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Complex Posterior Urethral Disruptions: Management by Combined Abdominal Transpubic Perineal Urethroplasty
Trauma/Reconstruction/Diversion Complex Posterior Urethral Disruptions: Management by Combined Abdominal Transpubic Perineal Urethroplasty Akshay Pratap,* C. S. Agrawal, Awadhesh Tiwari, Bal Krishna Bhattarai, Rakesh Kumar Pandit and Nitish Anchal From the Departments of Surgery, Radiology (AT) and Anaesthesia (BKB), B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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. Key Words: urethra; fractures, bone; impotence; urinary incontinence; urethral stricture
raumatic disruption of the posterior urethra occurs in 3.5% to 10% of patients with pelvic fractures.1 In 10% of these patients the stricture is complex due to a gap exceeding 3 cm or to associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair.2 Surgical repair of such CPUD remains one of the most challenging problems in urology. Urethral reconstruction of CPUD is accomplished using the progressive perineal elaboration technique3 or the abdominal transpubic perineal approach.4 The stricture-free rate following abdominal transpubic perineal approach is between 70% and 100% according to various investigators.2,5 Therefore, apart from the factor of surgical expertise one is forced to conclude that this difference in success rates among various reports is primarily related to the details of the operative technique adopted by various investigators. We report our short-term results in 21 patients with CPUD treated with combined abdominal transpubic perineal urethroplasty and suggest modifications to improve the success rate of this procedure.
T
Submitted for publication June 22, 2006. * Correspondence and requests for reprints: Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal (telephone: 977-25-25555, extension 2047; FAX: 977-25-20251; e-mail: [email protected]).
0022-5347/06/1755-1751/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS Patients We reviewed the medical records of patients who underwent surgical correction for CPUD following pelvic fracture from January 2000 to August 2005. CPUD was defined as a stricture gap exceeding 3 cm in length, or previous failed repair or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages or an open bladder neck.
Preoperative and Operative Procedure Immediate treatment in patients with urethral injury was placement of a suprapubic cystostomy tube with no attempt at primary realignment. Preoperative evaluation included history, physical examination, laboratory investigations, such as a full blood count, serum urea, electrolytes and creatinine, urinalysis, urine microscopy, culture and sensitivity. Voiding cystourethrogram with retrograde urethrogram and urethroscopy with antegrade cystourethroscopy were performed to evaluate the bladder neck, and stricture site and length. Povidone-iodine saline irrigation was performed through the suprapubic tube twice daily for 2 days before surgery. A soap and water enema was given a day before surgery. Patients were placed in the standard lithotomy position. Through a midline perineal incision the anterior urethra
1751
Vol. 175, 1751-1754, May 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00974-2
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COMPLEX POSTERIOR URETHRAL DISRUPTION TREATMENT
FIG. 1. Cystourethrography shows disruption of posterior urethra with more than 3 cm gap.
FIG. 2. Rectourethral fistula (black arrow) and false passage with bladder neck (white arrow).
RESULTS was dissected and the fibrous tissue of the stricture was completely excised. A midline subumbilical incision was made that extended over the symphysis. The attachments of the rectus abdominis muscles were cleared off of the outer surface of the pubis using a periosteal elevator for approximately 2 cm from each side of the symphysis pubis. A wedge of bone was removed from the superior surface of the pubis using an osteotome. The depth of osteotomy varied according to the exposure required. The prostate was freed from the retropubic callus, carefully avoiding dissection in the retroprostatic plane. The prostatic apex and distal urethra were spatulated anterior. A tension-free end-to-end anastomosis was performed using 6 to 8 sutures of 4-zero polyglactin over an 18Fr catheter. A pedicled cremaster muscle flap was dissected off the spermatic cord on each side and wrapped around the anastomosis. A dartos muscle flap from the scrotum was mobilized to wrap the subpubic part of the bulbar urethra and obliterate the periurethral cavity. The suspensory ligament was repaired in cases that required supracrural rerouting. A suprapubic tube was placed for urinary diversion and 2 suction drains were placed in the retropubic space. The urethral catheter was removed if extravasation was absent on retrograde urethrography 3 weeks after repair. Following a successful voiding trial the suprapubic catheter was removed. The first followup visit was 3 weeks after removal of the suprapubic catheter, when voiding cystourethrography was done to assess the anastomosis and bladder neck competence. Radiological studies were repeated at 6-month intervals for 1 year and once yearly thereafter. For symptomatic assessment direct questioning was done with regard to the urine stream, stress incontinence and quality of erections.
