Management of Posterior Urethral Strictures Secondary to Pelvic Fractures in Children

MOSTAFA A.

SALAR GAAFAR

From the Department of Urology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt

ABSTRACT

Bulboprostatic anastomotic urethroplasty was +r... strictures secondary to pelvic fractures. The ~-n.lrYrr,\~("1· abdominoperineal in 16, with good children the urethral disruption branous junction. In such cases the repair of the injury is advisable. In the case of common prostatomembranous significant. In such cases a transpubic approach is is deranged, it can be managed at the same time. ..,-,.A·...

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KEY WORDS:

urethral stricture, pelvic bones, pediatrics

Posterior urethral stricture after bony pelvic fracture and complete disruption of the prostatomembranous urethra is a misnomer, being neither urethral nor a stricture. It is either a fistulous or fibrous tract between the displaced prostate above and the bulbous urethra below the lesion.! posttraumatic urethral strictures in children have features warrant consideration the mEln2lge:me:nt. present our experience in the management of Ch].1dJ~en post-traumatic posterior urethral strictures. MATERIAL AND METHODS

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Between 1978 and 1985, 20 patients with suprapubic tubes indwelling were referred to us because of posterior urethral strictures secondary to bony pelvic fractures. Of the pwtleltlts 18 were 2 to 12 years old and 2 were 18 years old (the latter 2 had sustained the urethral were included because injury during childhood). The level of the was at prostatomembranous junction in 17 and across the prostate itself in 3 (fig. In 2 of the 20 patients had associated rectal injury that resulted in a rectourethral fistula and they were referred to us with a transverse COJlostolny addition a cystostomy Besides the routine and ... -o<>""' ..... "" urE~th.rOI;rra,ph.y assess the extent of obliterated fibrous tract as evaluate competency nism. Anastomotic months after the several years later. A was used in in whom the prostate was accessible and a combined tr2lnSDulblC a h,rln.1VY\1"nn.·n011"1Yloa I anastomotic was in 15 whom the prostate was markedly displaced One patient had complete obliteration of the entire length of the prostatic urethra; the urethral defect was by a distally based anterior bladder tube (fig. 2). The transpubic approach adopted in our series was essentially that of Waterhouse et al. 2 Dissection lateral and posterior to the prostate was avoided unless there was an associated rectourethral fistula. In addition, pubectomy was followed by cauterization of the bone edges to prevent new bone formation. The mucosa of the prostatic urethra was everted and pinned to the edges of the prostate gland to prevent its recession and to be sure that the anastomosis was actually mucosa-to-mucosa. .n"{7c,-rn.,n"1l"<:l,,,-,.h"{7

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Accepted for publication May 25,1990. 353

FIG. 1. Cystourethrography after transpubic urethroplasty in child who had prostatic amputation and funneling of bladder neck. Patient is incontinent.

354

AL-RIFAEI, GAAFAR AND ABDEL-RAHMAN

FIG. 2. A, combined antegrade cystogram and retrograde urethrogram shows complete obliteration of prostatic urethra with serrated outline of bladder neck. B, same patient after bridging urethral defect by distally based anterior bladder tube.

TABLE

Pt. No.-Age 1-11 2-12 3-3 4-12 5-5 6-10 7-18 8-11 9-11 10-4 11-12 12-12 13-11

14-18 15-6 16-3 17-7 18-12 19-12 20-5

TABLE

1. Preoperative, operative and postoperative data for all patients

Interval From Injury to Re-

Preop. State of Proximal Sphincteric Mechanism

Operation

Result

Late Complications

Prostatic urethra Membranous urethra Membranous urethra Membranous urethra Membranous urethra Membranous urethra Whole prostatic urethra Membranous urethra Membranous urethra Membranous urethra Membranous urethra and rectum Membranous urethra Membranous urethra and innervation of bladder neck Prostatic urethra Membranous urethra Membranous urethra Membranous urethra Membranous urethra

1 yr. 2 yrs. 1 yr. 1 yr. 6 mos. 6 mos. 6 yrs.

Deranged Competent Competent Competent Competent Competent Deranged

Transpubic Transpubic Transpubic Transpubic Perineal Perineal Transpubic, bladder tube

Poor Good Good Good Good Good Poor

Incontinence None None None None None Incontinence

1 yr. 3 yrs. 6 mos. 3 yrs.

Competent Competent Competent Competent

Good Good Good Good

None None None None

6 mos. 1 yr.

Competent Deranged

Transpubic Transpubic Transpubic Transpubic and repair of rectourethral fistula Transpubic Transpubic

Good Poor

None Incontinence

6 6 6 6 6

yrs. mos. mos. mos. mos.

