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Direct Urethra-Bladder Neck Anastomosis in the Surgical Correction of Posterior Urethral Strictures
Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
DIRECT URETHRA-BLADDER NECK ANASTOMOSIS IN THE SURGICAL CORRECTION OF POSTERIOR URETHRAL STRICTURES NHIEP TANG* From the Department of Urology, Memorial Medical Center, Savannah, Georgia
ABSTRACT
A direct anastomosis of the urethra and bladder neck is suggested for posterior urethral strictures, especially high lesions. The technique is described, and its advantages and complications are discussed. Strictures of the posterior urethra pose a difficult therapeutic problem, which many have tried to solve with varying degrees of success. A periurethral approximation suture over a stent catheter after a scar excision often results in a recurring stricture. Partial pubectomy or pubic symphysiotomy offers a better approach to the posterior urethra for scar removal and a technically satisfying end-to-end anastomosis. However, postoperative stricture is observed often and becomes increasingly more difficult to dilate. The 2-stage urethroplasty and the patch graft are the most popular techniques today. i-s However, in addition to the 2 hospitalizations that the 2-stage procedures require, they are difficult to perform if the stricture is high in the prostatic urethra. In addition, strictures of the new proximal meatus often require 1 or more revisions, resulting in a 3 or 4-stage urethroplasty. In 1950 Badenoch published results of a pull-through urethroplasty by intraprostatic intussusception of the mobilized anterior urethra.
A total of 16 direct urethra-bladder neck anastomoses has been done: 11 for high posterior urethral strictures (see table), 4 for rectourethral fistulas and 1 for a posterior urethrocutaneous fistula. Among the 11 stricture cases 9 were the result of pelvic bone fractures, .1 of a bullet wound and 1 of a shrapnel wound. The 4 cases of rectourethral fistula have been reported previously. Patients with strictures were treated initially by cystostomy and an indwelling urethral catheter, with or without traction. One patient had cystostomy alone. One patient had 6 operations before the current hospitalization. All patients with rectourethral fistulas had normal postoperative voiding. The patient with the urethrocutaneous fistula had mild postoperative bladder neck contracture but this responded well to transurethral resection. All cases will be discussed herein because it is worthwhile to know the voiding pattern after direct urethrovesical anastomosis. TECHNIQUE
A combined abdominoperineal approach was used with the patient in the lithotomy position. A Young perineal incision is made with a 3 cm. vertical midline extension toward the base of the penis. The perineo-bulbar urethra in its corpus spongiosum is mobilized and divided just distal to the stricture. Mobilization is then continued distally to 1 cm. proximal Accepted for publication January 28, 1977. * Current address: 4747 North 22 St., Suite 200, Phoenix, Arizona 85016.
772
to the base of the penis. Through a midline subumbilical incision a median vertical cystotomy is made and prolonged downward onto the bladder neck, which is thus bivalved. A transverse incision of the prostatic urethra, 5 mm. distal to the bladder neck, allows complete mobilization of the latter by blunt and sharp dissection. A channel is made with a long Kelly forceps from the prostatic urethra to the perineum. The new channel is dilated to 30F. The proximal end of the anterior urethra is pulled up through the new channel, spatulated and anastomosed to the bladder neck with 2-zero chromic interrupted sutures over a urethral stent catheter. A cystostomy is performed and the abdomen and perineum are closed as usual. The Foley catheter is removed after 2 weeks and the cystostomy catheter is clamped for a voiding test prior to its removal. In difficult cases, mainly after many unsuccessful operations, pubic symphysiotomy may be performed to allow a better approach to the retracted bladder neck. CASE REPORTS
Case 1. L. T. T., URP4426, a 14-year-old boy, had a stricture of the posterior urethra and a urethrocutaneous fistula at the medial surface of the right thigh, the result of a pelvic bone fracture treated in July 1972 with an indwelling urethral catheter and cystostomy. A preoperative urethrogram revealed a poorly visualized posterior urethra and numerous fistulous tracts behind the pubic symphysis towards the right thigh (fig. 1, A). Subsequently, a bladder calculus and bilateral multiple renal calculi developed and were removed after the urethral repair. The patient underwent cystostomy in March 1973 and direct urethra-bladder neck anastomosis 3 weeks later. The postoperative urethrogram showed a patent posterior urethra without a fistula (fig 1, B). Voiding remained normal until October 1974, when the patient spontaneously passed a bladder stone. Since then he has had normal voiding. A followup excretory urogram (IVP) showed no stone but slight bilateral chronic pyelonephritis. Erection has remained normal. Case 2. N. T. H., UR03553, a 19-year-old man, had a stricture of the posterior urethra, the result of a pelvic bone fracture treated in 1971 by cystostomy and a urethral indwelling catheter with traction. A preoperative urethrogram revealed a stricture of the posterior urethra with multiple fistulous tracts and a trabeculated bladder (fig 2, A). The patient underwent direct anastomosis of the urethra and bladder neck in June 1973. Postoperatively, the patient had normal voiding and slightly decreased potency. A urethrogram showed a posterior urethra without fistula (fig 2, B). He was last seen in May 1974 voiding normally. Case 7. T. P.H., URQ4866, a 13-year-old boy, had a pelvic bone fracture and rupture of the urethra in January 1973, treated initially with an indwelling urethral catheter and cystostomy without success. A preoperative urethrogram re-
URETHRA-BLADDER NECK ANASTOMOSIS IN CORRECTION OF URETHRAL STRICTURES
Posterior urethral strictures Results After Direct Urethra-Bladder Neck Anastomosis Age (yrs.)
