Treatment and prognosis of pelvic-related urethral injuries in children: a 20-year single-center study and systematic review

Abstract

Background

Management of pelvic fracture-related urethral injury (PFUI) in children remains debated due to various complications. Patients typically receive either primary realignment (PR) or suprapubic cystostomy with delayed urethroplasty (SCDU), but optimal outcomes are unclear. This study evaluates these two surgical techniques by reviewing 20 years of case data and existing literature.

Methods

We retrospectively analyzed patients treated for PFUI from 2004 to 2023, with a median follow-up of 2 years (1–15 years). Additionally, we performed a meta-analysis of relevant literature, searching PubMed, Web of Science, and Cochrane databases. Eight studies, including ours, were included in the analysis.

Results

Sixty-eight boys with PFUI (median age: 7.3 years; range: 4.8–10.8) underwent PR (39) or SCDU (29). Postoperative complications—urethral strictures, urinary incontinence, calculus, infections, and erectile dysfunction—occurred in PR vs. SCDU groups as follows: 38.5% vs. 51.7% (p = 0.276); 12.8% vs. 3.45% (p = 0.360); 7.7% vs. 13.8% (p = 0.678); 56.4% vs. 93.1% (p < 0.001); and15.4% vs. 3.5% (p = 0.231), respectively. PR was associated with lower costs and higher quality of life. The meta-analysis of eight studies involving 432 patients showed no significant differences between PR and SCDU in urethral stricture rates (OR = 0.60, 95% CI 0.33–1.10, p = 0.10), urinary incontinence (OR = 0.94, 95% CI 0.52–1.70, p = 0.84), and erectile dysfunction (OR = 0.85, 95% CI 0.41–1.76, p = 0.65).

Conclusion

There was no difference in complications between the two surgical modalities at long-term follow-up, however, PR presents more advantages in reduce operative times, frequency of postoperative infections, cost, and long-term quality of life.

Clinical trial number

Not applicable.

Introduction

Among children sustaining pelvic fractures, the incidence of urethral injury related to these fractures (PFUI) ranges from 0.47–4.2% [1]. A multicenter study in China further corroborated this range, reporting an incidence of approximately 2.3% [2]. Patients with PFUI experience a high rate of complications after surgery, including postoperative urinary tract infections, urethral stricture, erectile dysfunction, and urinary incontinence [3]. This makes treating PFUI in children a significant challenge for pediatric urologists. Due to the relatively low incidence of PFUI in children, treatment protocols often rely on principles used for adult urethral injuries, resulting in substantial controversy [4]. A major debate centers on whether to opt for suprapubic cystostomy with delayed urethroplasty (SCDU) or for primary realignment (PR).

SCDU is favored in the early phase because of its simplicity, lower blood loss, and its capacity to manage other associated injuries. Additionally, it avoids retropubic exploration, thereby reducing the risk of erectile dysfunction and urinary incontinence by preventing upward traction of the prostate and bladder [5]. However, this approach has significant drawbacks, including increased risks of catheter-related infections and stone formation, the complexity of delayed repair, and the psychological impact of requiring a second surgery and prolonged use of a drainage bag [6]. Consequently, if clinical conditions permit, many scholars advocate for PR. This method aims to realign the proximal urethra with the distal stump, minimizing the risk of stricture formation or defects. The introduction of endoscopic technology has added a new dimension to this debate, as endoscopic realignment may prevent adverse effects on erectile function and continence by sparing periprostatic tissues and cavernous nerves from additional trauma. Critics of primary realignment argue that it is technically demanding and, if unsuccessful, may complicate subsequent urethroplasty [7]. They contend that complete urethral disruptions do not heal by realignment alone and that successful cases often result from partial disruptions, which might be adequately treated with just suprapubic cystostomy [8].

Given the limited evidence on outcomes in pediatric patients with PFUI, this study aims to compare early PR with SCDU from multiple perspectives, including perioperative parameters, complication rates, patient satisfaction, treatment costs, and quality of life.

Methods

Study design

This study was approved by the Institutional Ethics Committee. A retrospective analysis was performed on patients treated for PFUI at the Urology Department of Children’s Hospital of Chongqing Medical University between January 2004 and December 2023. We excluded patients with incomplete urethral ruptures, prior micturition abnormalities, female patient, or incomplete clinical data, resulting in a cohort of 68 eligible male participants (Fig. 1). Data on demographics, treatment plans, outcomes, and outpatient records were retrospectively collected. Postoperative follow-ups occurred at 3, 6, and 12 months, and annually thereafter.

