Mechanism of continence after repair of posterior urethral disruption: evidence of rhabdosphincter activity

Urethral-sparing laparoscopic simple prostatectomy for the treatment of benign prostatic hyperplasia with asymptomatic urethral stricture after urethral stricture surgery

OBJECTIVE

To evaluate the efficacy of urethral-sparing laparoscopic simple prostatectomy (US-LSP) for the treatment of large-volume (>80 ml) benign prostatic hyperplasia (BPH) with asymptomatic urethral stricture (urethral lumen > 16 Fr) after urethral stricture surgery.

METHODS

We retrospectively analyzed clinical data of 39 large-volume BPH patients with asymptomatic urethral stricture after urethral stricture surgery who underwent US-LSP from January 2016 to October 2021. Postoperative follow-ups were scheduled at 1, 3, and 6 months.

RESULTS

All patients affected by significant BPH-related lower urinary tract symptoms (LUTS) including 22 cases with asymptomatic anterior urethral stricture and 17 cases with asymptomatic posterior urethral stricture. Median operative time was 118 min (interquartile range [IQR]100-145). Median estimated blood loss was 224 ml (IQR: 190-255). 33 patients(84.6%) avoided continuous bladder irrigation. Postoperative complications occurred in 5 patients (12.8%), including 4 cases with Clavien-Dindo grade 1 and grade 2 and 1 case with grade 3a. During follow-up, US-LSP presented statistically significant improvements in LUTS compared to baseline (P < 0.05). A total of 25 patients had normal ejaculation preoperatively and 3 patients (12%) complained retrograde ejaculation postoperatively. Two patients (5.1%) reported stress urinary incontinence (SUI) and no patient reported aggravated urethral stricture during follow-up.

CONCLUSIONS

US-LSP was safe and effective in treating large-volume BPH with asymptomatic urethral stricture after urethral stricture surgery. Meanwhile, US-LSP could reduce the risk of SUI in patients with asymptomatic posterior urethral stricture and maintain ejaculatory function in a high percentage of patients.

Young-Dees bladder neck reconstruction: An effective alternative in the treatment of urinary incontinence following urethroplasty for pelvic fracture urethral injury

Introduction:

We review our experience of Young-Dees bladder neck reconstruction (BNR) in treatment of urinary incontinence following anastomotic urethroplasty for pelvic fracture urethral injury (PFUI).

Material and methods:

Between January 2009 and June 2015, 11 patients presented with urinary incontinence following urethroplasty for PFUI. After evaluation with voiding cystourethrogram, urodynamics and cystoscopy, seven were found to be having genuine stress urinary incontinence. All seven underwent Young-Dees BNR. We also looked at whether there were any predictors of either poor or good outcome following surgical correction based on radiographic, endoscopic and urodynamic findings.

Results:

Of the seven patients who had undergone Young-Dees BNR, four had urethroplasty at our centre (4/89, 4.4%). Median age was 23 years (range = 14–31 years), and median time to definitive treatment was 15 months (range = 9–126 months). Age at injury <15 years in two and >15 years in five. Four (56%) had pubic diastases, in three, it was secondary to the injury, and in one, it was consequent to facilitating urethroplasty via a formal transpubic approach. There were no consistent radiographic findings on the pre-operative studies which could predict whether the configuration of the bladder neck or the degree of bladder descent might result in incontinence. The number of prior attempts at urethroplasty when compared to a similar cohort was also non-contributory. At urodynamics, all bladders were stable on filling and there were no issues related to compliance with the bladder neck being occluded. The detrusor pressure generated during voiding and with the bladder neck occluded did help us to counsel patients regarding the outcome of surgery and if there would be a need for clean intermittent self-catheterisation following surgery. All patients are voiding via naturalis without the need for clean intermittent self-catheterisation and are socially continent.

Conclusion:

Young-Dees BNR may be a forgotten procedure but is worth revisiting in patients with stress urinary incontinence following successful urethroplasty for PFUI. It is cost-effective and can be done without the Leadbetter modification.

