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Pelvic fracture urethral distraction defects in children managed by anterior sagittal trans anorectal approach: A facilitating and safe acess
Journal of Pediatric Urology (2011) 7, 349e355
Pelvic fracture urethral distraction defects in children managed by anterior sagittal trans anorectal approach: A facilitating and safe acess* ˜o*, Luciano Silveira Onofre, Jovelino Quintino de Souza Lea ˜o, Adriano Luis Gomes, Antonio Carlos Heinisch, Fernanda Ghilardi Lea ´ Carnevale Jose Hospital Infantil Darcy Vargas, Pediatric Urology Division, Seraphico de Assis Carvalho, 34, Sa˜o Paulo CEP 05614-040, Brazil Available online 27 April 2011
KEYWORDS Urethral injury; Anterior sagittal transanorectal approach; Pelvic fracture; Child
Abstract Purpose: Trauma injuries of the posterior urethra resulting from pelvic fracture in children tend to be complete ruptures, with upper dislocation of the prostate. This paper aims to show our experience in using an anterior sagittal transanorectal approach (ASTRA) in the treatment of such injuries. Materials and methods: The medical records of 11 patients with pelvic fracture urethral distraction defects who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Ages ranged from 1 year and 6 months to 23 years (mean age 11 years). Of the 11 patients, 8 had previously undergone failed urethroplasties. Results: In 10 patients it was possible to perform tension free urethroplasty. One patient required inferior pubectomy and separation of the corpora cavernosa. Patients’ follow-up time varied from 10 months to 10 years and 9 months (mean 41 months). One patient had a urethral fistula and evolved with a urethral diverticulum successfully managed by diverticulectomy. One patient presented a urethral stenosis managed by urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent. Two patients had no urethral flow. One is undergoing bladder catheterization through the Mitrofanoff principle and the other one through the urethra. No patient presented fecal incontinence or rectourethral fistula. Conclusion: This access, which is increasingly being used to approach posterior urethral diseases, has proved to be safe and effective in the treatment of pelvic fracture urethral distraction defects. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
*
Paper presented at the 1st World Congress of Pediatric Urology, San Francisco, California, 27e31 May 2010. * Corresponding author. Pediatric Urology Division, Hospital Infantil Darcy Vargas, Alceu de Campos Rodrigues, 247, Sa ˜o Paulo CEP 04544000, Brazil. Tel.: þ55 11 8467 4447; fax: þ55 11 3052 3880. E-mail address: [email protected] (J.Q. de Souza Lea ˜o). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.03.005
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Introduction Treatment of trauma injuries of the posterior urethra resulting from pelvic fracture in adults is well established, achieving successful rates between 90% and 98% in the larger series [1]. In most such patients, the posterior urethra approach for urethroplasty is through the perineal access [1e3], In children, due to anatomic peculiarities, urethroplasties are not as successful. Posterior urethra trauma injuries tend to be complete ruptures, with a more intense upper dislocation of the prostate [4], characteristics that increase their treatment complexity. It is also consensus that the need to resort to the transpubic perineal-abdominal access to perform the urethroplasty is more frequent in children [5]. The anterior sagittal transanorectal approach (ASTRA) is a surgical approach derived from treatment of anorectal malformations initially proposed for the management of high and intermediate urogenital sinus malformations. This approach has become an efficacious method of managing a wide number of anomalies of the anterior perineum in both sexes. This paper aims to show our experience in using ASTRA in the management of pelvic fracture urethral distraction defects.
Materials and methods The medical records of 11 patients with trauma injury of the posterior urethra resulting from pelvic fracture who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Patients’ age ranged from 1 year and 6 months to 23 years, mean age being 11 years. Three of the 11 patients were postpubertal. Of the 11 patients, 8 had previously undergone failed surgical interventions for the treatment of the injuries, 2 patients of which having had 2 urethroplasty attempts and 6 patients 1 attempt. Of the 10 urethroplasty attempts that failed, 3 were performed at our institution and 7 were performed at the original institution, with the approach routes being perineal in 6 of them and transpubic perineo-abdominal in 4 of the interventions. All patients had late urethral reconstruction as they were referred to our hospital at least three months after the trauma. All but one had cystostomies performed before they were referred. All patients underwent preoperative assessment that included a voiding cystourethrography combined with retrograde urethrography in the operation room under general anesthesia, to define the injury location and the distance between the urethral stumps (Figs. 1 and 2). Ten patients presented posterior urethral distraction defects (PUDD) and one had a urethral stricture. A clear distinction should be made between the terms urethral stricture, which is a continue stricture, and a distraction defect, where complete rupture of the membranous urethra results in a distraction defect between the bulbar and the prostatic urethra. In the patients with PUDD, the bulboprostatic urethral gap distance between the proximal and distal urethral stumps varied between 1,5 and 5 cm, mean distance between the stumps being 3 cm. The patient with a urethral stricture had previously undergone urethroplasty
Figure 1 Voiding cystourethrography combined with retrograde urethrography performed in the radiology sector.
