Key Words Competing Interests Article Information Female urethroplasty, pelvic fracture urethral injury, fistula, urethra, stricture None declared. Patient Consent: Obtained for clinical images. Received on October 6, 2021 Accepted on January 5, 2022 This article has been peer reviewed. Soc Int Urol J. 2022;3(2):77–86 DOI: 10.48083/MBXR6354 77SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada. ORIGINAL RESEARCH Pelvic Fracture Urethral Injury in Females Pankaj M. Joshi,1 Marco Bandini,1,2,3 Christian Yepes,1 Shreyas Bhadranavar,1 Vipin Sharma,1 Sandeep Bafna,1 Sanjay B. Kulkarni1 1 Kulkarni Reconstructive Urology Center, Pune, India 2 Unit of Urology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy 3 Centro Chirurgico Toscano, Arezzo, Italy P.J., M.B., and C.Y. contributed equally to the manuscript Abstract Background Pelvic fracture urethral injuries (PFUI) in females are very rare. The available literature on the management of this condition is scarce and not clear, mainly because of limited experience among reconstructive surgeons. We present our experience of management of these complex urethral injuries in female patients. Materials and Methods We collected data, retrospectively and prospectively for 22 female patients referred to our center for PFUI repair between 1995 and 2021. During the clinical assessment of these complex injuries, following our internal institutional protocol, all patients underwent pelvic MRI (bladder and urethra are filled with saline solution and jelly to enhance the urethral lumen and the level of the distraction) before anastomotic urethroplasty. Results PFUI compromised the mid urethra in 10 patients (45.5%). A transabdominal approach was used in 8 patients (80%), and urethra-vaginal fistula repair was undertaken in 6 patients (60%). After a median follow-up of 36 months, only 1 patient with proximal PFUI required a surgical revision without compromising urinary continence. Conclusions The most common site of urethral involvement in pelvic fracture is mid urethral, which is owing to avulsion. Urethra-vaginal fistula should be suspected. Treatment consists in anastomotic urethroplasty, mainly through the abdominal approach. Introduction Urethral injury in females with pelvic fractures is very rare[1–8]. The literature on the management of female urethral injuries is sparse and not consistent, largely because of limited experience worldwide. Further, patients include a wide spectrum from young girls to adult women, and so the referral may be to a pediatric urologist, a gynecologist, or a urologist. The earliest report of such injures was by Perry and Hussmann in 1992[5]. Injuries reported before this were longitudinal injuries, which may go unnoticed. The injuries we see in practice are usually avulsion injuries. The Kulkarni Reconstructive Urology Center is a unique center with referrals from all over the world. Over last 2 decades we have treated 22 patients with pelvic fracture urethral injury (PFUI) and have acquired substantial experience. We believe these injuries should be classified differently in terms of age, with different management algorithms for prepubertal girls compared with adult females. http://SIUJ.org mailto:drpankajmjoshi%40gmail.com?subject=SIUJ We present our experience of management of female pelvic fracture urethral injuries, and we note that many of our findings have been published in reports on complex urethral injuries[9–11]. Materials and Methods We retrospectively and prospectively collected data on girls and women referred to our center for PFUI repair between 1995 and 2021. A detailed history was obtained, and patients were examined in the outpatient clinic. We obtained an ultrasound of the abdomen. Additionally, we annotated the position of suprapubic catheter and any previous scars on the abdomen, and we performed a local examination of the vulva. The female urethra is about 4 cm in length, and even smaller in young women and girls. Retrograde urethrogram and voiding cystourethrogram were considered critical for assessment of the urethral injury, and all patients received pelvic MRI, in which the bladder and urethra were filled with saline solution and jelly to enhance the lumen and the level of the urethral distraction (Figures 1 and 2)[12]. All patients proceeded to surgery within 1 day of coming to the hospital. Patients were admitted and received a single dose of preoperative antibiotics. Intraop- eratively, we used the dorsal lithotomy position. Preoper- ative endoscopy was a critical part of evaluation, and the urethra was best visualized with a 0-degree endoscope. The best instrument for this proved