TRAUMA URETHRA

KHENZA NUR HASANAH

 Anatomi
urethra

Anterior Posterior
(bulbous&pen (prostatic
dulous &membranous
portions) portions)
 has been reported to occur in approximately 10% of males
 Insidensi terbanyak pada and up to 6% of females sustaining pelvic fractures
laki-laki

 Urethral disruption injuries

typically occur in conjunction with
multisystem trauma from
vehicular accidents, falls,or
industrial accidents

 pelvic fractures / straddle

type falls
TRAUMA URETRA POSTERIOR

Pars prostastika
Uretra
Posterior Pars SERING
membaranosa TERJADI
CIDERA

Trauma tumpul  Fraktur pelvis Melewati pelvic

floor and
Because the posterior urethra is densely adherent to voluntary
the pubis via both the urogenital diaphragm and the urinary
puboprostatic ligaments, the bulbomembranous sphincter
junction is more vulnerable to injury during pelvic
fracture than is the prostatomembranous junction
Tanda dan Gejala
TANDA GEJALA
Darah pada meatus urethra externum Nyeri perut bawah
Suprapubis tenderness Tidak bisa berkemih/ retensi urin
Fraktur pelvis
Kontusio pada daerah suprapubik/
perineal Riwayat
RT: prostat bergeser ke superior ( lig. crushing
Puboprostatik tidak intak) injury
NOTE!
Pemasangan kateter tidak
diperbolehkan karena akan
menyebabkan infeksi pada
URETROGRAFI
periprostatik,hematom perivesikal, dan
mengubah laserasi inkomplit menjadi
laserasi komplit
URETROGRAFI
 When blood at the urethral meatus is discovered, an immediate retrograde
urethrogram should be performed to rule out urethral injury

A small-bore urethral catheter (16 Fr) is placed

unlubricated 1 cm into the fossa navicularis, and the
balloon is filled with 1 cm of water.
Alternatively, a Brodney clamp or rolled gauze bandage
can be used to provide penile traction. Patients should be
placed in an oblique or lateral decubitus position, and it is
preferable to perform the study under fluorography when it
is available; 25 mL of contrast medium is injected gently
by a 60-mL catheter-tip syringe, and the film is taken
during injection.
 Kontras 20-30 ml
URETROGRAFI ( water soluble)

Ekstravasasi pada
prostatousmembranous
junction
Diagnosis banding

 Ruptur uretra posterior bersamaan dengan ruptur VU ( 20%

kasus )
Komplikasi
 Erectile Dysfunction/ impotensi
up to 82% of patients with pelvic fracture and urethral distraction
injury although the average reported rate is approximately 50%.
 The etiology is multifactorial and variably attributed to cavernous
nerve injury, arterial insufficiency, venous leak, and direct
corporeal injury
 Because impotent patients may be more vulnerable to restenosis
after posterior urethroplasty as a result of bulbar urethral
ischemia, some experts have suggested that “at-risk” patients
undergo preoperative penile arterial duplex Doppler studies to
identify candidates suitable for initial penile revascularization.
 Recurrent Stenosis.
After posterior urethroplasty, 5% to 15% of patients have
recurrent stenosis at the anastomosis). Fortunately, endoscopic
treatment (e.g., with direct vision internal urethrotomy) is often
successful in this setting.because the majority of fibrotic tissue
has been eliminated
 Incontinence.
Incontinence rates after reconstruction are surprisingly low,
less than 4% .
 TERAPI
Initial Management
1. Immediate Open Reconstruction.
Rekontruksi anastomosis segera  ruptur uretra posterior ditinggalkan  outcome yang
tidak memuaskan, impotensi, inkontinensia, striktur, kehilangan darah saat operasi

In cases of female urethral disruption related to pelvic fracture, most authorities suggest
immediate primary repair, or at least urethral realignment over a catheter, to avoid
subsequent urethrovaginal fistulas or urethral obliteration

2. Delayed reconstruction
is problematic because the female urethra is too short (about 4 cm) to be amenable
for mobilization during an anastomotic repair when it becomes embedded in scar
however, the authors have found that a suprapubic approach with partial pubectomy
provides excellent exposure enabling female bladder neck reconstruction
3. Suprapubic Cystostomy.
This may be accomplished through a small infraumbilical incision, which
allows inspection and repair of the bladder and proper placement of a
large-bore catheter at the bladder dome.

memungkinkan resolusi hematoma panggul, dan prostat

Pertahankan
dan kandung kemih perlahan akan kembali ke posisi
3 bulan
anatomi

Laserasi
inkomplit :
2-3 minggu
4. Primary Realignment
 An attempt at primary realignment of the distraction with a urethral
catheter is reasonable in patients whose condition is stable, either
acutely or within several days of injury. The authors prefer a simple
technique consisting of passage of a coudé catheter antegrade from an
anterior cystotomy to the urethral meatus, then tying it to another
catheter that is drawn back into the bladder.