Deranged Competent Competent Competent Competent

Transpubic Transpubic Transpubic Perineal Transpubic

Poor Poor Good Good Poor

Membranous urethra Membranous urethra and rectum

1 yr. 6 mos.

Competent Competent

Perineal Transpubic repair of rectourethral fistula

Good Good

Incontinence Obstruction None None Obstruction by new bone formation None None

Site of Lesion

2. Late complications after transpubic urethroplasty in 16 patients No. (%)

Incontinence New bone formation causing obstruction Recurrent obstruction of the urethra

4 (25)

1 (5.6) 1 (5.6)

urinary control and poor-recurrent urethral obstruction or urinary incontinence. RESULTS

The results are analyzed in table 1. The outcome of the urethroplasty was good in all patients who underwent a perineal operation. Of those who underwent a transpubic operation good results were obtained in 10 (62.5%) and poor results in 6 (37.5%) due to various reasons (table 2). The child whose

urethral defect was bridged by a distally based anterior bladder tube eventually had a patent neourethra but urinary control was inadequate (fig. 2). Both rectourethral fistulas were repaired successfully. Both patients with recurrent obstruction were explored again 6 months later. In 1 patient refashioning of the anastomosis was possible via an abdominoscrotal incision with a satisfactory result. In 1 child new bone formation (or callus) at the pubectomy site was found pressing on the site of the anastomosis. The callus was removed and the bone ends were cauterized. The anastomotic site remained patent after this therapy. In 1 of the incontinent patients a sling of fascia lata was wrapped around the bladder neck. However, the result was not satisfactory. One child is living with an external urine collecting device and 1 regained urinary control by a proximally based anterior bladder tube. Over-all, 3 early postoperative complications were encoun-

FIG. 3. A, combined antegrade cystogram and retrograde urethrogram in resting phase shows posterior urethral stricture with opened funneled bladder neck denoting derangement of proximal urethral sphincteric mechanism. B, same patient after transpubic urethroplasty. Patient is incontinent.

teredo One patient had excessive reactionary hemorrhage from the bone edges, which was managed with exploration and packing of the pubectomy site, 1 had a perineal hematoma that required evacuation and 1 a splinting urethral catheter slipped and re-exploration was necessary to reinsert it. Careful review of the resting cystograms showed that 4 children had evidence of incompetency of the urethral mechanism in the form of IUrln€~lln.g of the bladder neck with filling of the tatic in 1 3), an funneled 1) and neck with obliteration of the entire urethra with a serrated of the (fig. 2, ). operative restoration of the urethral patency (by anastomotic urethroplasty) these 4 children became incontinent. Erectile function in these children could not be evaluated in our series because of the young age. Vesicoureteral reflux was n1"c~n.n,01"a"tl'l:TO in 12 (60%) and it eV€~ntllall dls:appeclred POsl:OPlerlatrveJ.V in 9 after removal of all catheters. pr48o]:>eratlve, and postoperhT

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In the majority of adults with posterior urethral strictures prostatic displacement is not marked. Therefore, the perineal approach is sufficient for bulboprostatic anastomosis in most cases. 6 ,? On the other hand, 80% of our children required an abdominoperineal operation to reconstruct the urethra because of the marked upward displacement of the prostate. This is of Strong and Hodges. 8 On the consimilar to the Koff had excellent results with the perineal anastomosis did not state the of the urethral strictures in their children. 9 1 of our callus formation in the . . . "h.n..n+- ....... """""' ... gap encroached upon the urethral anastomosis and resulted recurrent obstruction. This also was Therefore, we resorted to cauterization later cases. In addition, mobilized omentum was interposed between the bone edges in some cases to fill the dead space and to provide a soft vascular mass of tissue directly anterior to the urethral anastomosis. This is in with the ence of Middleton and 10 derangement of the proximal sphincteric mechanism was demonstrated radiologically in 20% of our children, which is a high incidence to adults. The mechanism of this may be to the innervation of the bladder with a short ...... ~'~~+n+-',.n urethra incidence of AT,,,,lr,rn:T

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REFERENCES

1. Al-Rifaei, M. Transpubic approach for surgical repair of posttraumatic membranous urethral strictures over four years. Read at the XIX International Congress of the Societe Internationale d'Urology. San Francisco, California, September 5-10, 1982. 2. Waterhouse, K., Abrahams, J. I., Gruber, H., Hackett, R. E., Patil, U. B. and Peng, B. K.: The transpubic approach to the lower urinary tract. J. Urol., 109: 486, 1973. 3. Colapinto, V. and McCallum, R. W.: Injury to the male posterior urethra in fractured pelvis: a new classification. J. Urol., 118: 575,1977. 4. Pierce, J. M., Jr.: Posterior urethral stricture repair. J. Urol., 121: 739,1979. 5. Chiou, R. K. and Gonzalez, R.: Management of posterior urethral obliteration: comparison of transpubic urethroplasty and endoscopic treatment. J. Urol., part 2, 133: 232A, abstract 473,1985.