Outcome Analysis Postoperative results were classified as success—normal voiding and continence or failure—poor stream and/or incontinence. Urinary incontinence was defined as mild when no protective padding was used and severe when protective padding or treatment was necessary. The need for dilation, optical urethrotomy or repeat surgery was also considered failure. A patient was considered impotent if he presented with decreased erectile quality.
There were 21 patients with a mean followup of 28 months (range 9 to 40). The primary injury was explosive blast in 12 patients, motor vehicle accident in 8 and gunshot injury in 1. Seven of the 21 patients had undergone failed urethroplasty, which was done by the perineal approach in 5 and by scrotal flap inlay in 2. Mean stricture length ⫾ SD was 5.2 ⫾ 1.4 cm (fig. 1). A rectourethral fistula was present in 5 patients, a false passage was noted in 4 (fig. 2) and a periurethral cavity was present in 3 (figs. 2 and 3). The mean period between original trauma and repair in new cases and since the last attempt at repair in recurrent cases was 10.2 ⫾ 4.3 months. Mean operative time was 6.5 hours with an average blood loss of 600 ml. Mean hospital stay was 10 days. Urethroplasty could be achieved through the normal subpubic route in 16 cases, while 5 required supracrural rerouting. Cystourethrography done 3 weeks postoperatively and during followup showed a wide, patent anastomosis and normal voiding in 20 of 21 cases (95%) (figs. 4 and 5). This successful result was maintained during the entire followup. Of the 21 patients 19 (90.4%) reported normal urinary control, while 2 (9.5%) reported mild stress incontinence not requiring protective padding or treatment. Following pelvic fracture 14 patients (67%) remained potent, of whom 3 (21.4%) reported decreased erectile quality after urethroplasty. Preoperatively impotent patients did not show any improvement in
FIG. 3. Cystourethrogram reveals periurethral cavity, which may be mistaken for short distraction defect on urethrogram because urinoma cavity overlaps or is continuous with proximal segment.
COMPLEX POSTERIOR URETHRAL DISRUPTION TREATMENT
1753
erection after urethroplasty. No complications related to pubic resection occurred. Other complications, such as bowel herniation, chordee, periurethral cavity recurrence or rectourethral fistula, were also not seen. DISCUSSION Surgery for CPUD is compounded by problems of limited urethral length, surrounding fibrosis and distorted pelvic anatomy. These strictures have been managed by a progressive perineal elaboration technique, which consists of corporeal body separation, inferior pubectomy and supracrural rerouting of the mobilized urethra,3 or by an abdominal transpubic perineal technique, in which the mobilized bulbar urethra is rerouted around a corporeal body, passed transpubically and anastomosed to the apex of the prostate from the abdominal side.4 Important questions related to the most appropriate surgical approach of these 2 techniques remain controversial. Although a majority of urethral defects, even those as long as 10 cm, can be resolved through the progressive perineal elaboration technique, there are certain limitations to its use. The repair of a concomitant rectourethral fistula, open bladder neck and periurethral cavity require wider exposure of the pelvis, bladder neck repair, débridement and omentoplasty.6,7 Additionally, the success rate of the perineal elaborated technique is reportedly lower in prepubescent boys and in patients undergoing repeat urethroplasty.8 Abdominal transpubic perineal urethroplasty is now believed to be a safe procedure because complications related to pubic resection are infrequently seen.9,10 It not only provides wide and excellent exposure for urethral anastomosis, but also allows synchronous repair of bladder neck incompetence, urethral fistula to the bladder base or rectum and the excision of periurethral cavities.11 Furthermore, the transpubic route facilitates the use of a pedicled omental graft to obliterate the peri-anastomotic dead space, absorb inflammatory debris and prevent fibrosis.12 Interestingly there have been a few reports of bowel herniation after the use of an omental graft.13 To circumvent this complication we instead use cremaster muscle and a dartos muscle flap, thereby, remaining extraperitoneal throughout the procedure. Our series has a high number of CPUDs, possibly explained by the predominance of war injuries due to explosives in our country. In our study the
