Anatomy and techniques in posterior urethroplasty

Abstract

Given its complex anatomy, injury to the posterior urethra may result in a number of reconstructive challenges. With the appropriate operative planning and experience, surgical repair can be very successful. This review discusses the applicable techniques for the perineal approach to posterior urethral stenosis, including bulbomembranous anastomosis for pelvic fracture urethral injury and repair of vesicourethral anastomotic stenosis (VUAS) following prostate surgery. The advanced techniques reviewed include an adaptation allowing a bulbar artery sparing approach to posterior urethroplasty and an intrasphincteric urethroplasty procedure which may allow continence preservation in patients with membranous urethral stenosis.

Management of male pelvic fracture urethral injuries: Review and current topics

“…45 Surgical correction of urethral stenosis secondary to PFUI remains one of the most challenging issues in urology. 14,91 The technical inexperience of the surgeon has been reported to be the most common cause of failed urethroplasty, 26,73 and Mundy has recommended that urologists who are not routinely carrying out >15 urethroplasties a year should be referring patients to high-volume centers where the caseload is enough to maintain surgical expertise. 92 The patient's best chance of a cure is during the first attempt, and his QOL for the rest of his life depends on the decisions his surgeon makes.…”

“…The anterior urethra consists of the fossa navicularis, penile urethra and bulbar urethra, whereas the posterior urethra consists of the membranous urethra and prostatic urethra. The posterior urethra passes through the perineal diaphragm close to the pubic bone, to which it is adhered to the puboprostatic ligaments and the perineal membrane . Pelvic ring disruption can tear the ligaments from the attachments to the urethra at this level due to its lack of distensibility and the absence of protective surrounding spongy tissue or prostatic parenchyma, and certain fracture locations are associated with increased risk of urethral injury .…”

“…Substitution urethroplasty using skin flaps or ileal grafts is rarely necessary, except for patients with a long gap and/or limited residual bulbar length in re‐do cases . In brief, the patient is in a standard or exaggerated lithotomy position and the bulbar urethra is exposed by a midline or curved perineal incision depending on the surgeon's preference . The bulbar urethra is then circumferentially mobilized from the penoscrotal junction distally to the site of the disruption proximally to use the elasticity of the bulbar urethra, which can be stretched to overcome the gap between the two urethral ends after excision of the scar tissue to accomplish an overlapping spatulated anastomosis (first step of ancillary techniques; Fig.…”

“…The posterior urethra passes through the perineal diaphragm close to the pubic bone, to which it is adhered to the puboprostatic ligaments and the perineal membrane. 2,14 Pelvic ring disruption can tear the ligaments from the attachments to the urethra at this level due to its lack of distensibility and the absence of protective surrounding spongy tissue or prostatic parenchyma, and certain fracture locations are associated with increased risk of urethral injury. 2 Aihara et al reviewed 362 patients admitted with pelvic fracture in a level 1 trauma center in the USA, and reported that widened symphysis and fracture of the inferior pubic ramus are significant predictors of urethral injury on multivariate analysis.…”

Preoperative simulation by volume rendering image and intraoperative navigation by ultrasound for posterior urethroplasty: A report of initial three cases

“…In transperineal reconstruction of the posterior urethra, exposure of the proximal urethral stump is the most important step that determines surgical success . To access the stump, scar tissue is removed under the guidance of the cystoscope light in the proximal urethra.…”