Management of pelvic fracture urethral injury

Pelvic fracture urethral injury (PFUI) represents one of the most challenging entities in reconstructive urology. It predominantly affects the bulbomembranous junction because of its anatomical vulnerability to shearing and compression forces during pelvic trauma. These injuries often result from high-energy accidents, with associated pelvic instability and concomitant injuries, and frequently necessitate a multidisciplinary initial approach. Early management typically involves prompt suprapubic cystostomy (SPC) to divert urine, prevent further contamination, and allow stabilization of the patient. Delayed urethroplasty (DU) remaining the gold standard for definitive repair once the acute phase has resolved. Delayed repair most commonly consists of a perineal bulbomembranous anastomosis (BMA), a technique that has been extensively described and refined over decades, providing a tension-free anastomosis with consistently high success rates. In severe cases, however, where there is significant pelvic disruption, extensive urethral gaps, or difficult access due to scarring, an abdominoperineal approach may be required to achieve adequate exposure, mobilization, and excision of scar tissue. Complex PFUI scenarios, defined by dense periurethral fibrosis, long-segment defects, associated fistulae, or concomitant bladder neck injury, demand more advanced reconstructive strategies and are associated with lower success rates compared with primary BMA. Redo urethroplasty represents an even greater challenge due to altered anatomy, impaired vascularity, and a lack of healthy tissue available for mobilization. Common factors contributing to surgical failure include inadequate excision of fibrotic tissue, insufficient mobilization of the bulbar urethra, and poor tissue quality at the anastomotic site. When bulbar urethral necrosis (BUN) occurs or when the urethral gap cannot be bridged primarily, substitution techniques become necessary. Among these, the pedicled preputial tube has emerged as one of the most widely described and effective options, offering a robust vascularized tissue for reconstruction and demonstrating favorable long-term outcomes. Successful PFUI management therefore relies on individualized planning that integrates detailed preoperative imaging and refined surgical techniques tailored to the specific extent and complexity of the injury.