Early versus delayed urethroplasty for pediatric pelvic fracture-related urethral injury in boys: a retrospective comparative cohort study of complications and surgical success rates from a single center

Abstract

Background

The optimal timing of urethroplasty for pediatric pelvic fracture-associated urethral injury (PFUI) in boys remains controversial, with limited long-term data. This study aimed to compare the complications and surgical success rates between early (≤10 days) and delayed (≥3 months) urethroplasty in a long-term pediatric cohort.

Methods

This retrospective study included boys who underwent PFUI urethroplasty at a single center (2001–2023). Exclusion criteria included loss to follow-up, death, and prior realignment or urethral surgery elsewhere. Early repair was defined as ≤10 days post-injury, and delayed repair as ≥3 months. Outcomes included stricture (clinical or cystoscopic), incontinence (any leakage), erectile dysfunction (ED, by parental or self-report), and reoperation. Statistical comparisons used Mann-Whitney U and Fisher’s exact tests.

Results

Among 100 screened patients, 48 were analyzed (median follow-up 112 months): 15 in the early group and 33 in the delayed group. Surgical timing was determined by referral time rather than clinical severity; however, the two groups differed in post-injury management patterns, which may introduce selection bias. The overall complication rate was 54.2% (26/48): stricture 41.7% (20/48), incontinence 22.0% (9/41), ED 29.3% (12/41), and reoperation 37.5% (18/48). No significant differences were observed between early and delayed groups for stricture (5/15 vs. 15/33), reoperation (4/15 vs. 14/33), or overall complications (6/15 vs. 20/33; all P>0.05). Wide 95% confidence intervals (CIs) (e.g., reoperation rate difference: −15.7%, 95% CI: −41.3% to 12.4%) reflect small sample size (especially n=15 in early group) and insufficient power.

Conclusions

This single-center study does not provide conclusive evidence for superiority of either early or delayed urethroplasty in boys with PFUI. Potential clinically important differences cannot be ruled out. Larger multicenter studies are needed.

Highlight box.

Key findings

• Forty-eight boys with pelvic fracture-associated urethral injury (PFUI) (median follow-up 112 months). Early repair (≤10 days, n=15) vs. delayed (≥3 months, n=33).

• No significant differences in stricture (33.3% vs. 45.5%), incontinence (21.4% vs. 22.2%), erectile dysfunction (ED) (35.7% vs. 25.9%), reoperation (26.7% vs. 42.4%), or overall complications (40.0% vs. 60.6%), all P>0.05.

• Wide confidence intervals (CIs) (e.g., reoperation difference: −15.7%, 95% CI: −41.3% to 12.4%) indicate insufficient sample size; clinically important benefits/harms of early repair cannot be ruled out.

What is known and what is new?

• Pediatric PFUI is rare. Optimal timing of urethroplasty remains controversial. Most studies compare primary endoscopic realignment with delayed repair, showing no advantage for early realignment. Delayed repair (≥3 months) is conventional to avoid acute inflammation.

• This study directly compares early primary urethroplasty with delayed repair in a long-term pediatric cohort. Although no outcome reached statistical significance, wide CIs suggest potentially important clinical differences (e.g., early repair might reduce reoperation by up to 41.3%). Negative results are “inconclusive” not “null”. Sexual function observations (glans sensation, ejaculation) are reported.

What is the implication, and what should change now?

• Current evidence does not support a definitive recommendation. Clinicians should individualize timing based on patient stability, injury pattern, and local expertise. Larger multicenter prospective studies with standardized outcomes and validated sexual function instruments are needed.

Introduction

Pediatric pelvic fracture-associated urethral injury (PFUI) is an uncommon but serious consequence of high-energy blunt pelvic trauma (1,2). Traffic accidents are among the leading causes of PFUI (3). In boys with pelvic trauma, the reported incidence of urethral injury ranges from 7.4% to 13.5% (4,5). In the 1970s and 1980s, transpubic urethroplasty was considered the standard approach for complex post-traumatic posterior urethral strictures in both adults and children, as described by Turner-Warwick (6). To achieve a tension-free anastomosis, a progressive perineal approach has been advocated, including circumferential urethral mobilization (step 1), corporal body separation (step 2), inferior wedge pubectomy (step 3), and supracrural urethral rerouting (step 4) (7). Compared with adults, boys are more likely to sustain injuries involving the prostatic urethra and bladder neck because of the immature prostate and underdeveloped puboprostatic ligaments, which can result in more complex distraction defects (8,9). On the basis of these anatomical features, some authors have advocated emergency or early transperineal repair (10,11). However, PFUI is often accompanied by multiple associated injuries and hemodynamic instability, circumstances that may preclude early reconstruction. In addition, some reports have suggested that early surgery may be associated with more severe complications (12,13). Long-term pediatric data remain limited, most published series are small, and the optimal timing of urethroplasty remains controversial (14-16).

