Management of pelvic fracture urethral injury

Authors: Pankaj Mangalkumar Joshi, Meritxell Costa-Grau, Pawan Kandhari, Saurabh Mahesh Thakkar, Emmanuel Ugbede Oyibo, Jimena Navarro, Sanjay Balwant Kulkarni

Abstract

Pelvic fracture urethral injury (PFUI) represents one of the most challenging entities in reconstructive urology. It predominantly affects the bulbomembranous junction because of its anatomical vulnerability to shearing and compression forces during pelvic trauma. These injuries often result from high-energy accidents, with associated pelvic instability and concomitant injuries, and frequently necessitate a multidisciplinary initial approach. Early management typically involves prompt suprapubic cystostomy (SPC) to divert urine, prevent further contamination, and allow stabilization of the patient. Delayed urethroplasty (DU) remaining the gold standard for definitive repair once the acute phase has resolved. Delayed repair most commonly consists of a perineal bulbomembranous anastomosis (BMA), a technique that has been extensively described and refined over decades, providing a tension-free anastomosis with consistently high success rates. In severe cases, however, where there is significant pelvic disruption, extensive urethral gaps, or difficult access due to scarring, an abdominoperineal approach may be required to achieve adequate exposure, mobilization, and excision of scar tissue. Complex PFUI scenarios, defined by dense periurethral fibrosis, long-segment defects, associated fistulae, or concomitant bladder neck injury, demand more advanced reconstructive strategies and are associated with lower success rates compared with primary BMA. Redo urethroplasty represents an even greater challenge due to altered anatomy, impaired vascularity, and a lack of healthy tissue available for mobilization. Common factors contributing to surgical failure include inadequate excision of fibrotic tissue, insufficient mobilization of the bulbar urethra, and poor tissue quality at the anastomotic site. When bulbar urethral necrosis (BUN) occurs or when the urethral gap cannot be bridged primarily, substitution techniques become necessary. Among these, the pedicled preputial tube has emerged as one of the most widely described and effective options, offering a robust vascularized tissue for reconstruction and demonstrating favorable long-term outcomes. Successful PFUI management therefore relies on individualized planning that integrates detailed preoperative imaging and refined surgical techniques tailored to the specific extent and complexity of the injury.

Introduction

Pelvic fracture urethral injury (PFUI) represents one of the most complex and debated challenges in reconstructive urology. Most PFUIs are located at the bulbomembranous junction, a region particularly vulnerable due to its anatomy. The membranous urethra’s close relationship with the pubic rami and symphysis, combined with its stabilization by the puboprostatic ligaments and the urogenital diaphragm, makes it particularly vulnerable. The mechanism behind these injuries typically involves compression or shearing forces at the bulbomembranous junction, which can result in the partial or complete avulsion of the urethra from the fixed urogenital diaphragm. This traumatic disruption complicates both the injury and subsequent surgical repair, necessitating specialized surgical expertise and tailored treatment approaches (1-3).

Over the years, the management of PFUIs has evolved to include a range of surgical approaches, each with specific indications, advantages, and limitations. These strategies can be divided in primary or delayed surgeries, including endoscopic repair or realignment and posterior urethroplasties (1,2,4). The two most common techniques used are primary realignment and suprapubic cystostomy (SPC) with delayed urethroplasty (DU). In this review, we provide a brief analysis of these management options, focusing on DU techniques and complex cases. Additionally, we will present and describe our institutional (Urokul Institute) data, highlighting our experience with complex PFUI repairs, including pediatric urethroplasties, female urethroplasties, and repeat surgical repairs, while emphasizing the anatomical and functional challenges associated with each scenario.

Acute management PFUI: emergency room management

PFUI are commonly associated with severe trauma, often requiring a multidisciplinary approach for optimal management (1,2,4). While urethral injury itself is not life-threatening, its occurrence alongside pelvic fractures and other organ injuries is associated with longer hospital stays and increased mortality rates. Therefore, initial medical management should prioritize resuscitation and stabilization of the patient, followed by the identification and treatment of all associated injuries (4,5).

Once a urethral injury is identified, prompt bladder drainage is essential to prevent urinary retention, extravasation, and secondary infection. In unstable patients, retrograde urethrography (RGU) should be delayed until hemodynamic stabilization is achieved, and SPC should be placed (5). An attempt at gentle urethral catheterization may be performed by experienced personnel. If unsuccessful, SPC should be placed under ultrasound guidance or direct vision, for example, during laparotomy for associated injuries (4).