FIG. 5. Normal voiding postoperatively
stricture-free rate was 95%, which is in line with that in other studies.5,13,14 Urinary incontinence developed in 2 of 21 patients (19 %). Retrospectively these patients were noted to have had severe bladder neck lacerations after the primary injury. Therefore, it appears that urinary incontinence does not occur as a direct result of anastomotic surgery, rather as a result of bladder neck injuries sustained at the time of primary trauma, which is a finding consistent with other reports.4,15 Impotence has been usually related to the original pelvic fracture urethral injury rather than to urethroplasty.16,17 In our study postoperative impotence was seen in 3 patients (21.4%), which is higher than the rate reported in larger series. This complication represents a learning curve in our experience because these patients underwent extensive retropubic dissection, which we now believe was not necessary. Contrary to the findings of Morey and McAnich,18 we did not observe any delayed recovery of potency after urethroplasty. Transpubic surgery has been rewarding for achieving posterior urethral access in children.5,13,19 Our results clearly show how well transpubic perineal urethroplasty is adaptable to pediatric and adult patients. However radical this procedure may appear, it may be regarded as a reasonable price to pay for a success rate of 95% because it seems unlikely that any other procedure would provide a significantly better result for CPUD. 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 and potency. Complications of pubic resection are now rarely seen.
Abbreviations and Acronyms CPUD ⫽ complex posterior urethral disruption REFERENCES
FIG. 4. Cystourethrogram demonstrates wide, patent anastomosis
1. Webster, G. D. and MacDiarmid, S. A.: Posterior urethral reconstruction. In: Reconstructive Urology. Edited by Webster, G. Kirby, R. King and L. Goldwasser. B. Boston: Blackwell Scientific Publications, vol. 2, chapt. 49, pp. 687–702, 1993
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2. Koraitim, M. M.: Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol, 157: 641, 1997 3. Webster, G. D. and Ramon, J.: Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol, 145: 744, 1991 4. Turner-Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries—and from their surgical management. Urol Clin North Am, 16: 335, 1989 5. Podesta, M. L.: Use of the perineal and perineal-abdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: long-term outcome. J Urol, 160: 160, 1998 6. Webster, G. D.: Repair of the difficult posterior urethral stricture. World J Urol, 5: 30, 1987 7. Webster, G. D., Mathes, G. L. and Selli, C.: Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol, 130: 898, 1983 8. Flynn, B. J., Delvecchio, F. C. and Webster, G. D.: Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol, 170: 1877, 2003 9. Chatelain, C., Le Guillou, M., Petit, M., Jardin, A. and Kuss, R.: Symphysiotomy or transpubic approach to traumatic strictures of the posterior urethra. Eur Urol, 1: 140, 1975 10. Adam, S., Bourke, G. and Fitzgerald, R. J.: Pelvic distraction to improve exposure in radical surgery for pelvic tumours in children. Eur J Surg Oncol, 23: 538, 1997 11. Brock, W. A. and Kaplan, G. W.: Use of the transpubic approach for urethroplasty in children. J Urol, 125: 496, 1981 12. Turner-Warwick, R.: The use of the omental pedicle graft in urinary reconstruction. J Urol, 116: 341, 1976 12. Bissada, N. K., Barry, J. M., Morcos, R. and Hefty, T.: Hernias after transpubic urethroplasty. J Urol, 135: 1010, 1986 13. Patil, U. B.: Long-term results of transpubic prostatomembranous urethroplasty in children. J Urol, part 2, 136: 286, 1986 14. Koraitim, M. M.: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol, 173: 135, 2005 15. Andrich, D. E., Dunglison, N., Greenwell, T. J. and Mundy, A. R.: The long-term results of urethroplasty. J Urol, 170: 90, 2003 16. Koraitim, M. M.: The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol, 153: 63, 1995 17. Shenfeld, O. Z., Kiselgorf, D., Gofrit, O. N., Verstandig, A. G., Landau, E. H. and Pode, D.: The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol, 169: 2173, 2003
