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CASE REPORT
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 76-78
 

Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion


Department of Urology, PGIMER and Dr. RML Hospital, New Delhi, India

Date of Submission13-Apr-2017
Date of Acceptance08-Sep-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Nikhil Khattar
Department of Urology, PGIMER and Dr. RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_118_17

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   Abstract 

Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.



How to cite this article:
Singh RK, Kaushal D, Khattar N, Nayyar R, Manasa T, Sood R. Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion. Indian J Urol 2018;34:76-8

How to cite this URL:
Singh RK, Kaushal D, Khattar N, Nayyar R, Manasa T, Sood R. Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion. Indian J Urol [serial online] 2018 [cited 2019 Nov 13];34:76-8. Available from: http://www.indianjurol.com/text.asp?2018/34/1/76/221964



   Introduction Top


Female urethral injuries are uncommon and are associated with concurrent vaginal laceration in 75%–87% cases [1] and concurrent rectal injuries in 33% cases.[2] Complete avulsion or disruption of the vagina along with urethral injury is extremely rare. Blood at the vaginal introitus or the presence of a rectal injury in combination with a pelvic fracture should prompt the physician to consider a diagnosis of a female urethral injury. If expertise is available, immediate exploration is advocated as delay compromises the already short female urethra due to fibrosis, limiting the options.[3] The management is poorly defined, and the timing of repair is controversial with limited options. We report a case of complex urethrovaginal avulsion in a girl with a delayed presentation and discuss the challenges faced in restoring her urethral function and future sexuality.


   Case Report Top


A 10-year-old girl presented to our outpatient department as a neglected case of pelvic fracture with urethrovaginal injury with complaints of inability to pass urine per urethra. Following trauma, 6 months earlier, pelvic fracture fixation and urinary diversion in the form of suprapubic cystostomy was performed. The patient had no associated systemic injuries. On examination, the introitus was narrow to the extent that it did not admit even the tip of the little finger. The urethral meatus was found to be completely obliterated with just a pit at the site. Ultrasound revealed features of cystitis with normal upper tracts. Cystogram and computed tomography scan [Figure 1]a and [Figure 1]b revealed complete obliteration of the urethra beyond the level of bladder neck and communication with a cavity-an avulsed proximal portion of the vagina. On vaginoscopy, obliterated vagina was found.
Figure 1: (a and b) Preoperative cystogram and computed tomography films showing complete obliteration of the urethra beyond the level of bladder neck and communication with proximal obliterated vaginal cavity. (c) Postoperative Micturating CystoUrethrogram at 6-month follow-up

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Exploration was performed in lithotomy position with a lower midline incision given for ease of access to both bladder and vagina. A partial transpubic approach for access to the bladder neck and urethra was planned. Upon performing a cystotomy, the bladder was found to be normal. The obliterated proximal end of the urethra [Figure 2]a was identified by inserting a dilator through the bladder neck and dissecting the area of fibrosis. It was communicating with proximal vaginal cavity and was found to be dilated and completely obliterated [Figure 2]b. The obliterated distal vagina was then approached perineally; the proximal vaginal cavity pulled through and anastomosed circumferentially to the introitus with 3–0 interrupted vicryl sutures. A space was created behind the pubic arch using blunt dissection with a right angle forceps up to the base of clitoris where obliterated urethral meatus was situated. The defect measured 4 cm in length. A rectangular bladder mucosal strip was harvested as a free graft through the prior cystotomy [Figure 3]a and tubularized over a 14Fr Foley catheter to create a neourethra [Figure 3]b. Its distal end was wrapped with omentum and brought through a new opening in the introitus [Figure 3]c. Postoperative recovery was uneventful and the catheter was removed after 4 weeks. The patient was continent and voiding well at 2 years [Figure 1]c. She required vaginal dilatation twice before vaginal anastomosis became stable.
Figure 2: (a and b) Intact bladder neck, obliterated proximal urethra, no communication found with uterus. The vaginal cavity identified communicating with the proximal urethra

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Figure 3: (a) Bladder mucosa selected for tubularized free graft. (b) Tube being stitched to the proximal urethra. (c) Distal end of tube being brought down and wrapped with omentum