Etiology
Previous Operations Voiding
1- URP4426-14 2- UR03553-19
Pel vie fracture Pelvic fracture
3 - UR03673 - 23
Bullet wound Pel vie fracture Pelvic fracture Pelvic fracture
Urethral stent cystostomy Urethral stent with traction cystostomy 4 urethroplasties 1 urethroplasty Urethral stent cystostomy Urethral cystostomy
Pelvic fracture Pelvic fracture Pelvic fracture
Urethral cystostomy Urethral stent cystostomy Cystostomy
10- URQ4751-14
Shrapnel wound
11-URQ4665-42
Pelvic fracture
Urethral stent with traction cystostomy Urethral stent on traction cystostomy
4- UR03811-12 5- UR03602 -14 6 - URQ4590- 54 7- URQ4866-13
8-NT4605-19 9- URQ4867 -36
Continence
Erection
F0Hov1rup (mos.)
Normal Normal
Good Good
Unchanged Decreased
24
Normal Normal Normal Satisfactory, mild bladder neck contracture, bladder neck dilation every 3 mos. Normal Normal Normal
Good Good Good Good
Unknown Unknown Unchanged Unknown
2 18 17
Good Good Transient mild stress incontinence
Unknown Unchanged Unknown
Failure of direct anastomosis, successful Johanson 3 mos. later Failure
FIG. 1. A, preoperative urethrogram shows poorly visualized posterior urethra among numerous fistulous tracts. B, postoperative urethrogram shows patent posterior urethra without fistula.
vealed complete stenosis of the posterior urethra with marked periurethral and intravenous diffusion of the contrast medium (fig 3, A). The underwent direct anastomosis of the urethra and neck in February 1973, with pubic symphysiotomy and omentoplasty. Postoperatively, voiding has been normal. A urethrogram showed a well patent urethra. 3, B). DISCUSSION
In the Badenoch procedure the divided end of the anterior urethra is left without anastomosis in the prostatic urethra exposing it to ischemia and necrosis. r; When the stent catheter is removed after resorption of the anchoring chromic suture the anterior urethra is attached to the posterior by formed loose adherences, occasionally 1 or 2 chromic
11
16
15 18
Unchanged Decreased
FIG. 2. A, preoperative urethrogram shows stricture of nc.,,,~,,.,,.w urethra with multiple fistulous tracts. B, postoperative shows patent urethra without fistula.
sutures that Badenock used to fix the triangular the external surface of the anterior urethra. Since ~c,~L-uu·~,., obtained good results in about 50 per cent of his cases we speculated whether the unsuccessful cases were caused total retraction of the anterior urethra or stenosis of urethral stump. Direct anastomosis of the anterior urethra to the bladder neck should preclude urethral retraction. Transverse incision of the urethra just distal to the bladde, neck may cause vesicoureteral reflux by retraction of the ureteral orifices but this may be minimized by suturing bladder neck to the urethra. Wisp unilateral reflux was observed in 1 of the 16 cases reported herein. Sexual potency decreased in 4 cases in this series, was unchanged in 7 and unknown in 5. Wiggishoff and Kiefer, and Villanueva reported transient decrease in sexual
774
TANG
tered in this series nor was micropenis by retraction as reported by Judd and Donohue. 9 Postoperative bladder neck contracture has been observed in 2 cases in which one had a thick bladder neck and dense retropubic adherences. Preoperative bladder neck lesions may be partially responsible for this complication. Direct urethrabladder neck anastomosis is the final step in total prostatectomy. In the latter procedure, with a presumably normal bladder neck Turner and Belt reported 7 cases of bladder neck contracture after 229 perineal prostatectomies for cancer, of which only 1 required surgical correction. 10 Direct anastomosis of the urethra and bladder neck eliminates the risk of secondary stricture, which occurs whenever 2 small tubular structures are brought together by end-to-end anastomosis. Moreover, it is not a final procedure. If failure occurs other reconstructive operations can be performed. In case 10 a Johanson urethroplasty was successfully performed after failure of direct urethra-bladder neck anastomosis. REFERENCES