to be the 7 Fr mini nephroscope or a 4.5 Fr ureteroscope, which was passed retrograde from the meatus to assess the distal urethra. Urethrovaginal fistula should be suspected in every female patient with PFUI, and we found a urethrovag- inal fistula in most of our patients. If possible, a guide wire was passed through the urethra into the bladder with the outside end brought out through the introi- tus. Subsequently, we performed a vaginoscopy, which usually showed a normal vagina with visualization of the cervix (Figure 3), a post-traumatic transverse vagi- nal septum preventing visualization of the cervix, or stenosis of the vagina at the site of trauma. The next step was to perform endoscopy from the suprapubic catheter tract to visualize the bladder, the bladder neck, and the urethra proximal to the site of injury. We typically saw urethral avulsion at the bladder neck, in the proximal urethra, or in the mid urethra. Some patients also exhibited meatal stenosis and/or accompanying urethrovaginal fistula and/or vaginal stenosis. Approach The approach in prepubertal girls was always abdominal (Figure 4). In adult women, a vaginal approach was possible in some cases. FIGURE 1. MRI in female patient with pelvic fracture urethral injury FIGURE 2. MRI showing grossly dilated vagina and hematocolpos in a patient with prior repair of pelvic fracture urethral injury 78 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG ORIGINAL RESEARCH http://SIUJ.org Transection at bladder neck Injury at the bladder neck can result in transection of the bladder neck. When suprapubic endoscopy was performed in these cases, we could usually see a dimple that suggested the position of the bladder neck. Identification of the ureteric orifices and trigone also helped to locate the position of transected bladder neck. Surgical repair was performed through a lower abdominal incision. The extraperitoneal space was entered and the bladder was released from its anterior attachments. A posterior and superior pubectomy was then performed (Figure 5). Scar tissue at the site of injury was excised. The urethra distal to the injury was incised over a dilator passed through the urethra from the meatus (Figure 6). A 12 Fr mini nephroscope was passed through the suprapubic catheter site to guide the incision of the blad- der. The anastomosis between the bladder neck and the FIGURE 3. Vaginoscopy demonstrating cervix FIGURE 4. Clinical picture of a girl after surgical revision of a pelvic fracture urethral injury FIGURE 5. Abdominal approach with posterior and superior pubectomy FIGURE 6. Abdominal approach with posterior and superior pubectomy 79SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 Pelvic Fracture Urethral Injury in Females http://SIUJ.org urethra was performed with six 5-0 polydiaxone sutures. The posterior sutures were tied down (Figure 7) before passing a 14Fr silicon catheter across the anastomosis and tying down the anterior sutures. The omentum was mobilized and transposed onto the anastomosis. A drain was not usually required. Transection at proximal urethra In cases with a proximal urethral injury a short length of intact urethra remained attached to the bladder. The surgical steps were the same as for a bladder neck injury, except that the anastomosis was performed between the 2 urethral ends. This was more challenging than bladder neck repair, as there is very narrow space to work in the female pelvis. Transection at mid urethra The mid urethra was the commonest site of female PFUI. This type of injury is almost always associated with a urethrovaginal fistula, which can be missed (Figure 8). In these cases, transection of the mid urethra allows the distal urethra to connect to the anterior vaginal wall to form a fistula. Intraoperative endoscopy, preferably with a 7 Fr or 12 Fr mini nephroscope, depending on the age of the patient, was more important in these cases. Endoscopy through the meatus into the distal urethra showed the urethrovaginal fistula. A guide wire was passed through the fistula and back through the vagina. A confirmatory vaginoscopy was performed. The surgical steps were similar to the previously described procedure but more challenging. A more extensive posterior and superior pubectomy was neces- sary to expose healthy edges of the proximal and distal urethra. The distal urethra was opened, and the previously inserted guide wire was pulled through the abdominal wound. The vaginal fistula was then clearly visible. The edges were freshened, and the fistula closed with interrupted polydiaxone sutures. A long stay suture was placed and used to tuck the omentum between