Challenging the dogma of 6 steps for anastomotic urethroplasty in posterior urethral stricture: introducing step 3a

Joshi, Pankaj; Bandini, Marco; Montorsi, Francesco; Kulkarni, Sanjay

doi:10.1007/s00345-021-03823-1

Cited by 5 publications

(4 citation statements)

References 8 publications

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“…BUIN must be managed in high-volume centers by experts to achieve satisfactory long-term outcomes. These patients represent a challenging cohort requiring a versatile approach and a broad knowledge of different reconstructive techniques [23] . Preservation of the dorsal penile arteries should be prioritized and can be achieved by performing periosteal elevation [24] and inferior pubectomy, if necessary.…”

Section: Discussionmentioning

confidence: 99%

Flaps for bulbar urethral ischemic necrosis in pelvic fracture urethral injury

Joshi¹,

Bandini²,

Yepes³

et al. 2022

Plast Aesthet Res

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Bulbar urethral ischemic necrosis (BUIN) is an iatrogenic entity resulting from repeated attempts at performing anastomotic urethroplasty for pelvic fracture urethral injuries. Etiologically speaking, BUIN is related to a compromised blood supply of the bulbar urethra, which normally relies on anterograde supply from bulbar arteries and retrograde supply from recurrent branches of dorsal penile arteries, through the glans. At each transection of the bulbar urethra, both the anterograde and retrograde supplies are compromised, increasing the risk of BUIN. Even though this term is widely used among reconstructive urologists, BUIN is orphan of an accepted scientific definition. We aim to report our personal perspective on BUIN, to identify factors associated with its occurrence, and to describe the management options in these patients.

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Section: Discussionmentioning

confidence: 99%

Flaps for bulbar urethral ischemic necrosis in pelvic fracture urethral injury

Joshi¹,

Bandini²,

Yepes³

et al. 2022

Plast Aesthet Res

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“…The median (IQR) age of presentation in our series was 14 (11)(12)(13)(14)(15)(16)(17) years (Table 1).…”

Section: Pfui In Boysmentioning

confidence: 91%

“…Step Two: Separation of the corporal bodiesc. Step Three (A/B) [14]: Inferior wedge pubectomyd. Step Four: Supra‐crural re‐routing…”

Section: Methodsmentioning

confidence: 99%

Comprehensive analysis of paediatric pelvic fracture urethral injury: a reconstructive centre experience

et al. 2022

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To analyse our experience in pelvic fracture urethral injury (PFUI) in children and adolescents, with various anastomotic urethroplasties (AUs) used to accomplish tension-free anastomosis described and their surgical outcomes evaluated. Patients and methodsFrom 2008 to 2019, 192 cases including both primary and redo PFUI, which comprised 181 boys and 11 girls aged ≤18 years. The results are presented separately according to gender. Moreover, the two populations were divided in two age-related sub-groups for sensitivity analyses: Group 1 (children) aged ≤11 years and Group 2 (adolescent) aged 12-≤18 years. ResultsThe median (interquartile range [IQR]) age at presentation in our series was 14 (9-17) years for boys and 9 (6-10) years for girls. Primary vs redo cases were 85 (47%) vs 96 (53%) in boys and 10/11 vs one of 11 in girls. In the primary male cases (85), the bulbo-membranous junction was the commonest site of injury (63, 74.1%). In boys, transperineal AU (TPAU) was performed in 160 (88.4%) and transpubic urethroplasty (TPU) in 17 (9.4%). In girls, TPU was utilised in nine cases, where two received meatoplasty and vaginal episiotomy. In boys, the overall success rate for TPAU was 81.2% and in primary PFUI cases success for TPAU was 88.3%. Overall success for TPU was 64.7%. In girls, the success rate for TPU was 100%. In boys and girls, the success rates for various AUs utilised between the child and adolescent groups were comparable. The median (IQR) hospital stay was 3 (3-4) days for boys and girls. The median (IQR) followup duration was 25 (16-33) months and 20 (17-27) months for boys and girls, respectively. Secondary procedures were performed in 39 boys and one girl, which comprised laser optical internal urethrotomy in 26 (14.4%) boys and redo surgery in 13 (7.2%) boys and one (9.1%) girl. Of all patients, four of the 11 girls and 74 boys (38.5%) were lost to follow-up. ConclusionsMost paediatric PFUI can be addressed via a transperineal approach with reasonable long-term outcomes. In challenging cases salvage procedures utilising vascular-based flaps as a urethral substitute give satisfactory results. Even young children can be managed with a high success rate in expert hands and these injuries should be addressed by specialist reconstructive urologists.

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“…Surgical procedures for anastomotic urethroplasty were categorized according to the Webster classification (elaborated perineal approach) [ 6 , 11 ]: Step 1: urethral mobilization; Step 2: corporal body separation; Step 3: inferior wedge pubectomy with substeps (3a periosteal elevation, 3b-inferior wedge pubectomy); Step 4: supracrural urethral rerouting and combined abdominoperineal approach with or without an omental wrap. Rates of each step were compared.…”

Section: Methodsmentioning

confidence: 99%

Management of Pelvic Fracture Urethral Injury: Is Supracrural Urethral Rerouting (Step 4) Becoming Anecdotical or Does It Remain in Force?

Yepes

Oszczudłowski

Bandini

et al. 2023

JCM

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Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. We evaluated the outcomes of anastomotic urethroplasty (especially Step 4 or higher) or substitution urethroplasty in patients with PFUI at our center. Between 2013 to 2021, we retrospectively collected data on patients with PFUI. Surgical procedures were categorized according to the Webster classification and rates of each step were reported. The success rate was defined as Qmax above 10 mL/s and no need for further treatment. In this period, 737 male patients with PFUI were surgically treated. Notably, 18.8%, 17.6%, 46%, 1.8%, and 5.6% of included patients received steps 1, 2, 3, and 4 and the abdominoperineal approach, respectively. In 68 (9.2%) patients, the substitution of urethroplasty with a pedicled preputial tube (PPT) was needed. The success rate was 69.2% in Step 4, 74.4% in the abdominoperineal approach, and 86.4% in PPT; however, recurrence-free survival was not significantly different between groups (p = 0.22). Step 4 perineal anastomotic urethroplasty represents a surgical option in the armamentarium of PFUI treatment. Indications should be carefully reviewed to improve patient selection and avoid surgical failure, stopping at the step which first gives a tension-free anastomosis.

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Challenging the dogma of 6 steps for anastomotic urethroplasty in posterior urethral stricture: introducing step 3a

Cited by 5 publications

References 8 publications

Flaps for bulbar urethral ischemic necrosis in pelvic fracture urethral injury

Flaps for bulbar urethral ischemic necrosis in pelvic fracture urethral injury

Comprehensive analysis of paediatric pelvic fracture urethral injury: a reconstructive centre experience

Management of Pelvic Fracture Urethral Injury: Is Supracrural Urethral Rerouting (Step 4) Becoming Anecdotical or Does It Remain in Force?

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