1. Johanson, B.: Reconstruction of the male urethra in strictures.
Fm. 3. A, preoperative urethrogram shows complete stenosis of posterior urethra. B, postoperative urethrogram shows well patent urethra.
after the Badenoch procedure, all of their patients becoming sterile. 7• 8 Therefore, postoperative sterility must be considered when this operation is performed on a young patient without children unless the sexual functions had been altered by the trauma. Postoperative incontinence was not encoun-
Acta Chir. Scand., suppl. 176, 1953. 2. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures of the bulbous urethra. J. Urol., 83: 54, 1960. 3. Lapides, J.: Simplified modification of Johanson urethroplasty for strictures of deep bulbous urethra. J. Urol., 82: 115, 1959. 4. Swinney, J.: Reconstruction of urethra in the male. Brit. J. Urol., 24: 229, 1952. 5. Gil-Vernet, J. M.: Un traitement des stenoses traumatiques et inflammatoires de l'uretre posterieur: nouvelle methode d'uretroplastie. J. Urol. Nephrol., 72: 97, 1966. 6. Badenoch, A. W.: A pull-through operation for impassable traumatic stricture of urethra. Brit. J. Urol., 22: 404, 1950. 7. Villanueva, A.: Modification of the invagination technique to repair traumatic stricture of the posterior urethra. The attained result in 12 years. Urol. Int., 18: 207, 1964. 8. Wiggishoff, C. C. and Kiefer, J. H.: Pull-through reconstruction of the posterior urethra. J. Urol., 93: 233, 1965. 9. Judd, R. and Donohue, J. P.: Micro-penis following Badenoch pull-through procedure: a case report. J. Urol., 103: 104, 1970. 10. Turner, R. D. and Belt, E.: A study of 229 consecutive cases of total perinea! prostatectomy for cancer of the prostate. J. Urol., 77: 62, 1957.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
DIRECT URETHRA-BLADDER NECK ANASTOMOSIS IN THE SURGICAL CORRECTION OF POSTERIOR URETHRAL STRICTURES NHIEP TANG* From the Department of Urology, Memorial Medical Center, Savannah, Georgia
ABSTRACT
A direct anastomosis of the urethra and bladder neck is suggested for posterior urethral strictures, especially high lesions. The technique is described, and its advantages and complications are discussed. Strictures of the posterior urethra pose a difficult therapeutic problem, which many have tried to solve with varying degrees of success. A periurethral approximation suture over a stent catheter after a scar excision often results in a recurring stricture. Partial pubectomy or pubic symphysiotomy offers a better approach to the posterior urethra for scar removal and a technically satisfying end-to-end anastomosis. However, postoperative stricture is observed often and becomes increasingly more difficult to dilate. The 2-stage urethroplasty and the patch graft are the most popular techniques today. i-s However, in addition to the 2 hospitalizations that the 2-stage procedures require, they are difficult to perform if the stricture is high in the prostatic urethra. In addition, strictures of the new proximal meatus often require 1 or more revisions, resulting in a 3 or 4-stage urethroplasty. In 1950 Badenoch published results of a pull-through urethroplasty by intraprostatic intussusception of the mobilized anterior urethra.
A total of 16 direct urethra-bladder neck anastomoses has been done: 11 for high posterior urethral strictures (see table), 4 for rectourethral fistulas and 1 for a posterior urethrocutaneous fistula. Among the 11 stricture cases 9 were the result of pelvic bone fractures, .1 of a bullet wound and 1 of a shrapnel wound. The 4 cases of rectourethral fistula have been reported previously. Patients with strictures were treated initially by cystostomy and an indwelling urethral catheter, with or without traction. One patient had cystostomy alone. One patient had 6 operations before the current hospitalization. All patients with rectourethral fistulas had normal postoperative voiding. The patient with the urethrocutaneous fistula had mild postoperative bladder neck contracture but this responded well to transurethral resection. All cases will be discussed herein because it is worthwhile to know the voiding pattern after direct urethrovesical anastomosis. TECHNIQUE
A combined abdominoperineal approach was used with the patient in the lithotomy position. A Young perineal incision is made with a 3 cm. vertical midline extension toward the base of the penis. The perineo-bulbar urethra in its corpus spongiosum is mobilized and divided just distal to the stricture. Mobilization is then continued distally to 1 cm. proximal Accepted for publication January 28, 1977. * Current address: 4747 North 22 St., Suite 200, Phoenix, Arizona 85016.
