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

Abstract

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.

Graphical abstract

Keywords

emergency / pelvic fracture urethral injury / straddle trauma urethral injury / survey / urethral trauma

1 INTRODUCTION

Blunt urethral traumas mainly include straddle trauma urethral injuries (STUIs), which usually involve the bulbar urethra, and pelvic fracture urethral injuries (PFUIs), which involve the posterior urethra[1]. Although uncommon, blunt urethral traumas are potentially much more serious than iatrogenic injuries because the force required to damage the urethra in this way may be much greater[2]. Urethral traumas may lead to serious consequences if mismanaged. This is particularly relevant in the emergency department where urethral injuries are often referred late, especially when the patient has a bone fracture or other life-threatening injuries.

As the largest referral center for urethral strictures in China, we receive a large number of patients with urethral strictures after trauma[3,4]. There are great differences in the emergency diagnosis and treatment among these patients on their first visit to the hospital, which shows that the treatment concept of urethral trauma is not consistent. Both the prognosis of patients and the difficulty of further treatments are impacted by emergent management. Appropriate early management is likely to prevent further trauma-related problems, shorten hospital stays, and reduce urethral stricture rates[5]. However, doctors in many hospitals, especially those in nonurethral centers, lack relevant experience and have never participated in training related to urethral reconstruction, so they may have inappropriate opinions.

As effective treatment relies on a good clinical assessment and appropriate intervention, what is the reality of emergency blunt urethral trauma's diagnosis and treatment? In doctors' concepts, what kind of diagnosis and treatment strategy is appropriate? Currently, there are no relevant reports in China. Herein, we designed a questionnaire to appraise the opinions and habitual operations of Chinese doctors on the emergency diagnosis and treatment of urethral trauma. We expect this survey reflects the current situation of emergency diagnosis and treatment of urethral trauma in China. Further, we will make better awareness of relative evidence-based knowledge and technology according to the results of this survey.

2 MATERIALS AND METHODS

Chinese urologists were surveyed via an anonymous web-based questionnaire. The online questionnaire was distributed via a WeChat Official Account electronic message to members of the Learning Alliance of Urology (LAU). The WeChat Official Account is a popular online platform used by organizations to send messages to members in China.

The questionnaire was developed based on the European Association of Urology Urological Trauma Guidelines (2020 Edition)[6], Urotrauma: American Urological Association Guideline (Published 2014; Amended 2017, 2020)[7], and the Chinese Guidelines for the Diagnosis and Treatment of Urological and Andrological Diseases[8]. The initial questionnaire was based on a literature review and expert discussion. A preinvestigation was conducted to improve the question setting for better understanding. Finally, a 15-item (some with multiple sections) questionnaire was developed. It covered five major areas: (1) demographic information; (2) cognition of how to diagnose STUI and PFUI; (3) optimal emergency management of an STUI patient; (4) optimal emergency management of a hemodynamically stable PFUI patient; and (5) attitude toward early realignment for PFUIs.

The collected questionnaire data are presented as frequencies and percentages. Statistical analyses were performed using SPSS Statistic (version 26.0; SPSS Inc.).

3 RESULTS

3.1 Respondent demographics

The online anonymous questionnaire was distributed to 2118 members of the LAU. A total of 573 LAU members responded to the survey, including 538 valid responses, generating a response rate of 25.4%.

The respondents cover 31 provinces (including municipalities or autonomous regions) in the Chinese mainland. The general characteristics of the respondents are presented in Table 1 and Figure 1.

3.2 Urethral trauma diagnosis

When the respondents diagnosed urethral trauma in the emergency room (ER), they preferred attempted catheterization, computed tomography (CT), retrograde urethrography (RUG), and cystourethroscopy for diagnosis. For male patients with a suspected STUI, doctors in the ER preferred catheterization attempt, cystourethroscopy, and RUG. For male patients with a suspected PFUI, the preferred examinations were attempted catheterization, CT, and RUG (Figure 2).

3.3 The management of patients with STUIs

For patients with a bulbar urethral injury caused by straddle trauma, 41.3% (222/538) of the respondents performed or thought they should perform endoscopic realignment when indwelling catheterization failed. The doctors who preferred suprapubic cystostomy and immediate urethroplasty accounted 31.6% (170/538) and 25.5% (137/538) of respondents, respectively.

In order to further assess the response of respondents for the emergency treatment of patients with STUIs, we set up a situational simulation question. A 45-year-old male patient was unable to urinate for 5 h due to an “STUI” and indwelling catheterization failed. The patient's vital signs were stable, and the residual urine in the bladder was 300 mL. At this time, combined with the equipment and technical conditions available in their own hospitals, a total of 447 (83.1%) respondents preferred to place the catheter with the assistance of endoscopy as their first choice. If it failed, 225 (41.8%) chose suprapubic cystostomy and 222 (41.3%) would perform immediate urethroplasty. Seventy (13.0%) respondents preferred puncture suprapubic cystostomy only, open cystostomy was the first choice in 10 respondents (1.9%), and an additional 11 (2.0%) respondents did not pick any of the above methods as their first choice.

