RE Re Do urethroplasty after multiple failed surgeries of pelvic fracture urethral injury

Management of long-term functional sequelae of pelvic fracture urethral injury

Pelvic fracture (PF) is a rare emergency, which led to pelvic fracture urethral injury (PFUI) in 1.6% to 25% of cases. Urethral injury assessment requires a thorough analysis of the initial injury history and imaging that combine cystourethrography acutely, repeat urethral imaging as well as adjunctive use of MRI in the follow-up period. A more complex surgical approach to the delayed reconstruction of PFUI may be predicted by the urethral gap length (cysto-urethrography) or a lower pubo-urethral angle (MRI). Delayed urethroplasty is the treatment of choice, performed once the patient has recovered from other acute injuries, typically at least 3months post-injury. It consists in men in a bulbo-prostatic anastomotic urethroplasty which may require several steps of increasing complexity to allow a tension-free anastomosis: corpora splitting, partial inferior pubectomy, and rarely total pubectomy or urethra rerouting. More complex cases of PFUI repair may be encountered (long gap between the two urethral segments, bulbar necrosis, false passage after failed endoscopic realignment, orthopedic hardware in pubic symphyseal region, pediatric PFUI, failed previous urethroplasty, associated anterior urethral stricture, or recto-urethral fistula) and should be managed in expert centers. Urethral patency is achieved by surgical reconstruction with an overall success rate of 86%. Evaluation of potential associated sequelae including erectile dysfunction and urinary incontinence must be anticipated and taken into consideration in the path of rehabilitation.

Retrospective analysis of urethral anastomosis with ancillary maneuvers and intraoperative biaxial defect measurements to achieve a tension free guidance system for redo PFUDD treatment

OBJECTIVES

Redo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis.

PATIENTS AND METHODS

A total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed.

RESULTS

The overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence.

CONCLUSIONS

Ancillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis.

Redo inferior pubectomy for failed anastomotic urethroplasty in pelvic fracture urethral injury

Objectives

To assess the effect of redo inferior pubectomy on the management of complicated pelvic fracture urethral injury (PFUI) in patients with a history of failed anastomotic urethroplasty.

Materials and methods

We retrospectively reviewed all patients receiving redo anastomotic urethroplasty with redo inferior pubectomy for failed PFUI between January 2010 and December 2021. Patients with incomplete data and those who were lost to follow-up were excluded. Successful urethroplasty was defined as the restoration of a uniform urethral caliber without stenosis or leakage and further intervention. Functional results, including erectile function and urinary continence, were evaluated. Descriptive statistical analyses were then performed.

Results

Thirty-one patients were included in this study. Among them, concomitant urethrorectal fistula occurred in 2 patients, and concomitant enlarged bladder neck occurred in 1. The stenosis site was the bulbomembranous urethra in 2 patients and the prostatomembranous urethra in 29. The mean length of urethral stenosis in all patients was 3.1 cm (range, 2.0-5.0 cm). After a mean follow-up of 34.6 months, the final success rate was 96.8%. The incidence of erectile dysfunction reached 77.4% (24/31). Normal continence was achieved in 27 (87.1%) patients. One patient developed urinary incontinence of grade II requiring urinary pads because of an enlarged bladder neck. According to the Clavien-Dindo classification, postoperative complications of grade I occurred in 7 patients and grade II in 4.

Conclusions

Repeat anastomotic urethroplasty with repeat inferior pubectomy provides reliable success rates for failed PFUI. In complicated cases, it should be known and mastered.

Surgical and Patient-Reported Outcomes of Delayed Anastomotic Urethroplasty for Male Pelvic Fracture Urethral Injury at a Japanese Referral Center

We aimed to assess the surgical and patient-reported outcomes of delayed anastomotic urethroplasty (DAU) for pelvic fracture urethral injury (PFUI). We included 211 male patients who underwent DAU for PFUI. DAU success was considered when the urethral lumen was sufficiently large for the passage of a flexible cystoscope, without additional treatment required. The patients completed the lower urinary tract symptoms (LUTS)-related quality of life (QOL) questionnaire (scores: 0, not at all; 1, a little; 2, somewhat; 3, a lot), EuroQol-5 dimensions (EQ-5D), and EQ-5D visual analog scale (EQ-VAS). Postoperative overall satisfaction was evaluated using the following responses: “very satisfied,” “satisfied,” “unsatisfied,” or “very unsatisfied.” DAU was successful in 95.3% cases, with a median postoperative follow-up duration of 48 months. Multivariate logistic regression analysis revealed that “greater blood loss” was an independent predictor of failed urethroplasty. Questionnaire responses were obtained from 80.1% patients. The mean LUTS-related QOL, EQ-5D score and EQ-VAS improved significantly from 2.8, 0.63 and 54.4 at baseline to 0.9, 0.81 and 76.6 postoperatively (p < 0.0001 for all parameters). Moreover, 35.5% and 59.2% of the patients responded being “satisfied” and “very satisfied,” respectively, with their DAU outcomes. DAU not only had a high surgical success rate, but also a significant beneficial effect on both LUTS-related QOL and overall health-related QOL.

Efficacy of re-do urethroplasty for post-traumatic urethral stricture: An analysis of the anatomical and functional outcomes

OBJECTIVES

To investigate the efficacy of re-do urethroplasty for post-traumatic urethral stricture in terms of anatomical and functional outcomes.

METHODS

A total of 48 patients who underwent re-do urethroplasty for post-traumatic urethral stricture due to perineal trauma (n = 21) and pelvic fracture urethral injury (n = 27) between October 2010 and March 2020 were retrospectively reviewed. Patients were followed by uroflowmetry, post-void residual volume assessment and 17-Fr flexible cystoscopy after re-do urethroplasty. Successful urethroplasty was defined as having a urethral caliber adequate for the passage of a cystoscope and requiring no additional treatments. Patients completed a validated patient-reported outcome measure for urethral stricture surgery, including overall satisfaction, and the sexual health inventory for men.

RESULTS

The type of re-do urethroplasty was anastomotic urethroplasty in 45 (94%) patients and buccal mucosa urethroplasty in three (6%) patients. Urethroplasty was successful in 47 (98%) patients (median follow up 35 months, interquartile range 21-75). The patient-reported outcome measure for urethral stricture surgery and Sexual Health Inventory for Men were assessed in 36 (75%) patients, and the mean lower urinary tract symptom-specific quality of life, EuroQol-5D and EuroQol-visual analog scale scores improved from 2.86, 0.63 and 54.17 preoperatively to 0.78 (P < 0.001), 0.86 (P < 0.001) and 76.94 (P < 0.001) postoperatively, respectively. The pre- and postoperative mean Sexual Health Inventory for Men scores (5.92 and 4.94, respectively) did not significantly differ (P = 0.318). All 36 patients were satisfied with their urethroplasty outcomes, with 20 (56%) very satisfied patients.

CONCLUSIONS

Re-do urethroplasty for post-traumatic urethral stricture shows a high success rate and beneficial effects on both anatomical and functional outcomes.