Primary surgical repair

The concept of primary anastomotic repair for PFUIs was first introduced by Young in 1929 and involved immediate primary repair of the ruptured urethra via a perineal approach (6). This method was designed to evacuate the pelvic hematoma and establish a watertight repair of the urethra, aiming to prevent urine extravasation and mitigate complications such as infection. After this method was abandoned, a retroperitoneal approach was being reported. However, these techniques are no longer used in modern practice due to its associated risks, including substantial blood loss, moving to suprapubic tube catheterization and DU (6-10). Currently, primary surgical repair is only considered in really complex situations that include other concurrent injuries, such as bladder neck or rectal injuries that require immediate open surgical intervention (7,8,10).

Primary urethral realignment (PUR)

PUR involves repositioning and aligning the injured urethra without performing an immediate definitive repair. This technique aims to restore urethral continuity by reapproximating the urethral ends and maintaining a catheter for 3–6 weeks (10-13). That catheterization will allow the healing process while minimizing complications associated with more invasive surgical procedures. Over the years, PUR has evolved from open to endoscopic approaches, each with its own advantages and limitations (10,14-17). Typically performed within 24–96 hours following a pelvic fracture, PUR remains a subject of debate compared to suprapubic catheter placement with DU.

Open urethral realignment, initially described by Ormond and Cothran in 1934 (11), involves catheter placement through various methods such as sound-to-sound or retrograde placement under direct vision (10,17). Though initially favored for its simplicity, this approach often results in extensive periurethral mobilization, leading to significant fibrosis at the injury site or blood loss, being now substituted by endoscopic PUR.

Modern endourological techniques introduced in the 1980s, incorporating transurethral and transvesical approaches with fluoroscopic guidance, provided an alternative for open realignment. Currently, endoscopic PUR is the preferred approach, utilizing either retrograde or combined antegrade/retrograde methods (10,11,17). In the retrograde approach, a flexible cystoscope is advanced to the site of injury, a guidewire is passed into the bladder, and a catheter is placed over the guidewire. The combined approach uses fluoroscopic guidance, with two cystoscopes advanced from both the proximal and distal urethral ends to facilitate guidewire placement and catheterization. While less invasive and minimizing periprostatic tissue disruption, endoscopic PUR is not without drawbacks. Many patients require subsequent procedures such as urethral dilations, direct vision internal urethrotomy, or urethroplasty (10,14,17).

The term realignment can be inaccurate, as these techniques primarily restore urethral continuity rather than true anatomical alignment. Misalignment frequently results in an epithelial-lined cavity at the injury site, leading to fibrosis and stricture formation. As a result, many patients require further interventions, including intermittent self-catheterization or urethroplasty, suggesting treatment failure in a significant subset (10,14-16,18).

The impact of realignment on subsequent urethroplasty remains a subject of debate. Some studies suggest that PUR does not significantly increase the complexity of later reconstructive surgeries or even it makes the procedure easier, indicating comparable outcomes to other management approaches (14,15). Leddy* et al. *support early urethral realignment using endourological techniques based on literature review and clinical experience (11). While PUR leads to high stricture recurrence rates around 53%, it may spare a number of patients from requiring additional surgery.

However, multiple studies report that the resulting fibrosis and scarring, particularly from both open and endoscopic realignment, may create significant challenges for DU (16-19). Mundy suggested that endoscopic realignment may negatively impact subsequent urethroplasty by extending the inflammatory fibrotic process along the urethra (19). Horiguchi also suggests that surgeons may need to deal with a heavily epithelialized cavity and dense scar tissue, which can increase the technical difficulty of the repair and potentially compromise surgical outcomes (18). Morey further emphasized that endoscopic PUR is associated with a high rate of complications, including prolonged self-catheterization (>6 months), increased failure rates following urethroplasty, and other adverse events such as abscesses or incontinence (20).

The efficacy of PUR may also depend on regional trauma care variations. Kulkarni* et al. *noted differing urethral complication rates between Indian and Italian cohorts, attributing these discrepancies to differences in trauma management, injury mechanisms, patient demographics, and associated non-pelvic injuries (21).

