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Severe Pelvic Trauma In Prepubertal Children: The Significance of Bladder Neck Injury

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Ezekiel H. Landau, MD, FAAP1, Ofer N. Gofrit, MD, PhD2, Mordechai Duvdevani, MD2, Dov Pode, MD2, Guy Hidas, MD1, Shilo Rosenberg, MD2, Gideon Lorber, MD2 and Ofer Z. Shenfeld, MD3, (1)Pediatric Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel, (2)Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel, (3)Urology, Shaare Zedek Medical Center, Jerusalem, Israel

Purpose: Major pelvic trauma is more devastating in prepubertal children than in adults because of their small bodies and the soft pelvic bony ring. Among other disabilities caused by trauma to the lower urinary tract (LUT), urinary incontinence, secondary to damaged bladder neck (BN), is the most frustrating. We reviewed our experience with such injured children, and discussed management options, and outcome, with and without sphincteric injury.

Methods: Retrospective review of our trauma registry for all prepubertal children, with severe LUT injury due to major blunt pelvic trauma between 1993 and 2011 was conducted. This study was approved by the institutional review board.

Results: Eighteen patients were identified, and divided into 2 groups. Group 1 consisted of 8 patients (3 males, 5 females, aged 2-10 years, mean 8) who sustained pelvic trauma with severe demolishing injury to the BN. Group 2 included 10 males (aged 5-11 years, mean 8.2) with pelvic trauma without damaged BN. The 10 male urethral injuries in this group included membranous-7, bulbar-2, and combined-1, with average urethral stricture length 2.67 cm, range 1-4. Additional genital injuries included vaginal avulsion-5, and testicular laceration-2. Non-urogenital injuries included pelvic fracture-16, rectal tear-4, rectovesical fistula-2, crush injury to the thigh-2, and lacerated spleen-1. Five patients sustained hemorrhagic shock. Initial management included insertion of suprapubic cystostomy (SPC)-17 (one was converted to vesicostomy), primary urethral realignment-2, pelvic fixation-5, colostomy-4, internal iliac artery embolization-2, splenectomy, above knee amputation, and orchidectomy-1 each. Average time to urological reconstruction in group 1 was 53 months (range 11 to 96), mostly due to prolonged orthopedic rehabilitation, and psychological immaturity, and in group 2, 8.3 months (range 6-18, p<0.05). Prior to reconstruction, all group 1 patients had small-volume high-pressure fibrotic bladders, with vesicoureteral reflux in 6 renoureteral units. None of group 2 patients sustained significant bladder injury. LUT reconstruction in group 1 included bladder augmentation-5, Mitrofanoff urinary diversion-5, ureteroneocystostomy 6 units, BN closure, vaginal reconstruction, and rectovesical fistula repair 2 each, and Malone Continence Enema-1. One female patient, whose urethra was detached from the BN, required temporary catheter drainage only in order to achieve continence, while voiding spontaneously. Two females still await reconstruction. Urinary continence with intermittent catheterization was achieved in all group 1 reconstructed patients during 6-144 month follow-up. All male patients in group 2 underwent anastomotic urethroplasty. Eight (80%) patients were able to void with average Qmax of 15.5 ml/sec (6.5-25.9), with average post-void residual of 6.25 ml (0-30). Urethroplasty failed in two. Five males lost erections permanently. 

Conclusions: Complex LUT injuries in pre-pubertal children can be successfully repaired, and urinary continence is achievable, even in severe BN injuries. Musculoskeletal rehabilitation and psychological status are important factors for BN reconstruction timing.