To The Editor:
With great interest, we read "Spontaneous Urinary Voiding of a
Metallic Implant After Operative Fixation of the Pubic Symphysis. A Case
Report" (2003;85:1129-32), by Fridman et al. We described a similar case
of a patient who voided a screw nine years after internal fixation of
diastasis of the pubic symphysis1. The Advanced Trauma Life Support
program advises doctors to perform a retrograde urethrogram in patients in
whom urologic injury is suspected2. Did the authors make a
retrograde urethrogram or cystogram at presentation after the initial trauma
to diagnose an injury to the ureter or bladder? In a review of urethral
injuries after pelvic fractures in females, Perry and Husmann reported that
50% of urethral injuries were missed because of inadequate urologic
assessment3. The initial bladder injury may have been caused by the
trauma itself, but bladder herniation within the symphysis or iatrogenic
injury are also possibilities4.
Did the authors consider performing a cystogram to diagnose a fistula tract
to the osteosynthesis material? In the case that we presented, a cystogram
revealed a fistula from the anterior part of the bladder to the symphysis and
the osteosynthesis material after the screw was voided.
Did the authors consider the use of a suprapubic catheter? A recent review
of published randomized studies comparing urethral and suprapubic catheters in
patients undergoing colorectal surgery described favorable results with the
use of suprapubic compared with urethral catheterization5. The
study found that urinary tract infections were reduced, particularly in
females, and the ability to attempt normal voiding was facilitated,
particularly in males. In a series of forty-seven patients with dislocation of
the symphysis, Matta did not consider urethral or bladder injury to be a
contraindication to early internal fixation6. In his series, none
of the seven patients with an additional urologic injury treated with a
suprapubic catheter suffered deep infection. We would like to stress the
importance of an adequate urologic workup after dislocation of the symphysis,
and we agree with the authors that this complication should be considered
whenever urinary symptoms develop after operative fixation of a disrupted
symphysis pubis.
It was a great pleasure to learn that our article had a repercussion within
the group of traumatologists and urologists at Sint Lucas Andreas Hospital in
Amsterdam. It comes as a surprise that two similar articles about a new topic
have been published during a three-month interval in two well-known medical
journals. In response to their questions and observations, we provide the
following comments.
Indeed, the Advanced Trauma Life Support program advises the performance of
retrograde urethrocystography in patients with suspicion of a urologic lesion,
especially in the presence of urethral bleeding. However, this was not the
case in the patient seen by our group. As there was no evidence of a lesion in
the urinary tract, we just performed the routine urethral catheterization
indicated for patients with multiple
trauma7. Exploratory
laparotomy followed by splenectomy confirmed the integrity of the urinary
tract.
Regarding the comment about the work by Cass et
al.4, we are sure
that there was no urinary lesion at the moment of the trauma nor was there an
iatrogenic lesion, as was confirmed by the surgery, clinical course, and late
urethrocystoscopic investigation.
Even though we did not perform cystography and preferred to perform
urethrocystoscopy after the screw was voided, we agree that the former is a
useful method to identify vesical fistulas, although it is not infallible, as
false-negative results have been
reported8.
Despite the similarity of the two cases with regard to the voiding of a
screw through the urethra because of the instability created at the bone
synthesis and the resulting loosening of the implants, the two cases present
different evolutions. Our patient went on to heal with no bone infection and
without sequelae after the screw was voided, whereas the patient at Sint Lucas
Andreas Hospital had development of osteomyelitis with a bone sequestrum,
which certainly contributed to the voiding of the screw and to the maintenance
of the fistula. Considering the long asymptomatic period, we believe that the
fistula is neither related to the initial trauma nor of iatrogenic origin.
However, the true cause of the screw penetration through the vesical wall
still is a topic for debate.
In addition, we would like to point out that, in our patient, the washer
also went through the vesical wall and was found inside the detrusor muscle.
After the washer was removed, no fistula persisted.
To respond to the last question, we agree that the suprapubic catheter,
when adequately indicated, has advantages over the urethral catheter. However,
Porter et al.9
pointed to the suprapubic catheter as the main factor in the contamination of
orthopaedic implants used in the osteosynthesis of pelvic fractures. Thus,
another controversy.
To conclude, we agree that it is important to evaluate the integrity of the
urinary system in pelvic fractures. We stress that, in the case of our
patient, we removed the other implants from the pubic symphysis at a later
surgery, after confirming the absence of any fistula or residual lesion. We
emphasize that, to achieve better results, it is important that
traumatologists and urologists combine their efforts in the integrated
management of urologic lesions associated with complex pelvic fractures.
Heetveld MJ, Poolman RW, Heldeweg EA,
Ultee JM. Spontaneous expulsion of a screw during urination: an unusual
complication 9 years after internal fixation of pubic symphysis diastasis.
Urology.2003;61:
645.61645
2003
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