A variety of more elaborate approaches have been described,
frequently with retrograde and anterograde flexible cystoscopes
although the authors have observed that prolonged endoscopic
realignment attempts risk infection of the pelvic
 When the urethral catheter is removed after 4 to 6 weeks, it is
imperative to retain a suprapubic catheter because many patients
will, despite realignment, develop posterior urethral stenosis. If the
patient voids satisfactorily through the urethra, the suprapubic catheter
can be removed 7 to 14 days later.
 Primary realignment may sometimes allow healing
without stricture, but mild stenosis 1 to 2 cm in length develops in many
patients

 Complex Injuries
Some authors advocate open exploration with realignment in
cases of high-riding or “pie-in-the-sky” bladder or associated
bladder neck tear in males .
Associated rectal injuries require open exploration, repair, irrigation, and
placement of drains.
2. rekontruksi uretra
terlambat / Delayed Dilakukan dalam waktu 3
urethral bulan (tidak ada abses
panggul / infeksi panggul
reconstruction
yang persisten)

Sebelum

px gabungan
cystogram dan
urethrogram
 untuk menengetahui panjang striktur
uretra
 Penyempitan ini biasanya 1-2 cm dan
terletak tepat di belakang tulang pubis
1. Delayed recontruction
At 3 months, scar tissue at the urethral disruption site is stable
enough to allow posterior urethroplasty to be undertaken safely,
provided that associated injuries are stabilized and the patient is
ambulatory. Suprapubic cystostomy drainage should be maintained until
the associated injuries have healed and the patient can be appropriately
positioned for the reconstructive procedure
2. Preoperative Evaluation.
 Before the reconstructive procedure is planned, imaging studies are
necessary to delineate the characteristics of the urethral rupture defect.
 A cystogram and retrograde urethrogram should be obtained
simultaneously. The patient is asked to attempt to void with the bladder
filled. Ideally, the prostatic urethra should be visualized as the bladder
neck opens, enabling measurement of the distance between the severed
urethral ends. Should the bladder neck not open, flexible endoscopy
should be used to supplement
radiographic imaging.
 MRI has been used successfully to define defect length and to determine
the extent and direction of
urethral dislocation and the extent of prostatic displacement, and it may
help in planning the surgical approach
3. Endoscopic Treatments.
 Endoscopic treatments such as direct-vision internal urethrotomy are best
reserved for selected short urethral stenoses, such as partial distraction
injuries for which early catheterization achieved urethral continuity. In
most cases, when preoperative evaluation indicates defects 1 cm or longer,
endoscopic procedures such as cutting through the pelvic scar to provide a
channel between the two ends of the avulsed urethra (“cut-to-the-light”
procedure) are ineffective and have no advantage other than reduced operative
time. moreover, aggressive endoscopic treatments have been associated with
complications such
as coring of a false passage that inadvertently bypasses the bladder
neck
 Cut-to-the-light or similar corethrough procedures typically require multiple
urethrotomies or
long-term dilation by the patient or urologist to keep the channel
open. Inevitably, the fibrosis will contract, leading to difficult selfcatheterization,
false passage, and/or acute urinary retention. In such cases, a 3-month period of
“urethral rest” via suprapubic urinary diversion is advised before open
reconstruction
4. Surgical Reconstruction.
Open posterior urethroplasty
through a perineal anastomotic approach is the treatment of choice for
most urethral distraction injuries because it definitively cures the patient
without the need
TRAUMA URETRA ANTERIOR
 Stradle injury laserasi/ contusio dari uretra

involving all four pubic

rami and fractures
resulting in
both vertical and
rotational pelvic
instability are
associated with the
highest risk of urologic
injury
Tanda-tanda klinis cedera uretra anterior:
darah di meatus
hematoma perineum,
hematuria
dan retensi urin.
Di trauma berat, Buck fascia dapat terganggu,
menyebabkan darah dan ekstravasasi urin ke dalam skrotum
 Contusio Crush injury
uretra tanpa
gangguan
uretra
Patogenesis
Laserasi Cedera stradle yang
berat
uretra

Ekstravasasi urin

Tidak dikenali

Menyebar ke skrotum, penis, Memungkinkan

dan dinding abdomen terjadinya sepsis
 TANDA DAN GEJALA
TANDA GEJALA
Perineum lunak Nyeri local pada perineum Riwayat
jatuh
Discharge darah pada meatus
uretra eksterna
RT : prostat normal
 Pemberian kontras
Uretrogram
15-20 ml

Ekstravasasi dan
lokasi cidera
KOMPLIKASI

Infeksi dan sepsis debridemen dan drainage

Striktur pada lokasi tidak perlu rekontruksi bedah jika tidak ada
cidera penyempitan secara signifikan yang dapat
mengurangi laju aliran urin
 TERAPI
.

1. Kontusio uretra Post

(tidak ada bukti uretrografi
terdapat ekstravasasi
urin, uretra intak )

Pasien dapat
berkemih

Tidak
perdarahan
perdarahan

tidak drainage
dilakukan kateter
penatalaks uretra
anaa
 Laserasi
uretra

instumentasi
uretra dengan
uretrografi harus
di hindari
membuat sayataan kecil
cystotomi pada garis tengah
suprapubik suprapubik sehingga
tabung cystotomi dapat
masuk

ekstravasasi kecil 
dapat berkemih dalam
Laserasi uretra 7 hari setelah
dengan pemasangan
ekstravasasi urin suprapubik cystotomi
yang luas
Cedera yang lebih
melibatkan perineum, skrotum, dan perut bagian bawah luas 2-3 minggu
 Perbaikan segera

Perbaikan laserasi uretra segera dapat dilakukan, tetapi

prosedurnya sulit dan insiden striktur terkait tinggi
TERIMAKASIH
 Initial suprapubic cystostomy is the standard of care for major
straddle injuries involving the urethra. however, primary anterior urethral
realignment has shown promising results with respect to stricture rate and
erectile dysfunction in patients with straddle injuries of lesser magnitude.
Primary surgical repair is recommended for low-velocity urethral gunshot
injuries
 catheter alignment alone is associated with a far worse stricture rate
 Debridement of the corpus spongiosum after trauma should be limited
because corporeal blood supply is usually robust, enabling spontaneous
healing of most contused areas. Initial suprapubic urinary diversion is
recommended after high-velocity gunshot wounds to the
urethra, followed by delayed reconstruction.