LUTS (2014)
CASE REPORT
Bladder Neck Rupture and Vesicovaginal Fistula Associated with Pelvic Fracture in Female Koji ICHIHARA,1,∗ Naoya MASUMORI,1 Satoshi TAKAHASHI,1 Noriomi MIYAO,2 and Ryuichi KATO2 1
Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan and 2 Department of Urology, Muroran General City Hospital, Muroran, Japan
Case: Female urethral injury or bladder neck rupture associated with pelvic fracture is rare. The experience of this injury is limited and the management is still challenging. Here we describe a young female patient with urethral injury and vesicovaginal fistula associated with pelvic fracture due to traffic accident. We discuss the recommendation and management about this problem. Outcome: We selected staged surgical management for this case, and fortunately succeeded in the repair of the urethral and vaginal injury and acquired favorable continence. Conclusion: Appropriate management should be selected according to the condition in each patient. But it should be taken into consideration that a patient with pelvic fracture is critically ill, and an experienced urologist of this field is not always available at that time. Key words pelvic fracture, urethra, vesicovaginal fistula, wound and injuries 1. INTRODUCTION
Injury to the female urethra or bladder neck rupture associate associ ated d wit with h pel pelvic vic fra fractu cture re is rar rare. e. In the lit litera eratur ture, e, the incidence of this type of trauma was reported to be about 6%.1 Since the experience of the initial management of thiss pro thi proble blem m is lim limite ited, d, the man manage agemen mentt of ure urethr thral al inj injury ury in femal female e has not been standardize standardized. d. Most reports reports2 – 4 have focused on the challenges of managing the injured female urethra. Here we report our experience with a case cas e in a fem female ale pat patien ientt who suffere suffered d fr from om pro proxim ximal al urethral injury (bladder neck rupture) and vesicovaginal fistula associated with pelvic fracture by traffic accident. In add additi ition, on, we int intens ensive ively ly dis discu cuss ss the met method hod of the management both during and after surgery.
2. CASE REPORT
A 15-year-old girl presented at a previous hospital ER after a motor vehicle accident. After resuscitation at ER and treatment for pelvic fracture at the operating room, a placem pla cement ent of a ure urethr thral al cat cathet heter er was att attemp empted ted.. How Howeve ever, r, gross gro ss blo blood od ins instea tead d of uri urine ne was dra draine ined. d. In add additi ition, on, gen gen-ital bleeding was observed. So the ER doctor called a urologist and gynecologist, and an evaluation was performed under anest anesthesia hesia.. Intr Intravagi avaginal nal findin findings gs show showed ed lacer laceration ation in the ant anteri erior or vag vagina inall wal walll wit with h con connec nectio tion n to the bla bladde dderr neck, in effect, a vesicovaginal fistula (VVF). In addition, complete bladder neck rupture was detected. Then, they performed perfo rmed prima primary ry vagin vaginal al wall clos closure ure trans transvagin vaginally ally to control the bleeding and constructed suprapubic cystostom tos tomy. y. Two months months lat later, er, they ref referr erred ed her to our center to further evaluate and treat the injured urethra.
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2014 Wiley Publishing Asia Pty Ltd
We perf performed ormed re-evaluatio re-evaluation n of her condition condition under anesthesia. Saline solution with indigo carmine irrigated thro th roug ugh h cy cyst stos osto tomy my ca cath thet eter er wa wass le leak aked ed fr from om th the e anterior vaginal wall. The condition of VVF was about 10mm in di diam amet eter er an and d po posi siti tion oned ed 40mm fr from om th the e vaginal opening and anterior vaginal fornix. Antegrade and ret retrog rograd rade e cys cystou touret rethro hrosco scopy py sho showed wed tha thatt the uret ur ethr hra a wa wass bl blin indd-en end d at 40mm fr from om th the e ur uret ethr hral al meatus. Urethral Urethral sphincter was observed about 5– 10 mm distal dis tal fro from m the ure urethr thral al end end.. Ena Enable bled d ure urethr thral al len length gth was estimated to be 30 mm. Flexible cystoscopy cystoscopy arranged bladder neck dimple and metal sound at urethral end were wer e alm almost ost closed closed to eac each h oth other er wit with h mil mild d ten tensio sion n (Fig. (Fi g. 1). Based on the these se find finding ings, s, we per perfor formed med the closure of VVF and vesicourethral re-anastomosis. Retropubic Retro pubic extr extraperi aperitonea toneall appro approach ach was selec selected ted at first. firs t. How Howeve ever, r, Ret Retziu ziuss spa space ce sho showed wed rig rigid id adh adhesi esion. on. By tra transp nsperi eriton toneal eal app approa roach, ch, out outlin line e of the bla bladde dderr could be detected. VVF was identified and urethra was isolated using transurethral metal sound and transvaginal palpation. After resection of VVF together with scaring tissue, the vaginal wall defect was closed by two layers using absor absorbable bable sutur sutures. es. Vesi Vesicour couretera eterall neost neostomy omy was not necessary because the distance between the ureteral orifi or ifice ce an and d th the e ed edge ge of VV VVF F wa wass lo long ng en enou ough gh.. Ve Vesi si-courethral anastomosis and bladder neck reconstruction
∗
Correspondence:KojiIchihara,MD,DepartmentofUrology,SapporoMedical Correspondence: KojiIchihara,MD,DepartmentofUrology,SapporoMedical University Schoolof Medici University Medicine, ne, S1, W16 Chuo-k Chuo-ku, u, Sappor Sapporo o 060-8 060-8543,Japan. 543,Japan. Tel: +81-1181-11-611-2 611-2111 111 ext. 3472;Fax: +81-11-612-2709. Email:
[email protected] Receive Rece ived d 4 Dec Decemb ember er 201 2013;revise 3;revised d 5 Jan Januar uaryy 201 2014;accept 4;accepted ed 23Januar 23Januaryy 201 2014 4 DOI: 10.1111/luts.12056
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Koji Ichihara et al.
