of 0.8 ml/kg/h. There was no perineal hematoma. His hemoglobin was 8.4 gm/dL, blood urea 28 mg/dL, and serum creatinine 1.2 mg/dL. Abdominal ultrasonography (USG) showed free fluid with no solid organ injury. There was fracture of the left inferior pubic ramus on plain radiography. Contrast-enhanced computed tomography (CECT) reported intraperitoneal and extraperitoneal bladder rupture with urinoma formation. After resuscitation, he was taken up for surgery 24 h after the injury. Through a Pfannenstiel extraperitoneal incision, the perurethrally inserted Foley catheter bulb was found lying freely in the pelvis and draining the hemorrhagic urinoma [Figure 1]. There was complete transverse transection at the level of the bladder neck with the bladder and urethra lying apart.

Figure 1

(a) Plain radiograph following contrast-enhanced computed tomography scan shows full bladder with extravasation of contrast. (b) Intraoperative photograph of case 1 showing from front to back: Foleys catheter exiting the prostatic urethra, V-shaped bilateral vas deferens and bladder with stay suture. (c) Retrograde urethrogram of case 2 with arrow showing site of anastomosis just below bladder neck. (d) Cystoscopy showing suprapubic cystostomy, intact bladder neck, and suture material at anastomotic site (arrow), (e) Diagram of coronal section of lower urinary tract showing likely site of injury

The primary end-to-end vesicourethral anastomosis was done with interrupted Vicryl 4-0 sutures over a 6F perurethral Foleys catheter along with suprapubic cystostomy (SPC). The postoperative period was uneventful, and he was discharged 7 days later with both catheters. Cystoscopy with catheter change was done a month later, which showed an intact bladder neck with inflammation just below, suggesting that the injury was an avulsion of the proximal prostatic urethra from the bladder neck. The perurethral catheter was removed after 2 weeks in the outpatients after clamping the SPC. As the patient continued to pass urine in good stream, the SPC was removed after 1 week. For the first 2 months, although continent, he was having frequent micturition. Thereafter and at a follow-up period of 2.5 years, he is passing urine in good stream every 3–4 h and is continent in the day and night. He has had no episodes of urinary retention or urinary tract infections with USG showing normal kidneys with no significant postvoid residual. He has no urgency or stress incontinence and is attending school regularly.

Case 2

An 11-year-old male child presented with an alleged history of fall from a trolley and run over by the same. There was blunt trauma abdomen and closed fracture shaft of left femur and right superior pubic ramus. He was catheterized initially elsewhere and later referred. His vitals were stable. There was abdominal distension with generalized tenderness and hematuria with a urine output of 0.6 ml/kg/h, hemoglobin 9.6 g/dL, blood urea 24 mg/dL and serum creatinine 1.1 mg/dL. USG showed free fluid in peritoneal cavity. CECT abdomen reported extraperitoneal rupture of bladder with generalized free fluid. After resuscitation, he was explored 36 h after the injury through an infraumbilical midline incision. Approximately 1 litre of hemorrhagic fluid was drained with a large pelvic retroperitoneal hematoma. There was complete transverse transection of urethra at the bladder neck with the Foleys catheter bulb lying in the pelvis and draining collected urine. The primary vesicourethral anastomosis was done with a single layer interrupted Vicryl 4-0 sutures over an 8F Foleys catheter and SPC. He underwent surgery for fracture shaft of femur on POD-7. On POD-15, the perurethral catheter was accidentally pulled out. The SPC was left in situ and he was not re-catheterized. Subsequently, the child began passing urine perurethrally also. One month after surgery, under general anesthesia, retrograde urethrogram showed free flow of contrast from urethra to bladder and mild dilatation just below the bladder neck indicating the area of repair. An 11F cystoscope could be easily passed through the anastomotic site in the proximal prostatic urethra into the bladder and also showed a normally closing bladder neck. The SPC was removed. At 1.5-year follow-up, the patient is passing urine in good stream every 3 h and is continent during the day and night. He has no urgency or frequency or episodes of urinary tract infection. A recent USG shows normal kidneys and normal bladder wall thickness with insignificant postvoid residual.

DISCUSSION

Pediatric urethral trauma is uncommon and usually seen after road traffic accidents. The incidence of pediatric PFUI is 0.47%–4.2%.[1] The common injury seen in adults and older children is a complete or partial disruption at the level of the prostatomembranous-bulbar urethra junction. Our patients, however, had a complete horizontal transection at the level of the bladder neck with avulsion from the proximal prostatic urethra, which we have not encountered earlier. Avanoğlu et al., however, reported 10 of 27 children with complete disruption of urethra located at bladder neck over a 13-year period.[4] They did not describe whether this injury was horizontal or vertical. In younger children, the bladder is more intra-abdominal with the smaller softer prostate and its immature ligaments having less stabilizing effect.[4] Both our patients had a Type I pelvic fracture as per Young–Burgess classification with fracture of only one of the pubic rami.[5] In the first patient, the likely mechanism was a shearing force as he fell down from a moving school bus. A lateral compression to the innominate bone with the pelvis rotating toward the midline on the side of impact may have occurred causing a shortening of the anterior pelvic ligaments. The second child was run over, and the injury may have occurred by a crushing mechanism. Laceration of bladder neck area cannot be explained by a bone spicule because of its location. It is likely that the puboprostatic ligaments were partially disrupted, and the prostate/prostatic urethra as a whole may have moved with the unilateral fracture of the pubic ramus during the impact. The full bladder may have remained attached to its lateral ligaments and the lower posterior urethra to the sphincter muscles and perineal membrane.[6]

