Original Article: Clinical Investigation
Surgical treatment of urethral distraction defect associated with
pelvic fracture: A nationwide survey in Japan
Satoshi Kitahara,* Ryo Sato, Kosaku Yasuda, Gaku Arai, Hideo Nakai and Hiroshi Okada
Department of Urology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan
analyze outcomes of the treatment in Japan.
A questionnaire on surgical treatment for PFUDD to 3307 Japanese consultant urologists was sent. Responses were collected and
The number of respondents was 1290 (39%). Patients surgically treated for PFUDD in the previous 5 years totaled 0 for 919 urologists
(71%), one to two for 283 (22%), and three to ten for 83 (7%) urologists. Realignment for PFUDD was carried out within 2 weeks in 205 patients
(23%), after 2–6 months in 607 (69%) patients, and after more than 6 months in 72 (8%) patients. Urologists operated on 361 (61%) patients
endoscopically (ES), 108 (18%) by open anastomosis (OA) and 101 (17%) by pull-through operation (PT). According to the operator’s impression,
success rates were 65% for ES, 79% for PT and 69% for OA. Re-operation (RO) rates were 43%, 25% and 26% for ES, PT, and OA, respectively, (ES vs
PT or OA; P < 0.05). Postoperative repeated urethral dilatation (PORUD) was required in 71% of ES, 77% of PT and 38% of OA cases (OA vs ES or
PT; P < 0.05).
PFUDD represents a rare disorder for Japanese urologists. Deferred endoscopic realignment is the preferred treatment option.
Success rates were not different among three surgical treatments. OA was superior to ES and PT in terms of PORUD and RO.
To survey practice patterns in surgical treatment for urethral distraction defect associated with pelvic fracture (PFUDD) and to
endoscopic surgery, open anastomosis, pelvic fracture, pull-through operation, urethral distraction defect.
Complete urethral rupture or urethral distraction defects associated
with pelvic fracture (PFUDD) is a rare disease and has been thought to
be a troublesome disorder to almost all urologists.1,2Since Webster and
Roman reported results of trans-perineal anastomotic urethroplasty for
post-traumatic urethral disruption including PFUDD with very high
success-rate (96%), the method has been considered a gold standard
surgery.3Nonetheless, many urologists seem to think that the method
should need skill and experience. In erectile function and continence,
the method is not flawless.4On the other hand, many surgeons includ-
ing us treat PFUDD endoscopically and some choose a pull-through
operation for treatment of the disease.5,6There is still controversy on
timing of the treatment: immediate, intermediate or delayed, although
decision of the timing depends on nature of the injury.7–13Recently, a
survey on current practice of pelvic fracture-related urethral trauma
(i.e. PFUDD) in the UK was reported.14According to the report, the
urethral injury is, not surprisingly, uncommon in the UK and published
expert opinions were, interestingly, not accepted nationwide by con-
sultant urologists in the country.14A national practice pattern survey in
the USA on treatment of adult anterior urethral stricture has been
published recently.15The authors concluded that many urologists in the
USA were unfamiliar with the published reports on the disease and had
little or no experience with urethroplastic surgery.15The present situa-
tion on treatment of PFUDD in Japan appears to be almost the same as
that in the UK and that on urethral stricture in the USA.We thought that
surgical treatment for PFUDD in present practice should be evaluated
in Japan and results of the survey could be a guide for treatment.
The present study by questionnaire was carried out in order to
survey practice patterns of treatment of PFUDD and outcomes of the
During August of 2005, we sent our questionnaire on the treatment of
PFUDD by mail to 3307 urologists who had been working as urologists
for more than 10 years and were registered as consultant urologists in
the Japanese Urological Association. Contents of the questionnaire are
shown in Appendix I. The answers to our questionnaire from the
respondents were collected in September of 2005 and the outcomes of
the treatments were analyzed statistically using Friedman’s test.
The number of respondents was 1290 (39%).The respondents’ years in
practice are shown in Table 1. The numbers of patients whom the
respondents treated surgically for PFUDD during their whole careers
are shown in Table 2. Sixty percent of the respondents operated on
fewer than three patients with PFUDD in their whole careers and only
5% of the respondents had operated on more than 10 patients with
PFUDD in their whole careers. The numbers of patients with PFUDD
on whom the respondents operated during the past 5 years, between
August 2000 and August 2005, are shown in Table 3. Ninety-three
percent of the respondents had surgically treated less than three patients
with PFUDD during the last 5 years and none of the urologists had
operated on more than 10 patients with PFUDD during the past 5 years.
