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Transpubic posterior urethroplasty via perineal approach in children: A new technique
Journal of Pediatric Urology (2012) 8, 393e400
Transpubic posterior urethroplasty via perineal approach in children: A new technique* Samir Orabi Urology Department, Alexandria College of Medicine, Alexandria, Egypt Received 2 February 2011; accepted 18 August 2011 Available online 25 September 2011
KEYWORDS Transpubic; Children; Pelvic distraction defect
Abstract Objective: To evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children. Methods: Of 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median Z 8.5 years). The median distraction defect length was 4.8 cm (range 3.7e6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter. Results: Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9e3.2 h) with a mean blood loss of 200 ml (range 50e640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis. Conclusions: Transpubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Management of complex pelvic fracture urethral distraction defects (PFUDD) in children remains a challenging problem for the urologist. Complex PFUDD is characterized by the
* This paper was presented at the ESPU 2008 and AUA 2008 annual meetings. E-mail address: [email protected].
presence of a distraction defect more than 3 cm long, or any distraction defect that is accompanied by rectourethral fistula, periurethral cavity, false passage or open bladder neck [1,2]. Many surgical approaches have been described for management of complex PFUDD in children, such as direct abdominal transpubic urethroplasty [3], abdomino-perineal urethroplasty [1,4,5], symphysiotomy [6], anterior sagittal transrectal approach [7] and elaborating perineal technique [8].
1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.08.001
394
S. Orabi
All of these techniques aim to provide a good wide field that allows tension-free anastomosis, and excision of all fibrous tissues with minimal postoperative complications, especially avoiding re-stenosis, incontinence and impotence [9,10]. To date, there has been controversy about the most appropriate surgical technique for management. Many investigators reported a lot of complications after the direct transpubic approach and abdominal-perineal approach, such as abnormal gait, hernia and low stricture-free rate (70e100%) [9,10]. Moreover, the most common drawbacks of these techniques are the need for two qualified urologic teams, a large amount of blood transfusion, long operative time and prolonged hospital stay at high cost [6,9,12,13]. Additionally, a lower success rate for the progressive elaborating technique is reported in children with complex PFUDD [14], and many authors refused supra-crural re-routing (last step of the latter technique) as they considered it a source of ischemia and obstruction [13] In this series, we demonstrate a new technique of total pubectomy via perineal approach for the management of complex PFUDD in children, and its advantage over other techniques.
Patients and methods Figure 1
Between January 2005 and July 2010, 78 children with PFUDD were admitted to our service. The mechanism of injury was blunt trauma due to motor vehicle accident. All children were managed by suprapubic tube during initial trauma. Preoperative evaluation included history of timing and type of trauma, technique of initial management and history of any surgical or endoscopic interference after initial management. Routine investigation and radiological evaluation, in the form of pelvic plain X-ray to detect the presence of bladder stones and abnormal bone at the site of future anastomosis, ascending urethrogram, combined voiding cysto-urethrogram, and endoscopy were performed to evaluate the length of the distraction defect and the state of the bladder neck. Restoration of urethral continuity was initially attempted from the perineum by performing the perineal elaborating technique in every case. After perineal midline incision and excision of all fibrous tissues, 12 out of 78 children (15.4%) had a short urethra that could not bridge the gap (more than 5 cm) to achieve a tension-free anastomosis (Fig. 1); for the latter group, transpubic posterior urethroplasty via perineal approach was performed.
Preoperative cysto-urethrogram with straining.
The upper border of the symphysis pubis was palpated and midline separation of the corporal bodies was performed using diathermy. Dissection and separation of crus from the bone was started from the medial to lateral edge. The same procedure was performed on the other side
Technique We started with a midline perineal incision and identification of the bulbar urethra. Dissection was done beyond the area of fibrosis. Transection of the urethra was performed with excision of all fibrous tissues from the bulbar urethra as well as the anterior surface of the prostate. The bulbar urethra was mobilized up to the penoscrotal junction and the length of the defect was measured. If the gap was more than 5 cm, which cannot be bridged by the available healthy bulbar urethra (Fig. 2), instead of supra-crural rerouting of the urethra we performed excision of the pubic bone via the same perineal route to achieve a tension-free anastomosis.
Figure 2 Long distraction defect is encountered after removal of all fibrous tissues.