Fig. 1

Flow charts of 68 patients enrolled in the study. Note: PFUI, pelvic fracture-related urethral injury; PR, primary realignment; SCDU, suprapubic cystostomy with delayed urethroplasty; UTI, urinary tract infection; US, urethral stricture; ED, erectile dysfunction; UI, urinary incontinence; UC, Urinary calculus

We assessed parental satisfaction and patients’ health-related quality of life (HRQoL) through post-operative outpatient visits and telephone interviews. Satisfaction levels were categorized as “satisfied,” “neutral,” or “dissatisfied.” For patients aged 5–15, we used the PedsQL 4.0 Generic Core Scale, while patients aged 16 and above were assessed using the SF-36. The scale was completed by the patients themselves and accompanied by their parents.

The PedsQL 4.0 Generic Core Scale, suitable for children over two, assesses HRQoL across physical, emotional, social, and school dimensions, subdivided into sub-scales. The Chinese version has good reliability and validity [9, 10]. It uses a five-point Likert scale (0-never to 4-almost always), with scores transformed linearly to a 0–100 scale to indicate higher HRQoL.

The SF-36, a 36-item health survey for adolescents aged 16 and above, assesses HRQoL across eight dimensions. The scale includes physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). This widely validated tool is also adapted for use in China, with dimension scores summed and transformed to a 0-100 scale, where higher scores denote better health [11].

According to the guidelines of the American Academy of Pediatrics (AAP), a positive urine culture accompanied by urinary system symptoms is diagnosed as a urinary tract infection (UTI) [12]. Urinary incontinence is defined as the involuntary discharge of urine from the urethral opening, a condition of urinary control dysfunction. Patients were monitored for urethral stricture through voiding history, flow rate measurements, and determination of post-void residual urine volume. The diagnosis was ultimately confirmed by retrograde urethrography (RUG) or cystourethroscopy [13]. Treatment was deemed successful if no obstructive symptoms persisted and no further interventions, such as urethral dilation, internal urethrotomy, or urethroplasty, were required [5]. We find out about erectile function by asking the patients themselves or their parents.

For meta-analysis methods, see Supplementary methods.

Treatment process

All PFUI patients admitted to the hospital must undergo a comprehensive pre-treatment evaluation including medical history collection, physical examination, and assessment of urination (when possible). Radiographic, ultrasonic, and CT imaging should be performed to assess the upper urinary tract. Emergency conditions such as open fractures, spleen laceration, liver rupture, renal injuries, cranial trauma, or fractures of the vertebral arch must be identified and prioritized for immediate treatment. When we find urinary retention in the initial consultation and suspect a urethral break, we place a silicone urinary catheter about 1 cm into the urethral opening, pinch the urethral opening with our hand, and hit the contrast agent to look through the image to see if the urethra is open. So retrograde urethrograms are done preoperatively. Suprapubic tube placement: A transverse incision was made 3–5 cm above the pubic symphysis, adjusted according to the child’s body size. The skin, subcutaneous fat, and rectus abdominis muscle were incised layer by layer. A needle was then punctured to aspirate urine, confirming entry into the bladder cavity. The anterior bladder wall was incised for 1–2 cm, and a silicone Foley catheter was inserted. Finally, the fistula tube was fixed with sutures layer by layer. Urethral realignment: After a median transverse incision was made in the lower abdomen, the skin, subcutaneous tissue, and anterior sheath of the rectus abdominis muscle were incised to reveal the anterior wall of the bladder and the retro-pubic space. The anterior bladder wall was then opened, and the urine inside was aspirated. A probe was inserted through the external openings of both the bladder and the urethra, aligning the ends of the urethra. After a suitable catheter was placed, a drain was positioned in the suprapubic area. The incision was then closed layer by layer, and the catheter was secured. The choice of Foly catheter model needs to be based on the patient’s specific condition such as age, thickness of urethra and injuries etc. In children, the commonly used Foly catheter models include 8Fr, 10Fr and 12Fr. All our operations are done in the operating room.

Statistical analysis

Statistical analyses were conducted using SPSS version 25 and Review Manager version 5.4 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). The sociodemographic and clinical characteristics of the study population were described using frequency distributions, means with standard deviations (SD), and medians with interquartile ranges (IQR). For quantitative variables, group comparisons were made using the Student’s t-test and the Mann-Whitney U test. Qualitative variables were evaluated using either the chi-square test or Fisher’s exact test, depending on their appropriateness. The scores of patients with urethral rupture were compared to those of the general Chinese population using a single-sample t-test. To assess the factors contributing to urethral stricture, logistic regression analysis was employed, focusing on both combined effects and independent predictors.

Results

Characteristics of patients with PFUI

From 2004 to 2023, our institution treated 68 boys with PFUI, which accounted for 69.4% of all urethral rupture cases. The median age of the patients was 7.3 years (range: 4.8–10.8). The most common cause of injury was car accidents, which occurred in 52 cases (76.5%). At presentation, 23 patients (33.8%) were hemodynamically unstable.

