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Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique
Trauma/Reconstruction/Diversion
Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique Sanjay B. Kulkarni, Guido Barbagli, Jyotsna S. Kulkarni, Giuseppe Romano and Massimo Lazzeri* From the Kulkarni Urethroplasty Center (SBK, JSK), Pune, India, and Center for Reconstructive Urethral Surgery (GB) and Unità Operativa Urologia, Ospedale San Donato, Arezzo (GR) and Department of Urology, Santa Chiara Hospital (ML), Florence, Italy
Purpose: We compared posterior urethral strictures after pelvic fracture urethral distraction defects in India and Italy. Materials and Methods: We retrospectively analyzed the records of patients in India and Italy who underwent repair for posterior urethral stricture after pelvic fracture urethral distraction defect. We investigated etiology, emergency treatment type, the specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair, posterior urethroplasty techniques and results. Results: Of 255 patients with a median age of 33 years 117 (45.8%) and 138 (54.2%) were evaluated in India and Italy, respectively. In India the most common causes of pelvic fracture urethral distraction defects were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents. The most common emergency treatment was suprapubic cystostomy (79.5% of cases). Of the patients 70.1% were treated in emergency fashion by a surgeon and 85.4% had complex posterior urethral strictures. The most common technique was anastomosis with inferior and total pubectomy in 56.4% and 15.3% of cases, respectively. In Italy the etiology was mainly automobile accidents (39.2%). The most common emergency treatment was endoscopic realignment (49.2% of cases). Of the patients 92.7% were treated in emergency fashion by a urologist and 68.1% had simple urethral strictures. Perineal anastomosis and laser urethrotomy were the most used techniques (38.4% and 21.1% of cases, respectively). In India 92 cases (78.6%) were successful and 25 (21.4%) failed while in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Median followup was 74 months (range 12 to 239). Conclusions: Differences in emergency treatment for pelvic fracture urethral distraction defects influence the choice of delayed posterior repair and results.
Abbreviations and Acronyms PFUDD ⫽ pelvic fracture urethral distraction defect Submitted for publication July 19, 2009. Study received approval from local Indian and Italian institutional review boards. * Correspondence: Department of Urology, Santa Chiara, Piazza Indipendenza n. 11, 50129 Florence, Italy (telephone: ⫹39-055-50381; FAX: ⫹39-055-480676; e-mail: [email protected]).
Key Words: urethra; urethral stricture; fractures, bone; Italy; India THE historical evolution of the techniques suggested for posterior urethral stricture repair in patients with PFUDD can be summarized in 2 periods.1 In the 1970s to the 1980s transpubic urethroplasty, described by Pierce,2 Pain and Coombes,3 Waterhouse et al4 and Turner-Warwick,5,6
was considered the gold standard in most adults and children with PFUDD who had traumatic strictures that Turner-Warwick described as complex.6 In 1991 Webster and Ramon described an elaborated perineal approach to the posterior urethra using ancillary maneuvers (corporeal body
0022-5347/10/1833-1049/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
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POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
separation, inferior pubectomy and retrocrural urethral rerouting) to reduce the gap between the bulbar urethra and the prostatic apex, better remove scar tissue and achieve a tension-free anastomosis.7 In the 1990s this approach became the gold standard for simple and complex traumatic posterior urethral strictures.8 –10 However, the necessity of some ancillary maneuvers (pubectomy and retrocrural urethral rerouting) during posterior urethral reconstruction has become a contentious issue. Some studies from developed countries emphasize the limited role of these ancillary maneuvers.11–14 In developed countries this evolution of posterior urethroplasty is also related to the evolution of pelvic trauma pathogenesis. PFUDD has become less serious than many years ago and there has been notable improvement in early management.1 The final result is that in developed countries in most patients posterior urethral strictures after PFUDD are rarely associated with rectal injury, bladder neck disruption, iatrogenic fistula, false passage or abscesses.1 In contrast, in developing countries the etiology of PUFDD is quite different, emergency treatment is not currently standardized and most patients are treated by general surgeons who often use old maneuvers that add iatrogenic damage. The final result is that in developing countries posterior urethral strictures after PFUDD are rarely simple and in most cases may require complex repair using ancillary maneuvers.15–20 We compared the spectrum of posterior urethral strictures after PFUDD in developing (India) and developed (Italy) countries to evaluate whether differences in PFUDD etiopathogenesis and early treatment may influence the choice of surgical technique and the necessity of ancillary maneuvers during posterior urethral reconstruction as well as the results.
MATERIALS AND METHODS We retrospectively analyzed the medical charts of patients evaluated and treated for posterior urethral stricture at 1 center in India and 1 in Italy from April 1989 to April 2009. After the study was approved by the local Indian and Italian institutional review boards all data were entered into a computerized database. Data analysis ended on May 30, 2009. The study inclusion criterion was previous PFUDD treatment and the exclusion criterion was penile or urethral malignancy. In each patient age, etiology and type of emergency treatment for PFUDD (primary repair), the surgical specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair were investigated. Strictures were classified as simple or complex according to Turner-Warwick.6 Evaluation at secondary repair included history and evaluation of the medical details of emergency management for PFUDD, physical examination, evaluation of the mobility of each hip, laboratory investigations with urine culture and
sensitivity, and combined retrograde and voiding cystourethrography. Urethroscopy via the routine route or via the suprapubic sinus was done in select cases. All patients underwent repair for posterior urethral stricture resulting from prior PFUDD using different techniques. Assessments were scheduled 3, 6 and 9 months postoperatively, and annually thereafter. At followup patients underwent physical examination and uroflowmetry. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilation. Since the study was an investigative, retrospective, observational analysis, no comparative statistics were done at this point but descriptive statistical analysis was used.
