Partial Inferior Pubectomy in the Delayed Repair of Pelvic Fracture Urethral Injury: Adopting a Bone-nibbling Technique

 

Ikenna Ifeanyi Nnabugwu,1,2Fredrick Obiefuna Ugwumba,1,2, Anthony Alex Ilukwe2

1. Department of Surgery, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria

2. Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129, Enugu, Nigeria

 

Correspondence to: Dr Ikenna Ifeanyi Nnabugwu; email: ikenna.nnabugwu@unn.edu.ng

 

Received: 08 April 2020; Revised: 10 June 2020; Accepted: 19 June 2020; Available online: 7 July 2020

Abstract

Background: The use of wedge inferior pubectomy can be challenging to many urethral surgeons. Our objective was to introduce a bone-nibbling technique to accomplish a partial inferior pubectomy (PIP) in a resource-poor setting, and to report the medium- to long-term outcome of using the technique. Methods: Five patients were recruited (mean age: 38.8 years) who presented, over a 30-month period, with posterior urethral fibrosis from a pelvic fracture urethral injury (PFUI). One had failed a previous attempt at posterior urethral reconstruction elsewhere. The length of urethral defect was from 2 to 4 cm. We describe a bone-nibbling technique used to carry out PIP for the delayed repair of PFUI in these patients. The outcomes in the medium to long term of surgical procedures done with this technique are presented. Results: Immediate postoperative complications in all were essentially a Clavien–Dindo grade I. Peak flow rate assessed 12 weeks’ post operation was between 20 mL/s and 23 mL/s (mean: 21 mL/s). The longest duration of follow-up was 34 months, and all patients were voiding satisfactorily. Conclusions: A satisfactory and durable outcome can be obtained from nibbling at the bone from the inferior margin of the pubic bone to achieve PIP. This is of interest to lower urinary tract reconstructive surgeons who have concerns with chiseling-out wedge of the inferior pubis.

Keywords: Bone nibbling, Partial inferior pubectomy, PFUI, Posterior urethra, Urethral anastomosis
Ann Afr Surg. 2021; 18(2): 69–74
DOI: http://dx.doi.org/10.4314/aas.v18i2.2
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Generally, the management of pelvic fracture urethral injury (PFUI) continues to evolve but has remained a challenge. Short-term and long-term outcomes of its management have much improved in the last 2 decades (1). While some surgeons practice early realignment, others prefer delayed reconstruction of the stricture that develops with the healing of the injury (2). 
Both groups report acceptable outcomes (3). Repairing the stricture after the PFUI has healed can be challenging (4), and in the hands of a less experienced surgeon the outcome of such repair may be disappointing. Among the factors contributing to the poor outcome of repair is poor access to the site of surgery due to the rigid configuration of the bony pelvis (5). The unyielding bony pelvis limits access to the proximal healthy urethral segment, increases the chances of incomplete excision of the fibrotic urethral segment, which compromises the integrity of urethral anastomosis, and impairs a successful tension-free anastomosis (6).
Over the years, various maneuvers have been incorporated into the operative procedure with the primary objectives of improving access to the surgical site and shortening the gap to be breached after the complete excision of the fibrotic segment in a single-stage procedure (7). These maneuvers include splitting the corpora cavernosa in the midline, partially resecting the inferior aspect of the body of the pubic bone (partial inferior pubectomy, PIP), and supracrural rerouting of the urethra (7,8). Use of any or some of these maneuvers has been reported to improve significantly the outcome of such repairs (8,9). Therefore, when indicated, one or more of these maneuvers are frequently used by experienced surgeons (10,11).
A technique for PIP in the delayed repair of PFUI is described (12,13). Many surgeons, irrespective of how long they have been practicing, may have never used this maneuver because of the fear of uncontrollable hemorrhage and concerns about inadvertent injury to other surrounding structures. Nibbling at the pubic bone from the inferior margin may offer the same surgical value as chiseling out a mass of bone. The controlled use of the bone nibbler may increase a surgeon’s confidence in their ability to use the technique without collateral damage.
The study aims to describe the bone-nibbling technique of accomplishing a PIP and to give the outcome of its use in our center so far.
 

Methods

Medical records were retrieved of five male patients who underwent delayed repair of the PFUI between March 2017 and December 2019usingthe bone-nibbling technique to accomplish PIP. These records were used to audit the outcome. Four of these procedures were primary repairs while one was a repeat repair. The mean age of these men was 38.8±7.0 years, and the length of the urethral defect was from 2 to 5 cm. From the records, we reviewed the operating time, need for intraoperation blood transfusion, immediate post operation complications, need for re-establishing a urinary catheter, and urine peak flow rate 3 months post operation.
In addition, institutional records from April 2008 to January 2016 of delayed repair of a PFUI in men were retrieved. All 20 cases identified were undertaken without using PIP. The men were between 20 and 70 years of age with a mean age of 33.8±12.2 years. The median length of a urethral defect was 2.5 cm (range 1.5–5.0 cm). From these records, we determined the outcome of repair in terms of the need to re-establish a suprapubic cystostomy or to perform a repeated urethral dilatation and compared it with the test cohort. The mean age of the patients, mean length of urethral defect, and mean units of blood transfused were compared for the two groups using analysis of variance (ANOVA). Crosstab analysis was used to compare outcomes. The Statistical Package for Social Sciences (SPSS Statistics ver. 21.0; IBM, Armonk, NY, USA) was used for analysis.
Figure 1 highlights the bone-nibbling technique of carrying out a PIP: a combined retrograde urethrogram and a voiding cystogram image of a PFUI requiring repair. Briefly, with this repair technique, patient positioning, skin incis