Outcomes of Early Endoscopic Realignment Versus Suprapubic Cystostomy and Delayed Urethroplasty for Pelvic Fracture-related Posterior Urethral Injuries: A Systematic Review

Context
The evidence base for optimal acute management of pelvic fracture-related posterior urethral injuries needs to be reviewed because of evolving endoscopic techniques. The current standard of care is suprapubic cystostomy followed by delayed urethroplasty.

Objective
To systematically review the evidence base comparing early endoscopic realignment with cystostomy and delayed urethroplasty regarding stricture rate, the need for subsequent procedures, and functional outcomes.

Evidence acquisition
A systematic search in Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Review, and www.clinicaltrials.gov without time or language limitations. Both medical subject heading and free text terms as well as variations of root word were searched. Randomised controlled trials (RCTs), nonrandomised comparative studies and single-arm case series were included, as long as ≥10 patients were enrolled. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

Evidence synthesis
No RCTs were found. Six nonrandomised comparative studies and met inclusion criteria and were selected for data extraction. Noncomparative studies with more than 10 participants were included resulting in seven eligible studies. From the comparative papers the results of 219 patients were reported: 142 in the realignment group and 77 in the group undergoing cystostomy with delayed repair. The noncomparative studies reported on a further 150 cases. An overall stricture rate of 49% was evident in the endoscopic realignment group. Of these patients, 50% (28.1% overall) could be managed by endoscopic procedures and 40.3% (18.5% of intervention group) required anastomotic repair.

Conclusions
No RCTs were found and the included nonrandomised studies have heterogeneous populations and a high degree of bias. About half of the patients were free of stricture and thus did not undergo delayed urethroplasty in case early endoscopic realignment had been performed.

Patient summary
This systematic review of literature of urethral trauma revealed there are no well conducted comparative studies of newer endoscopic treatments versus standard treatments which include more extensive surgery. The results of the reports we selected based on specific characteristics are often influenced by variable factors. After careful analysis of these results we can conclude that the newer endoscopic techniques might resolve the risk of urethral injury due to pubic fractures in about half of the patients. Because of various confounders we cannot identify those patients who would benefit from this procedure or who might be possibly harmed.