RESULTS Patient Population From April 1989 to April 2009 at our 2 centers a total of 255 patients with a median age of 33 years (range 8 to 78) diagnosed with posterior urethral stricture were evaluated and treated. Of the patients 117 (45.8%) were evaluated in India and 138 (54.2%) were evaluated in Italy. Most patients in each country were adults (ages 19 to 78 years). In India 11 patients (9.4%) were children and 19 (16.2%) were adolescents but in Italy only 2 children (1.5%) and 9 adolescents (6.5%) were evaluated. Trauma Etiology, Emergency Treatment and Stricture Type In India the most common causes of PFUDD were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents (table 1). In Italy the most frequent causes were car (39.2%) and work site (25.3%) acciTable 1. Trauma etiology and stricture type No. India Pts (%)
No. Italy Pts (%)
13 (11) 3 (2.6) 41 (35) 15 (12.8) 31 (26.5) 2 (1.8)
14 (10.2) 35 (25.3) 4 (2.8) 3 (2.2) 17 (12.4) 54 (39.2) 2 (1.4) 9 (6.5)
Etiology Accident: Agricultural Work site Pedestrian Bicycle Motorcycle Automobile Fall from horse Other
12 (10.3)
Totals
117
138
Structure type Simple Complex: Longer than 3 cm With incontinent bladder neck With urethrorectal or urethroperineal fistula With false passage With cavity ⫹ abscess Other Totals
17 (14.6)
94 (68.1)
88 (75.2) 4 (3.4) 4 (3.4) 3 (2.6) 1 (0.8)
20 (14.5) 1 (0.7)
117
4 (2.9) 1 (0.7) 18 (13.1) 138
POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
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Table 2. Repair and success by patient age in India 1–12 Yrs Repair Cold knife urethrotomy Holmium laser urethrotomy Perineal bulboprostatic anastomosis Simple: With crural separation With inferior pubectomy With retrocrural urethra rerouting Badenoch pull-through Abdominal transpubic bulboprostatic anastomosis: Alone with omentoplasty 2-Stage urethroplasty Definitive perineal urethrostomy Totals
No. Pts (%)
No. Success (%)
Median Followup (mos)
No. Pts (%)
14 (12) 1 (0.8)
0 1 (100)
70 14
1 (7.1)
7 (6) 5 (4.3) 66 (56.4) 3 (2.6)
7 (100) 5 (100) 59 (89.4) 3 (100)
73 64 50 52
6 (5.1)
5 (83.3)
12 (10.2) 3 (2.6) 117
No. Success (%) 0
13–18 Yrs
19–78 Yrs
No. Pts (%)
No. Success (%)
No. Pts (%)
2 (14.2) 1 (100)
0 1 (100)
11 (78.7)
No. Success (%) 0
7 (100) 5 (100) 49 (74.2) 3 (100)
7 (100) 5 (100) 47 (95.9) 3 (100)
5 (7.6)
2 (40)
12 (18.2)
10 (83.3)
97
2 (33.3)
1 (50)
2 (33.3)
2 (100)
2 (33.3)
2 (100)
10 (83.3)
146
3 (25)
3 (100)
1 (8.3)
1 (100)
8 (66.7)
6 (75)
2 (66.7)
43
1 (33.3)
1 (100)
2 (66.7)
1 (50)
92 (78.6)
68
19 (16.2)
15 (78.9)
87 (74.4)
71 (81.6)
dents (table 1). In India the most common emergency treatment was suprapubic cystostomy in 79.5% of patients but in Italy 49.2% underwent 1 or 2-week delayed endoscopic urethral realignment. In each country an average of 19.3% of cases were managed by immediate surgical realignment. In India 70.1% of cases were managed in emergency fashion by general surgeons but in Italy 92.7% were managed by urologists. Traumatic urethral stricture was classified as complex in 100 cases (85.4%) and simple in 17 (14.6%) in India, and as complex in 44 (31.9%) and simple in 94 (68.1%) in Italy (table 1). Previous Treatments In India 44.5% and in Italy 49.3% of patients did not undergo prior treatment for traumatic stricture. In India patients underwent prior urethroplasty (33.3%), urethrotomy (14.6%), dilation (6.8%) or associated treatments (0.8%) before surgical repair at our referral
11 (9.4)
6 (54.5)
center. In Italy only 5.8% of patients underwent prior urethroplasty before surgical repair at our referral center while others underwent urethrotomy (10.8%), dilation (2.2%) or associated treatments (31.9%). Surgical Technique, Postoperative Care and Followup Tables 2 and 3 lists the surgical techniques used for delayed repair for posterior urethral stricture. The dressing was left in place for 3 days. The patient was discharged home after achieving mobility and feeling well. Postoperative complications included a few days of fever in 10 patients and a few weeks of abdominal discomfort in all with an omental wrap. The 16Fr Foley catheter was left in place for 3 to 4 weeks. Voiding urethrogram was then done and the suprapubic tube was removed in the absence of extravasation. Uroflowmetry and urine culture were repeated 3, 6 and 9 months postoperatively, and annually thereaf-
Table 3. Repair and success by patient age in Italy 1–12 Yrs Repair Cold knife urethrotomy Holmium laser urethrotomy Perineal bulboprostatic anastomosis Simple: With crural separation With inferior pubectomy With retrocrural urethra rerouting Badenoch pull-through Abdominal transpubic bulboprostatic anastomosis 2-Stage urethroplasty Definitive perineal urethrostomy Totals
No. Pts (%)
No. Success (%)
Median Followup (mos)
12 (8.7) 29 (21.1)
11 (92.3) 28 (96.5)
61 57
21 (15.2) 32 (23.2) 24 (17.4) 1 (0.7) 9 (6.5) 1 (0.7)
19 (90.4) 29 (90.6) 21 (87.5) 1 (100) 3 (33.3) 1 (100)
82 76 49 84 126
6 (4.3) 3 (2.2)
5 (83.3) 2 (66.7)
88 125
120 (86.9)
74
138
No. Pts (%)
1 (4.7) 1 (3.1)
2 (1.4)
No. Success (%)
1 (100) 0
1 (50)
13–18 Yrs No. Pts (%)
No. Success (%)
2 (9.5) 6 (18.7)
2 (100) 5 (83.3)
1 (11.1)
0
9 (6.6)
7 (77.8)
19–78 Yrs No. Pts (%)
No. Success (%)
12 (100) 29 (100)
11 (92.3) 28 (96.5)
18 (85.8) 25 (78.2) 24 (100) 1 (100) 8 (88.9) 1 (100)
16 (88.9) 24 (96) 21 (87.5) 1 (100) 3 (37.5) 1 (100)
6 (100) 3 (100)
5 (83.3) 2 (66.7)
127 (92)
112 (88.2)
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POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
ter. When symptoms suggested a poor stream and maximum flow was less than 12 ml per second, retrograde and voiding urethrography was repeated. When urethral narrowing was evident, urethroscopy was suggested. Followup was 12 to 239 months (median 74). Of 117 cases treated in India 92 (78.6%) were successful and 25 (21.4%) failed. Of 138 patients treated in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Tables 2 and 3 list results by patient age.
