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A transpubic approach for reconstructive surgery of genitourinary injuries and congenital malformations
A Transpubic Approach for Reconstructive Surgery of Genitourinary Injuries and Congenital Malformations By Zygmunt
H. Kalicit5ski+,
Tadeusz Bokwa, Wojciech Perdzyfiski, Ewa Zarzycka-Szczerbowska, Maria Harnik, and Wactaw RybaCko Warsaw, Poland and Vilnius, Lithuania
Four children were operated on by the transpubic approach for injury to the vagina or urethra and to correct malformations within the pelvis minor. One boy had posttraumatic stricture of the urethra, and a girl presented with disruption of the urethra and vagina. One of two boys who had congenital malformations was treated for epispadias and incontinence; the other for a large urethral diverticulum caused by anal
atresia. Total reconstruction tions of symphysis restoration J Pediatr Surg 321344-1347. Saunders Company.
A
then split using a scalpel or scissors and drawn apart with a thoracic retractor, giving a 4- to &cm window. No bone was excised in any child. The symphysis was repaired using Dexon 1-O sutures. Elastic tape was placed over the pelvis and anterior superior iliac spines for 2 to 3 weeks. The urethral catheter was removed after 10 to 14 days.
NATOMICAL AND FUNCTIONAL restoration of the posterior urethra, bladder, and vagina using the perineoabdominal or abdominal approach is not always possible because of inadequate exposure of the pelvic structures. This is particularly true with respect to those organs that lie just behind the pubic symphysis. The choice of surgical approach for the repair of urethral, vaginal or, in some cases, anal trauma, as well as for the repair of congenital defects, requires careful radiologic, sonographic, and endoscopic evaluation. MATERIALS
AND
METHODS
Between 1991 and 1993, four children (3 boys and 1 girl, aged 3 to 10 years) were operated on using the transpubic approach. One boy had extensive urethral damage, and one girl had suffered bladder. urethra and vaginal injury with numerous bone fragments pressing on the urethra. Two boys had congenital defects of the urethra and bladder neck and a cyst of the posterial urethra. Two had not undergone radiographic or endoscopic evaluation. All of the children had undergone surgery one to three times in other hospitals. The boy with urethral stricture had been operated on twice using the perineal approach. The girl who had disruption of the urethra and vagina had been operated on three times by the perineoabdominal approach. The boy who had epispadias had undergone three operations from the suprapubic approach. In each child an extraperitoneal midline incision was made in the linea alba from the middle of the lower abdomen to the lower margin of the public symphysis. After exposing the bladder, its neck was dissected away from the inner surface of the pubic symphysis. The symphysis was
From the Departments of Pediatric Surgery and Radiology, Center of Postgraduate Education, Military Medical Academy, Warsaw, Poland, and the Department of Pediatric Surgery, Klnius UniversiQ, Vilnius, Lithuania. fDeceased. Address reprint requests to Wojciech Perdzyn’ski, MD, Department of Pediatric Surgery, Centre of Postgraduate Education MMA. 00-909 Warsaw, Szasero’w 128, Poland. Copyright 0 1997 by WB. Saunders Company 0022-3468/97/3209-0020$03.00/O
1344
INDEX WORDS: approach.
Urethral
was achieved, and no complicawere observed. Copyright o 1997 by W.B.
