Dr. Sean Elliott, MD
Reconstructive Urologist
Urethroplasty for Pelvic Fracture Urethral Injury (PFUI)
In the normal male pelvis, the prostate is connected to the pelvic bone (pubis) by a ligament (in pink).
bladder
pelvic bone
rectum
prostate
Puboprostatic ligament
front
back
Fig. 1: Normal male pelvic anatomy (side-view).
This following descriptions and illustrations feature one type of pelvic fracture. Although there are many variations of pelvic fracture and they can each affect the urethra differently, these images tell a pretty typical story. The pelvic bone is fractured, and as the two pieces of bone move independently from each other, the parts of the urinary system that are attached to them will also move independently. Therefore the prostate and upper urethra can be torn from the the lower urethra.
bladder
pelvic bone
rectum
prostate
Puboprostatic ligament
Fig. 2: Male pelvic anatomy with pelvic fracture (side-view).
In the first few days after the accident, the broken bones and other torn tissues will bleed and form a large clot, we call a hematoma (shown in maroon). That hematoma will eventually turn into scar tissue as the tissues heal. Only an outline of the bones is shown here so that you can see the other things behind them.
In the emergency situation we must get the urine drained from the bladder. There are two ways of doing this. Either a catheter can be placed through the skin on the lower abdomen, directly into the bladder (we call this a suprapubic tube and it is shown here) or doctors can try to get a catheter from the lower urethra, across the hematoma, and into the bladder using camera scopes and x-rays.
bladder
rectum
subrapubic tube
prostate
Fig. 3: Male pelvic anatomy with pelvic fracture (side-view).
If a catheter is fished across the hematoma successfully then the hematoma will later form a scar tissue around the catheter (shown in green).
bladder
rectum
subrapubic tube
prostate
Fig. 4: Male pelvic anatomy with pelvic fracture (side-view).
As soon as the urethral catheter is removed, the area where the catheter was located will fill in with scar (shown in green).
bladder
rectum
subrapubic tube
prostate
Fig. 5: Male pelvic anatomy with pelvic fracture (side-view).
Whether we only place a suprapubic catheter or we get a catheter to fish from the lower urethra to the upper urethra and into the bladder, all of these urethras will eventually be blocked by scar tissue.
Some doctors will try to stretch this scar tissue but that is not recommended. There is so much unhealthy tissue in that area that stretching of the scar is never successful. The scar must be removed and the urethral ends reconnected.
bladder
rectum
subrapubic tube
prostate
Fig. 6: Male pelvic anatomy with pelvic fracture (side-view).
In a urethroplasty for pelvic fracture urethral injury, an incision is made in the perineum, which is the area between the scrotum (testicle sack) and the rectum.
bladder
rectum
subrapubic tube
prostate
Fig. 7: Male pelvic anatomy with pelvic fracture (side-view).
The urethra is divided where it meets the scar tissue (red dotted line). The lower urethra is then dissected from its surrounding structures all the way to where the urethra enters the beginning of the penis. This will give the urethra some flexibility to be able to stretch to reach the upper urethra.
bladder
rectum
subrapubic tube
prostate
Fig. 8: Male pelvic anatomy with pelvic fracture (side-view).
The scar tissue is removed. Sometimes this requires removing a little bit of the bone (this does not cause any problems later).
bladder
rectum
subrapubic tube
prostate
Fig. 9: Male pelvic anatomy with pelvic fracture (side-view).
The edges of the two ends of the urethra are freshened up so that they will connect back together nicely, with no scar. You can see in Figure 10 that unhealthy/scarred urethral ends are removed until the edges are pink and healthy.
bladder
rectum
subrapubic tube
prostate
Fig. 10: Male pelvic anatomy with pelvic fracture (side-view).
The two ends of the urethra are sewn together and the skin is closed. We will usually leave a catheter in the penis for 1 month.
bladder
rectum
prostate
Fig. 11: Male pelvic anatomy with pelvic fracture (side-view).
Although most injuries are not this bad, here is an example of a very difficult urethral injury that Dr. Elliott repaired using a urethroplasty.
6 cm (3 in) gap
bladder
urethra
Before
bladder
reconnection
urethra