Figure 2 Voiding cystourethrography combined with retrograde urethrography performed in the same patient under narcosis in the operating room. Notice the difference between the urethral stumps distance; the actual distance is shown.
Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children through the transpubic approach and presented no urethral flow. This was the only patient in the series referred to our department with a continent bladder catheterizable channel. At the time of the preoperative assessment, except for this patient and the one aged 1 year and 6 months, all patients who had a cystostomy underwent a surgical intervention for the creation of a continent bladder catheterizable channel. After the preoperative investigation and the confection of the continent bladder catheterizable channel, the urethroplasty was scheduled. Two patients had previously undergone colostomy. The first patient was referred with the stoma performed upon the trauma that led to the pelvic fracture with the injury to the posterior urethra. The second colostomy was performed at our institution given an unexpected rectal injury in an urethroplasty attempt through the transpubic perineo-abdominal approach. These were the two first patients in the series to undergo the ASTRA urethroplasty. All further patients had the surgical intervention (ASTRA urethroplasty) just with bowel preparation and without a protective colostomy. All patients underwent a standard mechanical bowel preparation associated with manitol intake and antimicrobial (amicacyn and metronidazole) as part of the preoperative routine. In order to approach the posterior urethra, the patient is placed in the knee-chest position, with the pelvis elevated by bolsters and gauze packed into the rectum to prevent any contamination (Fig. 3). A midline sagittal incision is made from the anterior margin of the anus to the scrotum. The incision is deepened through the perineal body and only the anterior rectal wall is opened, with the incision remaining at the precise midline. The bulbar urethra is identified and dissected until the healthy urethral tissue is identified. Scar tissue is complete excisioned. The dissection is prolonged until the prostate and the prostatic urethra above the stenosis are identified. The incision in the rectum can be extended as high as necessary to expose the prostate (Figs. 4 and 5). The bulbar urethra is
Figure 3
Patient positioned for ASTRA urethroplasty.
351
Figure 4 Mobilization of the bulbar urethra and exposure of the prostate urethra through ASTRA. The incision in the rectum can be extended as high as necessary to expose the prostate.
mobilized for a wide tension free anastomosis. When required, separation of the corpora cavernosa and inferior pubectomy can be applied to help rectify the natural curve of the bulbar urethra, reducing the distance to the prostatic urethra and, thus, the anastomosis tension. Following the termino-terminal anastomosis of the bulbar and prostatic urethra, the rectum wall is closed and the anal
Figure 5
ASTRA urethroplasty.
352 sphincter muscle complex and perineal muscles are reconstructed. Patients remained on hyperalimentation and intravenous antibiotics, with no oral intake, for 5 days post-operatively. At the end of the procedure, a silicone urethral catheter was left in place for urethral stenting. After 3 weeks, the catheter was removed and a voiding urethrography was routinely performed 6 weeks after the procedure. At this moment, a blind calibration of the urethra was done. The patients were followed at 3-monthly intervals in the first year after the procedure for urinary flow and continence evaluation and, when possible, also assessed for erectile dysfunction.