Level of evidence:

Not applicable

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.

Role of magnetic resonance imaging in the management of male pelvic fracture urethral injury

The management of male pelvic fracture urethral injury remains a urological challenge. Pelvic fracture urethral injury can be associated with sequelae, such as urethral gap, erectile dysfunction and urinary incontinence. Delayed anastomotic urethroplasty, the gold standard treatment for urethral gaps caused by pelvic fracture urethral injuries, is technically demanding, and reconstructive urologists should preoperatively obtain as much detailed anatomical information as possible. A combination of antegrade and retrograde urethrography is the fundamental preoperative evaluation, but it cannot accurately assess the urethral gap length, the degree of lateral prostatic displacement, the anatomical relationship of the urethra with its surrounding structures (such as the rectum and dorsal venous complex) or periurethral problems (such as minor fistulae or cavitation). To make up for these limitations of urethrography, magnetic resonance imaging has emerged as a non-invasive, multiplanar and high-resolution modality for the evaluation of pelvic fracture urethral injury. Magnetic resonance imaging has excellent soft-tissue contrast, and can clearly show the urethra and periurethral tissues without the effects of radiation, thus enabling clinicians to anticipate the required ancillary techniques for delayed anastomotic urethroplasty and to predict functional outcomes, such as erectile function and urinary continence, after delayed anastomotic urethroplasty. This review discusses the role of magnetic resonance imaging in the evaluation of pelvic fracture urethral injury and its impact on patient management.

Membranous urethral length on magnetic resonance imaging as a novel predictor of urinary continence after delayed anastomotic urethroplasty for pelvic fracture urethral injury

PURPOSE

We studied the impact of membranous urethral length (MUL) on magnetic resonance imaging (MRI) on post-urethroplasty continence in male patients with pelvic fracture urethral injury (PFUI).

METHODS

Of 169 male patients with PFUI who underwent delayed anastomotic urethroplasty between 2008 and 2020, 85 who underwent preoperative MRI, had no recurrent stenosis on cystoscopy, and underwent a 1-h pad test 1 year after surgery were included. MUL was defined as the distance from the distal end of the disrupted proximal urethra to the apex of the prostate, as measured using T2-weighted MRI. Urinary incontinence (UI) was defined as a 1-h pad test weight > 2.0 g.

RESULTS

None of the patients had UI before a pelvic fracture. Eighty-two patients (96.5%) had a measurable MUL, and the median length was 8.1 (interquartile range [IQR], 5.2-10.8) mm. The median weight of the 1-h pad test was 1.0 (IQR, 0.0-4.0) g, and 26 (30.6%) patients had UI. An open bladder neck (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.0-22.0; p = 0.04) and a short measurable membranous urethra (for every extra mm: OR, 1.2; 95% CI, 1.0-1.3; p = 0.04) were significant UI predictors on multivariate analysis.

CONCLUSIONS

A long MUL is significantly positively associated with urinary continence in male patients with PFUI. This could be of potential value to reconstructive urologists when counseling patients regarding post-urethroplasty continence before urethroplasty.

Subsphincteric Anastomosis During Laparoscopic Robot-Assisted Radical Prostatectomy and Its Positive Impact on Continence Recovery

Introduction: To assess the interest of a new sphincter preserving anastomosis technique for continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods: We performed a monocentric single-operator study on 187 consecutive RALP. Patients were divided into two groups: Group 1 (standard anastomosis, until December 2017) and Group 2 (subsphincteric anastomosis [SSA], since January 2018). The SSA consisted in respecting the sphincteric sleeve during the anastomosis suturing only the internal layer of the urethra with the bladder and thereby avoiding the loss of sphincteric length induced by the suture. Pre-, intra-, and postoperative data were prospectively collected and compared. Criteria of continence were as follows: no pad use and complete absence of leakage at catheter removal at 1 month and 1 year.