DISCUSSION Several differences were observed for the main parameters. One of the most striking differences was patient age. In India PFUDD occurred in children and male adolescents more commonly than in Italy (25.6% vs 8%), which greatly influenced the surgical steps and the outcome of posterior urethroplasty. More than in adults, PFUDD in children involves the prostatic tract and the bladder neck because of the rudimentary nature of the gland and puboprostatic ligaments so that complex urethral strictures may evolve.21–23 Prepubescent boys may have insufficient vascular connections in the glans, which is smaller than in adults, resulting in inadequate retrograde blood flow to the distally based bulbar urethral flap as a result of bulbar urethral transection and full mobilization.8 This compromised retrograde blood flow to the anastomotic site may explain the lower success rate of anastomotic urethroplasty in prepubescent boys than in adults.8 Thus, posterior urethroplasty in children may require an aggressive perineal or transpubic approach more than in adults.8,15,17,22 In India the most common causes of PFUDD are pedestrian, bicycle and motorcycle accidents but in Italy automobile accidents are one of the most common causes. Automobile accidents in developed countries are less serious than many years ago because of the increased inclusion of security devices (airbags) in modern automobiles. In contrast, pedestrian, bicycle and motorcycle accidents in developing countries are more serious and most patients with PFUDD have grievous injuries. Another important factor influencing the difference between developing and developed countries is early treatment in patients with PFUDD. In Italy orthopedic, surgical and urological evaluation and treatment in patients with PFUDD were done immediately in the emergency room but in India evaluation and treatment were delayed in most patients. Also, in India emergency treatment for PFUDD was provided by a general surgeon in 70.1% of cases, often using maneuvers that add iatrogenic damage, while in Italy it is done by a urologist in 92.7%. In India 79.5% of patients were treated with suprapubic cystostomy and in Italy 49.2% underwent endoscopic realignment. In each country open surgical realignment was done equally,
which is not in accordance with suggestions in the current literature.21 These data suggest the need for scientific urological societies in developing and developed countries in cooperation with the local scientific societies to urgently develop an educational program on this topic focusing primarily on correct immediate treatment for PFUDD. This remarkable difference in the pathogenesis of and early treatment for PFUDD also explains the differences in delayed strictures. In developing countries most patients with PFUDD have an obliterative complex posterior stricture as a consequence of more serious trauma and delayed primary treatment by a general surgeon (fig. 1). In developed countries most patients with PFUDD have a nonobliterative, short, uncomplicated posterior stricture as a consequence of early, correct primary treatment by a urologist (fig. 2). This differing spectrum of posterior urethral strictures after PFUDD influences the choice and surgical steps of delayed urethroplasty. Several groups from developed countries suggest that some ancillary maneuvers (inferior pubectomy and urethral rerouting around the corpora cavernosa) are unnecessary in most patients who require posterior urethroplasty.11–14 In contrast, several groups from developing countries suggest that these ancillary maneuvers are often necessary in adults or children with primary or repeat repair to achieve a tensionfree anastomosis.15–20 Our data seem to confirm that in developed countries these ancillary maneuvers are not often requested in patients with posterior urethral strictures due to PFUDD but they are commonly necessary in developing countries. Recently another factor influencing posterior urethroplasty steps and outcome was introduced in a discussion of penile length.24,25 Patients with a short penis may have a short bulbar urethra insufficient to cover the gap between the prostatic apex and the bulbar tract, and so inferior or total pubectomy and retrocrural urethral rerouting are more often necessary.25 Our survey seems to confirm these reports since these ancillary maneuvers are often used in populations with a short penis (children and the Asian population) compared to populations with a longer penis (adults and the white population).26,27 Also, bulbar urethral length and vascular supply may be decreased in repeat cases, requiring ancillary maneuvers such as inferior or total pubectomy, or urethral rerouting around the corpora cavernosa. In our series 33.3% of cases in India but only 5.8% in Italy were repeat cases. This factor also greatly influenced the choice of posterior urethroplasty surgical steps. The results of posterior urethroplasty were also different in Italy and India with a 78.6% and 86.9% success rate, respectively. The same technique of cold knife urethrotomy had a 0% success rate in India vs 92.3% success in Italy. This is because cold knife urethrotomy was
POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
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Figure 1. Schematic (A) and radiological (B) views show PFUDD evolution in patient who underwent suprapubic cystostomy with prostatic apex displaced and fixed to pubic bone by scar tissue. Schematic (C) and intraoperative (D) views show pubectomy to better expose prostatic apex and verumontanum. Schematic (E) and intraoperative (F) views show prostatic apex and verumontanum after pubectomy.
done in patients with a decreased peak flow of less than 12 ml per second and uncomplicated, nonobliterative strictures less than 1.5 cm occurring after endoscopic or surgical urethral realignment in 68.7% in Italy but in only 20.5% in India (tables 2 and 3). Our laser urethrotomy technique consists of making a 12 o’clock incision without scar margin
vaporization and leaving a 24Fr catheter in place for 1 month. This surgical approach is different from standard cold knife urethrotomy, which requires a 16Fr catheter for 3 to 7 days. However, the effectiveness of the laser vs the cold knife is controversial. We are currently working on performing a comparative study of these procedures.