3.4 The management of patients with PFUIs

For hemodynamically stable patients with a PFUI within 48 h after injury when indwelling catheterization failed, 42.2% (227/538) of respondents preferred suprapubic cystostomy and 34.9% (188/538) preferred endoscopic realignment for management. A total of 99 (18.4%) doctors preferred open realignment, and only 19 (3.5%) doctors preferred immediate urethroplasty.

We also included a situational simulation question for these respondents. A 27-year-old male patient came to the ER for a “pelvic fracture caused by car accident and unable to urinate for 3 h.” Upon attempted urethral catheterization, the catheter was obstructed at the posterior urethra. The patient's vital signs were stable and residual urine in the bladder was 350 mL. Considering actual medical conditions, 259 (48.1%) respondents preferred suprapubic puncture cystostomy combined with endoscopic urethral realignment, 158 (29.4%) respondents preferred suprapubic puncture cystostomy only, 99 (18.4%) preferred open cystostomy combined with open urethra realignment, 12 (2.2%) preferred immediate urethroplasty, 5 (0.9%) preferred open cystostomy, and 5 (0.9%) did not choose any of the above methods as their first choice.

3.5 Attitude toward early realignment for patients with PFUIs

For patients with a PFUI, 340 (63.2%) respondents believed that early realignment could effectively reduce the incidence of urethral stenosis, 285 (53.0%) thought it could shorten the length of secondary stenosis, and 98 (18.2%) thought that early realignment might increase the risk of erectile dysfunction or urinary incontinence. Regarding posterior urethral stenosis after realignment, 254 (47.2%) of the respondents believed that most patients could be cured via endoscopic treatment, and 170 (31.6%) believed that patients need to be treated with open surgery (Figure 3).

After realignment for a patient with a PFUI, 325 (60.4%) respondents considered the duration of catheterization to be approximately 4 weeks, 125 (23.2%) thought it should be about 8 weeks, and 72 (13.4%) would extend the duration of catheterization up to 12 weeks. A total of 294 (54.6%) respondents who considered catheter traction after the realignment had positive significance. By contrast, only 95 (17.7%) respondents believed there was no need for catheter traction after the realignment (Figure 4).

4 DISCUSSION

Both STUIs and PFUIs are blunt urethral trauma. Inappropriate emergency treatment and/or delay in management will cause secondary infection, urinary incontinence, and urethral stricture, which leads to low quality of life and can also negatively influence social productivity[5,9–11]. During recent years, there has been an increase in the incidence of urethral strictures caused by trauma[12], leading to a common concern of how to reduce the incidence of posttraumatic urethral strictures through emergency treatment. Although many organizations have issued guidelines for urethral trauma, and a substantial volume of research has been directed toward this topic, many gaps remain due to the scarcity of high-quality research.

As far as we know, this is the first cross-sectional survey on doctors' viewpoints and habitual operations of emergency diagnosis and treatment of blunt urethral trauma in China. Considering that many nontrauma centers and nonurethral centers also receive patients with urethral trauma in the emergency room, we sent the questionnaire to urologists with different professional levels from different types of hospitals. This enables us to have a relatively comprehensive understanding of the current facts of emergency diagnosis and treatment of urethral trauma.

The signs of urethral trauma are diverse. Difficulty or inability to pass a urethral catheter is an important sign of urethral injury, and is a critical factor in both diagnosis and treatment[1,13]. Urethral catheterization can not only assist in judging the degree of urethral injury but it is also used to drain urine and heal the incompletely injured urethra. It is extremely unlikely that the gentle passage of a urethral catheter will do any additional damage[14]. However, repeated or brute-forced catheterization may aggravate the injury and should be avoided.

As a simple operation, attempted catheterization was widely used by the respondents in our study. On the contrary, RUG is the gold standard for the diagnosis of urethral injury, but the operation is relatively complex and equipment dependent[13,15]. Therefore, only 46.5% of respondents chose RUG for suspected STUIs and 47.0% for PFUIs.

The radiographic appearance of the urethra permits classification of the injury and guides subsequent management[16–18]. Since only about half of respondents would choose RUG, it is difficult to judge the degree of urethral injury (partial or complete) in an emergency. Besides, flexible cystourethroscopy may help to distinguish between complete and partial rupture[15]. Unfortunately, many medical institutions in China do not carry out cystourethroscopy in the ER. The absence of these examinations makes it difficult to choose the appropriate treatment strategy according to the degree of injury.