Transpubic posterior urethroplasty via perineal approach (Fig. 3). Two crura were held laterally with tape and two longitudinal lines were performed over the pubic bone, the distance in between being about 4 cm (Fig. 4). By cutting diathermy over these lines, separation of the pubic bone was achieved. The separated bone was held by nipple forceps and complete separation from the posterior attachment was done by cutting diathermy (Fig. 5). Two stay sutures were made in the anterior surface of the prostatic capsule (Fig. 6) and a longitudinal incision was performed in between. The mucosa of the proximal urethra was fixed with 5/0 Vicryl. Spatulation and fixation of the mucosa of the bulbar urethra were done without any dissection at the prostatic apex. The anastomotic sutures were made (Fig. 7) over a suitable silicon catheter (usually 10e14 F). The tip of the urethral catheter was tied to the tip of a C-shaped sound and withdrawn through the suprapubic cystostomy (Fig. 8). An easy tension-free bulbo-prostatic anastomosis was achieved (Fig. 9). Closure of the wound was done in layers with fixation of the urethral catheter to the anterior abdominal wall to prevent slipping of the urethral catheter to the site of anastomosis (slipping causes either persistent leakage or disruption of the anastomosis) (Fig. 10). The suprapubic catheter was left in place. The drain was removed on the second postoperative day. Three weeks postoperatively (Fig. 11), a pericatheter ascending urethrogram was performed (Fig. 12) to detect healing at the anastomotic site. If no leakage was detected, the urethral
395
Figure 4 Two longitudinal lines, each 2 cm lateral to the midline, are marked by diathermy. A piece of the pubic bone is separated between the marked lines using cutting diathermy in younger children or bone and chisel in older children.
catheter was removed with closure of the suprapubic cystostomy for 5e7 days to be sure of normal voiding. The first follow-up visit was scheduled 1 month after suprapubic catheter removal when uroflowmetry, measurement of residual urine by ultrasound and an ascending urethrogram were done to assess the anastomosis and pattern of micturation. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter (Fig. 14). If the child complained of decrease of the force and caliber of stream, straining, suprapubic fistula or recurrent unresolved UTI, immediate ascending urethrogram and endoscopy were done. Urine culture and sensitivity were done if there was any irritative symptom or stress incontinence during the follow-up period.
Results
Figure 3 Complete separation and retraction of the two corporal bodies were done to expose the symphysis pubis till its upper surface (peno-scrotal junction).
Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. There were 12 patients with complex PFUDD with age ranging from 5.2 to 12 years (median Z 8.5 years; Table 1). The primary injury was motor vehicle accident. The median distraction defect length was 4.8 cm (range 3.7e6.4 cm). Mean period between the original trauma and the time of repair was 8 months (range 6e13 months). Mean operative time was 2.5 h (range 1.9e3.2 h) with a mean blood loss of 200 cc (range 50e640 cc) and mean hospital stay was 4 days.
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Figure 6 Mucosa of prostatic urethra (arrow) is exposed, incised between traction sutures and fixed to prostatic tissue to prevent proximal retraction.
Figure 5 Holding of the excised bone by nipple forceps (arrow) and complete separation from bladder neck and lateral attachments was achieved by cutting diathermy.
Cysto-urethroscopy was done 1 month postoperatively and on follow-up showed wide patent anastomosis and normal voiding in all cases (Fig. 13). This successful result was maintained during the entire follow up. Of 12 children, 9 (75%) reported normal urinary control while 3 (25%) reported stress incontinence requiring anticholinergic therapy that disappeared within 6 months on follow up. Out of 12 children, 9 (75%) had a retracted (short) penis after surgery. No complications related to perineal pubic resection were encountered such as abnormal gait, limping, or periurethral cavities. Neither recurrence nor urinary fistulas were reported on follow up. Potency state could not be evaluated due to the young age of the group.
Discussion Many authors have tried to explain why most children with a complex PFUDD need a different approach than used in adults. It has been reported that the types of pelvic fracture found in children are more serious than in adults,
Figure 7 prostate.
The final anastomotic sutures are made in the
Transpubic posterior urethroplasty via perineal approach
397
Figure 10 The tip of the urethral catheter is fixed to the anterior abdominal wall.
Figure 8 Tip of silicone catheter coming from anterior urethra is tied to the tip of the C-shaped sound and withdrawn out of the suprapubic cystostomy.
causing injury to the proximal urethra that extends to the prostate and bladder neck [16e18]. Also, cutting of the immature pubo-prostatic ligaments of children tends to involve pelvic trauma, causing a marked displacement of
Figure 9 Easy bulbo-prostatic anastomosis is done (arrow) around a silicon catheter.
the prostate upward and backward and resulting in long complex PFUDD [16,19]. There are many factors that compromise the success of the surgical management of complex PFUDD in children. The pediatric pelvis is shallow and broad, which limits the perineal approach and makes it suboptimal for adequate exposure [20]. Also, there is inadequate retrograde flow to the distal urethra due to an insufficient vascular connection which compromises healing at the anastomosis [14]. There is still controversy over how to manage children with complex PFUDD, either by the elaborating perineal technique or an abdomino-perineal approach. Since radiographic and instrumental gapometry is erroneously conceived, and the length of a gap is irrelevant to the planning procedure [1], restoration of urethral continuity
Figure 11 Post-operative plain X-ray pelvis showing urethral catheter (yellow arrow), SP cystostomy tube (red arrow) and the extent of the pubectomy (white arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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Figure 12 Three weeks postoperatively, a pericatheter ascending urethrogram is performed to confirm healing and urethral catheter is removed. Suprapubic cystostomy tube is closed for another week to confirm good micturation and then it is removed.