18. Morey, A. F. and McAninch, J. W.: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol, 157: 506, 1997 19. Jordan, G. H., Schlossberg, S. M. and Devine, C. J.: Surgery of the penis and urethra. In: Campbell’s Urology, 7th ed. Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. and A. J. Wein. Philadelphia: W. B. Saunders Co., vol. 3, sect. XIV, chapt. 107, pp. 3362–3370, 1998
EDITORIAL COMMENT The authors report a high success rate in the surgical treatment of this difficult group of patients, particularly given the fact that approximately half were prepubescent. However, despite this success with the abdominoperineal transpubic approach and the advantages outlined in this report it should be noted that the progressive perineal approach is also a reasonable option in this setting. As noted by the authors, lengthy urethral distraction defects may be bridged with a 4-step transperineal procedure. Rectourethral fistulas and large periurethral cavities can also be managed using gracilis muscle interposition when necessary. In the setting of an open bladder neck due to scar it is also reasonable to use a perineal approach because approximately 50% of patients will be continent without a bladder neck procedure, which can be done successfully at a later date if needed.1 Perhaps the most logical approach would be to start the reconstruction of a complex posterior urethral disruption with the patient in the exaggerated or high lithotomy position with subsequent patient repositioning for an abdominal incision when needed with the aid of the now widely used adjustable boot-type stirrups. Kenneth W. Angermeier Section of Prosthetic Surgery and Genitourethral Reconstruction Glickman Urological Institute Cleveland Clinic Foundation Cleveland, Ohio 1. Iselin, C. E. and Webster, G. D.: The significance of the open bladder neck associated with pelvic fracture urethral distraction defects. J Urol, 162: 347, 1999
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. Key Words: urethra; fractures, bone; impotence; urinary incontinence; urethral stricture
raumatic disruption of the posterior urethra occurs in 3.5% to 10% of patients with pelvic fractures.1 In 10% of these patients the stricture is complex due to a gap exceeding 3 cm or to associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair.2 Surgical repair of such CPUD remains one of the most challenging problems in urology. Urethral reconstruction of CPUD is accomplished using the progressive perineal elaboration technique3 or the abdominal transpubic perineal approach.4 The stricture-free rate following abdominal transpubic perineal approach is between 70% and 100% according to various investigators.2,5 Therefore, apart from the factor of surgical expertise one is forced to conclude that this difference in success rates among various reports is primarily related to the details of the operative technique adopted by various investigators. We report our short-term results in 21 patients with CPUD treated with combined abdominal transpubic perineal urethroplasty and suggest modifications to improve the success rate of this procedure.
T
Submitted for publication June 22, 2006. * Correspondence and requests for reprints: Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal (telephone: 977-25-25555, extension 2047; FAX: 977-25-20251; e-mail: [email protected]).
0022-5347/06/1755-1751/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS Patients We reviewed the medical records of patients who underwent surgical correction for CPUD following pelvic fracture from January 2000 to August 2005. CPUD was defined as a stricture gap exceeding 3 cm in length, or previous failed repair or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages or an open bladder neck.