the urethral anastomosis and the anterior vaginal wall to create an intervening layer. Transection at meatus Rarely, the injury was observed at the level of meatus (Figure 9), and this was usually associated with a vaginal injury. The meatus became hypospadic. The vaginal injury healed with scarring leading to vaginal outlet stenosis. These patients voided through the vagina, where urine accumulated, and the patients presented with intermittent incontinence. The diagnosis was confirmed by vaginoscopy with small caliber endoscope. These patients needed to be treated with vaginotomy. FIGURE 7. Anastomosis FIGURE 8. Urethrovaginal fistula seen on CT 80 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG ORIGINAL RESEARCH http://SIUJ.org Vaginal examination (which was difficult in pediat- ric patients because of narrow introitus) often revealed an almost bone-like scar on the posterior vaginal wall. Older patients sometimes needed a vaginal pull-through surgery, involving mobilization of the healthy edge of vagina down to be sutured to the introitus. Urethral lengthening In cases of meatal injur y where treatment with meatotomy would result in a hypospadiac urethra and intravaginal voiding, we usually recommend a urethral lengthening procedure. This can be done with a pedicled inner labial skin flap which is sutured to the urethra. We performed this in 1 patient, who was satisfied with the result. Vaginal injury As stated earlier, urethrovaginal fistula was commonly seen in mid-urethral injuries. Occasionally, the vagina was also transected. Resul- tant scarring sometimes led to the formation of a vagi- nal septum. As a result, the proximal vagina and uterus could become compartmentalized and separated from the distal vagina. Affected patients presented with amenorrhea and hematocolpos. Diagnosis was made by demonstrating these findings on ultrasound. Intra- operative vaginoscopy was very important in such cases. Inability to visualize the cervix during intraop- erative vaginoscopy confirmed the presence of a vaginal septum. These cases were treated with either laser inci- sion of the septum or vaginal pull-through. Complete urethral loss This is the rarest ty pe of injur y and requires a vascularized f lap for repair. This is most easily accomplished by making a bladder wall f lap and tubularizing it to form a neo-urethra. There remains a high risk of incontinence. We carried out this procedure in only 1 patient. Uroflow was performed after surgery to assess the success of the operation. Urinary continence was also assessed after surgery using a voiding diary. Results We retrieved the data of 22 patients: 10 girls (median age 9 years) and 12 women (median age 25 years). Median time from injury to surgery was 10 months. Urethral injury was in the proximal urethra in 5 cases (22.7%, 4 prepubertal girls and 1 adult woman), in the mid urethra in 10 cases (45.5%, 4 prepubertal girls and 6 adult women), and in the distal urethra in 6 cases (27.3%, 2 prepubertal girls and 4 adult women). One case presented with complete urethral loss (Table 1). Of the 10 patients presenting with mid PFUI, 8 were approached transabdominally and 6 (2 girls and 4 adults) underwent urethrovaginal fistula repair. The approach was transvaginal in all 6 distal patients with PFUI. Two prepubertal girls with distal injury had vaginal introital stenosis and required vaginotomy. We observed a trans- verse vaginal septum that was attributed to trauma in 2 patients who both required vaginal pull-through. The patient with complete urethral loss needed a bladder FIGURE 9. Distal urethral injury 81SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 Pelvic Fracture Urethral Injury in Females http://SIUJ.org TABLE 1. Summary of treatments and outcome No Age at accident (years) Interval to surgery (months) Group Mechanism of trauma Associated injuries Mode of treatment Location of injury Approach and surgery Continence Day Night Uroflow (mL /s) Follow-up (months) Further intervention Final result 1 5 3 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes No 9 47 None Success 2 2 36 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 0a 36 Redo Success 3 9 4 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes No 14 42 None Success 4 10 6 Prepubertal Road traffic accident Urethrovaginal fistula, lower limb fractures, degloving injury in thigh Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 18 46 None Success 5 11 4 Prepubertal Road traffic accident None Delayed Mid Abdominal, anastomotic urethroplasty Yes Yes 16 63 None Success 6 10 3 Prepubertal Road traffic accident Urethrovaginal fistula, lower limb