Results Of the patients referred 10 had a cystostomy and only 1 had undergone the creation of a continent bladder catheterizable channel in the service of origin, after a failed urethroplasty. Of these 10 patients, 9 had a Mitrofanoff principle and 1 a Yang-Monti conduit done. The period of cystostomy permanence from the time of the trauma to the definitive urethroplasty ranged from 3 months to 36 months, mean time of permanence being 11.9 months. In 10 patients it was possible to perform the terminoterminal tension free anastomosis between the bulbar and prostatic urethra, just by excising the fibrous scar tissue and mobilizing the distal portion of the bulbar urethra (Fig. 6). One patient required inferior pubectomy and
Figure 6 ASTRA urethroplasty. White arrow: anterior rectal wall; yellow arrow: bulbar urethra; red arrow: prostate and prostatic urethra. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
L.S. Onofre et al. separation of the corpora cavernosa to ensure tension-free anastomosis. In the control voiding cystourethrography performed 6 weeks after the procedure one patient presented a urinary fistula that resolved spontaneously. Except for this patient, all further ones presented a normal urethra, with no stenosis detected. Patients’ follow-up time ranged from 10 months to 10 years and 9 months. The patient that had the urethral fistula evolved with a diverticulum in the urethra which was managed successfully by diverticulectomy. One patient presented with the complication of paresthesia in the lower limbs due to the positioning on the surgical table, which was transitory. During follow-up, one patient evolved with a symptomatic urethral stricture and was treated with urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent (Figs. 7e9). One patient evolved with stricture and loss of urethral lumen continuity. This patient, one of the first in the series to undergo such approach, had an improper post-operative follow-up due to social problems (the adolescent was imprisoned). This patient currently performs intermittent catheterism through a continent bladder catheterizable channel. The other patient, the oldest in our series, has normal urethra however with no urethral flow. He did not adjust himself to bladder catheterism through Mitrofanoff and currently he
Figure 7 Voiding cystourethrography combined with retrograde urethrography showing injury in the bulbar membranous prostatic urethra with a 3 cm distance between the urethral stumps.
Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children
Figure 8
Post-operative aspect after ASTRA urethroplasty.
does it via the urethra. All the other patients with functional urethral flow stopped using the continent bladder catheterizable channel. Just two patients get no erection. No rectourethral fistula or fecal incontinence occurred as complication of the procedures. The patients’ characteristics and evolution are described in Table 1.
Discussion Traumatic posterior urethral disruptions due to pelvic fracture in children are injuries difficult to treat due to
Figure 9 Free flowmetry of the same patient 6 months after the procedure.
353
anatomic peculiarities found in their pelvis. Pelvic fractures in children tend to be unstable, and if compared to those in adults, they are more likely to be associated with a posterior urethral injury [4]. Given the fragility of the membranous urethra and of the puboprostatic ligaments, associated with a still underdeveloped prostate, such posterior urethral injuries tend to be complete disruptions, with a more intense upper dislocation of the prostate [4]. Also more frequently the prostatic urethra and the bladder neck may be involved in the injury [4]. Thus, it is not only the fact that a child’s hips are smaller that renders urethroplasty difficult. This kind of injury in children tends to be more serious requiring a more complex treatment [5e7]. A successful urethroplasty of such traumatic posterior urethral injuries requires excision of the whole fibrotic tissue found between the urethral stumps [1]. Also fundamental is the mobilization of the bulbar urethra for a wide tension free anastomosis between the bulbar urethra and the prostatic urethra [1]. In adults, in most cases, this can be performed in a patient in the lithotomy position through a perineal approach [1]. However, when the distance between the stumps is too long, or the proximal bulbar urethra has been compromised in previous urethroplasty attempts, the alternative is the abdomino-perineal transpubic progression, where the retropubic space is dissected, the anterior surface of the prostate is exposed following pubic symphysis osteotomy, and bulbar urethra rerouted through a shorter course, without its natural curve [2,8]. A further alternative is the approach through the elaborated perineal route, in which alternative maneuvers are used to lessen the anastomosis tension when required, such as separation of corpora cavernosa, supracrural urethral rerouting and inferior pubectomy [3,9]. However, while in adults the need to use the transpubic route is the exception, in children, probably due to the peculiarity of the injury in the posterior urethra, it is almost the rule [5e7]. In the large series, the perineo-abdominal transpubic route for correction of such traumatic injuries of the posterior urethra in children is used in almost half the patients [5,7], and while the need for this route for urethroplasty in adults is discussed, its need in children’s urethroplasty appears to be consensus [10]. With the experience achieved in the treatment of anorectal anomalies, the posterior sagittal approach started being used to manage some posterior urethral diseases. First there were reports on the use of this approach to treat Mullerian rests [11]. In these first reports, the procedures were already performed without protective colostomy, but the anterior and posterior rectal wall were opened, as well as the entire anal sphincteric muscle complex. The evolution was the change of this approach, now to the management of urogenital sinus malformations, where only the anterior wall of the rectum and a portion of the anal sphincteric muscle complex used to be opened [12e14]. This access route, named anterior sagittal transanorectal approach e ASTRA [12], was first used in our institution in the management of pelvic fracture urethral distraction defects in the cases in which there was a treatment failure through the conventional perineal route associated or not with the transpubic one, and it is currently the approach used in the management of such injuries
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Table 1
Patients characteristics and evolution.