Preoperative and Operative Procedure Immediate treatment in patients with urethral injury was placement of a suprapubic cystostomy tube with no attempt at primary realignment. Preoperative evaluation included history, physical examination, laboratory investigations, such as a full blood count, serum urea, electrolytes and creatinine, urinalysis, urine microscopy, culture and sensitivity. Voiding cystourethrogram with retrograde urethrogram and urethroscopy with antegrade cystourethroscopy were performed to evaluate the bladder neck, and stricture site and length. Povidone-iodine saline irrigation was performed through the suprapubic tube twice daily for 2 days before surgery. A soap and water enema was given a day before surgery. Patients were placed in the standard lithotomy position. Through a midline perineal incision the anterior urethra
1751
Vol. 175, 1751-1754, May 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00974-2
1752
COMPLEX POSTERIOR URETHRAL DISRUPTION TREATMENT
FIG. 1. Cystourethrography shows disruption of posterior urethra with more than 3 cm gap.
FIG. 2. Rectourethral fistula (black arrow) and false passage with bladder neck (white arrow).
RESULTS was dissected and the fibrous tissue of the stricture was completely excised. A midline subumbilical incision was made that extended over the symphysis. The attachments of the rectus abdominis muscles were cleared off of the outer surface of the pubis using a periosteal elevator for approximately 2 cm from each side of the symphysis pubis. A wedge of bone was removed from the superior surface of the pubis using an osteotome. The depth of osteotomy varied according to the exposure required. The prostate was freed from the retropubic callus, carefully avoiding dissection in the retroprostatic plane. The prostatic apex and distal urethra were spatulated anterior. A tension-free end-to-end anastomosis was performed using 6 to 8 sutures of 4-zero polyglactin over an 18Fr catheter. A pedicled cremaster muscle flap was dissected off the spermatic cord on each side and wrapped around the anastomosis. A dartos muscle flap from the scrotum was mobilized to wrap the subpubic part of the bulbar urethra and obliterate the periurethral cavity. The suspensory ligament was repaired in cases that required supracrural rerouting. A suprapubic tube was placed for urinary diversion and 2 suction drains were placed in the retropubic space. The urethral catheter was removed if extravasation was absent on retrograde urethrography 3 weeks after repair. Following a successful voiding trial the suprapubic catheter was removed. The first followup visit was 3 weeks after removal of the suprapubic catheter, when voiding cystourethrography was done to assess the anastomosis and bladder neck competence. Radiological studies were repeated at 6-month intervals for 1 year and once yearly thereafter. For symptomatic assessment direct questioning was done with regard to the urine stream, stress incontinence and quality of erections.
Outcome Analysis Postoperative results were classified as success—normal voiding and continence or failure—poor stream and/or incontinence. Urinary incontinence was defined as mild when no protective padding was used and severe when protective padding or treatment was necessary. The need for dilation, optical urethrotomy or repeat surgery was also considered failure. A patient was considered impotent if he presented with decreased erectile quality.
There were 21 patients with a mean followup of 28 months (range 9 to 40). The primary injury was explosive blast in 12 patients, motor vehicle accident in 8 and gunshot injury in 1. Seven of the 21 patients had undergone failed urethroplasty, which was done by the perineal approach in 5 and by scrotal flap inlay in 2. Mean stricture length ⫾ SD was 5.2 ⫾ 1.4 cm (fig. 1). A rectourethral fistula was present in 5 patients, a false passage was noted in 4 (fig. 2) and a periurethral cavity was present in 3 (figs. 2 and 3). The mean period between original trauma and repair in new cases and since the last attempt at repair in recurrent cases was 10.2 ⫾ 4.3 months. Mean operative time was 6.5 hours with an average blood loss of 600 ml. Mean hospital stay was 10 days. Urethroplasty could be achieved through the normal subpubic route in 16 cases, while 5 required supracrural rerouting. Cystourethrography done 3 weeks postoperatively and during followup showed a wide, patent anastomosis and normal voiding in 20 of 21 cases (95%) (figs. 4 and 5). This successful result was maintained during the entire followup. Of the 21 patients 19 (90.4%) reported normal urinary control, while 2 (9.5%) reported mild stress incontinence not requiring protective padding or treatment. Following pelvic fracture 14 patients (67%) remained potent, of whom 3 (21.4%) reported decreased erectile quality after urethroplasty. Preoperatively impotent patients did not show any improvement in
FIG. 3. Cystourethrogram reveals periurethral cavity, which may be mistaken for short distraction defect on urethrogram because urinoma cavity overlaps or is continuous with proximal segment.