In this study, we report our single-center experience with urethroplasty for PFUI in boys and provide long-term follow-up data on postoperative complications and reintervention. We specifically examined whether the timing of primary urethroplasty was associated with differences in surgical outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0249/rc).

Methods

Patients

This retrospective cohort study included boys with PFUI who underwent urethroplasty between February 2001 and November 2023 at the Department of Urology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health (NCCH). All eligible cases during the study period were screened for inclusion. Patients were excluded if they were lost to follow-up, died, or had previously undergone urethral realignment or urethroplasty elsewhere.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments (17). The study was approved by the Ethics Committee of Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health (NCCH) (No. [2025]-E-047-R), and informed consent was obtained from all legal guardians (verbal consent via telephone, as the ethics committee granted a waiver of written informed consent due to the remote follow-up method). For participants who reached adulthood during follow-up, additional verbal consent was obtained from the participants themselves.

Data collection

We collected preoperative, intraoperative, and postoperative follow-up data. Preoperative variables included age, body weight, mechanism of trauma, prior urinary diversion or urethral procedures performed elsewhere (e.g., suprapubic cystostomy, urethral realignment, or urethroplasty), and the interval between injury and the first urethral surgery at our center. Intraoperative variables included urethral defect length, surgical approach, and adjunctive steps such as corporal body separation, inferior wedge pubectomy, and bladder neck reconstruction. Postoperative variables included postoperative length of stay (LOS), complications [urethral stricture, urinary incontinence, and erectile dysfunction (ED)], reoperation, and reported penile shortening.

All patients were evaluated with simultaneous retrograde urethrography (RUG) and voiding cystourethrography (VCUG) in the oblique position to assess the site of urethral injury, estimate the distraction defect length, and evaluate bladder neck morphology (Figures 1,2). In a few patients, preoperative RUG and VCUG were incomplete or suboptimal because the child could not void during imaging or image quality was inadequate.

Figure 1.

Combined cystography and retrograde urethrography in a boy with pelvic fracture-associated urethral injury during emergency evaluation. Contrast was injected through both a suprapubic access and a transurethral catheter. Marked contrast extravasation and cranial displacement of the bladder were observed.

Figure 2.

Three-dimensional CT reconstruction after contrast instillation in a boy with old pelvic fracture-associated urethral injury. Bladder elevation and obliteration of the posterior urethra are visible. CT, computed tomography.

Follow-up

We reviewed the medical records of all patients and conducted telephone follow-up interviews to obtain updated information on urethral stricture, urinary incontinence, ED, and penile shortening. In this study, urethral stricture was defined by meeting either of the following criteria: (I) clinical diagnosis—presence of obstructive voiding symptoms (e.g., dysuria, weak stream, dribbling) and a repeat maximum flow rate (Qmax) <15 mL/s, measured when voided volume reached ≥50% of expected bladder capacity [calculated by the Koff formula: expected capacity (mL) = (age + 2) × 30] (18); or (II) Gold-standard diagnosis—urethral stricture confirmed by cystourethroscopy, defined as significant luminal narrowing preventing passage of an endoscope of appropriate caliber. A diagnosis of urethral stricture was made if either criterion was fulfilled.

Urinary incontinence was defined as any involuntary leakage of urine. According to the 2025 European Association of Urology guidelines, ED is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance (19). In this cohort, erectile function was assessed mainly by parental or self-report rather than objective testing. For patients who had not yet entered puberty at follow-up (age <10 years), information on erectile function before and after injury was obtained from parental reports. For patients who were in puberty (≥10 years) or adulthood (≥19 years) at follow-up, erectile function was self-reported. Pubertal status was defined according to the World Health Organization classification (https://www.who.int/health-topics/adolescent-health).

Successful urethroplasty was defined as maintenance of a uniform urethral caliber without the need for subsequent dilation, urethrotomy, or secondary surgery (20).

Some studies have reported that early repair after urethral injury in boys is performed within 7 days post-injury (21,22), while others have reported within 10 days (23). In China, the Expert consensus on urethral injury in male children (2023) issued by the Group of Urological Surgery, Branch of Pediatric Surgery, Chinese Medical Association classifies the timing of urethral repair into emergency repair (within 48 hours post-injury), early repair (2–14 days post-injury), and secondary urethral repair after initial suprapubic cystostomy (after 3 months) (24). In addition, some studies have noted that previous scholars recommended waiting at least 3 months for delayed repair to ensure complete resolution of the hematoma and adequate healing of local tissues (25). In our clinical practice, the patients who underwent early repair received primary urethral repair at the latest within 10 days post-injury, while the earliest patient who underwent delayed repair had surgery at 3 months post-injury. Therefore, we divided the patients into an early repair group (≤10 days post-injury) and a delayed repair group (≥3 months post-injury).

