Preoperative factors associated with surgical complexity in pelvic fracture urethral injury: Systematic review.
OBJECTIVE To systematically evaluate preoperative clinical, urethrographic, and magnetic resonance imaging (MRI) factors associated with surgical complexity in delayed reconstruction of pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS This PROSPERO-registered systematic review (CRD420261369309) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. MEDLINE, Embase, Web of Science, and Cochrane Library were searched. Eligible studies reported preoperative factors associated with surgical complexity, defined as the need for progressive ancillary maneuvers during delayed anastomotic urethroplasty. Data were synthesised narratively using Synthesis Without Meta-analysis, grouped by assessment modality. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. RESULTS Of 1,653 records, 22 studies encompassing 2,176 reported patients published in 1992-2026 were included. Nine assessed conventional urethrographic/radiographic factors, seven MRI factors, five primary realignment pathway factors, and one mixed clinical-operative factor. Factors associated with surgical complexity included higher gapometry/urethrometry (G/U) index, longer defect length, and proximal stump position above the lower pubic symphysis. MRI-based factors included greater gap length, shorter pubourethral vertical distance, and smaller pubourethral stump angle. Evidence regarding primary realignment was inconsistent. No study had low overall QUIPS risk; 40.9% were moderate and 59.1% high. CONCLUSIONS Anatomical accessibility markers, particularly proximal stump position and MRI-derived stump geometry, appear to be associated with greater PFUI surgical complexity than gap length alone. Standardized prospective validation is required before routine clinical use can guide referral and operative planning.