Many classifications have been mentioned in the literature. None comprehensively address the various types of urethral, bladder, rectal, and vaginal injuries. Both our patients could be categorized into the following types: Type 1 Al Rifaei anatomic and functional classification (avulsion injury at the level of the bladder neck), Type IV Goldman extended anatomical classification (bladder neck injury extending into the urethra with extravasation of contrast around the bladder neck), Type 4 Chapple classification of posterior urethral injury (complex injury involving the bladder neck or rectum), and a Type V American Association of Surgery of Trauma classification (a complete disruption, complete transection with >2 cm of urethral separation or extension into prostate or vagina).[7]

An initial SPC with delayed repair is usually recommended in PFUI. Both our cases were referred early with a suspicion of bladder rupture based on the clinical findings and imaging. Here, also our policy is to explore and insert an SPC. However, the bladder was found lifted up exposing its posterior wall. The perurethral catheter tip was lying freely in the pelvis with a large undrained collection. Traction application on perurethral Foley's catheter helped in lifting the edges of the urethra and achieving tension-free primary end-to-end vesicourethral anastomosis. In the type of injury, we encountered, a SPC alone may have caused a further distraction from the urethra and sustained urinary extravasation. Previous reports also recommend primary surgical repair when urethral injury is associated with bladder neck injury or rectal injury requiring colostomy creation.[16]

Early repair may reduce the formation of dense stricture, genitourinary fistulae, and infectious complications secondary to associated rectal or vaginal injuries. Routh and Husmann described immediate repair of pediatric bladder neck lacerations, in eight boys and four girls with none achieving full continence in a 13-year follow-up.[8] However, all their cases had longitudinal bladder neck laceration extending into proximal urethra with associated pelvic fractures and pubic diastasis. Our patients on the other hand had a complete transverse transection at bladder neck level not extending longitudinally into the urethra. Mundy and Andrich described 15 cases in adults mostly with primary proximal urethral injury with secondary longitudinal bladder neck involvement after pelvic fracture.[6] There was only one case with transverse bladder neck injury who also had a simultaneous transverse disruption below the prostate. Most patients were incontinent, but their results cannot be extrapolated to ours because all the cases were associated with injury to distal prostatic urethra. Gite et al. described a similar case as ours in an adult who did not have incontinence, impotence, or stricture postoperatively.[3] Sawant et al. treated three patients aged 4–7 years, two with complete separation of bladder neck from posterior urethra and one with bladder neck injury, which extended into the right ureteric orifice.[1] Following primary repair, all were continent and did not develop stricture at 4-year follow-up. Similar good results were described by Soon.[2]

Although we cannot fully explain the reasons for normal continence in our patients, the injury had occurred just below the bladder neck and the intrinsic mechanism of the bladder neck was probably intact [Figure 1e]. Because of their age, intact sphincter muscles may be enclosing more parts of the posterior urethra compared to an adult where they get placed more distally due to the enlarging prostate. Unlike the more common injury in the proximal bulbar-membranous urethra region, which affects the rhabdosphincter and the neurovascular bundles, these structures are presumed to be intact in our patients because of the location of the injury. The suturing was done soon after the injury, i.e., vascularity was good in the anastomosed ends. In delayed anastomosis, fibrosis occurs in the tissues to be sutured as well as in the surrounding areas. Unless these are excised at the time of delayed anastomosis, stricture formation is common. Finally, pelvic fracture was mild.

The incidence of erectile dysfunction after PFUI in children is variable with a range of 31%–75% in some series and only a 16% incidence following primary realignment in others.[5] It can occur after pelvic fracture with or without a urethral injury. A vascular or neural injury at the apex of the prostate can occur in the presence of complete disruption and prostatic dislocation. Despite most patients having antegrade ejaculation, injury to lumbar sympathetic nerves and hypogastric and pelvic plexus is said to cause infertility in up to 90% PFUI patients. We cannot extrapolate these results to our patients as they describe a different cohort of patients.[3] The parents of both the patients have noted erection but long-term follow-up will be required. Urinary incontinence is said to occur in 5% men following PFUI.[5] In patients with bladder neck injury, continence has been noted in 57% of cases, but these are longitudinal injuries.[5] However, if circumferential integrity of bladder neck is confirmed, then continence is likely which we were able to demonstrate during cystoscopy in both our patients. It would appear that the associated injuries will dictate the final continence and other complications.

CONCLUSION

Drainage of urine in perurethral catheter does not rule out bladder neck injury. Clinical features and imaging have to be carefully interpreted. In avulsion injuries between the bladder neck and proximal prostatic urethra, a primary anastomosis is a viable option in a stable patient with good postoperative outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.