Surgical technique

For early repair, inferior wedge pubectomy was generally unnecessary. Primary transperineal urethroplasty included suprapubic bladder exposure, a reversed Y-shaped perineal incision with division of the bulbospongiosus muscle, mobilization of the urethra to identify the distal stump at the bulbomembranous junction, reduction of the elevated bladder and prostatic urethra toward the perineum to expose the proximal stump, and direct end-to-end mucosal anastomosis under direct vision. When the anastomosis was under excessive tension, partial corporal separation and further distal urethral mobilization were performed. Concomitant bladder neck or rectal injury was repaired at the same sitting when present. To protect the erectile nerves and reduce the incidence of ED, avoid retropubic exploration during surgery and do not pull the bladder and prostate cephalad. A silicone Foley catheter was left in place for 3 weeks, and suprapubic cystostomy drainage was maintained. A perineal rubber drain was placed and usually removed after 2–3 days (Figure 3).

Figure 3.

Intraoperative steps of emergency perineal urethroplasty in a boy with pelvic fracture-associated urethral injury. (A) Preoperative retrograde urethrography showing pelvic fracture and posterior urethral rupture. (B) Reversed Y-shaped perineal incision. (C) Midline scrotal incision. (D) Incision of the bulbospongiosus muscle with exposure of the bulbar urethra. (E) Circumferential urethral mobilization. (F) Identification of the distal urethral stump at the bulbar-membranous junction (white arrow). (G) Complete exposure of the distal urethral stump (white arrow). (H) Exposure of the proximal urethral stump (yellow arrow). (I) Placement of absorbable sutures in the proximal stump (yellow arrow). (J) Passage of the suture through the distal stump (white arrow). (K) A total of six sutures were used to complete the end-to-end anastomosis (yellow arrow). (L) Placement of a perineal rubber drain (black arrow). (M,N) Layered closure of the perineal wound. (O) Closure of the suprapubic bladder incision with a cystostomy tube left in place for drainage.

For delayed repair, most boys underwent transpubic anastomotic urethroplasty according to defect length and scar severity. The procedure generally included the following steps: (I) the bladder was opened through a transverse suprapubic incision; (II) a perineal incision was made to fully mobilize the distal urethra, including the bulbar urethra, with extension to the penoscrotal junction when needed to shorten the distance between urethral ends; (III) all intervening fibrotic scar tissue was excised; (IV) a urethral sound was passed through the bladder neck to identify the proximal urethral end, followed by circumferential mobilization of fibrotic tissue around both stumps; (V) when the residual gap was too long for direct anastomosis, partial corporal separation and inferior wedge pubectomy were performed; and (VI) an end-to-end mucosal anastomosis was completed under direct vision. When a rectourethral fistula was identified, it was repaired simultaneously.

If the urethral defect was too long for primary anastomosis or dense scarring precluded standard repair, substitution urethroplasty was considered. In this series, one patient underwent scrotal skin flap urethroplasty in March 2006 to repair a 5-cm defect. In patients with extensive urethral loss, definitive perineal urethrostomy was used as a temporary solution until further growth and tissue availability allowed redo reconstruction. Although scrotal flap urethroplasty can bridge long defects, it is associated with late complications such as hair growth within the neourethra and secondary stone formation after puberty; accordingly, it has not been performed at our center for more than a decade.

Statistical analysis

Statistical analyses were performed using R software version 4.2.2 (http://www.r-project.org). Normality was assessed before group comparisons using the Shapiro-Wilk or Pearson normality test, as appropriate. Normally distributed continuous variables are presented as mean ± standard deviation and were compared using the Student’s t-test, whereas non-normally distributed variables are presented as median with range and were compared using the Mann-Whitney U test. Categorical variables are expressed as counts and percentages and were compared using Fisher’s exact test, as appropriate. Analyses were based on available data, and denominators are reported when follow-up information was incomplete. All tests were two-sided, and P<0.05 was considered statistically significant.

Results

Patient characteristics

Among the 100 patients who initially met the criteria, 52 were excluded, including 16 who were lost to follow-up because their phone numbers were no longer valid, 1 who died of uremia, 20 who had undergone primary urethral realignment at outside hospitals, and 15 who had been referred after at least one failed urethroplasty elsewhere; the remaining 48 patients were included in the analysis (Figure 4).

Figure 4.

Flow diagram of patient selection. PFUI, pelvic fracture-associated urethral injury.