Despite potential benefits, no definitive evidence favors PUR over suprapubic catheterization with DU, which remains the standard of care in high-volume centers.

Primary SPC placement and DU

SPC followed by DU is the standard approach for managing PFUI (4,22). Originally proposed by Johanson in 1953 (2), SPC effectively achieves urinary diversion while avoiding entry into the fracture hematoma, thereby reducing the risk of infection and excessive blood loss. This approach allows for a well-planned elective surgical repair once the patient is stable (1,4,22). Concerns regarding SPC as an infection risk have been raised, but there is no clear evidence that it increases infection rates compared to urethral catheterization (23).

Following SPC alone, stricture formation occurs in nearly all the cases. After the SPC placement and stricture formation, bulbomembranous anastomosis (BMA) is the gold standard for PFUI reconstruction (1,2,4). BMA typically performed 3–6 months post-injury to allow hematoma resolution and healing of associated injuries. PFUI normally results in a fibrotic segment between the distracted urethral ends, necessitating its excision and end-to-end anastomosis.

BMA technique

The BMA technique is derived from the progressive perineal approach popularized by Webster in 1986 (24,25). This approach utilizes different individual techniques described by Webster, Paine and Waterhouse (24-27), to facilitate a tension free end-to-end primary anastomosis (EPA). Previously, in 1962, Pierce described the abdominal approach with pubectomy, which is also included in these techniques (28,29). We are going to describe in detail the BMA technique steps.

Patient positioning and anesthesia

The standard lithotomy position is commonly used for BMA, but some centers recommend the exaggerated lithotomy position to improve perineal visibility (30). Emerging evidence suggests that this position is associated with an increased risk of complications such as neuropraxia, rhabdomyolysis, ulcers, especially during prolonged hours (31,32). For this reason, some authors recommend using the exaggerated lithotomy position for enhanced access, but most of the authors prefer the standard lithotomy position (1,27,31).

Anesthesia usually is spinal for adults and general anesthesia for children. Antibiotic prophylaxis is administered based on urine culture results, and the perineum along with the subumbilical region is prepped as a unified surgical field. This preparation is often necessary, not only for the potential use of the suprapubic tract, but also in cases where progression into a combined perineo-abdominal procedure may be required (33-35).

BMA steps approach

Surgical approaches can be divided into different approaches. Simple perineal approach includes bulbar urethral mobilization and crural separation only, while elaborated or complex perineal approach incorporates inferior pubectomy and/or supracrural rerouting. Abdominoperineal approach is required when adequate access to the membranous urethra and prostate apex cannot be achieved using perineal techniques alone, sometimes necessitating suprapubic osteotomy with or without omentoplasty.

All surgical approaches start with a midline perineal incision, extending from the penoscrotal junction to about 1 cm from the anal verge (34-36). Some surgeons opt for an inverted “Y”-shaped lambda incision for additional exposure, though this may increase the risk of wound complications (37). This “Y”-shaped lambda incision can be needed in complex cases, as in PFUI combined with recto-urethral fistula (38). Following the perineal incision, different surgical steps are undertaken based on the specific needs and complexity of each case (1,2,34-37).

Step bulbar urethral mobilization

After the incision, the bulbospongiosus muscle is identified and split in the midline, allowing exposure of the bulbar urethra (Figure 1A). The bulbar urethral needs to be mobilized circumferentially up to the perineal diaphragm proximally and distally beyond the penoscrotal junction, being careful performing distal dissection that could cause penile chordee. Urethra is transected with the help of urethral sounds or catheters (Figure 1B) (39).

After urethral transection, the proximal urethral end can be identified by gently passing a urethral sound through the SPC tract. If identification is difficult, an antegrade cystoscopy can be done from the suprapubic tract to facilitate the identification (40). A sharp dissection is used to expose the normal membranous urethra, which is then dissected and spatulated. Complete excision of perineal fibrosis is critical, as inadequate removal of scar tissue is a leading cause of reconstruction failure (39).

Step crural separation

If proximal urethral identification is difficult due to the urethra being obscured behind the corpora cavernosa or the two urethral ends are apart to ensure a free tension anastomosis, crural separation is performed. The two corpora cavernosa are divided along the midline using sharp scissors or electrocautery, creating a virtual intercrural space (Figure 1C). This allows the distal mobilized urethra to pass between the crura, minimizing the anastomotic gap.