Results: The two groups were comparable in terms of prostate-specific antigen, gland volume, and Gleason score. In Group 2 (SSA), we observed a complete continence recovery in 75.6% at catheter removal (p = 0.0000035), in 82.9% at 1 month (p = 0.000092), and in 97.5% at 1 year (p = 0.028), independently of bladder neck preservation (p = 0.388). There was also a significant difference between the two groups concerning urinary reeducation requirement (p = 0.0006), pad use, and urinary quality of life (p = 0.0000002). No anastomosis complication was reported.

Conclusions: The SSA significantly improved the rates of immediate, early, and 1-year continence recovery after RALP. These results need further study among larger numbers of patients.

Urethral realignment with maximal urethral length and bladder neck preservation in robot-assisted radical prostatectomy: Urinary continence recovery

Purpose

To evaluate early recovery of urinary continence after robot-assisted radical prostatectomy (RARP) with urethral realignment using bladder neck preservation (BNP) and maximal urethral length preservation (MULP).

Methods

Patients who underwent RARP between 2014 and 2017 owing to prostate cancer with a Gleason score ≤ 7 (3+4), ≤ cT2c stage, and prostate-specific antigen level < 20 ng/ml were investigated. Patients with tumors of the bladder neck or apex on magnetic resonance imaging were excluded. A total of 266 patients underwent the operation using the standard method between 2014 and 2015 (group 1), while 305 patients underwent urethral realignment between 2016 and 2017 (group 2). Continence was defined as wearing no pad or one security pad.

Results

The continence rates immediately after Foley catheter removal, at 2 weeks, and at 1, 3, 6, and 12 months after operation in group 2 were 46.9%, 63.0%, 73.4%, 90.1%, 94.8%, and 98.7%, respectively. The continence rate at 1 month in group 2 was significantly higher than that in group 1 (65.4% versus 73.4%, p = 0.037). The multivariate regression analysis showed that age and surgical method were factors affecting early continence recovery. The positive surgical margin rates were 18.0% and 14.8% in groups 1 and 2, respectively (p = 0.288). Biochemical recurrence occurred in 14.7% and 8.2% in groups 1 and 2, respectively (p = 0.015).

Conclusion

Urethral realignment using BNP and MULP resulted in rapid continence recovery and good oncological results after RARP in young patients with a Gleason score ≤ 7 and organ-confined disease.

Modified transurethral resection of the prostate for the management of BPH-related refractory lower urinary tract symptoms in patients with a history of pelvic fracture urethral injury reconstruction

INTRODUCTION

To evaluate the impact of a modified transurethral resection of prostate (mTURP) in patients with a history of pelvic fracture urethral injury (PFUI) status post-urethroplasty, and subsequent lower urinary tract symptoms (LUTS) refractory to medical therapy caused by benign prostatic hyperplasia (BPH).

METHODS

Five patients were identified with a history of PFUI and a successful reconstruction of the urethra, who developed severe LUTS. After maximal medical therapy failed, these patients underwent a mTURP. Their continence status and voiding parameters were recorded before and after surgery.

RESULTS

Significant improvements in both post-void residual (172 ± 137.36 mL vs. 26.6 ± 24.44 mL), p = 0.026, and International Prostatic Symptom Score (23.6 ± 4.82 vs. 7.6 ± 4.30), p = 0.002 were observed in the study. Although maximum flow rate was not statistically significant, there was an overall improvement in Q_max in all patients (8.92 ± 3.71 vs. 16.78 ± 6.44 mL/sec). Furthermore, all patients remained continent after this modified intervention.

CONCLUSION

Our modified TURP provides an adjunctive option in the management of severe LUTS secondary to BPH in patients with a history of PFUI urethroplasty who are refractory to medical management. In our experience, the patients experienced a lasting response with no incontinence.

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

Pelvic fractures from high-energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.

Reconstruction of Membranous Urethral Strictures

PURPOSE OF REVIEW

Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures.