was initially attempted from the perineum by the perineal elaborating technique for every case in our series [8,15,21,22]. When the gap cannot be bridged by available healthy bulbar urethra, we performed excision of the pubic bone via the same perineal route to achieve a tension-free anastomosis, instead of supra-crural urethral re-routing that is not accepted by many authors because the urethra will compress beneath the corporal body leading to ischemic stricture and penile torsion [13,14]. In 1962, Pierce resected the symphysis pubis for treatment of PFUDD [23]. Waterhouse et al. depended on a preoperative combined cysto-urethrogram for perineal urethral mobilization with a simultaneous abdominal
Table 1
transpubic anastomosis [24]. While Turner-Warwick, disregarding the preoperative radiological finding, started via the perineal approach and then an abdominal transpubic anastomosis was done according to the intraoperative steps [25]. The abdomino-perineal approach is reserved for complex cases where adjunctive reconstructive steps beyond perineal urethral mobilization are needed for reconstruction [2,8,19,22,26,27]. However, many complications have been reported after the abdomino-perineal approach, such as abnormal gait, hernia, long operative time, excessive blood loss and prolonged hospital stay [9,11]. Kizer et al. believed that the least possible number of surgical steps should be used during urethroplasty to minimize the potential morbidity from the high lithotomy position [13]. From the present series, we have provided the first report of complete pubectomy via perineal approach in the management of complex PFUDD in children. In our series, the median PFUDD length was 4.8 cm. Pratap et al. [2], Senocak et al. [9] and Podesta [28] were able to bridge a gap of up to 6 cm by the abdomino-perineal approach. The average blood loss in our series was minimal (mean Z 200 ml) compared to other series (range 600e1000 ml) [2,20,29]. This can be explained by the cartilaginous and immature nature of bone in this age group and the limited area of excised bone. In the present series, the mean operative time was 2.5 h compared to 10e22 h for performing an abdomino-perineal urethroplasty [2,20,29]. Some authors advise two teams for the abdomino-perineal approach to decrease the surgical time to less than 4 h [13]. So, our new technique is a shorttime maneuver without any need for an extra team, and it avoids the morbidity of abdominal surgery so decreasing hospital stay. The success rate in our study was 100% over the entire follow-up period. According to many authors, the stricturefree rate following the abdomino-perineal transpubic approach is between 70% and 100% [2e5].
Results for 12 patients with complex PFUDD.
Patient
Age (years)
PFUDD length (cm)
Intraoperative Blood loss (ml)
Potencya
1 2 3 4 5 6 7 8 9 10 11 12 Total Mean Median
8 10 7 8.5 12 9 5.3 6.8 9.7 12 8.5 7 103.8 8.65 8.5
4.2 5.4 4.1 4.7 5.1 4.9 5.4 3.7 6.4 5.3 4.8 5.7 59.7 4.975 4.8
100 150 50 300 180 200 180 340 430 640 370 280 3220 268.3333 200
e e e e e e e e e e e e
a
could not be evaluated due to young age group.
Stress incontinence
Penile shortening present
present
present present
present present present present present present present present
Transpubic posterior urethroplasty via perineal approach
Figure 13
399
Postoperative ascending urethrograms after perineal transpubic urethroplasty showing patent anastomosis.
Twenty-five per cent of our patients suffered from stress incontinence after surgery and anti-cholinergic drugs resolved this temporary problem completely. This can be explained by the occurrence of bladder contracture due to prolonged bladder diversion and associated UTI, which decrease the bladder capacity in this young age group. The incidence of urinary incontinence after the abdominoperineal approach ranges from 25% to 50% [6,20,24,30]. Middleton noted that after pubectomy the bladder descends noticeably in the pelvis causing postoperative stress incontinence [31]; this was not observed in our series as we did not dissect the bladder from its attachment. In the present study, excision of a small part of the pubic bone by the perineal approach should preserve potency state, as this approach is superior to all other routes because the vascular and nerve supply of the corpus cavernosa can be
preserved [32]; however, the potency state could not be evaluated due to the young age of the group. In the present study, Penile shortening (retraction) was observed in 75% of cases. Turner-Warwick [25,33] stated that the division of the suspensory ligament is a natural consequence of a total pubectomy that prevents penile chordee, and the base of the penis slides back a little. Neither loss of the suspensory ligament or a centimeter or two of penile length results in a significant disability. However, long-term follow up is needed to determine whether this is a permanent condition or will be resolved by the natural growth of children towards adulthood.