Patient Date
Age
Distance between urethral stumps
Anterior urethroplasty
Colostomy
Complications
Urethral flow
Erection
APS 08/1997 RFA 05/2002 TA 05/2000 WFT 04/2006 JMA 01/2006 MMCF 01/2007 VPSJ 02/2008 HRCS 06/2008 RAAD 05/2009
11 years 10 years 5 years 12 years 11 years 9 years 17 years 12 years 1 year 6 months 23 years 15 years
5 cm 2 cm 2 cm 3 cm 3 cma 4 cm 2.5 cm 4 cm 1.5 cm
Transpubic Transpubicb Perinealb Perineal Perineal Perineal transpubic No Perineal perineal No
Yes Yesc No No No No No No No
Fistula þ diverticulum Stenosis no follow-up No No Stenosis No Transitory paresthesia No No
Yes No Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes No Yes Yes Yes Yes
3 cm 2 cm
No Transpubicb
No No
No No
No Yes
Yes No
ESS 06/2009 ECLA 08/2009 a b c
Patient with stenosis, without loss of urethral continuity, however with no urethral flow. Patients who underwent anterior urethroplasty at our institution. Patient who underwent colostomy in our service for inadvertent rectal injury.
This approach offers an excellent exposure of the posterior urethra. In the cases in which the prostate had an upper dislocation due to trauma, the opening of the anterior rectal wall can be widened as necessary to identify the prostatic urethra. It also enables an ample mobilization of the bulbar urethra for tension free anastomosis and, in the cases in which this maneuver alone will not suffice, the separation of the corpora cavernosa and the inferior pubectomy can be easily performed. It can be safely performed simply through proper bowel preparation, with no need for a protective colostomy, imposing no great risk to the continence provided the midline is respected. This approach is also limited to the inferior portion of the prostate, avoiding the plexus that, if injured, could lead to erectile dysfunction [15]. The patients who underwent unsuccessful urethroplasty, before being referred undergone urethral dilatations or internal urethrotomy. They stayed with a cystostomy for a mean time of 11.9 months. One of these patients had a cystostomy for 3 years before he was referred. They would certainly benefit from a continent bladder catheterizable channel creation to perform intermittent catheterization, a procedure of little morbidity. Since we are a reference center in the treatment of urologic diseases in our country and most patients treated at our institution come from different areas, we consider the creation of a bladder catheterism mechanism to be a safe way to follow such patients. The treatment of posterior urethral injuries is a challenge for surgical teams. Although primary urethroplasty is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases [16e18]. In conclusion, the sagittal transanorectal approach, that is increasingly being used to approach posterior urethral diseases, has shown to be safe and effective in the treatment of pelvic fracture posterior urethral distraction defects, since it allows severe lesions to be treated with ample exposure of the surgical area, without incurring into complications such as fecal incontinence or rectourethral fistulae.
References [1] Koraitim MM, Marzouk ME, Atta MA. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77: 876. [2] Koraitim MM. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997;157:641. [3] Das K, Charles AR, Alladi A. Traumatic posterior urethral disruptions in boys: experience with the perineal/perinealtranspubic approach in ten cases. Pediatr Surg Int 2004;20: 449. [4] Orabi S, Badawy H, Saad A. Post-traumatic posterior urethral stricture in children: how to achieve a successful repair. J Pediatr Urol 2008;4:290. [5] Koraitim MM. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 2005;173:135. [6] Turner-Warwick R. Prevention of complications resulting from pelvic fracture urethral injuries-and from their surgical management. Urol Clin North Am 1989;16:335. [7] Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999;161:1433. [8] Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol 1991;145:744. [9] Mundy AR. Transperineal bulbo-prostatic anastomic urethroplasty. World J Urol 1998;16:164. [10] Barbagli G. History and evaluation of transpubic urethroplasty: a lesson for young urologists in training. Eur Urol 2007;52:1290. [11] Siegel JF, Brock WA, Pena ˜ A. Transrectal posterior sagital approach to the prostatic utricule (mullerian duct cyst). J Urol 1995;153:785. [12] Di Benetto V, Giovale M, Bagnara V. The anterior sagital transanorectal approach: a modified approach to 1-stage clitoral vaginoplasty in severely masculinized female pseudohermaphrodites-preliminary results. J Urol 1997;157:330. [13] Do `mini R, Rossi F, Ceccarelli PL. Anterior sagittal transanorectal approach to the urogenital sinus in the Androgenital syndrome: preliminary report. J Pediatr Surg 1997;32: 714. [14] Rossi F, Castro R, Ceccarelli PL. Anterior sagittal transanorectal approach to the posterior urethra in the pediatric age group. J Urol 1998;160:1173.
Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children [15] Dalpiaz M, Mitterberger M, Kerschbaumer A. Anatomical approach for surgery of the male posterior urethra. Br J Urol 2008;102:1448. [16] Freitas Filho LG, Carnevale J, Melo Filho AR. Posterior urethral injuries and the Mitrofanoff principle in children. Br J Urol 2003;91:402.
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[17] Nerli RB, Koura AC, Ravish IR. Posterior urethral injury in male children: long-term follow up. J Pediatr Urol 2008;4:154. [18] Hosseini J, Kaviani A, Mazloomfard MM, Golshan AR. Monti’s procedure as an alternative technique in complex urethral distraction defect. International Braz J Urol 2010;36(3): 317e26.
Pelvic fracture urethral distraction defects in children managed by anterior sagittal trans anorectal approach: A facilitating and safe acess* ˜o*, Luciano Silveira Onofre, Jovelino Quintino de Souza Lea ˜o, Adriano Luis Gomes, Antonio Carlos Heinisch, Fernanda Ghilardi Lea ´ Carnevale Jose Hospital Infantil Darcy Vargas, Pediatric Urology Division, Seraphico de Assis Carvalho, 34, Sa˜o Paulo CEP 05614-040, Brazil Available online 27 April 2011
KEYWORDS Urethral injury; Anterior sagittal transanorectal approach; Pelvic fracture; Child
Abstract Purpose: Trauma injuries of the posterior urethra resulting from pelvic fracture in children tend to be complete ruptures, with upper dislocation of the prostate. This paper aims to show our experience in using an anterior sagittal transanorectal approach (ASTRA) in the treatment of such injuries. Materials and methods: The medical records of 11 patients with pelvic fracture urethral distraction defects who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Ages ranged from 1 year and 6 months to 23 years (mean age 11 years). Of the 11 patients, 8 had previously undergone failed urethroplasties. Results: In 10 patients it was possible to perform tension free urethroplasty. One patient required inferior pubectomy and separation of the corpora cavernosa. Patients’ follow-up time varied from 10 months to 10 years and 9 months (mean 41 months). One patient had a urethral fistula and evolved with a urethral diverticulum successfully managed by diverticulectomy. One patient presented a urethral stenosis managed by urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent. Two patients had no urethral flow. One is undergoing bladder catheterization through the Mitrofanoff principle and the other one through the urethra. No patient presented fecal incontinence or rectourethral fistula. Conclusion: This access, which is increasingly being used to approach posterior urethral diseases, has proved to be safe and effective in the treatment of pelvic fracture urethral distraction defects. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
*
Paper presented at the 1st World Congress of Pediatric Urology, San Francisco, California, 27e31 May 2010. * Corresponding author. Pediatric Urology Division, Hospital Infantil Darcy Vargas, Alceu de Campos Rodrigues, 247, Sa ˜o Paulo CEP 04544000, Brazil. Tel.: þ55 11 8467 4447; fax: þ55 11 3052 3880. E-mail address: [email protected] (J.Q. de Souza Lea ˜o). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.03.005
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Introduction Treatment of trauma injuries of the posterior urethra resulting from pelvic fracture in adults is well established, achieving successful rates between 90% and 98% in the larger series [1]. In most such patients, the posterior urethra approach for urethroplasty is through the perineal access [1e3], In children, due to anatomic peculiarities, urethroplasties are not as successful. Posterior urethra trauma injuries tend to be complete ruptures, with a more intense upper dislocation of the prostate [4], characteristics that increase their treatment complexity. It is also consensus that the need to resort to the transpubic perineal-abdominal access to perform the urethroplasty is more frequent in children [5]. The anterior sagittal transanorectal approach (ASTRA) is a surgical approach derived from treatment of anorectal malformations initially proposed for the management of high and intermediate urogenital sinus malformations. This approach has become an efficacious method of managing a wide number of anomalies of the anterior perineum in both sexes. This paper aims to show our experience in using ASTRA in the management of pelvic fracture urethral distraction defects.