trauma,
CASE
pelvic
trauma,
transpubic
REPORTS
Case I A 9-year-old girl had incurred extensive injury to the pelvis. including pubic bone and femur fractures, and disruption of the urethra as the result of a traffic accident. After three unsuccessful operations in another hospital, permanent suprapubic urinary diversion with an ileal loop had been created. When admitted to our department, the girl had massive bladder infection. Ultrasound examination showed a large fluid reservoir behind the bladder (Fig I). Cystography visualized a preserved bladder neck but no urethra (Fig 2). Urethroscopy showed that an approximately 2 to 3-cm fragment of the distal urethra was preserved, but the proximal part was obliterated. A proximally obliterated 2-cm segment of the vagina was visualized on vaginoscopy. After 3 weeks of intensive antibiotic therapy and lavage with a 0.05% hibitdne solution, a urethral and vaginal reconstruction through a transpubic approach was attempted. This approach gave a good view of the urethra. vagina, and the area around the bladder and permitted the identification of the nature of the reservoir (Fig 3). We found a well-preserved bladder neck and the urethra. which was disrupted about I .5 cm from it. The reservoir close to the bladder was the proximal part of the vagina that had fused with it. The bladder and vagina were separated and both orifices sutured with a double layer of chromic catgut. Both ends of the vagina were opened and anastomosed end to end with single interrupted absorbable sutures. The bladder neck was anastomosed end to end with the urethra on a Foley catheter using single sutures. The suprapubic urinary diversion (ileal loop) was removed after 6 months. Follow-up cystography results showed a normal urethra (Fig 4). whereas vaginoscopy showed full continuity. Four years after surgery the girl has normal micturition and is continent.
Case 2 A lo-year-old boy sustained extensive pelvic damage as the result of a car accident. His injuries included detachment of the posterior urethra and its transposition by bone fragments. He had been operated on twice Journal
ofPediatric
Surgery,
Vol32,
No 9 (September),
1997: pp 1344-1347
TRANSPUBIC
APPROACH
Fig 1. Ultrasound the bladder.
FOR GENITOURINARY
scan demonstrating
INJURIES
large fluid reservoir
behind
unsuccessfully through a perineal approach at the hospital where he was initially admitted. The length of the damaged part of the urethra was 4 cm. The bone fragments compressing the urethra were removed through a transpubic approach. Because of the long segment of the damaged urethra, and in an attempt to preserve the seminal colliculus, the narrowed urethm was incised longitudinally on its anterior wall, and a 2.5. X 5.0~cm mucosal graft. obtained from the bladder mucosa, was xnured to the wall of the urethra. widening it by 4/5 of its circumference. The urethra was dilated several times after surgery. Cystography findings I year after surgery showed normal urethral flow (Fig 5).
Cuse 3 A IO-year-old boy was admitted to out- department from another hospital where he had been operated on three times for congenital epispadias and complete urinary incontinence. The urethra and penis had been fully reconstructed, but the bladder neck remained very wide (Fig 6). After incising the pubic symphysis. a 2.5cm wide strip was excised from the front wall of the bladder and urethra. The edges were sutured so as to narrow the neck and lengthen the urethra. Follow-up
Fig 2. Preoperative cystogram performed urinary diversion demonstrates bladder without
through urethra.
Fig 3. u, uterus;
(A) Preoperative and (6) postoperative v, vagina; u, urethra.
anatomy.
a, bladder;
after I year showed normal bladder voiding and an increase capacity to 480 mL. The boy was fully continent.
in its
Case 4 A 3-year-old boy was admitted to our department from Vilnius, Lithuania. He had been born with anal atresia and had undergone anorectal reconstruction at age 9 months by the method of Romualdi, including ligation of the rectourethral fistula. Postoperative cystography showed a large diverticulum (3.0 X 3.0 cm), which was located between the posterior urethra and rectum (Fig 7). Cystourethroscopy findings confirmed the connection between the urethra and diverticulum. After incision of the pubic symphysis. a catheter was inserted through the bladder and urethra to the inlet of the fistula and diverticulum. The latter was completely excised, while the 4 X 5 mm foramen in the urethra was closed with three layers of chromic catgut sutures. Two calculi were also removed from the bladder. The postopera-
suprapubic Fig 4.
Postoperative
voiding
cystourethrogram.
1346
Fig 5. (A) Preoperative rowed posterior urethra. cystourethrogram.