Conclusion Complex PFUDD in children is a challenge for both the parent and urologist. The total perineal transpubic approach provides an advantage over the elaborating perineal technique in creating a tension-free anastomosis without supra-crural urethral re-routing. It is a feasible, safe and easy technique. A small part of the bone is excised without affecting the gait. The technique has the following further advantages: -
-
-
Figure 14 Ascending urethrogram 5 years after transpubic urethroplasty showing new callous formation.
It is completely performed through the perineum without any need for another team for abdominal exposure, with minimal blood loss and short hospital stay. It is performed under direct vision instead of via a limited suprapubic window, thereby minimizing the risks of injury to the bladder neck and corporal bodies. Immobilization of the bladder and prostate during the procedure reduces the incidence of hernia and stress incontinence, and leaves the neurovascular bundle intact for future potency.
In our opinion, the perineal total pubectomy may be considered as the final step of the ‘elaborating perineal technique’, instead of supra-crural re-routing of the urethra, in children with complex PFUDD.
400
Conflict of interest None.
Funding None.
References [1] Turner-Warwick R. Complex traumatic posterior urethral stricture. J Urol 1977;118:564e71. [2] Pratap A, Agrawal CS, Tiwari A, Bhattarai BK, Pandit RK, Anchal N. Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol 2006;175:1751e4. [3] Pierce Jr JM. Management of dismemberment of the prostatic membranous urethra and ensuing stricture disease. J Urol 1972;107:259. [4] Waterhouse K, Abrahams JI, Grober H. Transpubic approach to the lower urinary tract. J Urol 1973;109:486e96. [5] Brock WA, Kaplan GW. Use of the transpubic approach for urethroplasty in children. J Urol 1981;125:496e5001. [6] Basiri A, Shadpour PH, Moradi MR, Ahmadinia H, Madaen K. Symphysiotomy : a vaible approach for delayed management of posterior urethral injuries in children. J urol 1998;166: 1173e7. [7] De Castro R, Ceccarelli PL, Domini R. Anterior sagittal transrectal approach to the posterior urethra in the pediatric age group. J Urol 1998;166:1173e7. [8] Webster GD, Remon J. Repair of pelvic fracture posterior urethral defect an elaborating perineal approach: experience with 74 cases. J Urol 1991;145:744. [9] Senocak ME, Ciftci AO, Bu ¸u N, Hic ¸so ¨nmez A. ¨yu ¨kpamukc Transpubic urethroplasty in children: report of 10 cases with review of the literature. J Pediatr Surg 1995;30:1319. [10] Patil UB. Long term results of transpubic prostatemembranous urethroplasty in children. J Urol 1984;136:286. [11] Bissada NK, Barry JM, Morcos R, Hefty TS. Hernias after transpubic urethroplasty. J Urol 1986;135:1010. [12] Koraitim MM. Perineal versus transpubic urethroplasty. J Urol; suppl, 153:371A, Abstract572, 1995. [13] Kizer WS, Armenakas NA, Brandes SB, Cavalcauti AG, Santucci RA, Morey AF. Simplified reconstruction of posterior urethral disruption defects: limited role of supra-crural rerouting. J Urol 2007;177:1378e82. [14] Zhang J, Xu YM, Qiao Y, Jin SB, Wu DL, Gu BJ. An evaluation of surgical approach from posterior urethral distraction defects in boys. J Urol 2006;176:292e5. [15] Orabi S, Badawy H, Saad A, Youssef M, Hanno A. Post-traumatic posterior urethral stricture in children: how to achieve a successful repair. J Pediatr Urol 2008;4:290.
S. Orabi [16] Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77:876. [17] Boone TB, Wilson WT, Hussmann DA. Post-pubertal genitourinary function following posterior urethral disruption in children. J Urol 1992;148:1232. [18] Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999;161:1433. [19] Koraitim MM. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997;157:641. [20] Kramer SA, Furlow WL, Barrett DM, Kelalis PP. Transpubic urethroplasty in children. J Urol 1981;126:767e9. [21] Shenfeld OZ, Gdor J, Katz R, Gofrit ON, Pode D, Landan EH. Urethroplasty, by perineal approach, for bulbar and membranous urethral strictures in children and adolescent. Urology 2008;71:430e3. [22] Rourke KF, McCammon KA, Sumfest JM, Jordan GH, Kaplan GW. Open reconstruction of pediatric and adolescent urethral strictures: long-term followup. J Urol 2003;169: 1818e21. [23] Pierce JM. Exposure of the membranous and posterior urethra by total pubectomy. J Urol 1962;88:256e8. [24] Waterhouse K, Laungani G, Patil U. The surgical repair of membranous urethral strictures: experience with 105 consecutive cases. J Urol 1980;123:500. [25] Turner-Warwick R. The prevention of complications resulting from pelvic fracture urethral injuries and from their surgical management. Urol Clin N Am 1989;16(2):335e58. [26] Morey AF, McAninch JW. Reconstruction of posterior urethral injuries: outcomes analysis in 82 patients. J Urol 1997;157:506. [27] Hafez AT, El-assmy A, Sarhan O, El-hefnawy AS, Ghoneim MA. Perineal anastomotic urethroplasty for management posttraumatic urethral strictures in children: long-term outcome. Br J Urol Int 2005;95:403e6. [28] Podesta ML. Use of the perineal and perineal eabdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterates strictures in children: long-term outcome. J Urol 1998;160:160e4. [29] Pratap A, Agrawal CS, Pandit RK, Sapkota G, Anchal N. Factors contributing to a successful outcome of combined abdominal transpubic perineal urethroplasty for complex posterior urethral disruptions. J Urol 2006;176:2514. [30] Al-Refaei MA, Gaafer S, Abdelrahman M. Management of posterior urethral strictures secondary to pelvic fractures in children. J Urol 1991;145:353e6. [31] Middleton AG. Pubectomy and the use of omentum in urologic surgery. AUA update series, vol. 5, lesson 37, p. 1, 1986. [32] Ennemoser O, Colleselli K, Reissigle A, Poisel S, Janetschek G, Bartsch G. Posttraumatic posterior urethral stricture repair: anatomy, surgical approach and long-term results. J Urol 1997;157:499e505. [33] Turner-Warwick R. Observation on the treatment of traumatic urethral injuries and the value of the fenestrated urethral catheter. Br J Surg 1968;10:78.
