基于尿道近端深度与耻骨支宽度的骨盆-尿道关系新分型在预测骨盆骨折尿道损伤后尿道狭窄手术难度中的应用研究

Application of a new classification of pelvic-urethral relationship based on proximal urethral depth and pubic ramus width in predicting surgical difficulty of posterior urethral stricture after pelvic fracture urethral injury

摘要

目的 研究以尿道近心端断端深度、骨盆耻骨支宽度为基础的新型四型解剖分类法在预测骨盆骨折尿道损伤（PFUI）后尿道狭窄（PUS）手术复杂度中的有效性、实用性，以克服传统二维尿道造影评估的不足。方法 对2021-2023年于上海市第六人民医院泌尿外科接受后尿道成形术的516例PFUI后PUS患者的临床资料进行回顾性分析。根据术前计算机断层扫描（CT）三维重建和尿道造影，把骨盆-尿道解剖关系分为四型：Ⅰ型（浅-宽型）、Ⅱ型（浅-窄型）、Ⅲ型（深-宽型）、Ⅳ型（深-窄型）。比较四型患者手术复杂度指标（手术时间、手术入路选择），安全性指标（术中出血量、并发症发生率），有效性指标（狭窄复发率、术后尿失禁发生率）。结果 随着分型级别的增加（Ⅰ型～Ⅳ型），手术难度指标呈阶梯式上升。Ⅰ型、Ⅱ型、Ⅲ型、Ⅳ型患者的手术时间分别为（45±15）min、（58±17）min、（68±14）min、（82±15）min，四型患者间比较差异具有统计学意义（P＜0.001）；术中出血量分别为（100±25）mL、（145±23）mL、（168±21）mL、（235±31）mL，四型患者间比较差异具有统计学意义（P＜0.001）；需要做耻骨下缘切除的比例分别为4.8%、20.2%、34.9%、84.6%，四型患者间比较差异具有统计学意义（P＜0.001）。Ⅳ型患者术后总体并发症发生率（24.4%）和狭窄复发率（25.6%）均高于其它分型，差异具有统计学意义（P＜0.001）。四型患者间的术后尿失禁发生率比较，差异无统计学意义（P＞0.05）。结论 本研究提出的四型骨盆-尿道关系分类法是一种简单、实用的术前评估工具，可以更准确地预测PFUI后PUS的手术难度，有利于术前规划、资源调配和患者咨询，建议临床常规使用。

Abstract

Objective To investigate the effectiveness and utility of a new four-type anatomical classification based on the proximal urethral depth and the pubic ramus width in predicting the surgical complexity of posterior urethral stricture（PUS）after pelvic fracture urethral injury（PFUI），and to overcome the limitations of traditional two-dimensional urethrography assessment. Methods The clinical data of 516 PUS patients after PFUI who underwent posterior urethroplasty in our hospital during 2021 and 2023 were retrospectively analyzed. Based on preoperative three-dimensional（3D）computerized tomography（CT）reconstruction and urethrography，the pelvic-urethral anatomical relationship was classified into four types：Type Ⅰ（superficial-wide），Type Ⅱ（superficial-narrow），Type Ⅲ（deep-wide），and Type Ⅳ（deep-narrow）. Surgical complexity indicators（operation time，surgical approach），safety indicators（intraoperative blood loss，complications），and efficacy indicators（stricture recurrence rate，urinary continence rate）were compared among the groups. Results As the classification level increased（Type Ⅰ to Ⅳ），the surgical difficulty indicators showed a stepwise increase. The mean operation time for Type Ⅰ to Type Ⅳ patients was（45±15）min，（58±17）min，（68±14）min and（82±15）min，respectively（P＜0.001）；intraoperative blood loss was（100±25）mL，（145±23）mL，（168±21）mL and（235±31）mL，respectively（P＜0.001）；the rate of inferior pubectomy was 4.8%，20.2%，34.9%，and 84.6%，respectively（P＜0.001）. The rate of postoperative complications（24.4%）and recurrence rate of stricture（25.6%）in Type Ⅳ patients were significantly higher than those in other types（P＜0.001）. There was no statistically significant difference in the incidence of postoperative urinary incontinence among the four groups（P＞0.05）. Conclusion The four-type pelvic-urethral relationship classification proposed in this study is a simple and practical preoperative assessment tool. It can accurately predict the surgical difficulty of PUS after PFUI，helping to optimize preoperative planning，resource allocation，and patient counseling，and is recommended for clinical application.

关键词

骨盆骨折尿道损伤 / 后尿道狭窄 / 骨盆-尿道关系分类法 / 尿道造影

Key words

pelvic fracture urethral injury / posterior urethral stricture / classification of pelvic urethral relationship / urethrography

参考文献

[1] REVELS JW， WANG SS， WEAVER JS， et al. A multimodality review of male urethral imaging：pearls and pitfalls with an update on urethral stricture treatment[J]. Br J Radiol， 2022， 95（1134）： 20211034.

[2] CHOU CP， HUANG JS， WU MT， et al. CT voiding urethrography and virtual urethroscopy：preliminary study with 16-MDCT[J]. AJR Am J Roentgenol， 2005， 184（6）： 1882-1888.

[3] FRANKIEWICZ M， VETTERLEIN MW， MARKIET K， et al. Ultrasound imaging of male urethral stricture disease：a narrative review of the available evidence，focusing on selected prospective studies[J]. World J Urol， 2024， 42（1）： 32.

[4] HORIGUCHI A， EDO H， SHINCHI M， et al. Membranous urethral length on magnetic resonance imaging as a novel predictor of urinary continence after delayed anastomotic urethroplasty for pelvic fracture urethral injury[J]. World J Urol， 2022， 40（1）： 147-153.

[5] ANDRICH DE， MUNDY AR. The nature of urethral injury in cases of pelvic fracture urethral trauma[J]. J Urol， 2001， 165（5）： 1492-1495.

[6] KORAITIM MM. Pelvic fracture urethral injuries：the unresolved controversy[J]. J Urol， 1999， 161（5）： 1433-1441.

[7] FRETON L， MADEC FX， FOUREL M， et al. Management of male posterior urethral stenosis following trauma and prostatic treatments，techniques and results[J]. Fr J Urol， 2024， 34（11）： 102716.

[8] ZHANG K， LIU M， WANG T， et al. Retrospective analysis of urethral anastomosis with ancillary maneuvers and intraoperative biaxial defect measurements to achieve a tension free guidance system for redo PFUDD treatment[J]. BMC Urol， 2024， 24（1）： 82.

[9] EL-KASSABY AW， OSMAN T， ABDEL-AAL A， et al. Dynamic three-dimensional spiral computed tomographic cysto-urethrography：a novel technique for evaluating post-traumatic posterior urethral defects[J]. BJU Int， 2003， 92（9）： 993-996.

[10] SHEEHAN JL， NARINGREKAR HV， MISIURA AK， et al. The pre-operative and post-operative imaging appearances of urethral strictures and surgical techniques[J]. Abdom Radiol（NY）， 2021， 46（5）： 2115-2126.

[11] SA YL， XU YM， FENG C， et al. Three-dimensional spiral computed tomographic cysto-urethrography for post-traumatic complex posterior urethral strictures associated with urethral-rectal fistula[J]. J Xray Sci Technol， 2013， 21（1）： 133-139.

[12] MA Y， JIAN Z， ZHOU L， et al. A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients：a retrospective analysis[J]. World J Urol， 2021， 39（11）： 4227-4234.

[13] ZHANG XM， HU WL， HE HX， et al. Diagnosis of male posterior urethral stricture：comparison of 64-MDCT urethrography vs. standard urethrography[J]. Abdom Imaging， 2011， 36（6）： 771-775.

[14] WANG Z， SONG G， XIAO Y， et al. The value of magnetic resonance imaging geometric parameters in pre-assessing the surgical approaches of pelvic fracture urethral injury[J]. Transl Androl Urol， 2020， 9（6）： 2596-2605.

[15] HORIGUCHI A， EDO H， SOGA S， et al. Pubourethral stump angle measured on preoperative magnetic resonance imaging predicts urethroplasty type for pelvic fracture urethral injury repair[J]. Urology， 2018， 112： 198-204.

[16] PRATAP A， AGRAWAL CS， TIWARI A， et al. Complex posterior urethral disruptions：management by combined abdominal transpubic perineal urethroplasty[J]. J Urol， 2006， 175（5）： 1751-1754.

[17] ALWAAL A， SANFORD TH， HARRIS CR， et al. Urethral stricture score is associated with anterior urethroplasty complexity and outcome[J]. J Urol， 2016， 195（6）： 1817-1821.

[18] KORAITIM MM. Predictors of surgical approach to repair pelvic fracture urethral distraction defects[J]. J Urol， 2009， 182（4）： 1435-1439.

[19] FAROOQ M， NAGASUBRAMANIAN S， JAYASIMHA S， et al. Pelvic fracture urethral injury in adolescents-predictors of outcomes and surgical complexity[J]. J Pediatr Urol， 2024， 20（3）： 503.e1-503.e8.

[20] KORAITIM MM， MARZOUK ME， ATTA MA， et al. Risk factors and mechanism of urethral injury in pelvic fractures[J]. Br J Urol， 1996， 77（6）： 876-880.

[21] CHAPPLE C， BARBAGLI G， JORDAN G， et al. Consensus statement on urethral trauma[J]. BJU Int， 2004， 93（9）： 1195-1202.