To assess selection bias, we compared the baseline characteristics of all excluded patients (n=52) with those of the patients finally included in the analysis (n=48) (Table 1). The results showed no statistically significant differences between the two groups in age [excluded group: 86 (range, 9–162) months vs. included group: 80 (range, 13–171) months, P=0.14], incidence of post-injury shock (excluded group: 21.2% vs. included group: 31.3%, P=0.36), or proportion undergoing emergency pelvic fracture surgery after injury (excluded group: 19.2% vs. included group: 20.8%, P>0.99; Table 1).

Table 1. Baseline clinical characteristics of patients in the exclusion and inclusion groups.

Variable	Exclusion group (n=52)	Inclusion group (n=48)	P value
Age (months)	86 [9–162]	80 [13–171]	0.14
Post-traumatic shock	11 (21.2)	15 (31.3)	0.36
Emergency pelvic fracture surgery	10 (19.2)	10 (20.8)	>0.99

Data are presented as median [range] or n (%).

The early group consisted of 15 patients, all of whom presented to our hospital and underwent urethral repair within 10 days after injury. The delayed surgery group consisted of 33 patients. Among them, 31 patients presented to other hospitals after injury and underwent suprapubic cystostomy, then were referred to our hospital after several months for delayed surgery. The other 2 patients first presented to other hospitals after injury, where they were managed with indwelling urethral catheterization; they were referred to our hospital around 2 weeks after injury and, having missed the opportunity for early repair, underwent suprapubic cystostomy only, and then waited for delayed urethral repair. The median time from injury to delayed urethral repair in these 33 patients at our hospital was 9 months (range, 3–24 months). The timing of delayed surgery in all patients in the delayed group was determined by when they were referred to our hospital, not by active choice of the physician.

Traffic accidents were the dominant mechanism of injury (93.8%). Two patients sustained crush injuries and one was injured after a fall from height. All patients had posterior urethral disruption. Age at injury ranged from 13 to 171 months, with a median of 80 months, and the median age at the last follow-up was 186 months (range, 73–350 months). Median body weight was 22 kg. Forty-seven patients underwent end-to-end anastomotic urethroplasty and one underwent scrotal flap urethroplasty for a long defect. Two patients required concomitant bladder neck repair at the time of urethroplasty. Three boys in the delayed group had rectal injuries, which were repaired simultaneously (Table 2).

Table 2. Characteristics and outcomes of all patients and the early group vs. delayed group.

Variables	All (n=48)	Early group (n=15)	Delayed group (n=33)	Median difference/rate difference (early group minus delayed group)†	95% CI	P value
Age (months)	80 [13–171]	90 [13–147]	76 [43–171]	+11	−3 to 26	0.15
Age at follow-up (months)	186 [73–350]	185 [117–298]	186 [73–350]	+8	−24 to 40	0.50
Follow-up time (months)	112 [5–220]	113 [10–220]	110 [5–218]	+3	−35 to 41	0.95
Weight (kg)	22.0 [14–75.2]	26.0 [14–52]	20.0 [14–75.2]	+6.2	−5.5 to 18.2	0.29
Trauma type						0.68
Traffic accident	45 (93.8)	14 (93.3)	31 (93.9)
Crush injury	2 (4.1)	1 (6.67)	1 (3.03)
Fall from height	1 (2.1)	0	1 (3.03)
Rectum injury	3 (6.3)	0	3 (9.09)			0.54
Length of urethral defect (cm)	1.7 [0.2–5.0]	1.8 [0.8–3.5]	1.5 [0.2–5.0]	+0.3	−0.5 to 1.1	0.48
Proportion undergoing emergency pelvic fixation surgery	10 (20.8)	1 (6.7)	9 (27.3)	−20.6%	−40.1% to 0.3%	0.14
Surgery type						>0.99
Urethroplasty	47 (97.9)	15 (100.0)	32 (97.0)
Scrotal flap urethroplasty	1 (2.1)	0	1 (3.03)
Surgical steps
Corporeal body separation	44 (91.7)	14 (93.3)	30 (90.9)			>0.99
Inferior wedge pubectomy	5 (10.4)	0	5 (15.2)			0.17
Bladder neck repair	2 (4.1)	1 (6.67)	1 (3.03)			0.53
LOS (days)	17 [6–59]	16 [6–59]	19 [6–35]	−3	−14 to 10	0.83
Reoperation	18 (37.5)	4 (26.7)	14 (42.4)	−15.7%	−41.3% to 12.4%	0.47
Complications	26 (54.2)	6 (40.0)	20 (60.6)	−20.6%	−48.0% to 9.6%	0.31
Urethral stricture	20 (41.7)	5 (33.3)	15 (45.5)	−12.2%	−40.0% to 17.5%	0.64
Urinary incontinence (n=41)	9 (22.0)‡	3 (21.4)§	6 (22.2)¶	−0.8%	−27.6% to 22.7%	>0.99
Erectile dysfunction (n=41)	12 (29.3)‡	5 (35.7)§	7 (25.9)¶	+9.8%	−19.8% to 35.8%	0.73