Step periosteum elevation and inferior pubectomy

When crural separation alone is insufficient for a tension-free anastomosis, inferior pubectomy usually is required. A wedge of the inferior pubic bone is excised using rongeurs after careful elevation of the periosteum.

Step 3 has been suggested by Joshi* et al. *to be divided into two sub-steps: step 3a, in which the surgeon restricts the dissection to the elevation of the periosteum without removing a wedge of pubic bone (Figure 1D), and step 3b, where an inferior pubectomy is carried out (Figure 1E) (35).

This subdivided step improves access to the proximal urethra while maintaining pelvic ring integrity (Figure 1F). Care is taken to identify and preserve or ligate the dorsal vein to avoid excessive bleeding and to prevent injury to the dorsal penile arteries that can compromise new anastomosis vascularization (34).

Step supracrural rerouting

If the urethral gap remains significant despite crural separation and inferior pubectomy, supracrural rerouting is considered. This involves creating a space between the left or right crura and the pubic bone. This will allow repositioning the urethra, thereby reducing the anastomotic tension (41).

Steps 5 and suprapubic osteotomy and omentoplasty

The abdominoperineal approach is required when adequate access to the membranous urethra and prostate apex cannot be achieved using perineal techniques alone. The abdominoperineal approach usually includes suprapubic osteotomy (step 5) with or without omentoplasty (step 6) to ensure a tension-free anastomosis (42).

Once a tension-free anastomosis is achieved, the healthy urethral ends are sutured together using 6–8 interrupted 4/0 or 5/0 multifilament or monofilament absorbable sutures in a parachute fashion (1,33). A 16 Fr silicone urethral catheter is placed and maintained for 3–4 weeks (34,39). A pericatheter urethrogram is usually performed before catheter removal to ensure a well-healed anastomosis (39).

Our 2020 publication on BMA urethroplasty reported an overall success rate of 84.9% in a cohort of 1,307 patients, with a median follow-up of 56.7 months (34). Expanding the cohort to 1,442 patients by 2024, the success rate remains consistent at 85.2%, with an extended follow-up period.

Preoperative evaluations for predicting surgical stage approach

Preoperative evaluation for PFUI relies on a multimodal imaging approach to assess the extent of injury, but it is still unclear if these findings can predict the steps needed at the surgery. Conventional radiological images include voiding cystourethrography (VCUG) via SPC tract and RGU. These studies can provide information regarding bladder neck integrity, urethral defect length, and the availability of bulbar urethra for reconstruction (Figure 2A,2B). However, as suggested by Andrich* et al.*, conventional urethrography has limitations in accurately delineating the bladder neck and prostatic urethra due to its two-dimensional representation of three-dimensional organs, thereby limiting its predictive value for surgical approach selection (43).

Koraitim proposed that the ratio of urethral gap length to total bulbar urethral length, referred to as the “gapometry-urethrometry index”, could serve as a more objective parameter for surgical planning. Additionally, he identified urethral gap length and prostatic displacement as potentially useful factors, though their applicability is limited (44).

To address these limitations, an advanced magnetic resonance imaging (MRI) protocol has been developed in 2017 by Joshi called Joshi-Shah protocol (17,45,46). These MRI protocol consists in the pre-administration of an alpha-blocker, SPC clamping, and urethral instillation of saline mixed with lubricating jelly to enhance contrast on T2-weighted imaging. This technique facilitates visualization of the urethral defect, the degree of prostatic dislocation, and associated soft tissue injuries. This MRI protocol gives a three-dimension representation that may provide a more objective method for surgical planning (Figure 3A,3B) (46).

Complex PFUI management

Repair of complex post-traumatic posterior urethral strictures remains one of the major challenges in reconstructive urology. Although first extensively described by Turner-Warwick (47), these injuries have received limited attention in the urological literature despite their significant impact on patient outcomes.

Complicating factors can reduce urethroplasty success rates, alter typical patient presentation, and necessitate innovations from standard surgical procedures. Turner-Warwick originally classified posterior urethral strictures as complex in three

• ❖ Strictures exceeding 2 cm in length with dense surrounding fibrosis.
• ❖ Strictures associated with extravasation, diverticula, false passages, or fistulae.
• ❖ Concomitant bladder neck damage.