In regard to the timing of surgical treatment for PFUDD after pelvic
fracture, 205 (23%) patients underwent immediate or intermediate (less
than 2 weeks later) operation, 607 underwent delayed (2–6 months
later) repair after initial cystostomy, and 72 (8%) underwent realign-
ment more than 6 months after primary injury, during the 5-year study
Correspondence: Satoshi Kitahara MD PhD, Division of Urology, Tama-
Nanbu Regional Hospital, 2-1-2, Nakazawa, Tama-City, Tokyo 206-0036,
Japan. Email: firstname.lastname@example.org
*Present address: Division of Urology,Tama-Nanbu Regional Hospital,Tama-
City, Tokyo 206-0036, Japan.
Received 19 June 2007; accepted 18 March 2008.
Online publication 4 May 2008
International Journal of Urology (2008) 15, 621–624doi: 10.1111/j.1442-2042.2008.02064.x
© 2008 The Japanese Urological Association
period. During that time, 361 (61%) patients underwent endoscopic
surgery, 108 (18%) underwent open urethral anastomosis including
trans-perineal, -abdominal, and -pubic approach, 101 (17%) underwent
the pull-through opearation,615 (3%) underwent the skin flap or
mucosa graft urethroplasty, three (1%) had only cystostomy, and one
(less than 1%) had cystectomy with ileal conduit (Table 4).
The numbers of patients whose outcome of the surgery was evalu-
ated by the operator (subjective judgment) were 269 in endoscopic
surgery, 48 in pull-through operation and 106 in open anastomosis
(Table 5). In endoscopic surgery, outcomes were very good in 50 (19%)
patients, pretty good in 123 (46%), quite good in 69 (25%), fairly good
in 17 (6%) and poor in 10 (4%). In pull-through operations, outcomes
were very good in 12 (25%), pretty good in 26 (54%), quite good in
three (6%), fairly good in five (10%) and poor in two (4%). In open
anastomosis, outcomes were very good in 33 (31%), pretty good in 53
(50%), quite good in 24 (23%), fairly good in 12 (11%) and poor in
In 269 patients who underwent endoscopic realignment, laser inci-
sion was carried out in 11 (4%), guide by ultrasound was done in 21
(8%), light guide was done in 13 (5%), and guide by radiography was
carried out in three (1%) patients. Urethral stent was placed in 30
(11%) patients after endoscopic operation.After the surgery, 116 (43%)
patients underwent re-operation mainly with urethrotomy and 190
(71%) underwent temporal or permanent repeated urethral dilatation
with sound due to postoperative urethral stricture (PORUD). Failure of
endoscopic re-routing was reported in three (1%) patients. In compli-
cations of the surgery, postoperative incontinence was reported in 20
(7%) patients and postoperative erectile dysfunction in 53 (20%)
In 48 patients who underwent the pull-through operation, 12 (25%)
patients needed additional operation and 37 (77%) required temporal or
permanent PORUD due to urethral stricture. Urethral stent was placed
in two (4%) patients for urethral stricture after surgery. As complica-
tions of the surgery, incontinence was reported in seven (15%) patients,
erectile dysfunction in four (8%), urethro-rectal fistula in one (2%), and
urethro-cutaneous fistula in one (2%) patient.
In 106 patients who underwent open anastomosis, 28 (26%) under-
went additional surgery and 40 (38%) received temporal or permanent
PORUD with sound for stricture. Prostatectomy was carried out in one
(1%) patient. Total cystectomy and ileal conduit was carried out in
patient (1%) due to failure of urethral re-alignment. As complications
of open surgery, incontinence was reported in 10 (9%) patients, erectile
dysfunction in 17 (16%) and fistula in one (1%) patient.
Concerning complications after three surgical treatments, statistical
analyses showed that no significant differences in outcome of the
operation for PFUDD were confirmed among the three surgical treat-
ments; endoscopic surgery, pull-through operation and open anastomo-
sis. The statistical analyses also showed that open anastomosis was
superior to the other methods in the rate of PORUD (P < 0.05) and
endoscopic surgery was inferior to the other methods in the rate of
re-operation (P < 0.05).