356

AL-RIFAEI, GAAFAR AND ABDEL-RAHMAN

6. Webster, G. D., Stone, A. R. and Sihelnick, S.: Surgical management of strictures of the membranous urethra. J. Urol., part 2, 133: 226A, abstract 451, 1985. 7. Devine, P. C., Jordan, G. H., Vortsman, B. and Devine, C. J., Jr.: Reconstruction of the disrupted posterior urethra. J. Urol., part 2, 133: 227A, abstract 453, 1985. 8. Strong, D. W. and Hodges, C. V.: Transpubic urethroplasty for membranous urethral strictures. Urology, 9: 27,1977. 9. Hayden, L. J. and Koff, S. A.: One-stage membranous urethroplasty in childhood. J. Urol., 132: 311, 1984. 10. Middleton, R. G. and Sutphin, M. D.: Pubectomy in urological surgery. J. Urol., 133: 635, 1985. 11. Turner-Warwick, R.: A personal view of the management of traumatic urethral strictures. Urol. Clin. N. Amer., 4: 111, 1977. 12. Waterhouse, K.: The surgical repair of membranous urethral strictures in children. J. Urol., 116: 363, 1976.

EDITORIAL COMMENT This study is important because it calls attention to some of the differences that may be seen in urethral injuries in boys compared to those in men. The majority of these differences result from the fact that the entire posterior urethra in the child is fairly flimsy, while the posterior urethra of men is supported by the mature prostate. Thus, while posterior urethral injuries in men are virtually always limited to a short area of membranous urethra distal in the prostate, those of the child may occur anywhere along the course of the posterior urethra, even at the bladder neck. This fact has 2 important considerations. One consideration relates to the question of whether the philosophy of placement of a suprapubic tube as a limited primary approach to the acute injury is as appropriate for the child, in whom the injury may be fairly high, as it is for the adult, in whom the injury essentially is always low. Although the authors take a stand for aggressive primary realignment in these cases the answer is not really known. Primary realignment of the high injury may make secondary reconstruction easier but the idea of grubbing around in the depths of a bleeding pelvis to find the 2 ends of a structure only a few millimeters in diameter has never had great appeal to me. The other consideration relates to the manner in which the reconstruction itself should be done. In men

whose injury is likely to be at or near the urogenital diaphragm and whose bladder neck is likely to be intact a perineal approach often is appropriate. In boys this decision should be made with greater care. A perineal approach usually defunctionalizes the external urethral sphincter and if the injury has been high enough to affect the competency of the bladder neck the child faces a significant risk of incontinence with this approach. The same is true for the Waterhouse procedure, which bypasses the external urethral sphincter altogether. In this series 4 of 20 patients had varying degrees of incontinence after the Waterhouse operation. My own philosophy regarding the reconstruction of these children is to begin with an accurate assessment of the exact location of the injury. Injuries above the urogenital diaphragm are approached transpubically with direct reanastomosis of the 2 ends of the remaining normal urethra, rather than by the Waterhouse operation, to preserve the external urethral sphincter mechanism, which in these cases may be completely intact. In young children the pubic symphysis simply may be cut and distracted for exposure but it is better in adolescents to remove a segment of pubic bone to avoid tearing the sacroiliac ligaments by spreading the pubic symphysis too widely. I have not found it necessary to pack the dead space with omentum and have noted that when this is done an intestinal hernia through the soft tissue can occur. These are difficult and challenging cases, and the authors are to be congratulated for their efforts to restore these children to normal. Terry D. Allen Department of Urology University of Texas Southwestern Medical Center Dallas, Texas REPLY BY AUTHORS We do not consider primary realignment of a prostatic InjUry in children a difficult task. It is possible to suture a prostatic tear, since the prostate is far more accessible than the membranous urethra. Moreover, there may be no need for secondary reconstruction and we do not advise primary suturing of the membranous urethra. On the other hand, we agree that high injury in children should be reconstructed by the transpubic route in an attempt to preserve the external urethral sphincter mechanism.