A total of 39 patients underwent PR, while 29 received SCDU. A comparative analysis revealed no significant differences between the two groups in terms of age, cause of PFUI, intraoperative blood loss, hemodynamics upon admission, or parental satisfaction (all p > 0.05, as shown in Table 1). However, PR was associated with a significantly shorter median operative time of 90 min (range: 72.5–120.0), compared to the SCDU group (p < 0.001). Additionally, the PR group experienced lower treatment costs, with an average of 2653 USD (range: 2247.0-2970.2), and required fewer procedures, with a median of 1 (range: 1–3) (all p < 0.05). The median follow-up period of 2 years (range 1–15 years).

Table 1 Characteristics of patients with PFUI

Management of complications

In 68 patients with PFUI who received treatment, 49 (72.1%) developed a urinary tract infection postoperatively. The incidence was significantly higher in the SCDU group, with 27 cases (93.1%), compared to 22 cases (56.4%) in the PR group (p < 0.001), as shown in Table 2. Our study demonstrated that Gram-negative bacteria were more prevalent, accounting for 68.8% of the 77 isolated strains. The remaining 31.2% were Gram-positive bacteria. Among the Gram-negative pathogens, Escherichia coli and Pseudomonas aeruginosa were most common, each accounting for 9 strains (11.7%). In the Gram-positive cohort, Enterococcus faecalis was the predominant pathogen, with 12 strains (15.6%) isolated. Additionally, four patients’ culture results revealed fungal infections. The detailed distribution of these pathogens is shown in Supplementary Fig. 2 and Supplementary Table 1.

Table 2 Comparison outcomes of different operations in patients with PFUI

Among the 30 patients with urethral stricture, there was no significant difference in incidence between the PR group (15 cases, 38.5%) and the SCDU group (15 cases, 51.7%) (p = 0.28). Notably, 90% of these cases occurred within one year following injury. Thirteen patients underwent urethral dilatation, with a success rate of 53.8% (66.7% in the PR group and 42.9% in the SCDU group). Three patients underwent internal urethrotomy, with a success rate of 13.3% (100% in the PR group and 0% in the SCDU group). Fourteen patients underwent resection of the urethral stricture with end-to-end anastomosis, achieving a success rate of 50% (25% in the PR group and 83.3% in the SCDU group), as shown in Table 3. The specific treatment details for the 30 urethral stricture patients are provided in Supplementary Table 2.

Table 3 Management and success rate of urethral stricture after different treatment modalities

Multivariate logistic regression analysis revealed that hemodynamic instability (OR 5.02, 95% CI 1.46 to 17.26; p = 0.010) were independent risk factors for developing urethral stricture, as shown in Supplementary Table 3. Furthermore, there were no significant differences between the PR and SCDU groups in terms of the incidence of urinary incontinence or urinary calculus (all p > 0.05).

HRQoL of patients with PFUI

Questionnaire feedback from 18 patients with PFUI, aged between 5 and 15 years. The results indicate that their scores in all modules, except for Emotional Functioning, were significantly lower than the norms established for the general Chinese population based on a comprehensive survey (p < 0.05) [14]. Similarly, data from 28 patients aged over 16 years show that scores in the modules of PF, RP, BP, GH, SF, RE, and MH were also substantially below the standard norms derived from multiple provinces in China (p < 0.05) [15] (see supplementary Table 4). Subsequently, the patients were divided into two groups: PR and SCDU, for comparative analysis. Among patients aged 5–15 years, the PR group exhibited significantly higher scores in Physical Health, Psychological Health, and the Total Scale compared to the SCDU group. Furthermore, among patients over 16 years of age, the PR group scored significantly higher in BP, GH, and MH compared with the SCDU group (see supplementary Table 5).

Meta-analysis of surgical approaches in PFUI in children

All investigations were retrospective, non-randomized comparative studies. Supplementary Fig. 2 illustrates the PRISMA flow diagram, detailing the studies incorporated in the present analysis. Quality assessment of the included studies using the Newcastle-Ottawa Scale (NOS) revealed that all studies were rated as moderate or good quality. The quality assessment details for each study are summarized in Supplementary Table 2.

Heterogeneity analysis showed that the exclusion of any individual study did not significantly affect the overall statistical significance, thereby affirming the robustness of the meta-analysis results. Moreover, the funnel plot exhibited symmetrical distribution, suggesting no evidence of publication bias in this study. The corresponding funnel plots are displayed in Supplementary Figs. 3, 4, and 5.

The meta-analysis encompassed eight studies with a total of 432 patients. The characteristics of PFUI patients included in the analysis are outlined in Table 4 [6, 16,17,18,19,20,21]. The results revealed no significant differences in the incidence of urethral stricture (OR 0.60, 95% CI 0.33–1.10, p = 0.10; Fig. 2A), urinary incontinence (OR 0.94, 95% CI 0.52–1.70, p = 0.84; Fig. 2B), or erectile dysfunction (OR 0.85, 95% CI 0.41–1.76, p = 0.65; Fig. 2C) among treated children with PFUI.