Additionally, further complicating factors have been recognized by Kulkarni* et al. *(38), requiring even more individualized surgical strategies. These

• ❖ Previous urethroplasty failure.
• ❖ Bulbar urethral necrosis (BUN) with long urethral defects.
• ❖ Pediatric cases (boys aged <12 years), where growth-related factors could complicate repair.
• ❖ Double block injuries involving both the bulbomembranous urethra and the bladder neck-prostate junction.

PFUI redo urethroplasties

Redo PFUI urethroplasties present significant challenges due to altered anatomy, extensive fibrosis, and compromised vascularity from previous surgeries. While primary anastomotic urethroplasty can boast a success rate of approximately 85–95%, outcomes in redo cases can decrease to 78–83%, largely due to scarring, reduced healthy tissue availability, and impaired blood supply (48-51).

The amount of urethral defect that can be successfully repaired using repeated pubectomies is generally smaller than in primary urethroplasty cases. This is due to factors such as previous bone resection, scarring, and tissue fibrosis, which limit how much additional length can be gained through repeat inferior pubectomy. Clinical experience suggests that defects up to 5 cm can be successfully repaired (49). If staged perineal approaches prove insufficient, additional techniques such as the abdominoperineal approach or urethral substitution may be considered (48,50).

Kulkarni* et al. *have described some previous urethroplasty factors that could be responsible for BMA failure (50):

• ❖ Inadequate mobilization of the bulbar mobilizing the bulbar urethra from the penoscrotal junction to the bulbomembranous junction is crucial to obtain a good outcome. It has been described that insufficient mobilization can lead to a failure and to a repeat urethroplasty (50).
• ❖ Inadequate excision of scar tissue and use of inferior optimal inferior pubectomy is critical to achieve a tension-free repair without excessive bone resection. In redo cases, extensive fibrosis needs careful excision of all scar tissue until the posterior urethra appears well-vascularized and mobile, and usually that includes performing an inferior pubectomy (48,49).
• ❖ Compromised urethral vascularity and risk of BUN: repeated mobilization and transection of the bulbar arteries can lead to ischemia. If inferior pubectomy is performed without preserving the deep dorsal penile artery, the retrograde blood supply to the urethra could be endangered, increasing the risk of ischemia or necrosis.

Looking at the success rates of the redo BMA urethroplasties, our 2018 publication included 541 redo cases, in which patients had undergone up to five prior attempts at anastomotic urethroplasty. The mean follow-up duration was 68 months. The overall success rate for redo cases was 79.13% (48). Looking at the actualized results from 2020 to 2024, 48 patients underwent a redo BMA urethroplasty and completed at least 12 months of follow up (mean time 25 months). Success rate is 73%, including complex cases like BUN repair or pediatric redo cases.

BUN repair

BUN, historically referred to as “spongionecrosis”, is a rare condition reported following failed treatments of PFUI (48). This necrosis can occur due to lateral pubectomy or excessive cautery during crural separation, which may damage the deep dorsal arteries and compromise retrograde urethral vascularization (50,52). Additionally, during BMA urethroplasty, the anterograde vascular supply from the bulbar arteries is often impaired. If retrograde vascularization is also disrupted, it can lead to BUN. To assess vascular status preoperatively, penile Doppler ultrasonography should be performed. Patients exhibiting compromised dorsal penile arterial flow often require vascularized flaps for augmentation in stenotic cases or complete substitution in necrotic cases (48).

BUN can be identified on RGU combined with VCUG. In the VCUG and RGU images, the bulbar urethra will appear as a long stenotic segment or non-opacified segment, depending if it presents ischemia or complete necrosis (Figure 4) (50,52).

In cases of BUN, urethral substitution is often required due to the extent of tissue loss. Various reconstructive techniques have been described, each tailored to optimize functional and vascular outcomes.

One of the most used and reported flaps is the pedicled preputial flap (52-54). In uncircumcised patients, a pedicled preputial tubed flap is usually the preferred approach, as it allows a single-stage repair with a well-vascularized tissue substitute (48,54). This technique eliminates the need for vascular microanastomosis, as the flap is based on the dartos fascia, preserving its intrinsic blood supply.

