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An American Association for the Surgery of Trauma (AAST) prospective multi-center research protocol: outcomes of urethral realignment versus suprapubic cystostomy after pelvic fracture urethral injury.

  • Author(s): Moses, Rachel A
  • Selph, John Patrick
  • Voelzke, Bryan B
  • Piotrowski, Joshua
  • Eswara, Jairam R
  • Erickson, Bradley A
  • Gupta, Shubham
  • Dmochowski, Roger R
  • Johnsen, Niels V
  • Shridharani, Anand
  • Blaschko, Sarah D
  • Elliott, Sean P
  • Schwartz, Ian
  • Harris, Catherine R
  • Borawski, Kristy
  • Figler, Bradley D
  • Osterberg, E Charles
  • Burks, Frank N
  • Bihrle, William
  • Miller, Brandi
  • Santucci, Richard A
  • Breyer, Benjamin N
  • Flynn, Brian
  • Higuchi, Ty
  • Kim, Fernando J
  • Broghammer, Joshua A
  • Presson, Angela P
  • Myers, Jeremy B
  • from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS)
  • et al.
Abstract

Background:Pelvic fracture urethral injuries (PFUI) occur in up to 10% of pelvic fractures. It remains controversial whether initial primary urethral realignment (PR) after PFUI decreases the incidence of urethral obstruction and the need for subsequent urethral procedures. We present methodology for a prospective cohort study analyzing the outcomes of PR versus suprapubic cystostomy tube (SPT) after PFUI. Methods:A prospective cohort trial was designed to compare outcomes between PR (group 1) and SPT placement (group 2). Centers are assigned to a group upon entry into the study. All patients will undergo retrograde attempted catheter placement; if this fails a cystoscopy exam is done to confirm a complete urethral disruption and attempt at gentle retrograde catheter placement. If catheter placement fails, group 1 will undergo urethral realignment and group 2 will undergo SPT. The primary outcome measure will be the rate of urethral obstruction preventing atraumatic passage of a flexible cystoscope. Secondary outcome measures include: subsequent urethral interventions, post-injury complications, urethroplasty complexity, erectile dysfunction (ED) and urinary incontinence rates. Results:Prior studies demonstrate PR is associated with a 15% to 50% reduction in urethral obstruction. Ninety-six men (48 per treatment group) are required to detect a 15% treatment effect (80% power, 0.05 significance level, 20% loss to follow up/death rate). Busy trauma centers treat complete PFUI approximately 1-6 times per year, thus our goal is to recruit 25 trauma centers and enroll patients for 3 years with a goal of 100 or more total patients with complete urethral disruption. Conclusions:The proposed prospective multi-institutional cohort study should determine the utility of acute urethral realignment after PFUI.

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