Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis
Bibliographic record
Abstract
OBJECTIVE: Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU. METHODS: PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9). RESULTS: From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82). CONCLUSION: For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.021 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.017 | 0.033 |
| Bibliometrics | 0.006 | 0.007 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".