772
to the base of the penis. Through a midline subumbilical incision a median vertical cystotomy is made and prolonged downward onto the bladder neck, which is thus bivalved. A transverse incision of the prostatic urethra, 5 mm. distal to the bladder neck, allows complete mobilization of the latter by blunt and sharp dissection. A channel is made with a long Kelly forceps from the prostatic urethra to the perineum. The new channel is dilated to 30F. The proximal end of the anterior urethra is pulled up through the new channel, spatulated and anastomosed to the bladder neck with 2-zero chromic interrupted sutures over a urethral stent catheter. A cystostomy is performed and the abdomen and perineum are closed as usual. The Foley catheter is removed after 2 weeks and the cystostomy catheter is clamped for a voiding test prior to its removal. In difficult cases, mainly after many unsuccessful operations, pubic symphysiotomy may be performed to allow a better approach to the retracted bladder neck. CASE REPORTS
Case 1. L. T. T., URP4426, a 14-year-old boy, had a stricture of the posterior urethra and a urethrocutaneous fistula at the medial surface of the right thigh, the result of a pelvic bone fracture treated in July 1972 with an indwelling urethral catheter and cystostomy. A preoperative urethrogram revealed a poorly visualized posterior urethra and numerous fistulous tracts behind the pubic symphysis towards the right thigh (fig. 1, A). Subsequently, a bladder calculus and bilateral multiple renal calculi developed and were removed after the urethral repair. The patient underwent cystostomy in March 1973 and direct urethra-bladder neck anastomosis 3 weeks later. The postoperative urethrogram showed a patent posterior urethra without a fistula (fig 1, B). Voiding remained normal until October 1974, when the patient spontaneously passed a bladder stone. Since then he has had normal voiding. A followup excretory urogram (IVP) showed no stone but slight bilateral chronic pyelonephritis. Erection has remained normal. Case 2. N. T. H., UR03553, a 19-year-old man, had a stricture of the posterior urethra, the result of a pelvic bone fracture treated in 1971 by cystostomy and a urethral indwelling catheter with traction. A preoperative urethrogram revealed a stricture of the posterior urethra with multiple fistulous tracts and a trabeculated bladder (fig 2, A). The patient underwent direct anastomosis of the urethra and bladder neck in June 1973. Postoperatively, the patient had normal voiding and slightly decreased potency. A urethrogram showed a posterior urethra without fistula (fig 2, B). He was last seen in May 1974 voiding normally. Case 7. T. P.H., URQ4866, a 13-year-old boy, had a pelvic bone fracture and rupture of the urethra in January 1973, treated initially with an indwelling urethral catheter and cystostomy without success. A preoperative urethrogram re-
URETHRA-BLADDER NECK ANASTOMOSIS IN CORRECTION OF URETHRAL STRICTURES
Posterior urethral strictures Results After Direct Urethra-Bladder Neck Anastomosis Age (yrs.)
Etiology
Previous Operations Voiding
1- URP4426-14 2- UR03553-19
Pel vie fracture Pelvic fracture
3 - UR03673 - 23
Bullet wound Pel vie fracture Pelvic fracture Pelvic fracture
Urethral stent cystostomy Urethral stent with traction cystostomy 4 urethroplasties 1 urethroplasty Urethral stent cystostomy Urethral cystostomy
Pelvic fracture Pelvic fracture Pelvic fracture
Urethral cystostomy Urethral stent cystostomy Cystostomy
10- URQ4751-14
Shrapnel wound
11-URQ4665-42
Pelvic fracture
Urethral stent with traction cystostomy Urethral stent on traction cystostomy
4- UR03811-12 5- UR03602 -14 6 - URQ4590- 54 7- URQ4866-13
8-NT4605-19 9- URQ4867 -36
Continence
Erection
F0Hov1rup (mos.)
