title: Complex posterior urethral injury.
abstract: OBJECTIVE
  To assess treatment strategies for seven different scenarios for treating complex pelvic fracture urethral injury (PFUI), categorised as repeat surgery for PFUI, ischaemic bulbar urethral necrosis (BUN), repair in boys and girls aged ⩽12 years, in patients with a recto-urethral fistula, or bladder neck incontinence, or with a double block at the bulbomembranous urethra and bladder neck/prostate region.
  
  
  METHODS
  We retrospectively reviewed the success rates and surgical procedures of these seven complex scenarios in the repair of PFUI at our institution from 2000 to 2013.
  
  
  RESULTS
  In all, >550 PFUI procedures were performed at our centre, and 308 of these patients were classified as having a complex PFUI, with 225 patients available for follow-up. The overall success rates were 81% and 77% for primary and repeat procedures respectively. The overall success rate of those with BUN was 76%, using various methods of novel surgical techniques. Boys aged ⩽12 years with PFUI required a transpubic/abdominal approach 31% of the time, compared to 9% in adults. Young girls with PFUI also required a transpubic/abdominal urethroplasty, with a success rate of 66%. In patients with a recto-urethral fistula the success rate was 90% with attention to proper surgical principles, including a three-stage procedure and appropriate interposition. The treatment of bladder neck incontinence associated with the tear-drop deformity gave a continence rate of 66%. Children with a double block at the bulbomembranous urethra and at the bladder neck-prostate junction were all continent after a one-stage transpubic/abdominal procedure.
  
  
  CONCLUSIONS
  An understanding of complex pelvic fractures and their appropriate management can provide successful outcomes.
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Sanjay B
authors.initials: SB
authors.lastname: Kulkarni
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Pankaj M
authors.initials: PM
authors.lastname: Joshi
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Craig
authors.initials: C
authors.lastname: Hunter
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Sandesh
authors.initials: S
authors.lastname: Surana
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Walid
authors.initials: W
authors.lastname: Shahrour
authors.affiliation: Center for Reconstructive Urology, Pune, India.
authors.forename: Faisal
authors.initials: F
authors.lastname: Alhajeri
keywords: BMG, buccal mucosal graft; BMU, bulbomembranous urethra; BNP, bladder neck prostate; BUN, bulbar urethral necrosis; Bladder neck injury; Bulbar urethral necrosis; Female; OMF, oral mucosal flap; PFUI, pelvic fracture urethral injury; RUG, retrograde urethrography; Recto-urethral fistula; UVF, urethrovaginal fistula; VCUG, voiding cysto-urethrography