KALICINSKI
voiding cystogram demonstrates LB) No stenosis on a subsequent
tive period was uneventful. Cystography showed normal urethral flow.
findings
ET AL
the narvoiding
3 weeks after surgery
Fig 7. (Al Preoperative cystourethrogram showing lum of the posterior urethra. (B) After reconstruction.
the diverticu-
DISCUSSION
In urethral injuries in adults, endoscopic laser tunnelization has been proposed.’ Unfortunately, long-term observations have shown not only that this method is ineffective, but that damage to the bladder neck, and even seminal colliculus, can occur. Dilatation of the urethra usually gives only temporary relief. Posterior sagittal approach has been proposed to repair posttraumatic stenosis of the urethra.2 But this method may be used only for very selected patients. We believe that only full reconstruction offers the best chance for complete recovery. Commonly used approaches to structures in the pelvis minor, include the perineal, perinealabdominal, and abdominal. Not infrequently these methods fail to provide good access to injured or malformed organs. The transpubic approach
Fig 6. (A) Preoperative cystourathrogram bladder neck. LB) Postoperative control.
demonstrates
very wide
proposed to repair posttraumatic stenosis of the membranous urethra is an alternative procedure.3 In using this approach in the four children described, we were impressed by the easy access and possibility of full reconstruction of the urethra, vagina, and the region between the urethra and rectum. We were also impressed by the lack of complications and good results. Some investigators4-9 recommend the transpubic Waterhousei or Turner-Warwick” operation, which involves resection of portions of the pubic bone. The reason of such conduct was anxiety about straining the sacroiliac joints and postoperative pain. We believe that incision of the symphysis in children permits a sufficient opening (4.0 to 8.0 cm) and very good exposure of the operative field. Pediatric pelvis is more elastic that of the adult. None of the children reported sacroiliac pain. Burbige,12 using combined transpubic and perineal approach (without pubic resection), stated no orthopedic complications. Peters and Hendreni3 operated on 46 patients using the transpubic approach (symphysiotomy) and did not observe pubic instability or disruption of the sacroiliac joints in any of this large series of patients. We have noticed that this approach is not used very often in children, although it offers much wider access to the structures behind the pubic bone and greater ease in performing complicated procedures than any other technique. In the literature, a period of 4 to 6 weeks of immobilization is given as the time necessary for healing of the pubic symphysis. Our patients were immobilized for only 2 to 3 weeks. During a follow-up period of 5 to 3 years, we have not observed any early or late complications.
TRANSPUBIC
APPROACH
FOR GENITOURINARY
INJURIES
REFERENCES 1. Prelich A, Jeromin L: Endoskopowa tunelizacja zarosnietej tylnej cewki u meicyzn. Urol Po147: l-2,34-37, 1994 2. Flah LM, Alpuche JOC, Castro RS: Repair of postraumatic stenosis of the urethra through a posterior aagittal approach. J Pediatr Surg 27: 1465-1470, 1992 3. Pierce JM: Exposure of membranous and posterior urethra by total pubectomy. J Ural 88:256-258. 1962 4. Allen TD: The transpubic approach for strictures of the membranous urethra. J Urol 114:63-68, 1975 5. Borkowski A, Czaplicki M, Judycki J, et al: Leczenie operacyjne cewki tylnej z dostepu przezlonowego. Urol Po139: 103-109, 1986 6. Kardar AH, Sundin T, Ahmed S: Delayed management of posterior urethral disruption in children. Br J Urol75:543-549, 1995 7. Khan AU, Furlow WL: Transpubic urethroplasty. J Urol 116:447450, 1976
8. Kramer SA. Furlow WL. Barrett plasty in children. J Urol I26:767-769,
DM, et al: Transpubic 19X1
urethro-
9. Senocak ME. Ciftci AO. Buyukpamukcu N. et al: Transpubic urethroplasty in children: Report of IO c:t\es with review of the literature. J Pediatr Surg 30: 13 19-1325. I995 IO. Waterhause K. Abraham\ Jl. Gruber H, et al: The transpubic approach to the lower urinary tract. J Ural 109:4X6-490. I973 I I. Turner-Warwick R: The repair of urethral strictures of the membranous urethra. J Urol 100:303-3 14. 1968 12. Burbige KA: Transpubic-perineal urethral using a substitution graft. J Ural 148: 1235-123X.