Our nationwide survey by questionnaire on PFUDD has shown the
present practice patterns in surgical treatment of the disorder in Japan.
Almost all Japanese consultant urologists recently treated very few
patients with PFUDD. Approximately 10% of the patients with pelvic
fracture are thought to have urethral injuries.1,2In Japan, the numbers of
both traffic and industrial accidents have been decreasing, which might
result in a small number of patients with PFUDD in present study. The
same result was recently reported in the UK.14These findings tell us
that surgical skill for PFUDD may not be mandatory to every urologist
and the disorder should be treated only by specialists of the disease.5,15
In the present study, we chose not to analyze the relationship between
surgical experience (numbers of operations per surgeon) and outcome
of the operations in surgery for PFUDD. Very few urologists as spe-
cialists had enough experience to be evaluated in each surgical method.
Techniques vary among operators in the same method as mentioned
below. Further, severity of the disease such as length of urethral defect
in each case was not available in our questionnaire. In our experience,
more than five cases in total and more than one case per year might be
necessary to be considered a surgical specialist of PFUDD.
In present study, the timing of realignment was 2–6 months after
pelvic fracture in 70% of cases. Approximately 20% of patients
received re-routing immediately or within less than 2 weeks (so-called
intermediate) after the injury. It was reported that immediate endo-
scopic surgery or the railroad technique makes urethral stricture less
frequently compared with the delayed one technique.16On the other
hand, early open surgery is reported to cause incontinence and erectile
dysfunction more frequently than delayed surgery.1,12Reports with
converse results were also published.7,8,10Nevertheless, the timing of
the surgery mainly depends on severity of the injury.17Nowadays,
external pelvic fixation or device is often used for pelvic fracture and
embolization of bleeding arteries is often carried out against intrapelvic
hemorrhage in an emergency room, which might have cause the
deferred surgery in Japan.9,18
In treatment modalities, we have four major methods: endoscopic
surgery, open anastomosis, pull-through operation and urethroplasty.
Endoscopic surgery was chosen in approximately 60% of PFUDD
Table 1 Number of years in practice of the respondents
0 21 2324 16
NA, not available.
Table 2 Number of patients with urethral distraction defect associated
their whole careers
Table 3 Number of patients with urethral distraction defect associated
the past 5 years (2000–05).
S KITAHARA ET AL.
© 2008 The Japanese Urological Association
patients in our study. The methods were carried out in part under
ultrasound or radiographic monitoring, with light guide or with laser
incision.5,18In open anastomosis, the patients were treated via three
different routes; trans-perineal approach, trans-abdominal approach,
and trans-pubic approach.8Urethroplasty was carried out using skin
flap or buccal mucosa. As conditions of the injury and the treatment in
itself vary in each case as mentioned above, evaluation of the treat-
ments appears to be difficult. However, in this study we dared to
compare three treatment methods in view of the outcome. Urethro-
plasty was omitted because the number of surgeries was too small to
evaluate. Our results showed that overall outcomes of the three different
methods for PFUDD seem to be almost the same. The result might be
due to the fact that criteria of the evaluation were not strictly defined in
this study. Further, the evaluation of the outcome is based completely
on impression of the operator who may not be able to carry out all the
three methods and may have had very limited experience. The rate of
success by surgery seems to be low compared with recent reports,
especially for the open operation.3,8,9The difference of success rates
might be due to experience because the reports of high success rates
were made by experienced specialists in the published reports.3,8,9In the
present study, we did not try to evaluate the relationship between
responder’s experience and success rates after surgery because of the
small number of urologists experienced in PFUDD.
In re-operations, the rate of endoscopic surgery was apparently
higher than the other methods, open anastomosis and the pull-through
operation. The rate of PORUD in open anastomosis was significantly
lower than that in endoscopic surgery and the pull-through operation.