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   Discussion Top


Incidence of urethral injuries in females with pelvic fracture is about 4.5%–6%. Concomitant vaginal laceration/tear occurs in 75%–87%[1] of the cases, and urethrovaginal fistula is a very rare presentation. Preliminary diversion with a suprapubic cystostomy without any treatment of the urethra will invariably result in either a urethral stricture, urinary fistula, or both. Delayed urethral repair and establishment of urinary continence by bladder neck reconstruction, sling, or artificial urinary sphincter placement can be associated with incontinence, urethral erosion with fistula formation, or proximal urethral obliteration. It is usually feasible to provide a single-stage reconstruction with optimal outcomes in most patients.[4]

The procedure for urethral reconstruction must be carefully selected based on clinical limitations. End-to-end anastomosis is considered the gold standard wherever feasible. We used an anterior bladder mucosal tube to construct the entire urethra as sufficient labial and vaginal tissue were scarce and the opened bladder was readily available for graft retrieval. Knowledge of the facts that tubularized free buccal mucosal graft, devoid of any muscular backing, has been successfully used in the past for replacing fibrotic female urethra and formation of supple neourethra [5] and that bladder mucosa tube has been successfully used in anterior urethral strictures in males [6] encouraged us to use bladder mucosal tube in this case. The tube was covered as low as possible with omentum as it has a rich vascular and lymphatic supply which contributes to healing despite infection.[7] Blaivas and Heritz [8] have reported the use of bladder tube in one patient who presented with anatomical damage to the urethra or vesical neck. Tanhago anterior bladder flap has been described as a reasonable option wherein continence is achieved without suspension and the whole urethra can be created; we did not consider it because our patient had an intact proximal urethra. Modified Young-Dees repair and vaginal flaps are other options that have been used for continent female urethral reconstruction. Transpubic approach has been recommended for patients with complete urethral disruption and severe urethral stricture, especially when associated with urethrovaginal fistula.[9] In difficult complicated posttraumatic urethral injuries, very limited options are available and bladder mucosal tube should be recommended when extensive urethral tissue is lost.


   Conclusion Top


Preservation of continence, urethral patency, and sexual function are the long-term challenges in females with complex urethral injuries. The surgeon should be familiar with multiple reconstructive options to provide the most suitable procedure. Bladder tube is an excellent choice for complete urethral loss in young girls where end-to-end anastomosis is not possible and vaginal and labial tissue is inadequate to raise a flap.

Declaration of patient consent

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

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

 
   References Top

1.
Podestá ML, Jordan GH. Pelvic fracture urethral injuries in girls. J Urol 2001;165:1660-5.  Back to cited text no. 1
    
2.
Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int 1999;83:626-30.  Back to cited text no. 2
[PUBMED]    
3.
Dorairajan LN, Gupta H, Kumar S. Pelvic fracture-associated urethral injuries in girls: Experience with primary repair. BJU Int 2004;94:134-6.  Back to cited text no. 3
[PUBMED]    
4.
Wadie BS, Elhifnawy A, Khair AA. Reconstruction of the female urethra: Versatility, complexity and aptness. J Urol 2007;177:2205-10.  Back to cited text no. 4
[PUBMED]    
5.
Park JM, Hendren WH. Construction of female urethra using buccal mucosa graft. J Urol 2001;166:640-3.  Back to cited text no. 5
[PUBMED]    
6.
Ozgök Y, Ozgür Tan M, Kilciler M, Tahmaz L, Erduran D. Use of bladder mucosal graft for urethral reconstruction. Int J Urol 2000;7:355-60.  Back to cited text no. 6
    
7.
Wein AJ, Malloy TR, Greenberg SH, Carpiniello VL, Murphy JJ. Omental transposition as an aid in genitourinary reconstructive procedures. J Trauma 1980;20:473-7.  Back to cited text no. 7
[PUBMED]    
8.
Blaivas JG, Heritz DM. Vaginal flap reconstruction of the urethra and vesical neck in women: A report of 49 cases. J Urol 1996;155:1014-7.  Back to cited text no. 8
[PUBMED]    
9.
Huang CR, Sun N, Wei-Ping, Xie HW, Hwang AH, Hardy BE, et al. The management of old urethral injury in young girls: Analysis of 44 cases. J Pediatr Surg 2003;38:1329-32.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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