Data are presented as median [range] or n (%) unless otherwise indicated. ^†, for non-normally distributed continuous variables, group differences are presented as the Hodges-Lehmann median difference (early group minus delayed group) with 95% CIs derived from the Mann-Whitney U test; for categorical variables, the difference is expressed as the rate difference (early group minus delayed group). ^‡, a total of 41 urinary incontinence and erectile dysfunction assessment reports were received; 7 patients declined to provide them. ^§, 14 urinary incontinence and erectile dysfunction assessment reports were received from the early group. ^¶, 27 urinary incontinence and erectile dysfunction assessment reports were received from the delayed group. CI, confidence interval; LOS, length of stay.

Median postoperative follow-up was 112 months. Overall, 26 patients developed postoperative complications, corresponding to an overall complication rate of 54.2%. Urethral stricture occurred in 20 patients, urinary incontinence in 9, and ED in 12. Among the 20 patients with suspected or confirmed stricture, two underwent cystoscopy for voiding symptoms without definite evidence of recurrent narrowing, whereas 18 patients (37.5%) required secondary intervention, including repeated urethral dilation or internal urethrotomy in four, redo urethroplasty in 13, and urethrostomy followed by stoma closure after puberty in one. The overall surgical success rate was therefore 62.5% (Table 2).

During follow‑up, we also used the Incontinence Impact Questionnaire-7 (IIQ-7) to assess urinary incontinence (IIQ-7 raw scores were graded as 0–4 minimal impact, 5–8 mild impact, 9–14 moderate impact, or 15–21 severe impact). Patients who self‑reported or were reported by parents as having no urinary incontinence all scored 0, indicating no impact on quality of life. Among the nine patients with urinary incontinence, only 8 patients completed the IIQ-7, as shown in Table 3. Among the nine patients with postoperative urinary incontinence, symptoms improved after puberty in two.

Table 3. IIQ-7 scores of patients with urinary incontinence.

Index	Case No.
	1	2†	3‡	4	5	6	7	8	9‡
Age at follow-up (months)	250	225	226	127	159	134	155	130	145
IIQ-7 score	5	–	5	15	10	3	7	3	4

^†, patient who failed to complete the IIQ-7 questionnaire. ^‡, patients with improved urinary incontinence after puberty. IIQ-7, Incontinence Impact Questionnaire-7.

Erectile function was evaluated in 41 patients, of whom 12 (29.3%) were reported by parents or self-assessment to have no penile erection after trauma. Among the 48 cases included in the study, 12 patients had reached adulthood (≥19 years) at follow-up, and 4 of them considered themselves to have ED. Among these 12 patients, 9 were younger than 10 years at the time of injury, and none of these children paid attention to the difference in glans sensitivity before and after injury. Among the 3 patients who were older than 12 years at the time of injury, 2 were satisfied with erectile function, ejaculation, and glans sensitivity (one of them was married and had fathered children); 1 reported no erection after injury, and stimulation of the glans could not induce erection, while glans tactile and pain sensation were reduced compared with before injury. Nineteen patients responded to questions regarding penile length at follow-up (age range, 127–298 months); six provided specific measurements, whereas 13 reported only whether penile length was normal or shortened (Tables 4,5).

Table 4. Follow-up results of erectile function assessment in 41 patients.

Index	Age at follow-up			Total
	Prepuberty (<10 years)	Adolescence (10–19 years)	Adulthood (>19 years)
Erectile function assessment (n)	2	27	12	41
Erectile dysfunction (n)	2	6	4	12
Normal erectile function (n)	0	21	8	29

Table 5. Age at follow-up and penile length data of included patients.

Index	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patients 7–9	Patients 10–19
Age at follow-up (months)	163	270	210	159	252	130	155–250	127–298
Penile length (cm)	7.5	7	5	4.2	3	3	Short	Normal

Early versus delayed urethroplasty

Fifteen boys underwent primary urethroplasty within 10 days after injury and were assigned to the early group, whereas 33 underwent urethroplasty 3 months or more after injury and were assigned to the delayed group. Age, body weight, and use of adjunctive surgical steps were comparable between groups. The overall postoperative complication rate was 40.0% (6/15) in the early group and 60.6% (20/33) in the delayed group (rate difference: −20.6%, 95% CI: −48.0% to 9.6%; P=0.31). In the early group, urethral stricture occurred in 5/15 (33.3%), urinary incontinence in 3/14 (21.4%), and self-reported ED in 5/14 (35.7%). In the delayed group, the corresponding rates were 15/33 (45.5%), 6/27 (22.2%), and 7/27 (25.9%). Reoperation was required in 4 patients in the early group and 14 in the delayed group (rate difference: −15.7%, 95% CI: −41.3% to 12.4%; P=0.47). Although urethral stricture and reoperation were numerically more frequent after delayed repair, none of the between-group differences reached statistical significance (Table 2).