Considering re-operation and PORUD, open anastomosis seems to be
superior to the two other methods. PFUDD results in a severe scar a few
months after the initial injury. Fibrosis is the most difficult problem to
cope with in surgery. Open anastomosis and pull-through operations
contain excision of the scar. Open anastomosis means direct anasto-
mosis of the departed urethra. We believe that the outcome of delayed
operation mainly depends on the severity of fibrous defects of the
urethra. Nowadays, endoscopic re-routing has come to be applicable
even in long defects of the urethra due to several innovations; ultra-
sound, radiography, flexible endoscopy and laser.18However, in each
case of PFUDD with long defects of the urethra we must strictly
evaluate whether endoscopic surgery is suitable, considering our
results. In our experience, more than a 20-mm urethral defect, deviation
of separated urethra, or bulging of the rectum to the urethral defect
makes the rate of success very low.5
PFUDD indicates a general membranous urethral injury. In this
condition, the apex of the prostate and proximal end of the torn urethra
is often dislocated toward the bladder. Many urologists may believe that
the anatomical condition of the disease could cause bleeding during
open surgery and result in incontinence and/or erectile dysfunction.4,12
This belief may hinder most urologists from carrying out open anasto-
mosis. Regretfully, blood loss during surgery was not included in the
present questionnaire. It was reported that neither erectile dysfunction
Table 4 Surgical treatments for urethral distraction defect with pelvic fracture (PFUDD) carried out by the respondents during the past 5 years (2000–05)
Operation Endoscopic Open anastomosis†Pull-through‡Urethroplasty Others§
†Open anastomosis including trans-perineal, trans-abdominal and trans-pubic approach. ‡Pull-through operation by Badenoch. §Cystostomy in three
patients and cystectomy in one patient.
Table 5 Outcomes and complications of the three surgical treatments for complete urethral rupture associated with pelvic fracture in the evaluable 423
Surgical treatmentEndoscopic surgeryPull-through operationOpen anastomosis
Outcomes by operator’s impression
* and ** are P < 0.05 compared with the other two treatments. †Commented on in Discussion.
Survey of surgical treatment for PFUDD
© 2008 The Japanese Urological Association
nor urinary incontinence occurred after open anastomosis for
Our results could be interpreted that there are no differences in the
rates of incontinence and erectile dysfunction as surgical complications
among the three methods studied (Table 5). However, almost all
patients with PFUDD have severe erectile dysfunction before delayed
urethral surgery. In the present study, erectile dysfunction may be
reported in immediate surgery. Because the present study did not ask
for this detail for each case of PFUDD, we can show no conclusion on
erectile dysfunction as a complication of surgery. We think that urinary
continence is maintained only by normal bladder neck function without
an external sphincter. Open bladder neck as a result of prostate atrophy
due to severe prostatitis and so on causes restriction to the function of
the bladder neck. In general, the function may be maintained in many
patients with PFUDD. However, the function of the bladder neck was
not included in our questionnaire. We cannot conclude that urinary
incontinence is caused by surgery for PFUDD.
Almost all consultant urologists in Japan recently treated very few
patients with PFUDD. Delayed urethral re-alignment 2–6 months after
initial cystostomy was a common procedure. PFUDD was treated by
endoscopic methods in approximately 60% of cases, by open anasto-
mosis in less than 20% of cases and by pull-through operation in less
than 20% of cases. Outcomes of the surgery evaluated by the operator’s
impression were almost the same among the three methods. However,
postoperative stricture requiring re-operation and/or repeat urethral
dilatation by sound occurred less frequently in patients treated by open
anastomosis in comparison with those by endoscope or pull-through
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Questionnaire of urethral distraction defect (complete urethral rupture)
associated with pelvic fracture (PFUDD)
How long have you been a urologist in practice?
How many patients with PFUDD have you treated in your career?
How many patients with PFUDD have you treated during the last
Please answer the following questions based on your experience during
the last 5 years.
When did you perform surgery for PFUDD?
Numbers of patients
(1) Immediately or within 2 weeks after injury.
(2)2–6months after injury except initial cystostomy.
(3)More than 6 months after injury except initial cystostomy.
What kind of surgery did you perform for treatment of PFUDD?
Numbers of patients
(1)Urethral stenosis requiring re-operation.
(2)Urethral stricture requiring repeat dilatation.
(3) Incontinence after surgery.
(4)Erectile dysfunction after surgery.
Overall outcome of the surgery by your impression.
(5)Not good (Poor)
S KITAHARA ET AL.
© 2008 The Japanese Urological Association