Materials and methods The medical records of 11 patients with trauma injury of the posterior urethra resulting from pelvic fracture who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Patients’ age ranged from 1 year and 6 months to 23 years, mean age being 11 years. Three of the 11 patients were postpubertal. Of the 11 patients, 8 had previously undergone failed surgical interventions for the treatment of the injuries, 2 patients of which having had 2 urethroplasty attempts and 6 patients 1 attempt. Of the 10 urethroplasty attempts that failed, 3 were performed at our institution and 7 were performed at the original institution, with the approach routes being perineal in 6 of them and transpubic perineo-abdominal in 4 of the interventions. All patients had late urethral reconstruction as they were referred to our hospital at least three months after the trauma. All but one had cystostomies performed before they were referred. All patients underwent preoperative assessment that included a voiding cystourethrography combined with retrograde urethrography in the operation room under general anesthesia, to define the injury location and the distance between the urethral stumps (Figs. 1 and 2). Ten patients presented posterior urethral distraction defects (PUDD) and one had a urethral stricture. A clear distinction should be made between the terms urethral stricture, which is a continue stricture, and a distraction defect, where complete rupture of the membranous urethra results in a distraction defect between the bulbar and the prostatic urethra. In the patients with PUDD, the bulboprostatic urethral gap distance between the proximal and distal urethral stumps varied between 1,5 and 5 cm, mean distance between the stumps being 3 cm. The patient with a urethral stricture had previously undergone urethroplasty
Figure 1 Voiding cystourethrography combined with retrograde urethrography performed in the radiology sector.
Figure 2 Voiding cystourethrography combined with retrograde urethrography performed in the same patient under narcosis in the operating room. Notice the difference between the urethral stumps distance; the actual distance is shown.
Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children through the transpubic approach and presented no urethral flow. This was the only patient in the series referred to our department with a continent bladder catheterizable channel. At the time of the preoperative assessment, except for this patient and the one aged 1 year and 6 months, all patients who had a cystostomy underwent a surgical intervention for the creation of a continent bladder catheterizable channel. After the preoperative investigation and the confection of the continent bladder catheterizable channel, the urethroplasty was scheduled. Two patients had previously undergone colostomy. The first patient was referred with the stoma performed upon the trauma that led to the pelvic fracture with the injury to the posterior urethra. The second colostomy was performed at our institution given an unexpected rectal injury in an urethroplasty attempt through the transpubic perineo-abdominal approach. These were the two first patients in the series to undergo the ASTRA urethroplasty. All further patients had the surgical intervention (ASTRA urethroplasty) just with bowel preparation and without a protective colostomy. All patients underwent a standard mechanical bowel preparation associated with manitol intake and antimicrobial (amicacyn and metronidazole) as part of the preoperative routine. In order to approach the posterior urethra, the patient is placed in the knee-chest position, with the pelvis elevated by bolsters and gauze packed into the rectum to prevent any contamination (Fig. 3). A midline sagittal incision is made from the anterior margin of the anus to the scrotum. The incision is deepened through the perineal body and only the anterior rectal wall is opened, with the incision remaining at the precise midline. The bulbar urethra is identified and dissected until the healthy urethral tissue is identified. Scar tissue is complete excisioned. The dissection is prolonged until the prostate and the prostatic urethra above the stenosis are identified. The incision in the rectum can be extended as high as necessary to expose the prostate (Figs. 4 and 5). The bulbar urethra is
Figure 3
Patient positioned for ASTRA urethroplasty.
351
Figure 4 Mobilization of the bulbar urethra and exposure of the prostate urethra through ASTRA. The incision in the rectum can be extended as high as necessary to expose the prostate.
mobilized for a wide tension free anastomosis. When required, separation of the corpora cavernosa and inferior pubectomy can be applied to help rectify the natural curve of the bulbar urethra, reducing the distance to the prostatic urethra and, thus, the anastomosis tension. Following the termino-terminal anastomosis of the bulbar and prostatic urethra, the rectum wall is closed and the anal
Figure 5
ASTRA urethroplasty.
352 sphincter muscle complex and perineal muscles are reconstructed. Patients remained on hyperalimentation and intravenous antibiotics, with no oral intake, for 5 days post-operatively. At the end of the procedure, a silicone urethral catheter was left in place for urethral stenting. After 3 weeks, the catheter was removed and a voiding urethrography was routinely performed 6 weeks after the procedure. At this moment, a blind calibration of the urethra was done. The patients were followed at 3-monthly intervals in the first year after the procedure for urinary flow and continence evaluation and, when possible, also assessed for erectile dysfunction.