in the region
reconstruction 1992
in boy\
13. Peters CA, Hendren WH: Splittin g the pubis for exposure difftcult reconstructions for incontinence. J Ural lJ2:527-534. 1989
in
H. Kalicit5ski+,
Tadeusz Bokwa, Wojciech Perdzyfiski, Ewa Zarzycka-Szczerbowska, Maria Harnik, and Wactaw RybaCko Warsaw, Poland and Vilnius, Lithuania
Four children were operated on by the transpubic approach for injury to the vagina or urethra and to correct malformations within the pelvis minor. One boy had posttraumatic stricture of the urethra, and a girl presented with disruption of the urethra and vagina. One of two boys who had congenital malformations was treated for epispadias and incontinence; the other for a large urethral diverticulum caused by anal
atresia. Total reconstruction tions of symphysis restoration J Pediatr Surg 321344-1347. Saunders Company.
A
then split using a scalpel or scissors and drawn apart with a thoracic retractor, giving a 4- to &cm window. No bone was excised in any child. The symphysis was repaired using Dexon 1-O sutures. Elastic tape was placed over the pelvis and anterior superior iliac spines for 2 to 3 weeks. The urethral catheter was removed after 10 to 14 days.
NATOMICAL AND FUNCTIONAL restoration of the posterior urethra, bladder, and vagina using the perineoabdominal or abdominal approach is not always possible because of inadequate exposure of the pelvic structures. This is particularly true with respect to those organs that lie just behind the pubic symphysis. The choice of surgical approach for the repair of urethral, vaginal or, in some cases, anal trauma, as well as for the repair of congenital defects, requires careful radiologic, sonographic, and endoscopic evaluation. MATERIALS
AND
METHODS
Between 1991 and 1993, four children (3 boys and 1 girl, aged 3 to 10 years) were operated on using the transpubic approach. One boy had extensive urethral damage, and one girl had suffered bladder. urethra and vaginal injury with numerous bone fragments pressing on the urethra. Two boys had congenital defects of the urethra and bladder neck and a cyst of the posterial urethra. Two had not undergone radiographic or endoscopic evaluation. All of the children had undergone surgery one to three times in other hospitals. The boy with urethral stricture had been operated on twice using the perineal approach. The girl who had disruption of the urethra and vagina had been operated on three times by the perineoabdominal approach. The boy who had epispadias had undergone three operations from the suprapubic approach. In each child an extraperitoneal midline incision was made in the linea alba from the middle of the lower abdomen to the lower margin of the public symphysis. After exposing the bladder, its neck was dissected away from the inner surface of the pubic symphysis. The symphysis was
From the Departments of Pediatric Surgery and Radiology, Center of Postgraduate Education, Military Medical Academy, Warsaw, Poland, and the Department of Pediatric Surgery, Klnius UniversiQ, Vilnius, Lithuania. fDeceased. Address reprint requests to Wojciech Perdzyn’ski, MD, Department of Pediatric Surgery, Centre of Postgraduate Education MMA. 00-909 Warsaw, Szasero’w 128, Poland. Copyright 0 1997 by WB. Saunders Company 0022-3468/97/3209-0020$03.00/O
1344
INDEX WORDS: approach.
Urethral
was achieved, and no complicawere observed. Copyright o 1997 by W.B.
trauma,
CASE
pelvic
trauma,
transpubic
REPORTS
Case I A 9-year-old girl had incurred extensive injury to the pelvis. including pubic bone and femur fractures, and disruption of the urethra as the result of a traffic accident. After three unsuccessful operations in another hospital, permanent suprapubic urinary diversion with an ileal loop had been created. When admitted to our department, the girl had massive bladder infection. Ultrasound examination showed a large fluid reservoir behind the bladder (Fig I). Cystography visualized a preserved bladder neck but no urethra (Fig 2). Urethroscopy showed that an approximately 2 to 3-cm fragment of the distal urethra was preserved, but the proximal part was obliterated. A proximally obliterated 2-cm segment of the vagina was visualized on vaginoscopy. After 3 weeks of intensive antibiotic therapy and lavage with a 0.05% hibitdne solution, a urethral and vaginal reconstruction through a transpubic approach was attempted. This approach gave a good view of the urethra. vagina, and the area around the bladder and permitted the identification of the nature of the reservoir (Fig 3). We found a well-preserved bladder neck and the urethra. which was disrupted about I .5 cm from it. The reservoir close to the bladder was the proximal part of the vagina that had fused with it. The bladder and vagina were separated and both orifices sutured with a double layer of chromic catgut. Both ends of the vagina were opened and anastomosed end to end with single interrupted absorbable sutures. The bladder neck was anastomosed end to end with the urethra on a Foley catheter using single sutures. The suprapubic urinary diversion (ileal loop) was removed after 6 months. Follow-up cystography results showed a normal urethra (Fig 4). whereas vaginoscopy showed full continuity. Four years after surgery the girl has normal micturition and is continent.