RECENT FINDINGS

Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Complete bladder neck preservation promotes long-term post-prostatectomy continence without compromising midterm oncological outcome: analysis of a randomised controlled cohort

PURPOSE

The only RCT available on complete bladder neck preservation (cBNP) during radical prostatectomy reported superior continence and QoL outcomes in the first 12 months after cBNP. We provide the first data on long-term urinary continence, QoL and biochemical recurrence (BCR) after complete bladder neck preservation in a randomised controlled cohort.

METHODS

After approval by IRB, 199 men recruited for the randomised, controlled single-blind Heidelberger cBNP Study had prostatectomy performed with (cBNP) or without (noBNP) complete bladder neck preservation. Only men with renewed consent for this follow-up were evaluated for continence, QoL outcomes and BCR by ICIQ-SF self-assessment questionnaire, Pad-use/day and PSA levels. Students-t test, Pearson´s Chi-square, Fishers exact test and multiple logistic regression analyses were applied.

RESULTS

Mean follow-up was approx. 4 years. There were no significant differences in baseline characteristics between responders/non-responders or between study groups. We noted significantly higher continence rates (p = 0.004), less pad-use (p < 0.001), reduced frequency (p = 0.023) and amount (p = 0.009) of urine loss, and higher QoL outcomes (p = 0.012) after cBNP. A younger age positively influenced continence (OR = 0.91), but the multivariate analysis found cBNP to be the only independent predictor of continence (p = 0.008; OR = 8.1). pT stage was the only predictor for positive surgical margins (PSM; p < 0.001). There was no significant difference in pT stage (p = 0.23) or BCR (p = 0.63) between study groups and also no significant correlation between BCR and presence (p = 0.26) or localisation (p = 0.11) of PSM, nerve sparing (p = 0.70), surgeon (p = 0.41), preoperative PSA (p = 0.53) or pT stage (p = 0.17). No cancer-related death was noted.

CONCLUSIONS

Results of this first follow-up on a prospective randomised controlled cohort demonstrate that cBNP is associated with significantly higher continence and QoL outcomes without compromising cancer control making cBNP a novel objective during radical prostatectomy.

Magnetic Resonance Imaging and Pelvic Fracture Urethral Injuries

Pelvic fracture urethral injuries (PFUI) are devastating lesions that lead to fibrosis and urethral disruption, which result in recurrent strictures, urinary incontinence, fistulae, and even erectile dysfunction, representing a management problem for the urologist. Magnetic resonance imaging (MRI) may be a valuable tool in establishing or confirming the diagnosis by providing detailed anatomy and estimating disease extent. We present a comprehensive review of the current literature on the role of MRI on diagnostic evaluation and surgical management of patients with PFUI.

Experience with 32 Pelvic Fracture Urethral Defects Associated with Urethrorectal Fistulas: Transperineal Urethroplasty with Gracilis Muscle Interposition

PURPOSE

Pelvic fracture urethral defects associated with urethrorectal fistulas are rare and difficult to repair. The aim of this study was to evaluate the efficacy of transperineal urethroplasty with gracilis muscle interposition for the repair of pelvic fracture urethral defects associated with urethrorectal fistulas.

MATERIALS AND METHODS

We identified 32 patients who underwent transperineal urethroplasty with gracilis muscle interposition to repair pelvic fracture urethral defects associated with urethrorectal fistulas. Patient demographics as well as preoperative, operative and postoperative data were obtained.

RESULTS

Mean followup was 33 months (range 6 to 64). The overall success rate was 91% (29 of 32 cases). One-stage repair was successful in 17 of 18 patients (94%) using perineal anastomosis with separation of the corporeal body and in 12 of 14 (86%) using perineal anastomosis with inferior pubectomy and separation of the corporeal body. All 22 patients (100%) without a previous history of repair were successfully treated. However, only 7 of 10 patients (70%) with a previous history of failed urethroplasty and urethrorectal fistula repair were cured. Recurrent urethral strictures developed in 2 cases. One patient was treated successfully with optical internal urethrotomy and the other was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent urethrorectal fistulas associated with urethral strictures developed in an additional patient.

