PD44-07 PELVIC FRACTURE URETHRAL DISTRACTION DEFECT (PFUDD) WITH ASSOCIATED RECTAL INJURY: A REVIEW OF ACUTE AND DEFINITIVE UROLOGIC MANAGEMENT WITH LONG TERM OUTCOMES

INTRODUCTION AND OBJECTIVES: Bulbo-prostatic anastomotic urethroplasty (BPA) for urethral injuries associated with traumatic disruption of the pelvic ring is notoriously a surgical challenge, often requiring various manouvres to straighten the course of the bulbar urethra and bridge the resulting defect. There are however other factors which may render the reconstructive procedure more complex. This study investigates these factors. METHODS: 360 BPAs were performed in a single tertiary referral centre between October 1996 and October 2014. 77 (21%) were revision procedures. Mean patient age was 37.9 years. Mean follow-up was 51 months (range 9-115 months). Recurrence was defined radiologically and/or by the need for any further surgical intervention including dilatation or urethrotomy. RESULTS: 286 (79%) procedures were carried out transperineally (Step 1-4) while 74 (21%) required additional abdominal exposure to mobilise the bladder bladder base (n1⁄416), repair associated injuries (n1⁄441) or perform an entero-urethroplasty (n1⁄417). 29 of 74 (39%) abdomino-perineal (AP) procedures were revisions. 48 of 77 revisions (62%) were performed via a transperineal approach. The restricture rate was higher for revision procedures compared to primary ones when approached transperineally (15% vs 8%) but not for AP procedures (21% in both primary and revision cases). Overall, the recurrence rate for AP procedures was 21% compared to 9% for the transperineal approach. Associated bladder neck injury (n1⁄418), uro-rectal/perineal fistulae (n1⁄415), perineal degloving injury (n1⁄46), anterior urethral stricture (n1⁄419) and osteomyelitis/pelvic sepsis (n1⁄410) were identified as factors adding complexity to the procedure. CONCLUSIONS: A longer defect and revisional surgery often require corporal separation, inferior wedge pubectomy and rerouting of the urethra around the crura in a stepwise fashion in order to guarantee a tension-free anastomosis. These render the procedure more difficult but do not necessarily imply increasing complexity. Factors necessitating a change in approach (usually but not exclusively requiring additional abdominal exposure) to deal with multiple pathologies such as the need for bladder neck reconstruction or concominant anterior urethral strictures are what render the procedure complex.