fracture Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 20 80 None Success 7 43 24 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 16 66 None Success 8 23 6 Postpubertal Road traffic accident Lower limb fracture Delayed Distal Vaginal Yes Yes 19 112 None Success 9 35 3 Postpubertal Road traffic accident None Delayed Mid Vaginal Yes Yes 20 132 None Success 10 30 0b Postpubertal Road traffic accident Vaginal injury, lower limb fracture Primary Mid Vaginal Yes Yes 22 156 None Success 11 22 10 Postpubertal Road traffic accident Vaginal injury Delayed Distal Vaginal, meatoplasty Yes Yes 18 72 None Success 12 5 11 Prepubertal Road traffic accident Vaginal stenosis Delayed Distal Vaginal, meatoplasty, vaginotomy Yes No 11 60 Vaginal pull-through Success 13 21 3 Postpubertal Road traffic accident Lower limb fracture, complete urethral loss Delayed Proximal, Mid, Distal Abdominal, bladder flap Yes No 6 37 None Success 14 6 24c Prepubertal Road traffic accident Lower limb fracture, anterior vaginal wall loss Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty, Martius flap with skin forming the anterior vaginal wall Yes Yes 12 12 None Success 15 26 37d Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 22 14 None Success 16 24 10 Postpubertal Road traffic accident Lower limb fracture, vaginal stenosis Delayed Distal Vaginal, pedicled labial flap, vaginotomy Yes No 14 48 None Success 17 27 14 Postpubertal Road traffic accident None Delayed Distal Vaginal, urethroplasty with laser incision of vaginal septum Yes Yes 14 24 Vaginal pull- through Vaginal septum Amenorrhea 18 21 11 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 22 32 None Success UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff 82 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG ORIGINAL RESEARCH http://SIUJ.org TABLE 1. Summary of treatments and outcome No Age at accident (years) Interval to surgery (months) Group Mechanism of trauma Associated injuries Mode of treatment Location of injury Approach and surgery Continence Day Night Uroflow (mL /s) Follow-up (months) Further intervention Final result 1 5 3 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes No 9 47 None Success 2 2 36 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 0a 36 Redo Success 3 9 4 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes No 14 42 None Success 4 10 6 Prepubertal Road traffic accident Urethrovaginal fistula, lower limb fractures, degloving injury in thigh Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 18 46 None Success 5 11 4 Prepubertal Road traffic accident None Delayed Mid Abdominal, anastomotic urethroplasty Yes Yes 16 63 None Success 6 10 3 Prepubertal Road traffic accident Urethrovaginal fistula, lower limb fracture Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 20 80 None Success 7 43 24 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 16 66 None Success 8 23 6 Postpubertal Road traffic accident Lower limb fracture Delayed Distal Vaginal Yes Yes 19 112 None Success 9 35 3 Postpubertal Road traffic accident None Delayed Mid Vaginal Yes Yes 20 132 None Success 10 30 0b Postpubertal Road traffic accident Vaginal injury, lower limb fracture Primary Mid Vaginal Yes Yes 22 156 None Success 11 22 10 Postpubertal Road traffic accident Vaginal injury Delayed Distal Vaginal, meatoplasty Yes Yes 18 72 None Success 12 5 11 Prepubertal Road traffic accident Vaginal stenosis Delayed Distal Vaginal, meatoplasty, vaginotomy Yes No 11 60 Vaginal pull-through Success 13 21 3 Postpubertal Road traffic accident Lower limb fracture, complete urethral loss Delayed Proximal, Mid, Distal Abdominal, bladder flap Yes No 6 37 None Success 14 6 24c Prepubertal Road traffic accident Lower limb fracture, anterior vaginal wall loss Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty, Martius flap with skin forming the anterior vaginal wall Yes Yes 12 12 None Success 15 26 37d Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 22 14 None Success 16 24 10 Postpubertal Road traffic accident Lower limb fracture, vaginal stenosis Delayed Distal Vaginal, pedicled labial flap, vaginotomy Yes No 14 48 None Success 17 27 14 Postpubertal Road traffic accident None Delayed Distal Vaginal, urethroplasty with laser incision of vaginal septum Yes Yes 14 24 Vaginal pull- through Vaginal septum Amenorrhea 18 21 11 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 22 32 None Success UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff continued on page 84 83SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 Pelvic Fracture Urethral Injury in Females http://SIUJ.org wall flap. One child needed a complex