Urethral Reconstruction for Traumatic Posterior Urethral Disruption: Outcomes of a 25-Year Experience

Abstract

Purpose: Management of posterior urethral disruption due to pelvic trauma can be quite challenging and is the subject of ongoing controversy. This study presents an update of the University of California, San Francisco experience with delayed anastomotic posterior urethroplasty for management of these injuries. Materials and Methods:Since 1979 all patients undergoing posterior urethroplasty by a single surgeon at University of California, San Francisco and its affiliated hospitals have been entered prospectively into a patient registry. For this cohort descriptive statistics were calculated and recurrence was analyzed with the Kaplan-Meier method. Success was defined as no recurrence (by symptoms and/or retrograde urethrogram) or a mild recurrence managed successfully with a single internal urethrotomy. Results: A total of 134 male patients were analyzed with a mean of 32.9 and a median of 12 months followup. Mean patient age at surgery was 34.8 years. Of the patients 35% had undergone at least 1 prior procedure for stricture including prior urethroplasty in 16%. In addition, 22% required partial pubectomy and 4% a combined abdominal-perineal approach with total pubectomy. Of patients with a closed bladder neck on urethrography 34% vs 7% of those with an open bladder neck required pubectomy (p Ͻ0.001). Stricture length tended to be longer in pubectomy cases (mean 3.2 vs 2.1 cm by urethrography, p ϭ 0.055). Of the patients 14% experienced recurrent stricture at a mean of 12 months, 42% of whom were treated successfully with a single urethrotomy. The overall success rate allowing 1 direct vision internal urethrotomy was 93%. Conclusions: Anastomotic urethroplasty offers excellent long-term results to patients with posterior urethral trauma and stricture disease even after multiple prior procedures.Key Words: urethra; urethral stricture; anastomosis, surgical; wounds and injuries P osterior urethral injury complicates up to 25% of pelvic fractures arising from blunt pelvic trauma. 1 These injuries pose a significant management challenge, aggravated by the frequently severe extent of associated organ injuries, initial medical instability of many patients, distortions of pelvic and lower urinary tract anatomy, and the potentially extensive fibrotic response to urinary extravasation. Multiple approaches to these patients have been used in past and recent series. Patients treated at or referred to UCSF undergo initial suprapubic cystostomy urinary diversion and some patients referred within the last 10 years have also had an unsuccessful attempt at primary realignment. In this article we present our experience with delayed perineal anastomotic urethroplasty for treatment of these patients in the last 25 years. METHODS All operations were performed by a single surgeon (JWM).The technique for anastomotic posterior urethroplasty has been reported previously. 2,3 Key aspects of management include accurate preoperative definition of the stricture, which is usually possible via retrograde and antegrade urethrography (RUG/VCU...

Urethral trauma. Part II: Types of injury and their management

“…It also has the potential to cause significant additional morbidity from further damage to recently traumatised tissues. SPC drainage alone has a higher incidence of stenosis and the need for DU, ≈ 90%, but this is now a very reliable procedure in expert hands, in patients who have had the opportunity to make a full recovery from their injury and with no risk of additional trauma to the urethra [60][61][62][63][64]. Thus, by consensus, the 'gold standard' is SPC and DU 3-6 months later when the patient is otherwise fit and well, because the potential morbidity of PR is absent and because the long-term, instrumentation-free, stenosisfree outcome is better [30,65].…”

“…Having gone to this extreme Turner-Warwick [82,83] reduced the degree of mobilisation of the urethra to just the bulbar part and promoted the transperineal approach for short stenoses of < 2-2.5 cm; and reduced the degree of resection of the pubis during an abdomino-perineal procedure for longer stenoses ( > 2.5 cm) by doing a posterior wedge resection rather than a total pubectomy. Webster and Ramon [84] then popularised the transperineal approach, rather than a routine abdomino-perineal approach, which has been in general use for uncomplicated cases, almost irrespective of length (see below), for the last 20 years [17,41,53,[60][61][62]64].…”

“…This so-called 'transperineal progression approach' to BMA starts with perineal mobilisation of the bulbar urethra and transection through the site of obliteration or stenosis [17,41,53,[60][61][62]64]. The bulbar urethra is then mobilised back to the attachment of the suspensory ligament or otherwise as far as necessary (Fig.…”

One-Stage Direct-Vision Internal Urethrotomy and Penile Prosthesis Implantation for Severe Erectile Dysfunction with Urethral Stricture

“…4 On the other hand, erectile dysfunction (ED) is a common sequel of pelvic fractures, particularly those associated with posterior urethral injury as a result of damage to the cavernous nerves or branches of the pudendal arteries. The incidence rate of ED in patients with pelvic fracture combined with urethral injury has reached to 72%.…”

Ejaculatory profiles and fertility in men after posterior urethroplasty for pelvic fracture‐urethral distraction defect injuries

“…In men who sustain a pelvic fracture-urethral distraction defect (PFUDD) injury, many steps might be required to realign and repair the urethra [1,2]. The urethral anastomosis is complicated, and located posteriorly at the junction of the membranous and prostatic urethra.…”