Figure 2. Schematic (A) and radiological (B) views show PFUDD evolution in patient who underwent endoscopic realignment. Prostatic apex and bulbar urethra are aligned. Endoscopic view shows nonobliterative posterior urethral strictures after realignment (C).
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POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
In Italy the Badenoch pull-through used at the beginning of our learning curve in patients with complex urethral strictures had the worst results vs those of the elaborated perineal approach with inferior pubectomy and retrocrural rerouting (33.3% vs 87.5% and 100% success rates, respectively). Posterior urethroplasty had a lower success rate in India than in Italy (78.6% vs 86.9%). This may be due to different factors such as patient age, the incidence of repeat cases and penile length.24–26 Our survey also suggests that some technical challenges that are practically obsolete in developed countries, such as pubectomy and retrocrural urethral rerouting, may again be emerging. Due to increasing migration rates urologists in developed countries may most likely again encounter forgotten complicated posterior urethral strictures that may require complex perineal or transpubic access in migrants who were treated incorrectly in their original countries.1 The implications are evident. Surgical training for urethral reconstruction surgery should be done in international approved surgical training programs that include clearly defined criteria to assess the proficiency and
competency of new young surgeons.1 Scientific urological societies in developed countries are requested to organize full immersion training opportunities at the centers specializing in reconstructive urethral surgery that are now increasing in developing countries to achieve a new set of professional values appropriate for the fluctuating clinical environment of urethral stricture related to PUFDD. The goal of those in the educational program would be to provide urologists in undeveloped countries with the opportunity to train at specialized centers where this surgery is currently done, using all the approaches that may be deemed necessary for specific intraoperative features.1
CONCLUSIONS PFUDD pathogenesis, emergency treatment and subsequent posterior urethral strictures show a great difference in India vs Italy. The populations with PFUDD are also different. These differences in the pathogenesis of and early treatment for PUFDD greatly influence the choice of surgical technique, the necessity of ancillary maneuvers during delayed posterior urethral reconstruction and the results.
REFERENCES 1. Barbagli G: History and evolution of transpubic urethroplasty: a lesson for young urologist in training. Eur Urol 2007; 52: 1290.
11. Morey AF and McAninch JW: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 1997; 157: 506.
19. Zhang J, Xu YM, Qiao Y et al: An evaluation of surgical approaches for posterior urethral distraction defects in boys. J Urol 2006; 176: 292.
2. Pierce JM: Exposure of the membranous and prostatic urethra by total pubectomy. J Urol 1962; 88: 256.
12. Kizer WS, Armenakas NA, Brandes SB et al: Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol 2007; 177: 1378.
20. Wu DL, Jin SB, Zhang J et al: Staged pendulousprostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra: an effective treatment for long-segment bulbar and membranous urethral strictures. Eur Urol 2007; 51: 504.
3. Paine D and Coombes W: Transpubic reconstruction of the urethra. Br J Urol 1968; 40: 78. 4. Watherhouse K, Abrahams JI, Gruber H et al: The transpubic approach to the lower urinary tract. J Urol 1973; 109: 486. 5. Turner-Warwick R: The use of the omental pedicle graft in urinary tract reconstruction. J Urol 1976; 116: 341. 6. Turner-Warwick R: Complex traumatic posterior urethral strictures. J Urol 1977; 118: 564. 7. Webster GD and Ramon J: Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol 1991; 145: 744. 8. Flynn BJ, Delvecchio FC and Webster GD: Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol 2003; 170: 1877. 9. Mundy AR: Surgical atlas. Anastomotic urethroplasty. BJU Int 2005; 96: 921. 10. Andrich DE and Mundy AR: What is the best technique for urethroplasty? Eur Urol 2008; 54: 1031.
13. Cooperberg MR, McAninch JW, Alsikafi NF et al: Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol 2007; 178: 2006. 14. Lumen N, Hoebeke P, De Troyer B et al: Perineal anastomotic urethroplasty for posttraumatic urethral stricture with or without previous urethral manipulations: a review of 61 cases with longterm followup. J Urol 2009; 181: 1196. 15. Koraitim MM: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 2005; 173: 135. 16. Wadhwa SN, Chahal R, Hemal AK et al: Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty. J Urol 1998; 159: 1898. 17. Pratap A, Agrawal CS, Tiwari A et al: Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol 2006; 175: 1751. 18. Pratap A, Agrawal CS, Pandit RK et al: Factors contributing to a successful outcome of combined abdominal transpubic perineal urethroplasty for complex posterior urethral disruptions. J Urol 2006; 176: 2514.
21. Chapple C, Barbagli G, Jordan GH et al: Consensus on Genitourinary trauma. Consensus statement on urethral trauma. BJU Int 2004; 93: 1195. 22. Koraitim MM: Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997; 157: 641. 23. Onen A, Subasi M, Arslan H et al: Long-term urologic, orthopedic, and psychological outcome of posterior urethral rupture in children. Urology 2005; 66: 174. 24. Barbagli G and Lazzeri M: Reconstructive urethral surgery to be addressed at 2009 GURS meeting. AUANews 2009; 14: 14. 25. Koraitim MM: Gapometry and anterior urethrometry in the repair of posterior urethral defects. J Urol 2008; 179: 1879. 26. Kulkarni SB: Does penile length affect surgical steps and outcome of posterior urethroplasty? The Indian experience. Presented at annual meeting of American Urological Association, Chicago, Illinois, April 25-30, 2009. 27. Wylie KR and Eardley I: Penile size and the “small penis syndrome”. BJU Int 2007; 99: 1449.