Normal Normal
Good Good
Unchanged Decreased
24
Normal Normal Normal Satisfactory, mild bladder neck contracture, bladder neck dilation every 3 mos. Normal Normal Normal
Good Good Good Good
Unknown Unknown Unchanged Unknown
2 18 17
Good Good Transient mild stress incontinence
Unknown Unchanged Unknown
Failure of direct anastomosis, successful Johanson 3 mos. later Failure
FIG. 1. A, preoperative urethrogram shows poorly visualized posterior urethra among numerous fistulous tracts. B, postoperative urethrogram shows patent posterior urethra without fistula.
vealed complete stenosis of the posterior urethra with marked periurethral and intravenous diffusion of the contrast medium (fig 3, A). The underwent direct anastomosis of the urethra and neck in February 1973, with pubic symphysiotomy and omentoplasty. Postoperatively, voiding has been normal. A urethrogram showed a well patent urethra. 3, B). DISCUSSION
In the Badenoch procedure the divided end of the anterior urethra is left without anastomosis in the prostatic urethra exposing it to ischemia and necrosis. r; When the stent catheter is removed after resorption of the anchoring chromic suture the anterior urethra is attached to the posterior by formed loose adherences, occasionally 1 or 2 chromic
11
16
15 18
Unchanged Decreased
FIG. 2. A, preoperative urethrogram shows stricture of nc.,,,~,,.,,.w urethra with multiple fistulous tracts. B, postoperative shows patent urethra without fistula.
sutures that Badenock used to fix the triangular the external surface of the anterior urethra. Since ~c,~L-uu·~,., obtained good results in about 50 per cent of his cases we speculated whether the unsuccessful cases were caused total retraction of the anterior urethra or stenosis of urethral stump. Direct anastomosis of the anterior urethra to the bladder neck should preclude urethral retraction. Transverse incision of the urethra just distal to the bladde, neck may cause vesicoureteral reflux by retraction of the ureteral orifices but this may be minimized by suturing bladder neck to the urethra. Wisp unilateral reflux was observed in 1 of the 16 cases reported herein. Sexual potency decreased in 4 cases in this series, was unchanged in 7 and unknown in 5. Wiggishoff and Kiefer, and Villanueva reported transient decrease in sexual
774
TANG
tered in this series nor was micropenis by retraction as reported by Judd and Donohue. 9 Postoperative bladder neck contracture has been observed in 2 cases in which one had a thick bladder neck and dense retropubic adherences. Preoperative bladder neck lesions may be partially responsible for this complication. Direct urethrabladder neck anastomosis is the final step in total prostatectomy. In the latter procedure, with a presumably normal bladder neck Turner and Belt reported 7 cases of bladder neck contracture after 229 perineal prostatectomies for cancer, of which only 1 required surgical correction. 10 Direct anastomosis of the urethra and bladder neck eliminates the risk of secondary stricture, which occurs whenever 2 small tubular structures are brought together by end-to-end anastomosis. Moreover, it is not a final procedure. If failure occurs other reconstructive operations can be performed. In case 10 a Johanson urethroplasty was successfully performed after failure of direct urethra-bladder neck anastomosis. REFERENCES
1. Johanson, B.: Reconstruction of the male urethra in strictures.
Fm. 3. A, preoperative urethrogram shows complete stenosis of posterior urethra. B, postoperative urethrogram shows well patent urethra.
after the Badenoch procedure, all of their patients becoming sterile. 7• 8 Therefore, postoperative sterility must be considered when this operation is performed on a young patient without children unless the sexual functions had been altered by the trauma. Postoperative incontinence was not encoun-
Acta Chir. Scand., suppl. 176, 1953. 2. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures of the bulbous urethra. J. Urol., 83: 54, 1960. 3. Lapides, J.: Simplified modification of Johanson urethroplasty for strictures of deep bulbous urethra. J. Urol., 82: 115, 1959. 4. Swinney, J.: Reconstruction of urethra in the male. Brit. J. Urol., 24: 229, 1952. 5. Gil-Vernet, J. M.: Un traitement des stenoses traumatiques et inflammatoires de l'uretre posterieur: nouvelle methode d'uretroplastie. J. Urol. Nephrol., 72: 97, 1966. 6. Badenoch, A. W.: A pull-through operation for impassable traumatic stricture of urethra. Brit. J. Urol., 22: 404, 1950. 7. Villanueva, A.: Modification of the invagination technique to repair traumatic stricture of the posterior urethra. The attained result in 12 years. Urol. Int., 18: 207, 1964. 8. Wiggishoff, C. C. and Kiefer, J. H.: Pull-through reconstruction of the posterior urethra. J. Urol., 93: 233, 1965. 9. Judd, R. and Donohue, J. P.: Micro-penis following Badenoch pull-through procedure: a case report. J. Urol., 103: 104, 1970. 10. Turner, R. D. and Belt, E.: A study of 229 consecutive cases of total perinea! prostatectomy for cancer of the prostate. J. Urol., 77: 62, 1957.