Results Of the patients referred 10 had a cystostomy and only 1 had undergone the creation of a continent bladder catheterizable channel in the service of origin, after a failed urethroplasty. Of these 10 patients, 9 had a Mitrofanoff principle and 1 a Yang-Monti conduit done. The period of cystostomy permanence from the time of the trauma to the definitive urethroplasty ranged from 3 months to 36 months, mean time of permanence being 11.9 months. In 10 patients it was possible to perform the terminoterminal tension free anastomosis between the bulbar and prostatic urethra, just by excising the fibrous scar tissue and mobilizing the distal portion of the bulbar urethra (Fig. 6). One patient required inferior pubectomy and
Figure 6 ASTRA urethroplasty. White arrow: anterior rectal wall; yellow arrow: bulbar urethra; red arrow: prostate and prostatic urethra. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
L.S. Onofre et al. separation of the corpora cavernosa to ensure tension-free anastomosis. In the control voiding cystourethrography performed 6 weeks after the procedure one patient presented a urinary fistula that resolved spontaneously. Except for this patient, all further ones presented a normal urethra, with no stenosis detected. Patients’ follow-up time ranged from 10 months to 10 years and 9 months. The patient that had the urethral fistula evolved with a diverticulum in the urethra which was managed successfully by diverticulectomy. One patient presented with the complication of paresthesia in the lower limbs due to the positioning on the surgical table, which was transitory. During follow-up, one patient evolved with a symptomatic urethral stricture and was treated with urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent (Figs. 7e9). One patient evolved with stricture and loss of urethral lumen continuity. This patient, one of the first in the series to undergo such approach, had an improper post-operative follow-up due to social problems (the adolescent was imprisoned). This patient currently performs intermittent catheterism through a continent bladder catheterizable channel. The other patient, the oldest in our series, has normal urethra however with no urethral flow. He did not adjust himself to bladder catheterism through Mitrofanoff and currently he
Figure 7 Voiding cystourethrography combined with retrograde urethrography showing injury in the bulbar membranous prostatic urethra with a 3 cm distance between the urethral stumps.
Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children
Figure 8
Post-operative aspect after ASTRA urethroplasty.
does it via the urethra. All the other patients with functional urethral flow stopped using the continent bladder catheterizable channel. Just two patients get no erection. No rectourethral fistula or fecal incontinence occurred as complication of the procedures. The patients’ characteristics and evolution are described in Table 1.
Discussion Traumatic posterior urethral disruptions due to pelvic fracture in children are injuries difficult to treat due to
Figure 9 Free flowmetry of the same patient 6 months after the procedure.
353
anatomic peculiarities found in their pelvis. Pelvic fractures in children tend to be unstable, and if compared to those in adults, they are more likely to be associated with a posterior urethral injury [4]. Given the fragility of the membranous urethra and of the puboprostatic ligaments, associated with a still underdeveloped prostate, such posterior urethral injuries tend to be complete disruptions, with a more intense upper dislocation of the prostate [4]. Also more frequently the prostatic urethra and the bladder neck may be involved in the injury [4]. Thus, it is not only the fact that a child’s hips are smaller that renders urethroplasty difficult. This kind of injury in children tends to be more serious requiring a more complex treatment [5e7]. A successful urethroplasty of such traumatic posterior urethral injuries requires excision of the whole fibrotic tissue found between the urethral stumps [1]. Also fundamental is the mobilization of the bulbar urethra for a wide tension free anastomosis between the bulbar urethra and the prostatic urethra [1]. In adults, in most cases, this can be performed in a patient in the lithotomy position through a perineal approach [1]. However, when the distance between the stumps is too long, or the proximal bulbar urethra has been compromised in previous urethroplasty attempts, the alternative is the abdomino-perineal transpubic progression, where the retropubic space is dissected, the anterior surface of the prostate is exposed following pubic symphysis osteotomy, and bulbar urethra rerouted through a shorter course, without its natural curve [2,8]. A further alternative is the approach through the elaborated perineal route, in which alternative maneuvers are used to lessen the anastomosis tension when required, such as separation of corpora cavernosa, supracrural urethral rerouting and inferior pubectomy [3,9]. However, while in adults the need to use the transpubic route is the exception, in children, probably due to the peculiarity of the injury in the posterior urethra, it is almost the rule [5e7]. In the large series, the perineo-abdominal transpubic route for correction of such traumatic injuries of the posterior urethra in children is used in almost half the patients [5,7], and while the need for this route for urethroplasty in adults is discussed, its need in children’s urethroplasty appears to be consensus [10]. With the experience achieved in the treatment of anorectal anomalies, the posterior sagittal approach started being used to manage some posterior urethral diseases. First there were reports on the use of this approach to treat Mullerian rests [11]. In these first reports, the procedures were already performed without protective colostomy, but the anterior and posterior rectal wall were opened, as well as the entire anal sphincteric muscle complex. The evolution was the change of this approach, now to the management of urogenital sinus malformations, where only the anterior wall of the rectum and a portion of the anal sphincteric muscle complex used to be opened [12e14]. This access route, named anterior sagittal transanorectal approach e ASTRA [12], was first used in our institution in the management of pelvic fracture urethral distraction defects in the cases in which there was a treatment failure through the conventional perineal route associated or not with the transpubic one, and it is currently the approach used in the management of such injuries
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Table 1
Patients characteristics and evolution.
