Pelvic fracture urethral injuries in girls

Purpose: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferent ial rupture. When disruption has occurred at the level of the proximal uret hra, it is usually complete and often associated with vaginal laceration. W e retrospectively reviewed the records of a series of girls with pelvic fra cture urethral stricture and present surgical treatment, to restore urethra l continuity and the outcome. Materials and Methods: Between 1984 and 1997, 8 girls 4 to 16 years old (me dian age 9.6) with urethral injuries associated with pelvic fracture were t reated at our institutions. Immediate therapy involved suprapubic cystostom y in 4 cases, urethral catheter alignment and simultaneous suprapubic cysto stomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with uret hral avulsion at the level of the bladder neck and in 5 with a proximal ure thral distraction defect, while a neourethra was constructed from the anter ior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Co ncomitant vaginal rupture in 7 cases was treated at delayed urethral recons truction in 5 and by primary repair in 2. The surgical approach was retropu bic in 3 cases, vaginal retropubic in 1 and vaginal-transpubic in 4. Associ ated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 y ears). Results: Urethral obliteration developed in all patients treated with supra pubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and, substitution urethroplasty was 100 %. In 1 girl complete urinary incontinence developed, while another has mil d stress incontinence. Retrospectively the 2 incontinent girls had had an a ssociated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of late ral labial flaps. Conclusions: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck da mage after traumatic pelvic fracture injury in female pediatric patients. A lthough our experience with the initial management of these injuries is lim ited, we advocate early cystostomy drainage and deferred surgical reconstru ction when life threatening clinical conditions are present or extensive tr aumatized tissue in the affected area precludes immediate ideal surgical re pair.