Posterior Urethral Stricture After Pelvic Fracture Urethral Distraction Defects in Developing and Developed Countries, and Choice of Surgical Technique Sanjay B. Kulkarni, Guido Barbagli, Jyotsna S. Kulkarni, Giuseppe Romano and Massimo Lazzeri* From the Kulkarni Urethroplasty Center (SBK, JSK), Pune, India, and Center for Reconstructive Urethral Surgery (GB) and Unità Operativa Urologia, Ospedale San Donato, Arezzo (GR) and Department of Urology, Santa Chiara Hospital (ML), Florence, Italy
Purpose: We compared posterior urethral strictures after pelvic fracture urethral distraction defects in India and Italy. Materials and Methods: We retrospectively analyzed the records of patients in India and Italy who underwent repair for posterior urethral stricture after pelvic fracture urethral distraction defect. We investigated etiology, emergency treatment type, the specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair, posterior urethroplasty techniques and results. Results: Of 255 patients with a median age of 33 years 117 (45.8%) and 138 (54.2%) were evaluated in India and Italy, respectively. In India the most common causes of pelvic fracture urethral distraction defects were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents. The most common emergency treatment was suprapubic cystostomy (79.5% of cases). Of the patients 70.1% were treated in emergency fashion by a surgeon and 85.4% had complex posterior urethral strictures. The most common technique was anastomosis with inferior and total pubectomy in 56.4% and 15.3% of cases, respectively. In Italy the etiology was mainly automobile accidents (39.2%). The most common emergency treatment was endoscopic realignment (49.2% of cases). Of the patients 92.7% were treated in emergency fashion by a urologist and 68.1% had simple urethral strictures. Perineal anastomosis and laser urethrotomy were the most used techniques (38.4% and 21.1% of cases, respectively). In India 92 cases (78.6%) were successful and 25 (21.4%) failed while in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Median followup was 74 months (range 12 to 239). Conclusions: Differences in emergency treatment for pelvic fracture urethral distraction defects influence the choice of delayed posterior repair and results.
Abbreviations and Acronyms PFUDD ⫽ pelvic fracture urethral distraction defect Submitted for publication July 19, 2009. Study received approval from local Indian and Italian institutional review boards. * Correspondence: Department of Urology, Santa Chiara, Piazza Indipendenza n. 11, 50129 Florence, Italy (telephone: ⫹39-055-50381; FAX: ⫹39-055-480676; e-mail: [email protected]).
Key Words: urethra; urethral stricture; fractures, bone; Italy; India THE historical evolution of the techniques suggested for posterior urethral stricture repair in patients with PFUDD can be summarized in 2 periods.1 In the 1970s to the 1980s transpubic urethroplasty, described by Pierce,2 Pain and Coombes,3 Waterhouse et al4 and Turner-Warwick,5,6
was considered the gold standard in most adults and children with PFUDD who had traumatic strictures that Turner-Warwick described as complex.6 In 1991 Webster and Ramon described an elaborated perineal approach to the posterior urethra using ancillary maneuvers (corporeal body
0022-5347/10/1833-1049/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 183, 1049-1054, March 2010 Printed in U.S.A. DOI:10.1016/j.juro.2009.11.045
AND
RESEARCH, INC.
www.jurology.com
1049
1050
POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
separation, inferior pubectomy and retrocrural urethral rerouting) to reduce the gap between the bulbar urethra and the prostatic apex, better remove scar tissue and achieve a tension-free anastomosis.7 In the 1990s this approach became the gold standard for simple and complex traumatic posterior urethral strictures.8 –10 However, the necessity of some ancillary maneuvers (pubectomy and retrocrural urethral rerouting) during posterior urethral reconstruction has become a contentious issue. Some studies from developed countries emphasize the limited role of these ancillary maneuvers.11–14 In developed countries this evolution of posterior urethroplasty is also related to the evolution of pelvic trauma pathogenesis. PFUDD has become less serious than many years ago and there has been notable improvement in early management.1 The final result is that in developed countries in most patients posterior urethral strictures after PFUDD are rarely associated with rectal injury, bladder neck disruption, iatrogenic fistula, false passage or abscesses.1 In contrast, in developing countries the etiology of PUFDD is quite different, emergency treatment is not currently standardized and most patients are treated by general surgeons who often use old maneuvers that add iatrogenic damage. The final result is that in developing countries posterior urethral strictures after PFUDD are rarely simple and in most cases may require complex repair using ancillary maneuvers.15–20 We compared the spectrum of posterior urethral strictures after PFUDD in developing (India) and developed (Italy) countries to evaluate whether differences in PFUDD etiopathogenesis and early treatment may influence the choice of surgical technique and the necessity of ancillary maneuvers during posterior urethral reconstruction as well as the results.
MATERIALS AND METHODS We retrospectively analyzed the medical charts of patients evaluated and treated for posterior urethral stricture at 1 center in India and 1 in Italy from April 1989 to April 2009. After the study was approved by the local Indian and Italian institutional review boards all data were entered into a computerized database. Data analysis ended on May 30, 2009. The study inclusion criterion was previous PFUDD treatment and the exclusion criterion was penile or urethral malignancy. In each patient age, etiology and type of emergency treatment for PFUDD (primary repair), the surgical specialist involved in emergency treatment, the type of stricture resulting from trauma and primary repair were investigated. Strictures were classified as simple or complex according to Turner-Warwick.6 Evaluation at secondary repair included history and evaluation of the medical details of emergency management for PFUDD, physical examination, evaluation of the mobility of each hip, laboratory investigations with urine culture and
sensitivity, and combined retrograde and voiding cystourethrography. Urethroscopy via the routine route or via the suprapubic sinus was done in select cases. All patients underwent repair for posterior urethral stricture resulting from prior PFUDD using different techniques. Assessments were scheduled 3, 6 and 9 months postoperatively, and annually thereafter. At followup patients underwent physical examination and uroflowmetry. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilation. Since the study was an investigative, retrospective, observational analysis, no comparative statistics were done at this point but descriptive statistical analysis was used.