Table 4 Characteristics of the studies about children PFUI

Fig. 2

Forest plot for comparison of A) stricture rate B) urinary incontinence rate C) erectile dysfunction following primary realignment and delayed urethroplasty in patient with pelvic fracture urethral injury

Discussion

The prevalence of PFUI in children is low, and there are relatively few studies on it, leading to treatments and management strategies that are often modeled after those used for adults [22]. However, urethral injuries in children are more complex than in adults. In children, prostatic dysplasia, intra-abdominal bladder, and smaller urethral caliber can result in injuries that extend proximally to the bladder neck and distally to the bulbous urethra. Additionally, the pelvis in children is less brittle and more elastic, and the periosteum is thicker. The increased elasticity of the pubic symphysis and sacroiliac joints means that PFUI in children typically requires greater amounts of energy [23]. As a result, patients with PFUI may also experience multiple simultaneous injuries, including bladder rupture, rectal rupture, and damage to the spleen, liver, or kidneys, as well as fractures, craniocerebral injuries, and pneumothorax. In our study, 23 patients (33.8%) presented with hemodynamic instability due to organ injuries. For these patients, life-threatening organ injuries should be prioritized, and management of urethral injuries should only begin once vital signs have stabilized.

The initial treatment of PFUI is controversial, with two main approaches: PR versus SCDU. PR prevents the extravasation of urine into surrounding tissues at an early stage, reduces inflammation, and facilitates the complete reapproximation of the separated urethral mucosal margins, promoting urethral regeneration. On the other hand, SCDU allows for the management of more complex and urgent injuries in other areas, without manipulating the urethra and prostate, thus reducing the risk of impotence and incontinence. Our results showed a high incidence of postoperative urinary tract infections, with 72.1% of patients with PFUI and 93.1% of patients in the SCDU group developing infections. This is significantly higher than the 56.4% in the PR group. The most common pathogens were Enterococcus faecalis, Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, in that order. This is similar to the results of previous studies [24]. It is important to note that in cases where antibiotics are ineffective, the possibility of fungal infections should be considered. In our study, 4.6% of infections were fungal, which may be linked to prolonged antibiotic use, indwelling urinary catheters, and reduced resistance after injury. There was no significant difference in the incidence of urethral stricture, urinary stones, urinary incontinence, or erectile dysfunction between the two groups, consistent with the findings of Wilbert et al. in their systematic review of initial PFUI treatment in children [25].

We reviewed seven papers on urethral injuries in children, with seven supporting the use of PR and one opposing it. The opponents argued that PR neither prevents urethral strictures nor simplifies subsequent urethroplasty, exposing patients to a higher number of surgeries. In their study, PR required an average of 3.5 procedures, while SCDU required only 2. However, our study, along with that of Qu et al., showed that patients who underwent PR required 2 and 1.1 fewer procedures, respectively, compared to those who underwent SCDU. Our meta-analysis showed no difference between PR and SCDU in the incidence of urethral stenosis. A systematic review of adults with PFUI concluded that early PR reduces the incidence of urethral strictures [26]. While there is ongoing debate about whether PR treatment can prevent strictures, it is clear that PR has not been shown to increase the risk of urethral strictures in any study. Moreover, multifactorial analysis identified hemodynamic instability at the time of presentation as an independent risk factor for subsequent urethral stricture, indicating that more severe trauma, often accompanied by significant scarring, leads to a higher likelihood of strictures.

The impact of PFUI on the quality of life and psychological well-being of children is substantial. Comparisons of PedsQL and SF-36 scores between patients with urethral rupture and the general population revealed that the HRQoL for these patients was lower, due to physical discomfort from trauma, repeated medical visits, and complex complications. Patients who received PR demonstrated better HRQoL than those who underwent SCDU. This difference may be due to the inconvenience of living with an ostomy tube in the SCDU group, the higher incidence of infections, and the increased number of surgeries required. Onen et al. found that approximately 43% of children with urethral injuries develop psychological disorders post-treatment [27]. In our study, two patients were seen in our psychological clinic. Several parents reported that their children became less willing to socialize and showed significant declines in academic performance following their injuries.

Our study has several limitations. The cohort analyzed is relatively small and derived from a single center. The number of erectile dysfunction cases may have been underreported, as some patients were too young to describe their symptoms and some parents may not have noticed them. Additionally, the lack of urodynamic studies is a limitation.

In conclusion, there was no difference in complication rates between PR and SCDU, but PR offers several advantages over SCDU as the initial treatment for PFUI, including shorter operative times, lower treatment costs, fewer required surgeries, a lower incidence of postoperative infections, and better long-term quality of life for patients.