Transpubic posterior urethroplasty via perineal approach in children: A new technique* Samir Orabi Urology Department, Alexandria College of Medicine, Alexandria, Egypt Received 2 February 2011; accepted 18 August 2011 Available online 25 September 2011
KEYWORDS Transpubic; Children; Pelvic distraction defect
Abstract Objective: To evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children. Methods: Of 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median Z 8.5 years). The median distraction defect length was 4.8 cm (range 3.7e6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter. Results: Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9e3.2 h) with a mean blood loss of 200 ml (range 50e640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis. Conclusions: Transpubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Management of complex pelvic fracture urethral distraction defects (PFUDD) in children remains a challenging problem for the urologist. Complex PFUDD is characterized by the
* This paper was presented at the ESPU 2008 and AUA 2008 annual meetings. E-mail address: [email protected].
presence of a distraction defect more than 3 cm long, or any distraction defect that is accompanied by rectourethral fistula, periurethral cavity, false passage or open bladder neck [1,2]. Many surgical approaches have been described for management of complex PFUDD in children, such as direct abdominal transpubic urethroplasty [3], abdomino-perineal urethroplasty [1,4,5], symphysiotomy [6], anterior sagittal transrectal approach [7] and elaborating perineal technique [8].
1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.08.001
394
S. Orabi
All of these techniques aim to provide a good wide field that allows tension-free anastomosis, and excision of all fibrous tissues with minimal postoperative complications, especially avoiding re-stenosis, incontinence and impotence [9,10]. To date, there has been controversy about the most appropriate surgical technique for management. Many investigators reported a lot of complications after the direct transpubic approach and abdominal-perineal approach, such as abnormal gait, hernia and low stricture-free rate (70e100%) [9,10]. Moreover, the most common drawbacks of these techniques are the need for two qualified urologic teams, a large amount of blood transfusion, long operative time and prolonged hospital stay at high cost [6,9,12,13]. Additionally, a lower success rate for the progressive elaborating technique is reported in children with complex PFUDD [14], and many authors refused supra-crural re-routing (last step of the latter technique) as they considered it a source of ischemia and obstruction [13] In this series, we demonstrate a new technique of total pubectomy via perineal approach for the management of complex PFUDD in children, and its advantage over other techniques.
Patients and methods Figure 1
Between January 2005 and July 2010, 78 children with PFUDD were admitted to our service. The mechanism of injury was blunt trauma due to motor vehicle accident. All children were managed by suprapubic tube during initial trauma. Preoperative evaluation included history of timing and type of trauma, technique of initial management and history of any surgical or endoscopic interference after initial management. Routine investigation and radiological evaluation, in the form of pelvic plain X-ray to detect the presence of bladder stones and abnormal bone at the site of future anastomosis, ascending urethrogram, combined voiding cysto-urethrogram, and endoscopy were performed to evaluate the length of the distraction defect and the state of the bladder neck. Restoration of urethral continuity was initially attempted from the perineum by performing the perineal elaborating technique in every case. After perineal midline incision and excision of all fibrous tissues, 12 out of 78 children (15.4%) had a short urethra that could not bridge the gap (more than 5 cm) to achieve a tension-free anastomosis (Fig. 1); for the latter group, transpubic posterior urethroplasty via perineal approach was performed.
Preoperative cysto-urethrogram with straining.
The upper border of the symphysis pubis was palpated and midline separation of the corporal bodies was performed using diathermy. Dissection and separation of crus from the bone was started from the medial to lateral edge. The same procedure was performed on the other side
Technique We started with a midline perineal incision and identification of the bulbar urethra. Dissection was done beyond the area of fibrosis. Transection of the urethra was performed with excision of all fibrous tissues from the bulbar urethra as well as the anterior surface of the prostate. The bulbar urethra was mobilized up to the penoscrotal junction and the length of the defect was measured. If the gap was more than 5 cm, which cannot be bridged by the available healthy bulbar urethra (Fig. 2), instead of supra-crural rerouting of the urethra we performed excision of the pubic bone via the same perineal route to achieve a tension-free anastomosis.
Figure 2 Long distraction defect is encountered after removal of all fibrous tissues.
Transpubic posterior urethroplasty via perineal approach (Fig. 3). Two crura were held laterally with tape and two longitudinal lines were performed over the pubic bone, the distance in between being about 4 cm (Fig. 4). By cutting diathermy over these lines, separation of the pubic bone was achieved. The separated bone was held by nipple forceps and complete separation from the posterior attachment was done by cutting diathermy (Fig. 5). Two stay sutures were made in the anterior surface of the prostatic capsule (Fig. 6) and a longitudinal incision was performed in between. The mucosa of the proximal urethra was fixed with 5/0 Vicryl. Spatulation and fixation of the mucosa of the bulbar urethra were done without any dissection at the prostatic apex. The anastomotic sutures were made (Fig. 7) over a suitable silicon catheter (usually 10e14 F). The tip of the urethral catheter was tied to the tip of a C-shaped sound and withdrawn through the suprapubic cystostomy (Fig. 8). An easy tension-free bulbo-prostatic anastomosis was achieved (Fig. 9). Closure of the wound was done in layers with fixation of the urethral catheter to the anterior abdominal wall to prevent slipping of the urethral catheter to the site of anastomosis (slipping causes either persistent leakage or disruption of the anastomosis) (Fig. 10). The suprapubic catheter was left in place. The drain was removed on the second postoperative day. Three weeks postoperatively (Fig. 11), a pericatheter ascending urethrogram was performed (Fig. 12) to detect healing at the anastomotic site. If no leakage was detected, the urethral
395
Figure 4 Two longitudinal lines, each 2 cm lateral to the midline, are marked by diathermy. A piece of the pubic bone is separated between the marked lines using cutting diathermy in younger children or bone and chisel in older children.
catheter was removed with closure of the suprapubic cystostomy for 5e7 days to be sure of normal voiding. The first follow-up visit was scheduled 1 month after suprapubic catheter removal when uroflowmetry, measurement of residual urine by ultrasound and an ascending urethrogram were done to assess the anastomosis and pattern of micturation. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter (Fig. 14). If the child complained of decrease of the force and caliber of stream, straining, suprapubic fistula or recurrent unresolved UTI, immediate ascending urethrogram and endoscopy were done. Urine culture and sensitivity were done if there was any irritative symptom or stress incontinence during the follow-up period.
Results
Figure 3 Complete separation and retraction of the two corporal bodies were done to expose the symphysis pubis till its upper surface (peno-scrotal junction).
Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. There were 12 patients with complex PFUDD with age ranging from 5.2 to 12 years (median Z 8.5 years; Table 1). The primary injury was motor vehicle accident. The median distraction defect length was 4.8 cm (range 3.7e6.4 cm). Mean period between the original trauma and the time of repair was 8 months (range 6e13 months). Mean operative time was 2.5 h (range 1.9e3.2 h) with a mean blood loss of 200 cc (range 50e640 cc) and mean hospital stay was 4 days.
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Figure 6 Mucosa of prostatic urethra (arrow) is exposed, incised between traction sutures and fixed to prostatic tissue to prevent proximal retraction.
Figure 5 Holding of the excised bone by nipple forceps (arrow) and complete separation from bladder neck and lateral attachments was achieved by cutting diathermy.
Cysto-urethroscopy was done 1 month postoperatively and on follow-up showed wide patent anastomosis and normal voiding in all cases (Fig. 13). This successful result was maintained during the entire follow up. Of 12 children, 9 (75%) reported normal urinary control while 3 (25%) reported stress incontinence requiring anticholinergic therapy that disappeared within 6 months on follow up. Out of 12 children, 9 (75%) had a retracted (short) penis after surgery. No complications related to perineal pubic resection were encountered such as abnormal gait, limping, or periurethral cavities. Neither recurrence nor urinary fistulas were reported on follow up. Potency state could not be evaluated due to the young age of the group.
Discussion Many authors have tried to explain why most children with a complex PFUDD need a different approach than used in adults. It has been reported that the types of pelvic fracture found in children are more serious than in adults,
Figure 7 prostate.
The final anastomotic sutures are made in the
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Figure 10 The tip of the urethral catheter is fixed to the anterior abdominal wall.
Figure 8 Tip of silicone catheter coming from anterior urethra is tied to the tip of the C-shaped sound and withdrawn out of the suprapubic cystostomy.
causing injury to the proximal urethra that extends to the prostate and bladder neck [16e18]. Also, cutting of the immature pubo-prostatic ligaments of children tends to involve pelvic trauma, causing a marked displacement of
Figure 9 Easy bulbo-prostatic anastomosis is done (arrow) around a silicon catheter.
the prostate upward and backward and resulting in long complex PFUDD [16,19]. There are many factors that compromise the success of the surgical management of complex PFUDD in children. The pediatric pelvis is shallow and broad, which limits the perineal approach and makes it suboptimal for adequate exposure [20]. Also, there is inadequate retrograde flow to the distal urethra due to an insufficient vascular connection which compromises healing at the anastomosis [14]. There is still controversy over how to manage children with complex PFUDD, either by the elaborating perineal technique or an abdomino-perineal approach. Since radiographic and instrumental gapometry is erroneously conceived, and the length of a gap is irrelevant to the planning procedure [1], restoration of urethral continuity
Figure 11 Post-operative plain X-ray pelvis showing urethral catheter (yellow arrow), SP cystostomy tube (red arrow) and the extent of the pubectomy (white arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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Figure 12 Three weeks postoperatively, a pericatheter ascending urethrogram is performed to confirm healing and urethral catheter is removed. Suprapubic cystostomy tube is closed for another week to confirm good micturation and then it is removed.
was initially attempted from the perineum by the perineal elaborating technique for every case in our series [8,15,21,22]. When the gap cannot be bridged by available healthy bulbar urethra, we performed excision of the pubic bone via the same perineal route to achieve a tension-free anastomosis, instead of supra-crural urethral re-routing that is not accepted by many authors because the urethra will compress beneath the corporal body leading to ischemic stricture and penile torsion [13,14]. In 1962, Pierce resected the symphysis pubis for treatment of PFUDD [23]. Waterhouse et al. depended on a preoperative combined cysto-urethrogram for perineal urethral mobilization with a simultaneous abdominal
Table 1
transpubic anastomosis [24]. While Turner-Warwick, disregarding the preoperative radiological finding, started via the perineal approach and then an abdominal transpubic anastomosis was done according to the intraoperative steps [25]. The abdomino-perineal approach is reserved for complex cases where adjunctive reconstructive steps beyond perineal urethral mobilization are needed for reconstruction [2,8,19,22,26,27]. However, many complications have been reported after the abdomino-perineal approach, such as abnormal gait, hernia, long operative time, excessive blood loss and prolonged hospital stay [9,11]. Kizer et al. believed that the least possible number of surgical steps should be used during urethroplasty to minimize the potential morbidity from the high lithotomy position [13]. From the present series, we have provided the first report of complete pubectomy via perineal approach in the management of complex PFUDD in children. In our series, the median PFUDD length was 4.8 cm. Pratap et al. [2], Senocak et al. [9] and Podesta [28] were able to bridge a gap of up to 6 cm by the abdomino-perineal approach. The average blood loss in our series was minimal (mean Z 200 ml) compared to other series (range 600e1000 ml) [2,20,29]. This can be explained by the cartilaginous and immature nature of bone in this age group and the limited area of excised bone. In the present series, the mean operative time was 2.5 h compared to 10e22 h for performing an abdomino-perineal urethroplasty [2,20,29]. Some authors advise two teams for the abdomino-perineal approach to decrease the surgical time to less than 4 h [13]. So, our new technique is a shorttime maneuver without any need for an extra team, and it avoids the morbidity of abdominal surgery so decreasing hospital stay. The success rate in our study was 100% over the entire follow-up period. According to many authors, the stricturefree rate following the abdomino-perineal transpubic approach is between 70% and 100% [2e5].
Results for 12 patients with complex PFUDD.
Patient
Age (years)
PFUDD length (cm)
Intraoperative Blood loss (ml)
Potencya
1 2 3 4 5 6 7 8 9 10 11 12 Total Mean Median
8 10 7 8.5 12 9 5.3 6.8 9.7 12 8.5 7 103.8 8.65 8.5
4.2 5.4 4.1 4.7 5.1 4.9 5.4 3.7 6.4 5.3 4.8 5.7 59.7 4.975 4.8
100 150 50 300 180 200 180 340 430 640 370 280 3220 268.3333 200
e e e e e e e e e e e e
a
could not be evaluated due to young age group.
Stress incontinence
Penile shortening present
present
present present
present present present present present present present present
Transpubic posterior urethroplasty via perineal approach
Figure 13
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Postoperative ascending urethrograms after perineal transpubic urethroplasty showing patent anastomosis.