RESULTS Patient Population From April 1989 to April 2009 at our 2 centers a total of 255 patients with a median age of 33 years (range 8 to 78) diagnosed with posterior urethral stricture were evaluated and treated. Of the patients 117 (45.8%) were evaluated in India and 138 (54.2%) were evaluated in Italy. Most patients in each country were adults (ages 19 to 78 years). In India 11 patients (9.4%) were children and 19 (16.2%) were adolescents but in Italy only 2 children (1.5%) and 9 adolescents (6.5%) were evaluated. Trauma Etiology, Emergency Treatment and Stricture Type In India the most common causes of PFUDD were pedestrian (35%), motorcycle (26.5%) and bicycle (12.8%) accidents (table 1). In Italy the most frequent causes were car (39.2%) and work site (25.3%) acciTable 1. Trauma etiology and stricture type No. India Pts (%)
No. Italy Pts (%)
13 (11) 3 (2.6) 41 (35) 15 (12.8) 31 (26.5) 2 (1.8)
14 (10.2) 35 (25.3) 4 (2.8) 3 (2.2) 17 (12.4) 54 (39.2) 2 (1.4) 9 (6.5)
Etiology Accident: Agricultural Work site Pedestrian Bicycle Motorcycle Automobile Fall from horse Other
12 (10.3)
Totals
117
138
Structure type Simple Complex: Longer than 3 cm With incontinent bladder neck With urethrorectal or urethroperineal fistula With false passage With cavity ⫹ abscess Other Totals
17 (14.6)
94 (68.1)
88 (75.2) 4 (3.4) 4 (3.4) 3 (2.6) 1 (0.8)
20 (14.5) 1 (0.7)
117
4 (2.9) 1 (0.7) 18 (13.1) 138
POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
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Table 2. Repair and success by patient age in India 1–12 Yrs Repair Cold knife urethrotomy Holmium laser urethrotomy Perineal bulboprostatic anastomosis Simple: With crural separation With inferior pubectomy With retrocrural urethra rerouting Badenoch pull-through Abdominal transpubic bulboprostatic anastomosis: Alone with omentoplasty 2-Stage urethroplasty Definitive perineal urethrostomy Totals
No. Pts (%)
No. Success (%)
Median Followup (mos)
No. Pts (%)
14 (12) 1 (0.8)
0 1 (100)
70 14
1 (7.1)
7 (6) 5 (4.3) 66 (56.4) 3 (2.6)
7 (100) 5 (100) 59 (89.4) 3 (100)
73 64 50 52
6 (5.1)
5 (83.3)
12 (10.2) 3 (2.6) 117
No. Success (%) 0
13–18 Yrs
19–78 Yrs
No. Pts (%)
No. Success (%)
No. Pts (%)
2 (14.2) 1 (100)
0 1 (100)
11 (78.7)
No. Success (%) 0
7 (100) 5 (100) 49 (74.2) 3 (100)
7 (100) 5 (100) 47 (95.9) 3 (100)
5 (7.6)
2 (40)
12 (18.2)
10 (83.3)
97
2 (33.3)
1 (50)
2 (33.3)
2 (100)
2 (33.3)
2 (100)
10 (83.3)
146
3 (25)
3 (100)
1 (8.3)
1 (100)
8 (66.7)
6 (75)
2 (66.7)
43
1 (33.3)
1 (100)
2 (66.7)
1 (50)
92 (78.6)
68
19 (16.2)
15 (78.9)
87 (74.4)
71 (81.6)
dents (table 1). In India the most common emergency treatment was suprapubic cystostomy in 79.5% of patients but in Italy 49.2% underwent 1 or 2-week delayed endoscopic urethral realignment. In each country an average of 19.3% of cases were managed by immediate surgical realignment. In India 70.1% of cases were managed in emergency fashion by general surgeons but in Italy 92.7% were managed by urologists. Traumatic urethral stricture was classified as complex in 100 cases (85.4%) and simple in 17 (14.6%) in India, and as complex in 44 (31.9%) and simple in 94 (68.1%) in Italy (table 1). Previous Treatments In India 44.5% and in Italy 49.3% of patients did not undergo prior treatment for traumatic stricture. In India patients underwent prior urethroplasty (33.3%), urethrotomy (14.6%), dilation (6.8%) or associated treatments (0.8%) before surgical repair at our referral
11 (9.4)
6 (54.5)
center. In Italy only 5.8% of patients underwent prior urethroplasty before surgical repair at our referral center while others underwent urethrotomy (10.8%), dilation (2.2%) or associated treatments (31.9%). Surgical Technique, Postoperative Care and Followup Tables 2 and 3 lists the surgical techniques used for delayed repair for posterior urethral stricture. The dressing was left in place for 3 days. The patient was discharged home after achieving mobility and feeling well. Postoperative complications included a few days of fever in 10 patients and a few weeks of abdominal discomfort in all with an omental wrap. The 16Fr Foley catheter was left in place for 3 to 4 weeks. Voiding urethrogram was then done and the suprapubic tube was removed in the absence of extravasation. Uroflowmetry and urine culture were repeated 3, 6 and 9 months postoperatively, and annually thereaf-
Table 3. Repair and success by patient age in Italy 1–12 Yrs Repair Cold knife urethrotomy Holmium laser urethrotomy Perineal bulboprostatic anastomosis Simple: With crural separation With inferior pubectomy With retrocrural urethra rerouting Badenoch pull-through Abdominal transpubic bulboprostatic anastomosis 2-Stage urethroplasty Definitive perineal urethrostomy Totals
No. Pts (%)
No. Success (%)
Median Followup (mos)
12 (8.7) 29 (21.1)
11 (92.3) 28 (96.5)
61 57
21 (15.2) 32 (23.2) 24 (17.4) 1 (0.7) 9 (6.5) 1 (0.7)
19 (90.4) 29 (90.6) 21 (87.5) 1 (100) 3 (33.3) 1 (100)
82 76 49 84 126
6 (4.3) 3 (2.2)
5 (83.3) 2 (66.7)
88 125
120 (86.9)
74
138
No. Pts (%)
1 (4.7) 1 (3.1)
2 (1.4)
No. Success (%)
1 (100) 0
1 (50)
13–18 Yrs No. Pts (%)
No. Success (%)
2 (9.5) 6 (18.7)
2 (100) 5 (83.3)
1 (11.1)
0
9 (6.6)
7 (77.8)
19–78 Yrs No. Pts (%)
No. Success (%)
12 (100) 29 (100)
11 (92.3) 28 (96.5)
18 (85.8) 25 (78.2) 24 (100) 1 (100) 8 (88.9) 1 (100)
16 (88.9) 24 (96) 21 (87.5) 1 (100) 3 (37.5) 1 (100)
6 (100) 3 (100)
5 (83.3) 2 (66.7)
127 (92)
112 (88.2)
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POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
ter. When symptoms suggested a poor stream and maximum flow was less than 12 ml per second, retrograde and voiding urethrography was repeated. When urethral narrowing was evident, urethroscopy was suggested. Followup was 12 to 239 months (median 74). Of 117 cases treated in India 92 (78.6%) were successful and 25 (21.4%) failed. Of 138 patients treated in Italy 120 (86.9%) were successful and 18 (13.1%) failed. Tables 2 and 3 list results by patient age.