Discussion

PFUI is an uncommon but challenging injury pattern that most centers encounter infrequently. Posterior urethral disruption is the hallmark lesion. In adults, the injury seldom involves the prostatomembranous junction, whereas in children this region is commonly affected because the bladder, prostate, and membranous urethra are displaced cranially at the time of pelvic trauma. Although the general principles of posterior urethral reconstruction in children resemble those in adults, pediatric tissue characteristics and anatomy make repair more demanding. End-to-end urethral anastomosis remains the standard reconstructive option for posterior distraction injuries. One factor that may influence outcomes across settings is the timing of treatment (3). Early repair may be particularly attractive when PFUI is accompanied by bladder neck laceration, because prolonged suprapubic diversion alone can be followed by a longer distraction defect and more difficult later reconstruction. However, many patients present with multiple injuries and physiologic instability, which makes early surgery impractical. Some authors have therefore favored delayed reconstruction under more controlled conditions and suggested that it may be safer or technically more reproducible (26-28). Despite these considerations, consensus on the optimal timing of repair in pediatric PFUI remains lacking (29). In addition, long-term data on postoperative urinary and sexual sequelae are scarce. In this study, we compared early and delayed urethroplasty to explore whether surgical timing was associated with different long-term outcomes.

Freedom from repeated intervention is commonly used to define success after urethroplasty. Pediatric series published over the past decade have reported success rates ranging from 25% to 90% (14,30-32). In our cohort, 18 of 48 patients (37.5%) underwent reoperation after their initial urethroplasty, yielding an overall success rate of 62.5%, which is lower than that reported in some pediatric series. This likely reflects, at least in part, the complexity of cases referred to our tertiary center and the rarity of this injury, which limits cumulative surgical experience at any single institution. These findings underscore the need for continued collaboration among referral centers to share technical experience and optimize reconstructive strategies.

The three major sequelae after PFUI are urethral stricture, urinary incontinence, and ED. Urethral stricture typically presents early after surgery with voiding difficulty and may require dilation, internal urethrotomy, or redo urethroplasty (33). Among the 48 patients in our case series, 20 (41.7%) developed stricture, of whom 18 (37.5%) required re-intervention. The difference between the two groups was not statistically significant. However, the absolute stricture rate in the early group was 12.2% lower, with the 95% CI crossing zero (−40.0% to 17.5%). As the stricture rate is the most important indicator of failure after urethral repair, the numerical advantage in the early group deserves attention, although the wide CI cannot rule out the possibility that the delayed group might be superior. The reoperation rate in the early group was numerically reduced by 15.7%; although not statistically significant, the upper limit of the 95% CI for the rate difference was only 12.4% (close to zero), while the lower limit was −41.3% (a clinically meaningful reduction). This trend suggests that early repair may have the potential to reduce reoperation, but confirmation requires larger sample sizes.

One possible explanation is that earlier repair may benefit from better vascularity and tissue pliability before dense scar maturation. In addition, early evacuation or resolution of hematoma may reduce subsequent fibrosis. Pelvic hematoma caused by PFUI can induce an initial inflammatory response and subsequent fibrosis. This pathological process participates in the repair of urethral injury and may also predispose to adverse outcomes such as urethral stricture (15). Urine extravasation can lead to severe interstitial edema and induce spongiofibrosis of the urethra. The fibrotic microenvironment drives the transformation of fibroblasts into myofibroblasts, accompanied by increased deposition of type I collagen and decreased type III collagen. This imbalance in the collagen ratio reduces tissue compliance and eventually leads to urethral stricture (34,35). Additionally, long distraction defects and concomitant bladder neck or rectal injuries are likely to increase the technical difficulty of reconstruction and the risk of restenosis. In our cohort, three patients had rectal injuries, and two of them developed postoperative urethral stricture. Although preoperative imaging suggested end separation of 0.2–5 cm, the true intraoperative defect was often longer. Previous studies have shown that most defects shorter than 3 cm can be repaired through a perineal approach, whereas longer gaps may require corporal body separation or partial inferior wedge pubectomy to achieve a tension-free anastomosis. In the present series, corporal body separation was used in 91.7% of patients and partial inferior wedge pubectomy in 10.4%. This suggests that the distraction defects in our cohort were frequently substantial, which may partly explain the relatively high rate of postoperative stricture.