The procedure begins with two parallel circumferential incisions around the prepuce (Figure 5A). The outer incision extends deep to the skin but remains superficial to the dartos fascia, while the inner incision extends deep to dartos but remains superficial to Buck’s fascia (Figure 5B). This ensures preservation of the dartos pedicle, which maintains the vascular supply to the mobilized prepuce (48,52).

Once dissected, the prepuce is carefully mobilized on its dartos pedicle and incised ventrally (Figure 5C). It is then transposed through a tunnel created at the base of the penis to reach the perineum. The flap is tubularized over a catheter, bridging the urethral defect and creating a neourethra with a continuous, vascularized epithelial surface (Figure 5D). The external skin of the prepuce is sacrificed, while the inner epithelial lining serves as the functional urethral substitute. An end-to-end anastomosis is performed between the two ends of the tube (Figure 5E).

In circumcised patients, a modification of this technique utilizes distal penile skin instead of the prepuce, employing similar pedicle principles to ensure adequate vascularity (e.g., Q-flap or McAninch flap). This approach is particularly advantageous as it maintains tissue integrity and provides a well-vascularized tube, minimizing stricture recurrence and optimizing long-term outcomes.

Other techniques that could be

• ❖ Oral mucosal initially, a buccal graft is placed and quilted onto the midline scrotal dartos. Over 2–4 weeks, the graft acquires vascularity from the underlying dartos, allowing for subsequent mobilization as a pedicled flap that can be transposed to the perineum and used as either an onlay or tubularized flap (51,54).
• ❖ Entero-urethroplasty: using colonic segments, as described by Mundy and Andrich, has shown favorable outcomes, with patients maintaining adequate voiding without the need for dilation (55).
• ❖ Pedicled anterolateral thigh used for extensive urethral defects requiring a large vascularized tissue substitute (54).
• ❖ Gracilis muscle flap with BMG: this approach provides a well-vascularized, dual-layer reconstruction option in complex cases (56,57).
• ❖ Radial forearm free flap with microvascular typically anastomosed to the inferior epigastric artery for robust vascularization (58).
• ❖ Tissue-engineering could represent another approach in urethral reconstruction. Cui* et al. *have demonstrated the feasibility of using tissue-engineered autologous urethras in adolescent patients, with encouraging long-term outcomes. These studies highlight the potential of regenerative medicine in managing urethral stricture disease (59,60).

While skin flaps offer a viable reconstructive option, they are associated with potential complications such as urethral diverticulum formation, which may necessitate subsequent reduction urethroplasty.

In 2022, our institution (Urokul Institute) reported an 86.4% success rate in a series of 132 cases using pedicled preputial flap tubes (54). An updated analysis including 146 cases until 2024 shows a slightly lower success rate of 84.2%, highlighting the complexity of these procedures. The majority of the patients required an inferior pubectomy step 3b BMA urethroplasty. Most treatment failures required internal urethrotomy. Other BUN surgical techniques exhibit similar success rates, though existing data is based on smaller patient cohorts.

Pediatric PFUI repair

The treatment of pediatric PFUI remains a considerable challenge for urologists due to its rarity and the limited availability of literature (61-64). Pediatric patients have distinct anatomical differences compared to adults, including an underdeveloped prostate and an intra-abdominal bladder, which contribute to a higher likelihood of severe urethral injuries. These injuries may extend proximally to the bladder neck or distally to the bulbar urethra, further complicating their management (Figure 6A) (64).

Pelvic fractures in children are less common than in adults due to the greater elasticity of sacroiliac joints and the symphysis pubis, as well as increased plasticity of the bones. However, when pediatric pelvic fractures do occur, they are often associated with major soft tissue and vascular injuries, including rectal and visceral injuries, which require immediate attention before definitive urethral repair (61). Consequently, as in adult patients, the initial focus should be on stabilizing the patient and managing life-threatening injuries before addressing the urethral trauma.

For bladder drainage, SPC placement is the preferred method, particularly in unstable patients, as it avoids the risks associated with blind urethral catheterization, such as infection and worsening of the urethral injury (61). If a urethral catheter is considered, it should be performed only by experienced personnel. Immediate repair of urethral injuries is generally discouraged, except in cases involving bladder neck injury, where early intervention may prevent complications such as pelvic abscess, urinoma, or osteomyelitis (61).