DISCUSSION Several differences were observed for the main parameters. One of the most striking differences was patient age. In India PFUDD occurred in children and male adolescents more commonly than in Italy (25.6% vs 8%), which greatly influenced the surgical steps and the outcome of posterior urethroplasty. More than in adults, PFUDD in children involves the prostatic tract and the bladder neck because of the rudimentary nature of the gland and puboprostatic ligaments so that complex urethral strictures may evolve.21–23 Prepubescent boys may have insufficient vascular connections in the glans, which is smaller than in adults, resulting in inadequate retrograde blood flow to the distally based bulbar urethral flap as a result of bulbar urethral transection and full mobilization.8 This compromised retrograde blood flow to the anastomotic site may explain the lower success rate of anastomotic urethroplasty in prepubescent boys than in adults.8 Thus, posterior urethroplasty in children may require an aggressive perineal or transpubic approach more than in adults.8,15,17,22 In India the most common causes of PFUDD are pedestrian, bicycle and motorcycle accidents but in Italy automobile accidents are one of the most common causes. Automobile accidents in developed countries are less serious than many years ago because of the increased inclusion of security devices (airbags) in modern automobiles. In contrast, pedestrian, bicycle and motorcycle accidents in developing countries are more serious and most patients with PFUDD have grievous injuries. Another important factor influencing the difference between developing and developed countries is early treatment in patients with PFUDD. In Italy orthopedic, surgical and urological evaluation and treatment in patients with PFUDD were done immediately in the emergency room but in India evaluation and treatment were delayed in most patients. Also, in India emergency treatment for PFUDD was provided by a general surgeon in 70.1% of cases, often using maneuvers that add iatrogenic damage, while in Italy it is done by a urologist in 92.7%. In India 79.5% of patients were treated with suprapubic cystostomy and in Italy 49.2% underwent endoscopic realignment. In each country open surgical realignment was done equally,
which is not in accordance with suggestions in the current literature.21 These data suggest the need for scientific urological societies in developing and developed countries in cooperation with the local scientific societies to urgently develop an educational program on this topic focusing primarily on correct immediate treatment for PFUDD. This remarkable difference in the pathogenesis of and early treatment for PFUDD also explains the differences in delayed strictures. In developing countries most patients with PFUDD have an obliterative complex posterior stricture as a consequence of more serious trauma and delayed primary treatment by a general surgeon (fig. 1). In developed countries most patients with PFUDD have a nonobliterative, short, uncomplicated posterior stricture as a consequence of early, correct primary treatment by a urologist (fig. 2). This differing spectrum of posterior urethral strictures after PFUDD influences the choice and surgical steps of delayed urethroplasty. Several groups from developed countries suggest that some ancillary maneuvers (inferior pubectomy and urethral rerouting around the corpora cavernosa) are unnecessary in most patients who require posterior urethroplasty.11–14 In contrast, several groups from developing countries suggest that these ancillary maneuvers are often necessary in adults or children with primary or repeat repair to achieve a tensionfree anastomosis.15–20 Our data seem to confirm that in developed countries these ancillary maneuvers are not often requested in patients with posterior urethral strictures due to PFUDD but they are commonly necessary in developing countries. Recently another factor influencing posterior urethroplasty steps and outcome was introduced in a discussion of penile length.24,25 Patients with a short penis may have a short bulbar urethra insufficient to cover the gap between the prostatic apex and the bulbar tract, and so inferior or total pubectomy and retrocrural urethral rerouting are more often necessary.25 Our survey seems to confirm these reports since these ancillary maneuvers are often used in populations with a short penis (children and the Asian population) compared to populations with a longer penis (adults and the white population).26,27 Also, bulbar urethral length and vascular supply may be decreased in repeat cases, requiring ancillary maneuvers such as inferior or total pubectomy, or urethral rerouting around the corpora cavernosa. In our series 33.3% of cases in India but only 5.8% in Italy were repeat cases. This factor also greatly influenced the choice of posterior urethroplasty surgical steps. The results of posterior urethroplasty were also different in Italy and India with a 78.6% and 86.9% success rate, respectively. The same technique of cold knife urethrotomy had a 0% success rate in India vs 92.3% success in Italy. This is because cold knife urethrotomy was
POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
1053
Figure 1. Schematic (A) and radiological (B) views show PFUDD evolution in patient who underwent suprapubic cystostomy with prostatic apex displaced and fixed to pubic bone by scar tissue. Schematic (C) and intraoperative (D) views show pubectomy to better expose prostatic apex and verumontanum. Schematic (E) and intraoperative (F) views show prostatic apex and verumontanum after pubectomy.
done in patients with a decreased peak flow of less than 12 ml per second and uncomplicated, nonobliterative strictures less than 1.5 cm occurring after endoscopic or surgical urethral realignment in 68.7% in Italy but in only 20.5% in India (tables 2 and 3). Our laser urethrotomy technique consists of making a 12 o’clock incision without scar margin
vaporization and leaving a 24Fr catheter in place for 1 month. This surgical approach is different from standard cold knife urethrotomy, which requires a 16Fr catheter for 3 to 7 days. However, the effectiveness of the laser vs the cold knife is controversial. We are currently working on performing a comparative study of these procedures.