COMPLEX POSTERIOR URETHRAL DISRUPTION TREATMENT
1753
erection after urethroplasty. No complications related to pubic resection occurred. Other complications, such as bowel herniation, chordee, periurethral cavity recurrence or rectourethral fistula, were also not seen. DISCUSSION Surgery for CPUD is compounded by problems of limited urethral length, surrounding fibrosis and distorted pelvic anatomy. These strictures have been managed by a progressive perineal elaboration technique, which consists of corporeal body separation, inferior pubectomy and supracrural rerouting of the mobilized urethra,3 or by an abdominal transpubic perineal technique, in which the mobilized bulbar urethra is rerouted around a corporeal body, passed transpubically and anastomosed to the apex of the prostate from the abdominal side.4 Important questions related to the most appropriate surgical approach of these 2 techniques remain controversial. Although a majority of urethral defects, even those as long as 10 cm, can be resolved through the progressive perineal elaboration technique, there are certain limitations to its use. The repair of a concomitant rectourethral fistula, open bladder neck and periurethral cavity require wider exposure of the pelvis, bladder neck repair, débridement and omentoplasty.6,7 Additionally, the success rate of the perineal elaborated technique is reportedly lower in prepubescent boys and in patients undergoing repeat urethroplasty.8 Abdominal transpubic perineal urethroplasty is now believed to be a safe procedure because complications related to pubic resection are infrequently seen.9,10 It not only provides wide and excellent exposure for urethral anastomosis, but also allows synchronous repair of bladder neck incompetence, urethral fistula to the bladder base or rectum and the excision of periurethral cavities.11 Furthermore, the transpubic route facilitates the use of a pedicled omental graft to obliterate the peri-anastomotic dead space, absorb inflammatory debris and prevent fibrosis.12 Interestingly there have been a few reports of bowel herniation after the use of an omental graft.13 To circumvent this complication we instead use cremaster muscle and a dartos muscle flap, thereby, remaining extraperitoneal throughout the procedure. Our series has a high number of CPUDs, possibly explained by the predominance of war injuries due to explosives in our country. In our study the
FIG. 5. Normal voiding postoperatively
stricture-free rate was 95%, which is in line with that in other studies.5,13,14 Urinary incontinence developed in 2 of 21 patients (19 %). Retrospectively these patients were noted to have had severe bladder neck lacerations after the primary injury. Therefore, it appears that urinary incontinence does not occur as a direct result of anastomotic surgery, rather as a result of bladder neck injuries sustained at the time of primary trauma, which is a finding consistent with other reports.4,15 Impotence has been usually related to the original pelvic fracture urethral injury rather than to urethroplasty.16,17 In our study postoperative impotence was seen in 3 patients (21.4%), which is higher than the rate reported in larger series. This complication represents a learning curve in our experience because these patients underwent extensive retropubic dissection, which we now believe was not necessary. Contrary to the findings of Morey and McAnich,18 we did not observe any delayed recovery of potency after urethroplasty. Transpubic surgery has been rewarding for achieving posterior urethral access in children.5,13,19 Our results clearly show how well transpubic perineal urethroplasty is adaptable to pediatric and adult patients. However radical this procedure may appear, it may be regarded as a reasonable price to pay for a success rate of 95% because it seems unlikely that any other procedure would provide a significantly better result for CPUD. 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 and potency. Complications of pubic resection are now rarely seen.