Urethral injuries in boys are often more severe than those in adults because of several anatomical features: the bladder is more intra-abdominal, the prostate is small and loosely connected to the bladder, and the puboprostatic ligaments are thin and underdeveloped. Consequently, the prostatomembranous region is particularly vulnerable. Trauma at this site can impair the external urethral sphincter and lead to stress urinary incontinence, the most common mechanism of postoperative leakage in these patients. In addition, rupture involving the proximal prostatic urethra or bladder neck may compromise the bladder neck-prostatic internal sphincter complex. Urinary incontinence therefore reflects both bladder neck integrity and overall injury severity. Except in cases of major bladder neck destruction or nerve injury, continence may improve over time. Reported rates of urinary incontinence after PFUI vary widely, from 2% to 25% (36). In our cohort, 9 of 41 evaluated patients (22.0%) had postoperative incontinence, and symptoms improved after puberty in two, consistent with partial recovery of stress incontinence. The urinary incontinence rates in the early and delayed groups were similar, but the confidence interval was wide (−27.6% to 22.7%), precluding a definitive conclusion due to the small sample size (only 41 patients). In addition, we obtained IIQ-7 scores from 8 patients with urinary incontinence. The results showed that, according to the IIQ-7 scoring system (0–4 minimal, 5–8 mild, 9–14 moderate, 15–21 severe impact), 3 patients had minimal impact, 3 had mild impact, 1 had moderate impact, and 1 had severe impact on quality of life. Once urinary incontinence occurs, it becomes a persistent problem for these patients and reduces their quality of life. Therefore, clinicians should proactively assess the severity of incontinence during long-term follow-up and provide appropriate treatment or management strategies to maximize patients’ quality of life.

Most available studies compare primary endoscopic realignment with delayed urethroplasty and have not shown that primary endoscopic realignment confers an advantage in preserving bladder neck integrity or nerve innervation. A meta‑analysis by Joe et al. (2025) (5 studies, 275 patients) found no significant difference in urinary incontinence rates between the early treatment group and the delayed urethroplasty group [odds ratio (OR) =0.65, 95% CI: 0.28–1.48, P=0.3] (37). Another meta‑analysis by Cui et al. (2025) in the pediatric population (8 studies, 432 patients) similarly reported no difference in incontinence rates (12.8% vs. 3.45%, P=0.36) (38). From a mechanistic perspective, the study by Koraitim (2015) revealed the underlying reason: bladder neck injury associated with pelvic fracture results from a different mechanical mechanism than urethral injury—the former is a direct shear injury by fracture fragments, whereas the latter is caused by a shearing force (39). If bladder neck injury occurs at the time of initial trauma, its severity is determined by the injury pattern rather than the timing of repair. Therefore, many authors believe that continence outcomes depend primarily on the degree of damage to the bladder neck structure and nerve innervation caused by the initial injury.

However, our early repair procedure was primary urethroplasty, which differs from simple primary endoscopic realignment; if bladder neck injury is identified, it is easier to repair concurrently. Koraitim et al. stated: “An incompetent bladder neck is suspected by finding an open rectangular bladder neck on cystography, and a fixedly open bladder neck on suprapubic cystoscopy” (39). If sufficient attention is paid to the bladder neck on preoperative imaging and during surgery, bladder neck injury might be detected in time and repaired simultaneously. Among the enrolled patients, one patient in the early group and one in the delayed group underwent bladder neck repair during surgery. Their IIQ-7 scores were 3 and 7, respectively. Due to the small sample size, comparisons are not possible, and further studies are needed to determine which approach is superior.

ED is another important long-term complication and is generally attributed to neurovascular injury caused by the pelvic fracture rather than the reconstructive procedure itself (40,41). According to Andrew, the main mechanism underlying ED following pelvic fracture urethral injury is direct trauma that lacerates or even avulses the posterior urethra, while also harming the penile nerves and arteries as they run through the pelvic floor behind the tip of the prostate before entering the penis. The relative contributions of nerve damage versus direct vascular injury remain a subject of debate, with limited studies available; however, most evidence points to neurogenic ED as the more frequent underlying cause (42).

The association between PFUI and ED may therefore reflect the severity and configuration of pelvic trauma. Koraitim reported that the risk of ED increases with a long urethral gap (≥2.5 cm) or lateral prostatic displacement (43). Waterloos et al. reported ED in two of five patients after straddle injury and in two of six after pelvic fracture (32). Possible mechanisms include lateral displacement of the prostatic urethra and post-traumatic arterial ischemia. In our study, the rate of ED was 29.3%, which is consistent with previously published series. We found no meaningful difference in ED or urinary incontinence between the early and delayed repair groups. The ED rate in the early group was slightly higher (+9.8%), with a 95% CI that included a possible harmful effect (−19.8% to +35.8%), suggesting that an adverse effect of early repair on erectile function cannot be ruled out. Due to the small sample size, further studies are needed.