The reasons for the controversy in treatment methods are not only due to the limitations of medical conditions but also due to the divergence in doctors' viewpoints. Blunt anterior urethral injuries are associated with spongiosal contusion. Evaluation of the limits of urethral debridement in the acute phase might be difficult. Consequently, it is reasonable to start with urinary diversion only[15]. About 31.6% (170/538) of the respondents preferred suprapubic cystostomy for urinary diversion, while 41.5% (222/538) preferred endoscopic urethral realignment with transurethral catheterization as their first choice. Although the available evidence cannot evaluate which method is more valuable, it seems that urologists in our study prefer to place the drainage catheter through a natural orifice. In fact, we have treated many patients with stricture secondary to realignment after STUI. Most have suffered urethral dilation or internal urethrotomy for months to even more than 10 years after emergency treatment. On the other hand, patients with suprapubic urinary diversion seem to have better acceptance of urethroplasty. Recently, Wang et al.[19] reported that in patients with a successful early endoscopic realignment attempt, urethral stricture occurred in 77.4% of patients and the mean stricture length was not statistically significant when compared with those of failed early endoscopic realignment (p = 0.103). In other words, a catheter does not significantly improve anterior urethral healing[19].

Most respondents in our study performed suprapubic cystostomy only or simultaneously endoscopic realignment for the emergency treatment of patients with PFUI. That is consistent with the recommended guidelines. In a partial injury, urinary diversion (suprapubic or transurethral) is sufficient as these injuries can heal without significant scarring or obstruction[1,11]. In PFUI with complete disruption, realignment may reduce stricture formation, shorten stricture length, slighter prostatic displacement, and facilitate subsequent urethroplasty without increasing the risk of impotence and incontinence[4,20,21]. It should be noted that prolonged attempts at realignment must be avoided because the repeated process might increase injury severity[22,23]. As some clinicians advocate that primary endoscopic realignment may minimize the incidence of urethral stricture disease, from the standpoint of cost-effectiveness, realignment is more cost-effective for emergency management of PFUI compared to suprapubic cystostomy only[22,24]. However, when considering repeated endoscopic urethral interventions after primary realignment[25], the results may change. Furthermore, in our previous study, stenosis resolution occurred at a mean of 23.5 months in the realignment group, which was longer than the 7.6 months in the cystostomy group[4]. Thus, endoscopic realignment is associated with a prolonged clinical course. Suprapubic catheterization with delayed urethroplasty can always be considered in the early phase, but a long period of disability and discomfort due to the suprapubic catheter seems to be a disadvantage to this treatment strategy. Although there is no supporting evidence that realignment could reduce the stenosis rate, considering the temporary effectiveness in the short term, the “suprapubic catheterization with delayed urethroplasty” strategy has been challenged by the “immediate realignment with (possible) delayed urethroplasty” strategy whenever the clinical condition of the patient allows it. Early realignment can be performed when a stable patient is on the operating table for another surgery or as a stand-alone procedure in the absence of concomitant injuries[26,27].

Most respondents consider it good sense to advocate early realignment for patients with PFUIs, but their understanding of early realignment may not be completely correct. In our study, 98 (18.2%) respondents still believe that early realignment may increase the risk of erectile dysfunction and urinary incontinence, although there is no evidence to support this view. Also, many respondents retain the catheter after a successful realignment for a long time, even up to 12 weeks. According to the guidelines, the duration of catheterization should be 3 weeks for partial and 6 weeks for complete ruptures with voiding urethrography upon catheter removal. The excessively prolonged catheterization period does not improve the success rate, but delays judging the success of the procedure, and further affects the following treatments. At the same time, prolonged catheterization has a negative impact on the patients' quality of life. To our surprise, 294 (54.6%) respondents in this survey believed that urethral catheter traction should be carried out after realignment, which does not help shorten the gap and also damages the remaining sphincter mechanism at the bladder neck[14].

This survey focused on the diagnosis and management of blunt urethral trauma in the ER. The results are only a reflection of clinical concepts of urologists in China, and not equal to the real-world situation. In other words, this does not elucidate patient outcomes and cannot claim one method is superior to another. The results of this survey will assist in the dissemination of relevant evidence-based concepts in the future. There are a few limitations of this study. First, survey-based studies are susceptible to flaws, such as response bias and recall bias with overestimation or underestimation of events. Second, as a self-reporting survey, the questionnaire may reflect ideals rather than actual practice.

5 CONCLUSION

This survey draws upon opinions and practices of Chinese urologists in how they currently diagnose and manage emergency blunt urethral traumas. Although the number of cases managed per year by participants was generally small, the opinions and practices of most urologists are consistent with the guidelines. Despite the controversial issues, some concepts supported by existing evidence need to be popularized. For example, the significance of RUG has not been fully understood and the harm of traction on the balloon should be known.

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