Fig. 1 Cystography showed that antegrade cystoscopy and retrograde metal sound were almost closed each other.
were performed in tension-free and water-tight fashions and finally 16 Fr urethral and 14 Fr cystostomy catheters were placed (Fig. 2). Three weeks after operation, voiding cystourethrogram (VCUG) was performed. She had slightly smaller bladder capacity because of the long catheter indwelling, but it was possible for her to void spontaneously and there was no sign of recurrent VVF. Therefore, we clamped the suprapubic cystostomy and the urethral catheter was removed. After that, she voided without trouble and we finally removed cystostomy. Eight months after the operation, her voiding condition was entirely favorable. The uroflowmetry showed that voided volume, maximal urinary flow rate and postvoided residual urine were 219mL, 34.5 mL/sec and 0 mL, respectively. There was no trouble in menstruation. 3. DISCUSSION
Female urethral trauma is divided into complete (avulsion) and incomplete (longitudinal) or partial injury.5,6 The occurrence of this trauma is very rare, and
(a)
(b)
there are no large series available. Therefore, there is still controversy for the timing of repair in injured female urethra. Some reports5,7 mention immediate repair should be selected in the case of injured mid-urethra and/or bladder neck and concomitant vaginal laceration, because female ruptured urethra may lead to complete obliteration due to surrounding tissue inflammation and dense scaring. On the other hand, some reports2,3 show that staged repair may be the best option because the condition of the patient is sometimes unstable and the construction of cystostomy allows pelvic hematoma reabsorption and reduction of tissue inflammation. We selected staged management in this case, because the patient condition was relatively ill, an experienced urologist in this field was not available and massive gross blood loss from urethra and vagina made it difficult to repair transvaginally. It has been thought that the timing of repair in injured female urethra is not related to satisfactory urinary control. It should be appreciated that the degree of preservation of the anatomical structure is important to urinary continence. In male cases, the strained sphincter is often injured in trauma and continence depends on the integrity of the bladder neck. On the other hand, the role of the bladder neck in continence is thought to be much less in female than in males.4 The urethra, in particular, mid-urethra contributes to continence. In our case, we fortunately succeeded in repair of the urethral and vaginal injury and acquired favorable continence. One of the reasons is thought that the defect of the injured urethra in this case was very short and enabled the urethral length and architecture of the bladder neck to be relatively maintained. The timing in removal of the urethral catheter after reconstruction was controversial. Previous reports 1 – 4 show several durations, which are from 10 days to 6 weeks in catheterization in each operative procedure. There is no recommendation when the catheter should be removed, but it is most commonly left for 3 weeks. Usually the patients have frequency just after urethral catheter removal due to long catheterization. In our case, we selected 3 weeks and acquired favorable voiding as
(c)
Fig. 2 The schema of operation procedure. (a) The urethra was isolated and vesicovaginal fistula (VVF) was identified (dotted line). (b) VVF with scaring tissue in 20 mm diameter was resected and the vaginal wall defect was closed by two layers with absorbable suture. (c) Vesicourethral anastomosis and bladder neck reconstruction were performed.
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2014 Wiley Publishing Asia Pty Ltd
Surgical Treatment for Female Urethral Injury
the result. Therefore, we think at least 3 weeks may be adequate for comfortable voiding. Female urethral injury is commonly associated with vaginal laceration. Therefore the management of vaginal injury is also important. Female urethral injury after pelvic fracture predominates in children and young adolescents. Appropriate repair can prevent vaginal stenosis that sometimes needs hysterectomy in the future. 8 Immediate surgical repair is usually recommended for female urethral injury, but staged management may not always lead to impairment of voiding function. Appropriate management should be selected according to the condition in each patient. However, it should be taken into consideration that a patient with pelvic fracture is critically ill, and an experienced urologist of this field is not always available at that time. Disclosure
The authors declare no conflict of interests.
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2014 Wiley Publishing Asia Pty Ltd
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REFERENCES 1. Black PC, Miller EA, Porter JR, Wessells H. Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J Urol 2006; 175 : 2140–5. 2. Hemal AK, Dorairajan LN, Gupta NP. Posttraumatic complete and partial loss of urethra with pelvic fracture in girls. An appraisal of management. J Urol 2000; 163: 282–7. 3. Podesta ML and Jordan GH. Pelvic fracture urethral injuries in girls. J Urol 2001; 165 : 1660–5. 4. Dorairajan LN, Gupta H, Kumar S. Pelvic fracture-associated urethral injuries in girls: experience with primary repair. BJU Int 2004; 94 : 134–6. 5. Bredael JJ, Kramer SA, Cleeve LK, Webster GD Traumatic rupture of the female urethra. J Urol 1979; 122 : 560–1. 6. Ahmed S, Neel KF. Urethral injury in girls with fractured pelvis following blunt abdominal trauma. Br J Urol 1996; 78 : 450–3. 7. Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992; 147 : 139–43. 8. Williams DI. Rupture of the female urethra in childhood. Eur Urol 1975; 1 : 129–33.