CONCLUSIONS

Transperineal urethroplasty with gracilis muscle interposition is a safe and effective surgical procedure for most pelvic fracture urethral defects associated with urethrorectal fistulas. Several other factors may affect its postoperative efficiency.

Posterior Urethral Strictures

Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty.

One-stage Anastomotic Urethroplasty for Traumatic Urethral Strictures. January 2004-January 2013

Purpose:

One-stage anastomotic urethroplasty is an attractive procedure for reconstructing the urethra following trauma. This prospective study highlights the advantages of the procedure and outcome of treatment.

Materials and Methods:

A total of 87 patients, age range 11–68 years with a mean of 35.4 years were included in the study. These patients were seen at two tertiary Institutions in South East Nigeria. The stricture lengths varied between 0.8 cm and 3.2 cm. All had suprapubic cystostomy initially followed by an end to end perineal anastomosis after thorough work up. Preoperatively 9 (10.3%) patients had impotence from the trauma. Postoperatively the patients were assessed with peri-catheter retrograde urethrogram, micturating cystourethrogram, and uroflowmetery.

Results:

All the patients were males. At 6 months, 13 out of 21 (62%) patients who had bulbo-prostatic anastomosis and 62 out of 66 (94%) patients that had bulbo-membranous, bulbo-bulbar anastomosis had satisfactory micturition with urine flow rate >15 ml/s. Totally, 12 (13.8%) patients had urine flow rate of <12 ml/s. At 1-year, there were 12 re-strictures, no urinary incontinence and four cases of a decrease in the strength of penile erection that needed no treatment.

Conclusion:

Delayed one-stage anastomotic urethroplasty provides for decreased incidence of postoperative morbidity, re-stricture, impotence and urinary incontinence for most short segment posttraumatic urethral strictures.

[Anatomy and anatomical foundations of urethral surgery]

To achieve an optimal outcome after urethral reconstructive surgery knowledge of urethral and urogenital anatomy is mandatory. It is necessary to know the anatomical characteristics of grafts and flaps to achieve successful surgical results. An ideal graft is not yet available and an optimal surgical outcome depends on the technique of harvesting, graft handling and histological transplant characteristics. Surgical technique and experience are building a successful urethral surgery out of the challenge.

Classification of pelvic fracture urethral injuries: Is there an effect on the type of delayed urethroplasty?

The posterior urethral injury due to pelvic fracture is a challenging problem. Because pelvic fractures are widely varying in severity, direction and mechanism, a wide spectrum of pelvic fracture urethral injuries (PFUIs) is clinically identified. Previously published data indicate that the proposed classifications of PFUIs are neither ideal nor universally acceptable. Moreover, these classifications might not have a significant effect on the delayed definitive techniques of urethral reconstruction. The currently available classifications and management strategies of PFUIs lack consensus and are based on accumulated surgical experience and clinical case studies. In the current era of evidence-based medicine there should be clear and appropriate guidelines for managing PFUIs, based on meta-analysis of well-designed controlled studies and evidence-based surgical science. In this way several controversies in the management of PFUIs will be resolved and the quality of life of patients who have sustained PFUIs will be improved.

Management of posterior urethral disruption injuries

Posterior urethral disruption is a traumatic injury to the male urethra, which most often results from pelvic fracture. After trauma, the distraction defect between the two ends of the urethra often scars and becomes fibrotic, blocking the urethra and bladder emptying. Increasing evidence suggests that many posterior urethral disruptions occur at the junction between the membranous urethra and the bulbar urethra, which is distal to the rhabdosphincter. In the acute setting, when a posterior urethral disruption is suspected, retrograde urethrography should be performed. Posterior urethral disruptions can be managed acutely by realignment of the urethra over a urethral catheter or by placement of a suprapubic catheter for bladder drainage only. Once fibrosis has stabilized, the patient can undergo posterior urethroplasty. In most cases, this procedure can be performed via a perineal approach in a single-stage surgery. The results of this single-stage perineal urethroplasty are excellent, and a patent urethra can be re-established in the majority of men who undergo surgery.