Sexual dysfunctions that may occur after PFUI also include ejaculatory dysfunction and glans sensory abnormalities. Andrew and colleagues reported that the rate of ejaculatory dysfunction was 60% after the initial injury, but declined to 40% following posterior urethroplasty. Before surgery, the mechanism could be explained by complete obliteration of the posterior urethra. After a successful, patent anastomosis, ongoing ejaculatory dysfunction can result either from neurogenic damage to the hypogastric somatic nerves needed for antegrade ejaculation, or from bulbospongiosus muscle dysfunction (42). The decrease in glans sensitivity after urethral trauma may be the result of multiple factors. Neurogenic factors (direct injury to the pudendal nerve and dorsal nerve of the penis, abnormal activation of pelvic floor reflexes) and vascular factors (impaired pelvic floor arterial blood supply) interact with each other, and psychological factors further affect the patient’s reported symptoms (44,45). In this study, three patients (who had reached adulthood at follow-up) answered questions regarding ejaculatory function and glans sensitivity. Two reported normal function, and one reported ED after injury along with reduced tactile and pain sensation of the glans compared with before injury. Although the number of cases in this group is limited and no statistically significant conclusions can be drawn, these preliminary observations may still provide some clinical reference.

In this study, the early group and the delayed group showed no statistically significant differences in key outcome measures including reoperation rate, complications, urethral stricture, urinary incontinence, and ED (all P>0.05). However, non-significant results should not be interpreted as clinical equivalence between the two groups. The 95% confidence intervals for most outcomes were generally wide. For example, the rate difference for reoperation was −15.7% (95% CI: −41.3% to 12.4%); the lower limit suggests that the early group could reduce the reoperation risk by as much as 41.3% compared with the delayed group, while the upper limit suggests a possible increase of 12.4%. This wide interval reflects that the current sample size (only 15 patients in the early group) is insufficient to precisely estimate the true effect size. The complication rate in the early group was 20.6% lower, with a CI of −48.0% to 9.6%, which is similarly wide. If future studies confirm that early repair can reduce complications by approximately 20%, this would be clinically significant. Therefore, the negative results in this study are likely due to type II error (insufficient power) rather than true therapeutic equivalence. All negative results should be considered “inconclusive” rather than “null”.

There are several limitations in this study. It was retrospective, single-center, and based on a relatively small cohort accumulated over a long study period. This study had a high exclusion rate (52/100), and selection bias may be present. Although the excluded group and the included group were balanced in terms of age, shock rate, rate of emergency pelvic fixation surgery, and other comparable variables, we were unable to obtain the Injury Severity Score (ISS) for all patients due to the retrospective nature of the data. ISS began to be systematically recorded in the clinical records of our center after the data collection period of this study; therefore, we could not determine whether the anatomical injury burden of the excluded patients was consistent with that of the included group. Incomplete reporting of erectile function or penile length may also introduce bias. Regarding the assessment of sexual function, the evaluation relied mainly on patient self-reporting without validation using standardized questionnaires or objective examinations. Furthermore, because the patients were young at the time of injury (median age 80 months, range 13–171 months), most were prepubertal, making it impossible to assess baseline sexual function before injury. At follow-up, most patients were still minors, and a complete picture of their sexual function could not be obtained; longer-term follow-up of these patients is needed for further assessment. In addition, data on bladder neck injury were insufficient for robust subgroup analysis. Larger multicenter prospective studies are needed to confirm these findings and to clarify the long-term influence of surgical timing on functional and reconstructive outcomes.

Conclusions

In this long-term single-center cohort of boys with PFUI, postoperative complications and reinterventions were common, highlighting the complexity of these injuries. Urethral stricture, urinary incontinence, and ED were the most frequent sequelae and warrant prolonged follow-up. The wide confidence intervals, reflecting the small sample size, cannot rule out either clinically important benefits or harms of early versus delayed repair. Therefore, this study does not provide conclusive evidence for the superiority of either surgical timing. Larger multicenter studies are needed to clarify the optimal timing of urethroplasty in this population.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health (NCCH) (No. [2025]-E-047-R), and informed consent was obtained from all legal guardians (verbal consent via telephone, as the ethics committee granted a waiver of written informed consent due to the remote follow-up method). For participants who reached adulthood during follow-up, additional verbal consent was obtained from the participants themselves.

Data Sharing Statement

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DOI: 10.21037/tau-2026-0249