UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

Complex Posterior Urethral Disruptions: Management by Combined Abdominal Transpubic Perineal Urethroplasty
Pratap A, Agrawal CS, Tiwari A, Bhattarai BK, Pandit RK, Anchal N
Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
J Urol. 2006; 175: 1751-4

  • Purpose: We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption.
  • Materials and Methods: From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram.
  • Results: There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence.
  • Conclusions: Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.


A Comparison of One-Stage Procedures for Post-Traumatic Urethral Stricture Repair
Berger AP, Deibl M, Bartsch G, Steiner H, Varkarakis J, Gozzi C
Department of Urology, University of Innsbruck, Innsbruck, Austria
BJU Int. 2005; 95: 1299-302

  • Objective: To compare the results and complication rates of various one-stage treatments for repairing a post-traumatic urethral stricture.
  • Patients and Methods: The medical records of 153 patients who had a post-traumatic urethral stricture repaired between 1977 and 2003 were evaluated retrospectively, and analysed for the different types of urethral reconstruction.
  • Results: The procedures included direct end-to-end anastomosis in 86 (56%) patients, free dorsal onlay graft urethroplasty using preputial or inguinal skin in 40 (26%), ventral onlay urethroplasty using buccal mucosa in seven (5%) and ventral fasciocutaneous flaps on a vascular pedicle in 20 (13%). At a mean (median, range) follow-up of 75.2 (38, 12-322) months, 121 (79%) patients had no evidence of recurrent stricture, while in 32 men (21%) they were detected at a mean follow-up of 30.47 (1-96) months. Patients having a dorsal onlay urethroplasty had the longest strictures. The re-stricture rate was lowest after a dorsal onlay urethroplasty (5% vs 27% when treated with end-to-end anastomosis, 15% after fasciocutaneous flaps and 57% after a ventral buccal mucosal graft). The surgical technique used had no effect on postoperative incontinence or erectile dysfunction rates.
  • Conclusion: In patients with strictures which are too long to be excised and re-anastomosed, tension-free dorsal onlay urethroplasty is better than ventral graft or flap techniques. In patients with short urethral strictures direct end-to-end anastomosis remains an option for the one-stage repair of urethral stricture.

  • Editorial Comment
    Certain cases of urethral disruption early surgical the re-alignment is immediately indicated (e.g. involvement of the rectum, wide separation of bladder and urethra, bladder or bladder neck injury). All other cases late intervention can be performed after immediate supply with a suprapubic catheterization after 3 – 6 months allowing the resorption of the retropubic hematoma, if no surgeon with extensive experience of the various techniques of primary open realignment is available. As an attractive option the early endoscopic realignment might be the best solution, using suprapubic and transurethral approach, on the one hand resulting in prevent the dislocation of the urethral stumps and the rapid transurethral drainage, on the other hand avoiding common complications of an early open approach (e.g. bleeding, higher stricture and impotence rate). The very disadvantage of this endoscopic technique is its dependence on especially skilled surgeons and their equipment. A prospective study would help to facilitate the final decision-making between early open, endoscopic and late reconstruction in the future, but barely possible because if the small incidents, until then the classification of the posterior urethral injuries might help (1,2).
    Opposite to the presented data, probably most of the pelvic floor urethral distraction defects can be managed by a one-stage perineal anastomotic urethroplasty in the exaggerated or high lithotomy position. Webster suggested certain maneuvers to achieve to shorten the distance of the defect: a) further circumferential mobilization of the distal urethra (2-3 cm), b) separation of the corporal bodies (1-2 cm), c) inferior pubectomy (1-2 cm), d) supra-crural re-routing after creating a tunnel in the bone beneath the corporal bone with a pubectomy (1-2 cm). Those maneuvers might help to manage defects up to 9 cm (3).
    The abdominal-perineal approach as used by the authors should be performed to improve the visualization and to remove fistula tracts, periurethral epitheliailized cavities, to excise scar tissue at the prostate and to perform a tension-free-anastomosis (4, 5). To have such a high success rat as reported by the authors an experts hand is required, particularly given the fact that approximately half were prepubescent, which is even better then the present literature (4-7). Beside the suggested use of a cremaster flap, which is an elegant approach, the gracilis muscle interposition can be suggested to manage perineal fistulas, recto-urethral fistulas or even to protect the anastomosis the support might be better and the possibility to use it to reconstruct the continence mechanism (8). The blood loss seems to be small in regard to the invasiveness of the surgical approach. Overall, the authors can be congratulated to the result of their surgical approach.

References
1. Goldman SM, Sandler CM, Corriere JN Jr, McGuire EJ: Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol. 1997; 157: 85-9.
2. Koraitim MM: Post-traumatic posterior urethral strictures: preoperative decision making. Urology. 2004; 64: 228-31.
3. Webster GD: Urethral Injuries. In: Whitfield HN, Hendry WF, Kriby RS, Duckett JW (eds), Textbook of Genito-Urethral Surgery, 2nd edition. Oxford, Blackwell Scientific; 1998.
4. McAninch JW: Pubectomy in repair of membranous urethral stricture. Urol Clin North Am. 1989; 16: 297-302.
5. Narumi Y, Hricak H, Armenakas NA, Dixon CM, McAninch JW: MR imaging of traumatic posterior urethral injury. Radiology. 1993; 188: 439-43.
6. Koraitim MM: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005; 173: 135-9.
7. Kardar AH, Sundin T, Ahmed S: Delayed management of posterior urethral disruption in children. Br J Urol. 1995; 75: 543-7.
8. Zinman L: Muscular, myocutaneous, and fasciocutaneous flaps in complex urethral reconstruction. Urol Clin North Am. 2002; 29: 443-66.

Dr. Karl-Dietrich Sievert, Dr. Joerg Seibold,
& Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany