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Anastomotic urethroplasty for failed previously treated membranous urethral rupture
ADULT UROLOGY
ANASTOMOTIC URETHROPLASTY FOR FAILED PREVIOUSLY TREATED MEMBRANOUS URETHRAL RUPTURE OFER Z. SHENFELD, OFER N. GOFRIT, YEHOSHUA GDOR, EZEKIEL H. LANDAU,
AND
DOV PODE
ABSTRACT Objectives. To determine whether delayed excision and primary anastomosis is appropriate after failed previous therapeutic attempts for post-traumatic membranous urethral strictures. Delayed excision and primary anastomosis is widely accepted as the first-line treatment of post-traumatic membranous urethral strictures. Methods. A review of the medical records identified 13 patients who had undergone anastomotic urethroplasty as a second procedure for traumatic membranous urethral strictures. The previous treatments in these patients included anastomotic urethroplasty in four, staged urethroplasty in four, and endoscopic urethrotomy or primary catheter realignment in five. The mean stricture length was 2.8 cm. All patients underwent excision and primary bulboprostatic anastomosis using the perineal approach. Results. Four patients required partial pubectomy and one required corporal rerouting to achieve anastomosis. The mean follow-up was 27 months. Urethrography performed 1 month postoperatively demonstrated a widely patent anastomosis in all cases. Flexible urethroscopy performed 1 year after surgery revealed a widely patent anastomosis with normal urethral mucosa in all patients but one. The mean maximal flow rate at the last follow-up visit was 23.5 mL/s compared with 3.9 mL/s preoperatively. No statistically significant postvoid residual urine volume was found in any patient. One patient developed an anastomotic stricture 3 months after surgery that was treated successfully by internal urethrotomy. Thus, the objective success rate was 92%. Subjectively, all patients but one reported satisfactory voiding. Complications were mild and included urinary tract infection, bladder stone formation, and decreased erectile function in 1 patient each. Conclusions. Even in patients with failed previous surgical attempts, excision and primary anastomosis is feasible and provides good surgical results in post-traumatic posterior urethral strictures. The complications were mild and easily treated. UROLOGY 63: 837–840, 2004. © 2004 Elsevier Inc.
D
elayed excision of the scarred posterior urethral segment and bulboprostatic anastomosis (excision and primary anastomosis) is considered the reference standard against which all treatment options for post-traumatic posterior urethral strictures are measured. Using this technique as the primary treatment modality, one may expect success in approximately 90% of patients.1 Other techniques for urethroplasty, such as the staged scrotal inlay, and less-invasive options, such as primary catheter realignment and endoscopic treatment, lead to lower success rates. The optimal treatment From the Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel Reprint requests: Ofer Z. Shenfeld, M.D., Department of Urology, Hadassah Hebrew University Medical Center, Kiryat Hadassah, P.O. Box 12000, Jerusalem 91120, Israel Submitted: July 31, 2003, accepted (with revisions): December 15, 2003 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
for patients who have undergone unsuccessful primary treatment for posterior urethral stricture disease is controversial. We report our experience using anastomotic urethroplasty in patients with failed previous treatments for traumatic posterior urethral strictures. MATERIAL AND METHODS We reviewed the medical records, after institutional review board approval, of all the patients treated by excision and primary anastomosis for post-traumatic membranous urethral strictures between 1998 and 2001 at our institution. Of 24 patients so treated, 13 were treated for failed previous treatments. The mean patient age at surgery was 29 years (range 11 to 55). The mean stricture length was 2.8 cm (range 1.5 to 4). The previous failed treatments in these patients included urethroplasty in 8 patients, of which four were anastomotic urethroplasties and four were staged scrotal skin inlays (Fig. 1). Primary catheter realignment of the ruptured urethra had previously failed in 5 patients, 3 of whom underwent additional 0090-4295/04/$30.00 doi:10.1016/j.urology.2003.12.016 837
FIGURE 1. Preoperative urethrogram demonstrating typical findings of failed staged inlay urethroplasty for membranous urethral stricture. Note diverticulum with stone between two strictures.
endoscopic laser urethrotomy for stricture after these procedures. All 13 patients underwent placement of a diverting suprapubic catheter before surgery. Additional instrumentation of the strictured urethras was restricted for at least 3 months before surgery to allow the stricture to stabilize. The patients were evaluated by retrograde and voiding urethrography, retrograde and antegrade (by way of the suprapubic tract) flexible urethroscopy, and uroflowmetry when possible. After providing informed consent, all patients underwent one-stage perineal excision and primary anastomosis urethroplasty using a stepwise approach of urethral mobilization, including complete mobilization of the bulbar urethra, separation of the cavernous bodies, inferior pubectomy, and supracrural urethral rerouting to accomplish tension-free bulboprostatic urethral reanastomosis.2 All the patients required extensive urethral mobilization and separation of the cavernous bodies. Partial inferior pubectomy was performed in 4 patients and corporal rerouting in 1 patient. All patients had their stenting urethral catheter removed 21 to 28 days after surgery and then underwent voiding cystourethrography by way of the suprapubic catheter. Patients were followed up every 3 months for the first postoperative year with uroflowmetry and ultrasound determination of the postvoid residual urine volume. One year postoperatively, all 13 patients underwent flexible retrograde urethroscopy. Surgery was considered successful at the end of the first year of follow-up in all patients. Annual follow-up examinations were continued thereafter. Failure was defined as any need for additional urethral instrumentation (except for visualization by cystoscopy) or surgery.
RESULTS The patients were followed up for a mean of 27 months (range 17 to 41). Postoperative urethrography demonstrated widely patent anastomoses in all patients (Fig. 2). The mean maximal flow rate rose from 3.9 mL/s in the patients who were able to void preoperatively to 23.5 mL/s postoperatively. All patients but one (92%) reported satisfactory voiding on follow-up. The 1 patient with persistent 838
FIGURE 2. Postoperative voiding urethrography; same patient as in Figure 1.
voiding difficulty developed a short anastomotic stricture 3 months after surgery and underwent visual internal urethrotomy, after which the stricture did not recur (16 months of follow-up). Flexible urethroscopy was performed in all patients 1 year after surgery and demonstrated regular anastomoses with no strictures, except for the previously mentioned patient with stricture recurrence. Urethroscopy in that patient revealed an irregularity of the urethral lumen at the point of anastomosis with a caliber of more than 14F. Postoperative complications included significant urinary tract infection in 1 patient, and a retained bladder stone that was removed using the suprapubic tract concurrent with removal of the diverting suprapubic catheter, 4 weeks after surgery, in another patient. Nine patients had preoperative erectile dysfunction, and one patient complained of decreased erectile function after surgery. Two patients reported mild urinary incontinence after surgery that did not require the use of pads. COMMENT Posterior urethral disruption and stricture occurs in approximately 10% of patients with pelvic fractures. Delayed excision and primary anastomosis is considered the reference standard of treatment for these strictures, with a long-term success rate of 85% to 97%.1,3,4 Even with these high success rates, one can expect occasional failure. Four of our patients had had previously failed anastomotic urethroplasty. Additionally, in patients treated with staged scrotal skin inlay urethroplasty, a greater restricture rate can be expected. The staged scrotal inlay urethroplasty carries a failure rate (restricture and diverticulum) of 15% to UROLOGY 63 (5), 2004
57%.3,5 Although this technique is seldom used currently, one will occasionally come across patients with recurrent strictures after having previously undergone this type of surgery. In our series, 4 patients had previously undergone staged scrotal inlay urethroplasty that failed. All had urethral strictures and three also had diverticula with hair and stones in them. Primary catheter realignment of the distracted posterior urethra using endoscopic or other techniques has recently gained popularity. These techniques are minimally invasive and are highly successful in the short term, but up to 53% of these patients develop recurrent strictures during follow-up. Some of the recurrent strictures may be effectively managed with dilation or internal urethrotomy.6,7 Five of our patients, previously treated by primary realignment, had recurrent posterior urethral strictures and underwent reconstruction with anastomotic urethroplasty. Although the primary treatment options for posterior urethral injuries associated with pelvic fractures are well understood, the best treatment for recurrent strictures in the posterior urethra after primary treatment has failed is not as well defined. The extensive fibrosis associated with previous failed treatments may hamper the recruitment of sufficient normal urethra for a tension-free anastomosis; thus, many urologists would prefer to avoid anastomotic urethroplasty in these cases. Many of these patients are treated by repeated dilations or even chronic self-dilation. Cold knife visual internal urethrotomy has been reported to resolve these recurrent strictures in 62% to 80% of patients with failed previous urethroplasty for posterior urethral stenosis.8 Neodymium:yttrium-aluminum-garnet laser urethrotomy was reported in 5 patients after failed previous urethroplasty for posterior urethral strictures.9 Short-term follow-up (up to 30 months) demonstrated good results in 3 patients. The remaining 2 patients required additional urethrotomy or dilation. Others have condemned the use of repeated dilations or urethrotomy in the posterior urethra for fear of undermining the chance for a successful anastomotic urethroplasty.3 We believe that, as in other parts of the urethra, techniques that do not address the problem of periurethral fibrosis carry a high risk of failure, although they may succeed when the strictures are very short with limited periurethral fibrosis. Thus, we prefer anastomotic repair in most of these patients. In our series, 3 of the 5 patients who had failed previous primary realignment, also had failed laser urethrotomy. Anastomotic urethroplasty was successful in these patients. The published reports concerning urethroplasty for recurrent post-traumatic strictures of the posterior urethra are scant.10 –12 Most of the patients in UROLOGY 63 (5), 2004
these reports (60% to 70%) were treated with anastomotic urethroplasty. The rest were treated using a variety of techniques, including staged procedures and free flaps. In these reports, the transpubic route was used in approximately one half of the patients who underwent anastomotic urethroplasty. In our experience, excision and primary bulboprostatic anastomosis could be performed in all the patients using the perineal route. Using the progressive, stepwise approach to gradually mobilize and foreshorten the distance the bulbar urethra must pass to reach the proximal urethral stump,2 we found that sufficient normal urethral length could be recruited for tension-free anastomoses in all our patients, including those who had previously undergone anastomotic urethroplasty. These steps included mobilization of the bulbar urethra to the suspensory ligament, removal of Buck’s fascia, and aggressive separation of the proximal corporal bodies in all patients; partial inferior pubectomy was required in 4 of 13 patients and rerouting of the urethra lateral to the corporal body in 1 patient to permit a tension-free anastomosis. We found that in all the patients with previously failed anastomotic urethroplasty, these steps had not been optimally performed in the previous procedure, and thus it was possible to gain additional urethral length by continuing where the previous surgeon had stopped. Using this approach, all but one of our patients did well (92%), with good subjective and objective results. The only patient in whom our treatment failed had previously undergone primary realignment with no difficulty in recruiting the urethral length for the anastomosis. His surgery may have failed as a result of anastomotic ischemia, because he had undergone surgery for hypostasis in infancy and thus may have had an abnormal corpus spongiosum. This patient was additionally treated with a single visual internal urethrotomy and had not required additional treatment at the latest follow-up visit (16 months). CONCLUSIONS We believe that delayed excision and primary bulboprostatic anastomosis is not only the best first-line treatment for posterior urethral strictures associated with pelvic fractures, but is also the appropriate treatment for recurrent strictures after failure of previous treatment for such strictures. In our experience, this approach was successful in most of these challenging cases, with only minor and infrequent complications. REFERENCES 1. Morey AF, and McAninch JW: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 157: 506 –510, 1997. 839
2. Carr LK, and Webster GD: Posterior urethral reconstruction: perineal approach, in Jordan GH (Ed): Atlas of the Urological Clinics of North America: Reconstruction for Urethral Stricture, vol 5. Philadelphia, WB Saunders, 1997, pp 125– 137. 3. Webster GD, and Sihelnik S: The management of strictures of the membranous urethra. J Urol 134: 469 –473, 1985. 4. Koraitim MM: The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol 153: 63–66, 1995. 5. Olsson CA, and Krane RJ: The controversy of single versus multistaged urethroplasty. J Urol 120: 414 –417, 1978. 6. El-Abd SA: Endoscopic treatment of posttraumatic urethral obliteration: experience in 396 patients. J Urol 153: 67– 71, 1995. 7. Koraitim MM: Pelvic fracture urethral injuries: the unresolved controversy. J Urol 161: 1433–1441, 1999.
840
8. Netto NR Jr, Lemos GC, and Claro JF: Internal urethrotomy as a complementary method after urethroplasties for posterior urethral stenosis. J Urol 141: 50 –51, 1989. 9. Dogra PN, and Nabi G: Neodymium-YAG laser core through urethrotomy in obliterative posttraumatic urethral strictures after failed initial urethroplasty. Urol Int 68: 265– 267, 2002. 10. Webster GD, Ramon J, and Kreder KJ: Salvage posterior urethroplasty after failed initial repair of pelvic fracture membranous urethral defects. J Urol 144: 1370 –1372, 1990. 11. Al-Rifaei MA, and Al-Rifaei A: Management of postoperative obstruction after bulboprostatic anastomotic urethroplasty for membranous urethral defects secondary to pelvic fracture. Scand J Urol Nephrol 35: 491–496, 2001. 12. Wadhwa SN, Chahal R, Hemal AK, et al: Management of obliterative post traumatic posterior urethral strictures after failed initial urethroplasty. J Urol 159: 1898 –1902, 1998.
UROLOGY 63 (5), 2004
ANASTOMOTIC URETHROPLASTY FOR FAILED PREVIOUSLY TREATED MEMBRANOUS URETHRAL RUPTURE OFER Z. SHENFELD, OFER N. GOFRIT, YEHOSHUA GDOR, EZEKIEL H. LANDAU,
AND
DOV PODE
ABSTRACT Objectives. To determine whether delayed excision and primary anastomosis is appropriate after failed previous therapeutic attempts for post-traumatic membranous urethral strictures. Delayed excision and primary anastomosis is widely accepted as the first-line treatment of post-traumatic membranous urethral strictures. Methods. A review of the medical records identified 13 patients who had undergone anastomotic urethroplasty as a second procedure for traumatic membranous urethral strictures. The previous treatments in these patients included anastomotic urethroplasty in four, staged urethroplasty in four, and endoscopic urethrotomy or primary catheter realignment in five. The mean stricture length was 2.8 cm. All patients underwent excision and primary bulboprostatic anastomosis using the perineal approach. Results. Four patients required partial pubectomy and one required corporal rerouting to achieve anastomosis. The mean follow-up was 27 months. Urethrography performed 1 month postoperatively demonstrated a widely patent anastomosis in all cases. Flexible urethroscopy performed 1 year after surgery revealed a widely patent anastomosis with normal urethral mucosa in all patients but one. The mean maximal flow rate at the last follow-up visit was 23.5 mL/s compared with 3.9 mL/s preoperatively. No statistically significant postvoid residual urine volume was found in any patient. One patient developed an anastomotic stricture 3 months after surgery that was treated successfully by internal urethrotomy. Thus, the objective success rate was 92%. Subjectively, all patients but one reported satisfactory voiding. Complications were mild and included urinary tract infection, bladder stone formation, and decreased erectile function in 1 patient each. Conclusions. Even in patients with failed previous surgical attempts, excision and primary anastomosis is feasible and provides good surgical results in post-traumatic posterior urethral strictures. The complications were mild and easily treated. UROLOGY 63: 837–840, 2004. © 2004 Elsevier Inc.
D
elayed excision of the scarred posterior urethral segment and bulboprostatic anastomosis (excision and primary anastomosis) is considered the reference standard against which all treatment options for post-traumatic posterior urethral strictures are measured. Using this technique as the primary treatment modality, one may expect success in approximately 90% of patients.1 Other techniques for urethroplasty, such as the staged scrotal inlay, and less-invasive options, such as primary catheter realignment and endoscopic treatment, lead to lower success rates. The optimal treatment From the Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel Reprint requests: Ofer Z. Shenfeld, M.D., Department of Urology, Hadassah Hebrew University Medical Center, Kiryat Hadassah, P.O. Box 12000, Jerusalem 91120, Israel Submitted: July 31, 2003, accepted (with revisions): December 15, 2003 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
for patients who have undergone unsuccessful primary treatment for posterior urethral stricture disease is controversial. We report our experience using anastomotic urethroplasty in patients with failed previous treatments for traumatic posterior urethral strictures. MATERIAL AND METHODS We reviewed the medical records, after institutional review board approval, of all the patients treated by excision and primary anastomosis for post-traumatic membranous urethral strictures between 1998 and 2001 at our institution. Of 24 patients so treated, 13 were treated for failed previous treatments. The mean patient age at surgery was 29 years (range 11 to 55). The mean stricture length was 2.8 cm (range 1.5 to 4). The previous failed treatments in these patients included urethroplasty in 8 patients, of which four were anastomotic urethroplasties and four were staged scrotal skin inlays (Fig. 1). Primary catheter realignment of the ruptured urethra had previously failed in 5 patients, 3 of whom underwent additional 0090-4295/04/$30.00 doi:10.1016/j.urology.2003.12.016 837
FIGURE 1. Preoperative urethrogram demonstrating typical findings of failed staged inlay urethroplasty for membranous urethral stricture. Note diverticulum with stone between two strictures.
endoscopic laser urethrotomy for stricture after these procedures. All 13 patients underwent placement of a diverting suprapubic catheter before surgery. Additional instrumentation of the strictured urethras was restricted for at least 3 months before surgery to allow the stricture to stabilize. The patients were evaluated by retrograde and voiding urethrography, retrograde and antegrade (by way of the suprapubic tract) flexible urethroscopy, and uroflowmetry when possible. After providing informed consent, all patients underwent one-stage perineal excision and primary anastomosis urethroplasty using a stepwise approach of urethral mobilization, including complete mobilization of the bulbar urethra, separation of the cavernous bodies, inferior pubectomy, and supracrural urethral rerouting to accomplish tension-free bulboprostatic urethral reanastomosis.2 All the patients required extensive urethral mobilization and separation of the cavernous bodies. Partial inferior pubectomy was performed in 4 patients and corporal rerouting in 1 patient. All patients had their stenting urethral catheter removed 21 to 28 days after surgery and then underwent voiding cystourethrography by way of the suprapubic catheter. Patients were followed up every 3 months for the first postoperative year with uroflowmetry and ultrasound determination of the postvoid residual urine volume. One year postoperatively, all 13 patients underwent flexible retrograde urethroscopy. Surgery was considered successful at the end of the first year of follow-up in all patients. Annual follow-up examinations were continued thereafter. Failure was defined as any need for additional urethral instrumentation (except for visualization by cystoscopy) or surgery.
RESULTS The patients were followed up for a mean of 27 months (range 17 to 41). Postoperative urethrography demonstrated widely patent anastomoses in all patients (Fig. 2). The mean maximal flow rate rose from 3.9 mL/s in the patients who were able to void preoperatively to 23.5 mL/s postoperatively. All patients but one (92%) reported satisfactory voiding on follow-up. The 1 patient with persistent 838
FIGURE 2. Postoperative voiding urethrography; same patient as in Figure 1.
voiding difficulty developed a short anastomotic stricture 3 months after surgery and underwent visual internal urethrotomy, after which the stricture did not recur (16 months of follow-up). Flexible urethroscopy was performed in all patients 1 year after surgery and demonstrated regular anastomoses with no strictures, except for the previously mentioned patient with stricture recurrence. Urethroscopy in that patient revealed an irregularity of the urethral lumen at the point of anastomosis with a caliber of more than 14F. Postoperative complications included significant urinary tract infection in 1 patient, and a retained bladder stone that was removed using the suprapubic tract concurrent with removal of the diverting suprapubic catheter, 4 weeks after surgery, in another patient. Nine patients had preoperative erectile dysfunction, and one patient complained of decreased erectile function after surgery. Two patients reported mild urinary incontinence after surgery that did not require the use of pads. COMMENT Posterior urethral disruption and stricture occurs in approximately 10% of patients with pelvic fractures. Delayed excision and primary anastomosis is considered the reference standard of treatment for these strictures, with a long-term success rate of 85% to 97%.1,3,4 Even with these high success rates, one can expect occasional failure. Four of our patients had had previously failed anastomotic urethroplasty. Additionally, in patients treated with staged scrotal skin inlay urethroplasty, a greater restricture rate can be expected. The staged scrotal inlay urethroplasty carries a failure rate (restricture and diverticulum) of 15% to UROLOGY 63 (5), 2004
57%.3,5 Although this technique is seldom used currently, one will occasionally come across patients with recurrent strictures after having previously undergone this type of surgery. In our series, 4 patients had previously undergone staged scrotal inlay urethroplasty that failed. All had urethral strictures and three also had diverticula with hair and stones in them. Primary catheter realignment of the distracted posterior urethra using endoscopic or other techniques has recently gained popularity. These techniques are minimally invasive and are highly successful in the short term, but up to 53% of these patients develop recurrent strictures during follow-up. Some of the recurrent strictures may be effectively managed with dilation or internal urethrotomy.6,7 Five of our patients, previously treated by primary realignment, had recurrent posterior urethral strictures and underwent reconstruction with anastomotic urethroplasty. Although the primary treatment options for posterior urethral injuries associated with pelvic fractures are well understood, the best treatment for recurrent strictures in the posterior urethra after primary treatment has failed is not as well defined. The extensive fibrosis associated with previous failed treatments may hamper the recruitment of sufficient normal urethra for a tension-free anastomosis; thus, many urologists would prefer to avoid anastomotic urethroplasty in these cases. Many of these patients are treated by repeated dilations or even chronic self-dilation. Cold knife visual internal urethrotomy has been reported to resolve these recurrent strictures in 62% to 80% of patients with failed previous urethroplasty for posterior urethral stenosis.8 Neodymium:yttrium-aluminum-garnet laser urethrotomy was reported in 5 patients after failed previous urethroplasty for posterior urethral strictures.9 Short-term follow-up (up to 30 months) demonstrated good results in 3 patients. The remaining 2 patients required additional urethrotomy or dilation. Others have condemned the use of repeated dilations or urethrotomy in the posterior urethra for fear of undermining the chance for a successful anastomotic urethroplasty.3 We believe that, as in other parts of the urethra, techniques that do not address the problem of periurethral fibrosis carry a high risk of failure, although they may succeed when the strictures are very short with limited periurethral fibrosis. Thus, we prefer anastomotic repair in most of these patients. In our series, 3 of the 5 patients who had failed previous primary realignment, also had failed laser urethrotomy. Anastomotic urethroplasty was successful in these patients. The published reports concerning urethroplasty for recurrent post-traumatic strictures of the posterior urethra are scant.10 –12 Most of the patients in UROLOGY 63 (5), 2004
these reports (60% to 70%) were treated with anastomotic urethroplasty. The rest were treated using a variety of techniques, including staged procedures and free flaps. In these reports, the transpubic route was used in approximately one half of the patients who underwent anastomotic urethroplasty. In our experience, excision and primary bulboprostatic anastomosis could be performed in all the patients using the perineal route. Using the progressive, stepwise approach to gradually mobilize and foreshorten the distance the bulbar urethra must pass to reach the proximal urethral stump,2 we found that sufficient normal urethral length could be recruited for tension-free anastomoses in all our patients, including those who had previously undergone anastomotic urethroplasty. These steps included mobilization of the bulbar urethra to the suspensory ligament, removal of Buck’s fascia, and aggressive separation of the proximal corporal bodies in all patients; partial inferior pubectomy was required in 4 of 13 patients and rerouting of the urethra lateral to the corporal body in 1 patient to permit a tension-free anastomosis. We found that in all the patients with previously failed anastomotic urethroplasty, these steps had not been optimally performed in the previous procedure, and thus it was possible to gain additional urethral length by continuing where the previous surgeon had stopped. Using this approach, all but one of our patients did well (92%), with good subjective and objective results. The only patient in whom our treatment failed had previously undergone primary realignment with no difficulty in recruiting the urethral length for the anastomosis. His surgery may have failed as a result of anastomotic ischemia, because he had undergone surgery for hypostasis in infancy and thus may have had an abnormal corpus spongiosum. This patient was additionally treated with a single visual internal urethrotomy and had not required additional treatment at the latest follow-up visit (16 months). CONCLUSIONS We believe that delayed excision and primary bulboprostatic anastomosis is not only the best first-line treatment for posterior urethral strictures associated with pelvic fractures, but is also the appropriate treatment for recurrent strictures after failure of previous treatment for such strictures. In our experience, this approach was successful in most of these challenging cases, with only minor and infrequent complications. REFERENCES 1. Morey AF, and McAninch JW: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 157: 506 –510, 1997. 839
2. Carr LK, and Webster GD: Posterior urethral reconstruction: perineal approach, in Jordan GH (Ed): Atlas of the Urological Clinics of North America: Reconstruction for Urethral Stricture, vol 5. Philadelphia, WB Saunders, 1997, pp 125– 137. 3. Webster GD, and Sihelnik S: The management of strictures of the membranous urethra. J Urol 134: 469 –473, 1985. 4. Koraitim MM: The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol 153: 63–66, 1995. 5. Olsson CA, and Krane RJ: The controversy of single versus multistaged urethroplasty. J Urol 120: 414 –417, 1978. 6. El-Abd SA: Endoscopic treatment of posttraumatic urethral obliteration: experience in 396 patients. J Urol 153: 67– 71, 1995. 7. Koraitim MM: Pelvic fracture urethral injuries: the unresolved controversy. J Urol 161: 1433–1441, 1999.
840
8. Netto NR Jr, Lemos GC, and Claro JF: Internal urethrotomy as a complementary method after urethroplasties for posterior urethral stenosis. J Urol 141: 50 –51, 1989. 9. Dogra PN, and Nabi G: Neodymium-YAG laser core through urethrotomy in obliterative posttraumatic urethral strictures after failed initial urethroplasty. Urol Int 68: 265– 267, 2002. 10. Webster GD, Ramon J, and Kreder KJ: Salvage posterior urethroplasty after failed initial repair of pelvic fracture membranous urethral defects. J Urol 144: 1370 –1372, 1990. 11. Al-Rifaei MA, and Al-Rifaei A: Management of postoperative obstruction after bulboprostatic anastomotic urethroplasty for membranous urethral defects secondary to pelvic fracture. Scand J Urol Nephrol 35: 491–496, 2001. 12. Wadhwa SN, Chahal R, Hemal AK, et al: Management of obliterative post traumatic posterior urethral strictures after failed initial urethroplasty. J Urol 159: 1898 –1902, 1998.
UROLOGY 63 (5), 2004