Case 2 A lo-year-old boy sustained extensive pelvic damage as the result of a car accident. His injuries included detachment of the posterior urethra and its transposition by bone fragments. He had been operated on twice Journal
ofPediatric
Surgery,
Vol32,
No 9 (September),
1997: pp 1344-1347
TRANSPUBIC
APPROACH
Fig 1. Ultrasound the bladder.
FOR GENITOURINARY
scan demonstrating
INJURIES
large fluid reservoir
behind
unsuccessfully through a perineal approach at the hospital where he was initially admitted. The length of the damaged part of the urethra was 4 cm. The bone fragments compressing the urethra were removed through a transpubic approach. Because of the long segment of the damaged urethra, and in an attempt to preserve the seminal colliculus, the narrowed urethm was incised longitudinally on its anterior wall, and a 2.5. X 5.0~cm mucosal graft. obtained from the bladder mucosa, was xnured to the wall of the urethra. widening it by 4/5 of its circumference. The urethra was dilated several times after surgery. Cystography findings I year after surgery showed normal urethral flow (Fig 5).
Cuse 3 A IO-year-old boy was admitted to out- department from another hospital where he had been operated on three times for congenital epispadias and complete urinary incontinence. The urethra and penis had been fully reconstructed, but the bladder neck remained very wide (Fig 6). After incising the pubic symphysis. a 2.5cm wide strip was excised from the front wall of the bladder and urethra. The edges were sutured so as to narrow the neck and lengthen the urethra. Follow-up
Fig 2. Preoperative cystogram performed urinary diversion demonstrates bladder without
through urethra.
Fig 3. u, uterus;
(A) Preoperative and (6) postoperative v, vagina; u, urethra.
anatomy.
a, bladder;
after I year showed normal bladder voiding and an increase capacity to 480 mL. The boy was fully continent.
in its
Case 4 A 3-year-old boy was admitted to our department from Vilnius, Lithuania. He had been born with anal atresia and had undergone anorectal reconstruction at age 9 months by the method of Romualdi, including ligation of the rectourethral fistula. Postoperative cystography showed a large diverticulum (3.0 X 3.0 cm), which was located between the posterior urethra and rectum (Fig 7). Cystourethroscopy findings confirmed the connection between the urethra and diverticulum. After incision of the pubic symphysis. a catheter was inserted through the bladder and urethra to the inlet of the fistula and diverticulum. The latter was completely excised, while the 4 X 5 mm foramen in the urethra was closed with three layers of chromic catgut sutures. Two calculi were also removed from the bladder. The postopera-
suprapubic Fig 4.
Postoperative
voiding
cystourethrogram.
1346
Fig 5. (A) Preoperative rowed posterior urethra. cystourethrogram.