Abbreviations and Acronyms CPUD ⫽ complex posterior urethral disruption REFERENCES
FIG. 4. Cystourethrogram demonstrates wide, patent anastomosis
1. Webster, G. D. and MacDiarmid, S. A.: Posterior urethral reconstruction. In: Reconstructive Urology. Edited by Webster, G. Kirby, R. King and L. Goldwasser. B. Boston: Blackwell Scientific Publications, vol. 2, chapt. 49, pp. 687–702, 1993
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COMPLEX POSTERIOR URETHRAL DISRUPTION TREATMENT
2. Koraitim, M. M.: Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol, 157: 641, 1997 3. Webster, G. D. and Ramon, J.: Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol, 145: 744, 1991 4. Turner-Warwick, R.: Prevention of complications resulting from pelvic fracture urethral injuries—and from their surgical management. Urol Clin North Am, 16: 335, 1989 5. Podesta, M. L.: Use of the perineal and perineal-abdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: long-term outcome. J Urol, 160: 160, 1998 6. Webster, G. D.: Repair of the difficult posterior urethral stricture. World J Urol, 5: 30, 1987 7. Webster, G. D., Mathes, G. L. and Selli, C.: Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol, 130: 898, 1983 8. Flynn, B. J., Delvecchio, F. C. and Webster, G. D.: Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol, 170: 1877, 2003 9. Chatelain, C., Le Guillou, M., Petit, M., Jardin, A. and Kuss, R.: Symphysiotomy or transpubic approach to traumatic strictures of the posterior urethra. Eur Urol, 1: 140, 1975 10. Adam, S., Bourke, G. and Fitzgerald, R. J.: Pelvic distraction to improve exposure in radical surgery for pelvic tumours in children. Eur J Surg Oncol, 23: 538, 1997 11. Brock, W. A. and Kaplan, G. W.: Use of the transpubic approach for urethroplasty in children. J Urol, 125: 496, 1981 12. Turner-Warwick, R.: The use of the omental pedicle graft in urinary reconstruction. J Urol, 116: 341, 1976 12. Bissada, N. K., Barry, J. M., Morcos, R. and Hefty, T.: Hernias after transpubic urethroplasty. J Urol, 135: 1010, 1986 13. Patil, U. B.: Long-term results of transpubic prostatomembranous urethroplasty in children. J Urol, part 2, 136: 286, 1986 14. Koraitim, M. M.: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol, 173: 135, 2005 15. Andrich, D. E., Dunglison, N., Greenwell, T. J. and Mundy, A. R.: The long-term results of urethroplasty. J Urol, 170: 90, 2003 16. Koraitim, M. M.: The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol, 153: 63, 1995 17. Shenfeld, O. Z., Kiselgorf, D., Gofrit, O. N., Verstandig, A. G., Landau, E. H. and Pode, D.: The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol, 169: 2173, 2003
18. Morey, A. F. and McAninch, J. W.: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol, 157: 506, 1997 19. Jordan, G. H., Schlossberg, S. M. and Devine, C. J.: Surgery of the penis and urethra. In: Campbell’s Urology, 7th ed. Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. and A. J. Wein. Philadelphia: W. B. Saunders Co., vol. 3, sect. XIV, chapt. 107, pp. 3362–3370, 1998
EDITORIAL COMMENT The authors report a high success rate in the surgical treatment of this difficult group of patients, particularly given the fact that approximately half were prepubescent. However, despite this success with the abdominoperineal transpubic approach and the advantages outlined in this report it should be noted that the progressive perineal approach is also a reasonable option in this setting. As noted by the authors, lengthy urethral distraction defects may be bridged with a 4-step transperineal procedure. Rectourethral fistulas and large periurethral cavities can also be managed using gracilis muscle interposition when necessary. In the setting of an open bladder neck due to scar it is also reasonable to use a perineal approach because approximately 50% of patients will be continent without a bladder neck procedure, which can be done successfully at a later date if needed.1 Perhaps the most logical approach would be to start the reconstruction of a complex posterior urethral disruption with the patient in the exaggerated or high lithotomy position with subsequent patient repositioning for an abdominal incision when needed with the aid of the now widely used adjustable boot-type stirrups. Kenneth W. Angermeier Section of Prosthetic Surgery and Genitourethral Reconstruction Glickman Urological Institute Cleveland Clinic Foundation Cleveland, Ohio 1. Iselin, C. E. and Webster, G. D.: The significance of the open bladder neck associated with pelvic fracture urethral distraction defects. J Urol, 162: 347, 1999