Figure 2. Schematic (A) and radiological (B) views show PFUDD evolution in patient who underwent endoscopic realignment. Prostatic apex and bulbar urethra are aligned. Endoscopic view shows nonobliterative posterior urethral strictures after realignment (C).
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POSTERIOR URETHRAL STRICTURE IN DEVELOPING AND DEVELOPED COUNTRIES
In Italy the Badenoch pull-through used at the beginning of our learning curve in patients with complex urethral strictures had the worst results vs those of the elaborated perineal approach with inferior pubectomy and retrocrural rerouting (33.3% vs 87.5% and 100% success rates, respectively). Posterior urethroplasty had a lower success rate in India than in Italy (78.6% vs 86.9%). This may be due to different factors such as patient age, the incidence of repeat cases and penile length.24–26 Our survey also suggests that some technical challenges that are practically obsolete in developed countries, such as pubectomy and retrocrural urethral rerouting, may again be emerging. Due to increasing migration rates urologists in developed countries may most likely again encounter forgotten complicated posterior urethral strictures that may require complex perineal or transpubic access in migrants who were treated incorrectly in their original countries.1 The implications are evident. Surgical training for urethral reconstruction surgery should be done in international approved surgical training programs that include clearly defined criteria to assess the proficiency and
competency of new young surgeons.1 Scientific urological societies in developed countries are requested to organize full immersion training opportunities at the centers specializing in reconstructive urethral surgery that are now increasing in developing countries to achieve a new set of professional values appropriate for the fluctuating clinical environment of urethral stricture related to PUFDD. The goal of those in the educational program would be to provide urologists in undeveloped countries with the opportunity to train at specialized centers where this surgery is currently done, using all the approaches that may be deemed necessary for specific intraoperative features.1
CONCLUSIONS PFUDD pathogenesis, emergency treatment and subsequent posterior urethral strictures show a great difference in India vs Italy. The populations with PFUDD are also different. These differences in the pathogenesis of and early treatment for PUFDD greatly influence the choice of surgical technique, the necessity of ancillary maneuvers during delayed posterior urethral reconstruction and the results.
REFERENCES 1. Barbagli G: History and evolution of transpubic urethroplasty: a lesson for young urologist in training. Eur Urol 2007; 52: 1290.
11. Morey AF and McAninch JW: Reconstruction of posterior urethral disruption injuries: outcome analysis in 82 patients. J Urol 1997; 157: 506.
19. Zhang J, Xu YM, Qiao Y et al: An evaluation of surgical approaches for posterior urethral distraction defects in boys. J Urol 2006; 176: 292.
2. Pierce JM: Exposure of the membranous and prostatic urethra by total pubectomy. J Urol 1962; 88: 256.
12. Kizer WS, Armenakas NA, Brandes SB et al: Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol 2007; 177: 1378.
20. Wu DL, Jin SB, Zhang J et al: Staged pendulousprostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra: an effective treatment for long-segment bulbar and membranous urethral strictures. Eur Urol 2007; 51: 504.
3. Paine D and Coombes W: Transpubic reconstruction of the urethra. Br J Urol 1968; 40: 78. 4. Watherhouse K, Abrahams JI, Gruber H et al: The transpubic approach to the lower urinary tract. J Urol 1973; 109: 486. 5. Turner-Warwick R: The use of the omental pedicle graft in urinary tract reconstruction. J Urol 1976; 116: 341. 6. Turner-Warwick R: Complex traumatic posterior urethral strictures. J Urol 1977; 118: 564. 7. Webster GD and Ramon J: Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol 1991; 145: 744. 8. Flynn BJ, Delvecchio FC and Webster GD: Perineal repair of pelvic fracture urethral distraction defects: experience in 120 patients during the last 10 years. J Urol 2003; 170: 1877. 9. Mundy AR: Surgical atlas. Anastomotic urethroplasty. BJU Int 2005; 96: 921. 10. Andrich DE and Mundy AR: What is the best technique for urethroplasty? Eur Urol 2008; 54: 1031.
13. Cooperberg MR, McAninch JW, Alsikafi NF et al: Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol 2007; 178: 2006. 14. Lumen N, Hoebeke P, De Troyer B et al: Perineal anastomotic urethroplasty for posttraumatic urethral stricture with or without previous urethral manipulations: a review of 61 cases with longterm followup. J Urol 2009; 181: 1196. 15. Koraitim MM: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 2005; 173: 135. 16. Wadhwa SN, Chahal R, Hemal AK et al: Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty. J Urol 1998; 159: 1898. 17. Pratap A, Agrawal CS, Tiwari A et al: Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol 2006; 175: 1751. 18. Pratap A, Agrawal CS, Pandit RK et al: Factors contributing to a successful outcome of combined abdominal transpubic perineal urethroplasty for complex posterior urethral disruptions. J Urol 2006; 176: 2514.
21. Chapple C, Barbagli G, Jordan GH et al: Consensus on Genitourinary trauma. Consensus statement on urethral trauma. BJU Int 2004; 93: 1195. 22. Koraitim MM: Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997; 157: 641. 23. Onen A, Subasi M, Arslan H et al: Long-term urologic, orthopedic, and psychological outcome of posterior urethral rupture in children. Urology 2005; 66: 174. 24. Barbagli G and Lazzeri M: Reconstructive urethral surgery to be addressed at 2009 GURS meeting. AUANews 2009; 14: 14. 25. Koraitim MM: Gapometry and anterior urethrometry in the repair of posterior urethral defects. J Urol 2008; 179: 1879. 26. Kulkarni SB: Does penile length affect surgical steps and outcome of posterior urethroplasty? The Indian experience. Presented at annual meeting of American Urological Association, Chicago, Illinois, April 25-30, 2009. 27. Wylie KR and Eardley I: Penile size and the “small penis syndrome”. BJU Int 2007; 99: 1449.