There is still controversy on how to treat female pediatric PFUI. The low incidence in these pathologies make it not possible to have an appropriate algorithm. Some authors suggest endoscopic treatment and others have reported really good results transpubic alone or combined with a vaginal approach (61). Some complex cases can require the need of bladder flaps or other complex repairs (65).

The primary goal of surgical management in male pediatric PFUI is to achieve a tension-free BMA following the excision of the stricture or distraction segment (61,66-68). Transperineal anastomotic urethroplasty is considered the gold standard for surgical reconstruction, with reported success rates ranging from 85% to 98% (Figure 6B-6E) (61,65-67). The use of primary realignment or optical internal urethrotomy is discouraged due to high failure rates and the risk of inducing further scarring, which can make future repairs more complex (67).

The choice of surgical technique depends on several factors, including the etiology, location, length of the urethral defect, and vascularization of the surrounding tissues. For pediatric PFUI, perineal BMA urethroplasty is performed with additional lengthening maneuvers, such as corporeal splitting, inferior pubectomy, or supracrural rerouting, when necessary. The need for such maneuvers in children is comparable to that in adults, despite the perception that distraction defects are proportionally larger in pediatric patients (65). If the PFUI also includes the bladder neck, an abdominal approach is usually required.

Our data from a large series analyzing 181 male pediatric PFUI cases from 2008 to 2019, further support the efficacy of transperineal anastomotic urethroplasty (61). We have incorporated our new results with a total of 208 boys operated between 2008 and 2024. The data reported an 89.9% success rate in primary PFUI cases and overall success rate of 82.9%. In more complex cases requiring transpubic urethroplasty, the overall success rate was lower at 64.7%, emphasizing the importance of selecting the appropriate surgical approach based on the severity of injury (61). In girls, transpubic urethroplasty demonstrated a 100% success rate in 12 patients from 2008 to 2024. These data also highlighted that pediatric PFUI can be managed successfully in expert hands, with even young children achieving favorable long-term outcomes.

Female PFUI repairs

Female PFUI are more exceptional than male PFUI, so there is still a lack of consensus on the best treatment. Immediate primary sutured anastomotic repair provides the best outcomes, reducing stricture and incontinence risks compared to primary realignment or delayed repair (4,69-71). Presentation can be seen mainly as incontinence, but can also be presented as urinary obstruction (70). Emergency management follows male PFUI protocols, but subsequent treatment differs. Three main approaches exist (4):

• ❖ Early realignment—high risk of stricture and fistula formation.
• ❖ Early repair (within 7 days)—preferred due to the lowest complication rates.
• ❖ Delayed repair (beyond 7 days)—often requires complex reconstruction, increasing risks of incontinence and vaginal stenosis.

Immediate primary sutured anastomotic repair provides the best outcomes, reducing stricture and incontinence risks compared to primary realignment or delayed repair (69,70).

The surgical approach depends on the location of the injury. Proximal and mid-urethral injuries are typically repaired via retropubic or transvaginal routes, ensuring primary suturing of the urethral ends while addressing any associated vaginal lacerations. Distal urethral injuries, if continence mechanisms remain intact, may be left hypospadic, but concurrent vaginal lacerations should be closed to prevent complications with a two-layer closure (69).

All these recommendations are based on case report studies. Given the limited data, further research is needed to refine treatment strategies and improve patient outcomes.

Conclusions

PFUI remains a complex urological condition with significant implications for urinary function, continence, and quality of life. While successful reconstruction is achievable, it requires meticulous preoperative assessment, precise surgical planning, and a high level of expertise in urethral reconstruction. The first surgical attempt is often the most critical, as failed repairs can lead to increased scarring, more complex reoperations, and worsened long-term outcomes.

Delayed repair with BMA urethroplasty remains the gold standard, offering the highest success rates with the lowest morbidity. The need for additional lengthening maneuvers, such as corporeal splitting, inferior pubectomy, or supracrural rerouting, is dictated by the severity of the distraction defect and the presence of fibrosis. Ultimately, the management of PFUI should be individualized based on patient factors, stricture characteristics, and associated injuries. Given the technical demands of these procedures, treatment should be performed in high-volume centers by reconstructive urologists with expertise in advanced urethral surgery.

Supplementary