The significance of the open bladder neck associated with pelvic fracture urethral distraction defects

Purpose: As a result of pelvic fracture urethral distraction defects, urina ry continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before uret hroplasty, the probability of postoperative urinary incontinence may be sig nificant. Unresolved issues are the necessity, the timing and the type of b ladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladde r neck. We also attempt to identify prognostic factors of incontinence befo re urethroplasty. Materials and Methods: We retrospectively reviewed the records of 15 patien ts with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. Results: Of the 15 patients 6 were continent and 8 were incontinent postope ratively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder n eck reconstruction, 1 artificial urinary sphincter and 1 periurethral colla gen implant. Five patients with bladder neck reconstruction are totally con tinent and 1 requires 1 pad daily. The patient who underwent collagen impla nt requires 2 pads daily and the patient who received an artificial urethra l sphincter has minor urge leakage. Conclusions: Open bladder neck before urethroplasty may herald postoperativ e incontinence which may be predicted by radiographic and cystoscopic featu res. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral dis traction defects and bladder neck problem sequentially. Bladder neck recons truction provides good postoperative continence rates and is our technique of choice.