Twenty-five per cent of our patients suffered from stress incontinence after surgery and anti-cholinergic drugs resolved this temporary problem completely. This can be explained by the occurrence of bladder contracture due to prolonged bladder diversion and associated UTI, which decrease the bladder capacity in this young age group. The incidence of urinary incontinence after the abdominoperineal approach ranges from 25% to 50% [6,20,24,30]. Middleton noted that after pubectomy the bladder descends noticeably in the pelvis causing postoperative stress incontinence [31]; this was not observed in our series as we did not dissect the bladder from its attachment. In the present study, excision of a small part of the pubic bone by the perineal approach should preserve potency state, as this approach is superior to all other routes because the vascular and nerve supply of the corpus cavernosa can be
preserved [32]; however, the potency state could not be evaluated due to the young age of the group. In the present study, Penile shortening (retraction) was observed in 75% of cases. Turner-Warwick [25,33] stated that the division of the suspensory ligament is a natural consequence of a total pubectomy that prevents penile chordee, and the base of the penis slides back a little. Neither loss of the suspensory ligament or a centimeter or two of penile length results in a significant disability. However, long-term follow up is needed to determine whether this is a permanent condition or will be resolved by the natural growth of children towards adulthood.
Conclusion Complex PFUDD in children is a challenge for both the parent and urologist. The total perineal transpubic approach provides an advantage over the elaborating perineal technique in creating a tension-free anastomosis without supra-crural urethral re-routing. It is a feasible, safe and easy technique. A small part of the bone is excised without affecting the gait. The technique has the following further advantages: -
-
-
Figure 14 Ascending urethrogram 5 years after transpubic urethroplasty showing new callous formation.
It is completely performed through the perineum without any need for another team for abdominal exposure, with minimal blood loss and short hospital stay. It is performed under direct vision instead of via a limited suprapubic window, thereby minimizing the risks of injury to the bladder neck and corporal bodies. Immobilization of the bladder and prostate during the procedure reduces the incidence of hernia and stress incontinence, and leaves the neurovascular bundle intact for future potency.
In our opinion, the perineal total pubectomy may be considered as the final step of the ‘elaborating perineal technique’, instead of supra-crural re-routing of the urethra, in children with complex PFUDD.
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Conflict of interest None.
Funding None.
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S. Orabi [16] Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77:876. [17] Boone TB, Wilson WT, Hussmann DA. Post-pubertal genitourinary function following posterior urethral disruption in children. J Urol 1992;148:1232. [18] Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999;161:1433. [19] Koraitim MM. Posttraumatic posterior urethral strictures in children: a 20-year experience. J Urol 1997;157:641. [20] Kramer SA, Furlow WL, Barrett DM, Kelalis PP. Transpubic urethroplasty in children. J Urol 1981;126:767e9. [21] Shenfeld OZ, Gdor J, Katz R, Gofrit ON, Pode D, Landan EH. Urethroplasty, by perineal approach, for bulbar and membranous urethral strictures in children and adolescent. Urology 2008;71:430e3. [22] Rourke KF, McCammon KA, Sumfest JM, Jordan GH, Kaplan GW. Open reconstruction of pediatric and adolescent urethral strictures: long-term followup. J Urol 2003;169: 1818e21. [23] Pierce JM. Exposure of the membranous and posterior urethra by total pubectomy. J Urol 1962;88:256e8. [24] Waterhouse K, Laungani G, Patil U. The surgical repair of membranous urethral strictures: experience with 105 consecutive cases. J Urol 1980;123:500. [25] Turner-Warwick R. The prevention of complications resulting from pelvic fracture urethral injuries and from their surgical management. Urol Clin N Am 1989;16(2):335e58. [26] Morey AF, McAninch JW. Reconstruction of posterior urethral injuries: outcomes analysis in 82 patients. J Urol 1997;157:506. [27] Hafez AT, El-assmy A, Sarhan O, El-hefnawy AS, Ghoneim MA. Perineal anastomotic urethroplasty for management posttraumatic urethral strictures in children: long-term outcome. Br J Urol Int 2005;95:403e6. [28] Podesta ML. Use of the perineal and perineal eabdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterates strictures in children: long-term outcome. J Urol 1998;160:160e4. [29] Pratap A, Agrawal CS, Pandit RK, Sapkota G, Anchal N. Factors contributing to a successful outcome of combined abdominal transpubic perineal urethroplasty for complex posterior urethral disruptions. J Urol 2006;176:2514. [30] Al-Refaei MA, Gaafer S, Abdelrahman M. Management of posterior urethral strictures secondary to pelvic fractures in children. J Urol 1991;145:353e6. [31] Middleton AG. Pubectomy and the use of omentum in urologic surgery. AUA update series, vol. 5, lesson 37, p. 1, 1986. [32] Ennemoser O, Colleselli K, Reissigle A, Poisel S, Janetschek G, Bartsch G. Posttraumatic posterior urethral stricture repair: anatomy, surgical approach and long-term results. J Urol 1997;157:499e505. [33] Turner-Warwick R. Observation on the treatment of traumatic urethral injuries and the value of the fenestrated urethral catheter. Br J Surg 1968;10:78.