Management of complex and redo cases of pelvic fracture urethral injuries

Objectives:Pelvic fracture urethral injuries(PFUI)result from traumatic disruption of the urethra.A significant proportion of cases are complex rendering their management challenging.We described management strategies for eight different complex PFUI scenarios.Methods:Our centre is a tertiary referral centre for complex PFUI cases.We maintain a prospective database(1995e2016),which we retrospectively analysed.All patients with PFUI managed at our institute were included.Results:Over two decades 1062 cases of PFUI were managed at our institute(521 primary and 541 redo cases).Most redo cases were referred to us from other centres.Redo cases had up to five prior attempts at urethroplasty.We managed complex cases,which included bulbar ischemia,young boys and girls with PFUI,PFUI with double block,concomitant PFUI and iatrogenic anterior urethral strictures.Bulbar ischemia merits substitution urethroplasty,most commonly,using pedicled preputial tube.PFUI in young girls is usually associated with urethrovaginal fistula.Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach.Our success rate with individualised management is 85.60%in primary cases,79.13%in redo cases and 82.40%in cases of bulbar ischemia.Conclusion:The definition of complex PFUI is ever expanding.The best chance of success is at the first attempt.Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

Open pelvic fractures associated with anorectal injuries:emergency management strategies and risk factors for mortality

Objective To investigate emergency management strategies and risk factors for mortality of open pelvic fractures associated with anorectal injuries.Methods Between April 2001 to April 2010,25 patients of openpelvic fractures

A survey of emergency blunt urethral injury management in China:Reality versus guidelines

Background:Although urethral trauma may lead to serious consequences if mismanaged,treatment concepts are inconsistent.We designed a survey to investigate the current diagnosis and management of emergency blunt urethral trauma to aid future dissemination of relevant concepts.Methods:A 15‐item anonymous questionnaire was distributed via an online platform.It addressed items such as the cognition of how to diagnose of urethral trauma,optimal emergency management of a urethral trauma patient,and attitude towards early realignment for pelvic fracture urethral injuries.Results:Of 538 respondents,94.2%and 84.9%had received patients with straddle trauma urethral injuries or pelvic fracture urethral injuries,respectively,within the past year.In the emergency room,attempted urethral catheterization was the most selected examination method by respondents for diagnosis of both straddle injury(500/538)and pelvic fracture urethral injury(469/538).For patients with straddle injury,41.3%of respondents performed endoscopic realignment and 31.6%preferred suprapubic cystostomy.For hemodynamically stable patients with PFUI,42.2%of respondents preferred suprapubic cystostomy and 34.9%preferred endoscopic realignment.Most respondents felt favorably toward early realignment for pelvic fracture urethral injuries.After realignment,61.3%,24.5%,and 13.8%of respondents performed catheterization for 4,8,and 12 weeks,respectively.Further,54.6%of respondents believed catheter traction should be applied after realignment.Conclusion:Although the number of yearly emergency urethral trauma cases was small,the opinions and practices of most urologists were consistent with guidelines.However,the significance of retrograde urethrography was not fully understood,and some respondents had incorrect views on catheter traction after realignment.

Percutaneous Sacroiliac Screw Placement： A Prospective Randomized Comparison of Robot？assisted Navigation Procedures with a Conventional Technique

Background： Sacroiliac （SI） screw fixation is a demanding technique, with a high rate of screw malposition due to the complex pelvic anatomy. TiRobot- is an orthopedic surgery robot which can be used for SI screw fixation. This study aimed to evaluate the accuracy of robot-assisted placement of SI screws compared with a freehand technique. Methods：Thirty patients requiring posterior pelvic ring stabilization were randomized to receive freehand or robot-assisted SI screw fixation, between January 2016 and June 2016 at Beijing Jishuitan Hospital. Forty-five screws were placed at levels S1 and S2. In both methods, the primary end point screw position was assessed and classified using postoperative computed tomography. Fisher＇s exact probability test was used to analyze the screws＇positions. Secondary end points, such as duration of trajectory planning, surgical time after reduction of the pelvis, insertion time for guide wire, number of guide wire attempts, and radiation exposure without pelvic reduction, were also assessed. Results： Twenty-three screws were placed in the robot-assisted group and 22 screws in the freehand group; no postoperative complications or revisions were reported. The excellent and good rate of screw placement was 100% in the robot-assisted group and 95% in the freehand group. The P value （0.009） showed the same superiority in screw distribution. The fluoroscopy time after pelvic reduction in the robot-assisted group was significantly shorter than that in the freehand group （median [Q1, Q3]： 6.0 [6.0, 9.0] s vs. median [Q1, Q3]： 36.0 [21.5, 48.0] s; χ2 = 13.590, respectively, P 〈 0.001）; no difference in operation time after reduction of the pelvis was noted （χ2 = 1.990, P = 0.158）. Time for guide wire insertion was significantly shorter for the robot-assisted group than that for the freehand group （median [Q1, Q3]： 2.0 [2.0, 2.7] min vs. median [Q1, Q3]： 19.0 [15.5, 45.0] min; χ2 = 20.952, respectively, P 〈 0.001）. The number of guide wire attempts in the robot-assisted group was significantly less than that in the freehand group （median [Q1, Q3]： 1.0 [1.0,1.0] time vs. median [Q1, Q3]： 7.0 [1.0, 9.0] times; χ2 = 15.771, respectively, P 〈 0.001）. The instrumented SI levels did not differ between both groups （from S1 to S2, χ2 = 4.760, P = 0.093）. Conclusions： Accuracy of the robot-assisted technique was superior to that of the freehand technique. Robot-assisted navigation is safe for unstable posterior pelvic ring stabilization, especially in S1, but also in S2. SI screw insertion with robot-assisted navigation is clinically feasible.