KALICINSKI
voiding cystogram demonstrates LB) No stenosis on a subsequent
tive period was uneventful. Cystography showed normal urethral flow.
findings
ET AL
the narvoiding
3 weeks after surgery
Fig 7. (Al Preoperative cystourethrogram showing lum of the posterior urethra. (B) After reconstruction.
the diverticu-
DISCUSSION
In urethral injuries in adults, endoscopic laser tunnelization has been proposed.’ Unfortunately, long-term observations have shown not only that this method is ineffective, but that damage to the bladder neck, and even seminal colliculus, can occur. Dilatation of the urethra usually gives only temporary relief. Posterior sagittal approach has been proposed to repair posttraumatic stenosis of the urethra.2 But this method may be used only for very selected patients. We believe that only full reconstruction offers the best chance for complete recovery. Commonly used approaches to structures in the pelvis minor, include the perineal, perinealabdominal, and abdominal. Not infrequently these methods fail to provide good access to injured or malformed organs. The transpubic approach
Fig 6. (A) Preoperative cystourathrogram bladder neck. LB) Postoperative control.
demonstrates
very wide
proposed to repair posttraumatic stenosis of the membranous urethra is an alternative procedure.3 In using this approach in the four children described, we were impressed by the easy access and possibility of full reconstruction of the urethra, vagina, and the region between the urethra and rectum. We were also impressed by the lack of complications and good results. Some investigators4-9 recommend the transpubic Waterhousei or Turner-Warwick” operation, which involves resection of portions of the pubic bone. The reason of such conduct was anxiety about straining the sacroiliac joints and postoperative pain. We believe that incision of the symphysis in children permits a sufficient opening (4.0 to 8.0 cm) and very good exposure of the operative field. Pediatric pelvis is more elastic that of the adult. None of the children reported sacroiliac pain. Burbige,12 using combined transpubic and perineal approach (without pubic resection), stated no orthopedic complications. Peters and Hendreni3 operated on 46 patients using the transpubic approach (symphysiotomy) and did not observe pubic instability or disruption of the sacroiliac joints in any of this large series of patients. We have noticed that this approach is not used very often in children, although it offers much wider access to the structures behind the pubic bone and greater ease in performing complicated procedures than any other technique. In the literature, a period of 4 to 6 weeks of immobilization is given as the time necessary for healing of the pubic symphysis. Our patients were immobilized for only 2 to 3 weeks. During a follow-up period of 5 to 3 years, we have not observed any early or late complications.
TRANSPUBIC
APPROACH
FOR GENITOURINARY
INJURIES
REFERENCES 1. Prelich A, Jeromin L: Endoskopowa tunelizacja zarosnietej tylnej cewki u meicyzn. Urol Po147: l-2,34-37, 1994 2. Flah LM, Alpuche JOC, Castro RS: Repair of postraumatic stenosis of the urethra through a posterior aagittal approach. J Pediatr Surg 27: 1465-1470, 1992 3. Pierce JM: Exposure of membranous and posterior urethra by total pubectomy. J Ural 88:256-258. 1962 4. Allen TD: The transpubic approach for strictures of the membranous urethra. J Urol 114:63-68, 1975 5. Borkowski A, Czaplicki M, Judycki J, et al: Leczenie operacyjne cewki tylnej z dostepu przezlonowego. Urol Po139: 103-109, 1986 6. Kardar AH, Sundin T, Ahmed S: Delayed management of posterior urethral disruption in children. Br J Urol75:543-549, 1995 7. Khan AU, Furlow WL: Transpubic urethroplasty. J Urol 116:447450, 1976
8. Kramer SA. Furlow WL. Barrett plasty in children. J Urol I26:767-769,
DM, et al: Transpubic 19X1
urethro-
9. Senocak ME. Ciftci AO. Buyukpamukcu N. et al: Transpubic urethroplasty in children: Report of IO c:t\es with review of the literature. J Pediatr Surg 30: 13 19-1325. I995 IO. Waterhause K. Abraham\ Jl. Gruber H, et al: The transpubic approach to the lower urinary tract. J Ural 109:4X6-490. I973 I I. Turner-Warwick R: The repair of urethral strictures of the membranous urethra. J Urol 100:303-3 14. 1968 12. Burbige KA: Transpubic-perineal urethral using a substitution graft. J Ural 148: 1235-123X.
in the region
reconstruction 1992
in boy\
13. Peters CA, Hendren WH: Splittin g the pubis for exposure difftcult reconstructions for incontinence. J Ural lJ2:527-534. 1989
in