reconstruction with use of a Martius flap along with the overlying labial skin to reconstruct the vaginal wall. Overall, 17 patients (77.3%) were continent at night and during the day. Of those with proximal PFUI, 3/5 patients (60%) were continent at night and during the day. The patient with bladder wall flap was continent but voided with low pressure. This patient’s urethra was patent on urethroscopy, and there was no obstruction. The median postoperative Qmax was 18 mL/s. After a median follow-up of 36 months, 1 patient with proxi- mal PFUI required a surgical revision but was continent thereafter. Discussion Management of female PFUI is evolving slowly, and only a few reports are available in the literature. Ours is one of the largest reported series of such patients to date. Usually, the injury goes unnoticed in the acute post trauma evaluation. It is recognized by the inability to catheterize the patient or the presence of acute urinary retention. Examination of the vulva needs the lithot- omy position, which is challenging in the acute setting of trauma. In the series by Perry and Husmann[5], the patients presented with extravasation and persistent incontinence, which suggests that the urethral injuries were overlooked on initial evaluation. The favored management strategy for PFUI is to place a suprapubic catheter in the acute setting, stabilize the patient, and perform a definitive repair after 3 months. Rarely, if there is an acute transection that is accessible, and no other injuries, a primary repair can be attempted in an adult female. The true incidence of female urethral injuries is unknown. Pelvic fracture urethral injuries are generally less common in females[8]. Factors likely include the flexibility provided by the vagina, as well as the inher- ent elasticity of female urethra in adults. Podestá et al. reported a concurrent vaginal laceration in 75% to 87% of cases[13], which is consistent with the experience of Venn et al.[8]. Singh et al. described a case of urethral distraction defect causing complete urethrovaginal avulsion[14]. Venn et al. reported 12 female patients, aged 7 to 51, with urethral injuries[8]. Four had concomitant rectal injuries. In 5 cases urethral continuity was preserved because the urethral injury was longitudinal. Two of these 12 patients presented in follow-up with stress urinary incontinence. Although the cause of incontinence is unclear, the authors suggested a mixed etiology including direct urethral damage and damage to innervation. In our study, the majority of patients were continent after urethroplasty, although 5 had nocturnal inconti- nence. The fear of incontinence should not deter the urologist from performing anastomotic urethroplasty in women with PFUI. An artificial urinary sphincter can even be considered[8], although this was not needed in our patients. Over the last 2 decades, we have gained the greatest experience of male PFUI[10], and our experience with female PFUI has simultaneously grown. Female PFUI is particularly challenging to manage because of the diver- sity of urethral injuries observed. Venn et. suggested that it was difficult to produce recommendations on treatment of these injuries based on their patients. After operating on 22 such patients we are able to provide a TABLE 1. Summary of treatments and outcome No Age at accident (years) Interval to surgery (months) Group Mechanism of trauma Associated injuries Mode of treatment Location of injury Approach and surgery Continence Day Night Uroflow (mL /s) Follow-up (months) Further intervention Final result 19 38 22 Postpubertal Road traffic accident Urethrovaginal fistula, limb fracture Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 21 18 None Success 20 9 11 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Bladder neck Abdominal, anastomotic urethroplasty Yes Yes 19 12 None Success 21 10 10 Prepubertal Road traffic accident None Delayed Distal Meatoplasty, vaginal pull-through Yes Yes 11 12 None Success 22 24 9 Postpubertal Fall from train Urethrovaginal fistula Delayed Mid Abdominal, anastomotic urethroplasty Yes Yes 22 12 None Success UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff , Cont’d 84 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG ORIGINAL RESEARCH http://SIUJ.org clear algorithm to assist reconstructive urologists in the management of these injuries (Figures 10 and 11). We suggest categorizing patients in 2 groups: young females and adult females. Always suspect a urethrovaginal fistula in urethral injuries, especially in prepubertal girls. Anastomotic urethroplasty through an abdominal approach is the favored procedure. The