Patient Date
Age
Distance between urethral stumps
Anterior urethroplasty
Colostomy
Complications
Urethral flow
Erection
APS 08/1997 RFA 05/2002 TA 05/2000 WFT 04/2006 JMA 01/2006 MMCF 01/2007 VPSJ 02/2008 HRCS 06/2008 RAAD 05/2009
11 years 10 years 5 years 12 years 11 years 9 years 17 years 12 years 1 year 6 months 23 years 15 years
5 cm 2 cm 2 cm 3 cm 3 cma 4 cm 2.5 cm 4 cm 1.5 cm
Transpubic Transpubicb Perinealb Perineal Perineal Perineal transpubic No Perineal perineal No
Yes Yesc No No No No No No No
Fistula þ diverticulum Stenosis no follow-up No No Stenosis No Transitory paresthesia No No
Yes No Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes No Yes Yes Yes Yes
3 cm 2 cm
No Transpubicb
No No
No No
No Yes
Yes No
ESS 06/2009 ECLA 08/2009 a b c
Patient with stenosis, without loss of urethral continuity, however with no urethral flow. Patients who underwent anterior urethroplasty at our institution. Patient who underwent colostomy in our service for inadvertent rectal injury.
This approach offers an excellent exposure of the posterior urethra. In the cases in which the prostate had an upper dislocation due to trauma, the opening of the anterior rectal wall can be widened as necessary to identify the prostatic urethra. It also enables an ample mobilization of the bulbar urethra for tension free anastomosis and, in the cases in which this maneuver alone will not suffice, the separation of the corpora cavernosa and the inferior pubectomy can be easily performed. It can be safely performed simply through proper bowel preparation, with no need for a protective colostomy, imposing no great risk to the continence provided the midline is respected. This approach is also limited to the inferior portion of the prostate, avoiding the plexus that, if injured, could lead to erectile dysfunction [15]. The patients who underwent unsuccessful urethroplasty, before being referred undergone urethral dilatations or internal urethrotomy. They stayed with a cystostomy for a mean time of 11.9 months. One of these patients had a cystostomy for 3 years before he was referred. They would certainly benefit from a continent bladder catheterizable channel creation to perform intermittent catheterization, a procedure of little morbidity. Since we are a reference center in the treatment of urologic diseases in our country and most patients treated at our institution come from different areas, we consider the creation of a bladder catheterism mechanism to be a safe way to follow such patients. The treatment of posterior urethral injuries is a challenge for surgical teams. Although primary urethroplasty is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases [16e18]. In conclusion, the sagittal transanorectal approach, that is increasingly being used to approach posterior urethral diseases, has shown to be safe and effective in the treatment of pelvic fracture posterior urethral distraction defects, since it allows severe lesions to be treated with ample exposure of the surgical area, without incurring into complications such as fecal incontinence or rectourethral fistulae.
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Anterior sagittal transanorectal approach in trauma injuries to the posterior urethra in children [15] Dalpiaz M, Mitterberger M, Kerschbaumer A. Anatomical approach for surgery of the male posterior urethra. Br J Urol 2008;102:1448. [16] Freitas Filho LG, Carnevale J, Melo Filho AR. Posterior urethral injuries and the Mitrofanoff principle in children. Br J Urol 2003;91:402.
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[17] Nerli RB, Koura AC, Ravish IR. Posterior urethral injury in male children: long-term follow up. J Pediatr Urol 2008;4:154. [18] Hosseini J, Kaviani A, Mazloomfard MM, Golshan AR. Monti’s procedure as an alternative technique in complex urethral distraction defect. International Braz J Urol 2010;36(3): 317e26.