urethra can be accessed with posterior and superior pubectomy keeping the rim of pubic bone intact. Incontinence is rare in such patients. FIGURE 10, FIGURE 11. Algorithm for management of female pelvic fracture urethral injury Mid Urethral Mid • Look for associated Urethrovaginal �stula • Commonest injury • Can have vaginal septum Proximal • Posterior pubectomy • Scar excision • Anastomotic urethroplasty Bladder Neck / Proximal Distal • Meatal stenosis • Vaginal introital stenosis Vaginotomy / Pull through Algorithm Distal Female PFUI History, clinical examination MRI with our protocol: full bladder and lignocaine jelly in urethra Preoperative urethroscopy Look for urethrovaginal �stula Anastomotic urethroplasty (urethrovaginal �stula closure) Vaginoscopy (Look for cervix) If cervix not visualized, suspect traumatic vaginal septum TABLE 1. Summary of treatments and outcome No Age at accident (years) Interval to surgery (months) Group Mechanism of trauma Associated injuries Mode of treatment Location of injury Approach and surgery Continence Day Night Uroflow (mL /s) Follow-up (months) Further intervention Final result 19 38 22 Postpubertal Road traffic accident Urethrovaginal fistula, limb fracture Delayed Proximal Abdominal, closure of UVF, anastomotic urethroplasty Yes Yes 21 18 None Success 20 9 11 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Bladder neck Abdominal, anastomotic urethroplasty Yes Yes 19 12 None Success 21 10 10 Prepubertal Road traffic accident None Delayed Distal Meatoplasty, vaginal pull-through Yes Yes 11 12 None Success 22 24 9 Postpubertal Fall from train Urethrovaginal fistula Delayed Mid Abdominal, anastomotic urethroplasty Yes Yes 22 12 None Success UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff 85SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 Pelvic Fracture Urethral Injury in Females http://SIUJ.org Few patients need a tai lored approach to eit her lengthen the urethra if short or a full reconstruction in case of complete urethral loss. For these cases blad- der or vaginal flaps are harvested for reconstruction. A bladder pubovaginal stenosis should be suspected in dista l injuries. Such patients can present with amenorrhea and hematocolpos in the adolescent age. Scar excision, good tension-free anastomosis, and omental interposition are key steps in performing the anastomotic urethroplasty. Conclusions Female pelvic fracture urethral injuries are uncommon. When they occur, the commonest PFUI is the mid urethral avulsion. Urethrovaginal fistula should be suspected. The injury is best repaired with anastomotic urethroplasty, mostly through the abdominal approach, which we show leads to excellent outcomes. This surgery requires specialized expertise. We present here our experience of management of these injuries with an operative algorithm. References 1. Simpson-Smith A . Traumatic rupture of the urethra: eight personal cases with a review of 3 81 recorded ruptures. Br J Surg.1936;24:309–332. 2. 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Am J Emerg Med.1993;11:218–220. doi: 10.1016/0735-6757(93)90128-x. 8. Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries o f t h e f e m ale ur e t h r a. BJ U I nt.19 9 1; 8 3 : 6 2 6 – 6 3 0 . d oi: 10.1046/j.1464-410x.1999.00001.x. 9. Kulkarni SB, Surana S, Desai DJ, Orabi H, Iyer S, Kulkarni J, et al. Management of complex and redo cases of pelvic fracture urethral injuries. Asian J Urol. 2018 Apr;5 (2):107–117. doi: 10.1016/j. ajur.2018.02.005. Epub 2018 Mar 2. 10. Joshi PM, Kulkarni SB. Management of pelvic fracture urethral injuries in the developing world. World J Urol.2020 Dec;38(12):3027–3034. doi: 10.1007/s00345-019-02918-0. Epub 2019 Aug 29. 11. Kulkarni SB, Joshi PM, Hunter C, Surana S, Shahrour W, Alhajeri F. Complex posterior urethral injury. Arab J Urol.2015 Mar;13(1):43–52. doi: 10.1016/j.aju.2014.11.008. Published online 2015 Jan 20. 12. Joshi PM, Desai DJ, Shah D, Joshi DP, Kulkarni SB. Magnetic resonance imaging procedure for pelvic fracture urethral injuries and recto urethral fistulas: a simplified protocol. Turk J Urol.2021 Jan;47(1):35–42. doi: 10.5152/tud.2020.20472. Epub 2021 Jan 1. 13. Podestá ML, Jordan GH. Pelvic fracture urethral injuries in girls. J Urol.2001 May;165(5):1660–1665. 14. Singh RK, Kaushal D, Khattar N, Nay yar R, Manasa T, Sood R. Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion. Indian J Urol.2018 Jan-Mar;34(1):76–78. doi: 10.4103/iju.IJU_118_17 86 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG ORIGINAL RESEARCH https://dx.doi.org/10.1016%2Fj.aju.2014.11.008 https://dx.doi.org/10.4103%2Fiju.IJU_118_17 http://SIUJ.org