Hernias after transpubic urethroplasty

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.

Clinical factors that predict successful posterior urethral anastomosis with a gracilis muscle flap

Purpose

We evaluated the preoperative clinical factors that affect the surgical outcome of posterior urethral anastomosis (PUA) with a gracilis muscle flap (GMF) to determine which factors predict benefit from the use of the GMF.

Materials and Methods

This was a retrospective analysis of 49 patients who underwent a delayed PUA with a GMF. A successful clinical outcome was defined as achieving a peak urinary flow rate greater than 15 mL/s at 3 and 12 months postoperatively without evidence of stricture recurrence on a retrograde urethrogram or cystourethroscopy at 3 months postoperatively. Multiple clinical factors were evaluated by use of univariate and multivariate analyses.

Results

The outcome of 21 of 49 patients (42.9%) was deemed successful. The mean age of the 49 patients was 37.2±13.5 years and the mean follow-up duration was 43.4±28.0 months. The length of the urethral defect was significantly shorter in patients with a successful outcome than in patients with an unsuccessful outcome (p=0.010). The outcome differed significantly depending on whether the patients had a previously successful urethroplasty (p=0.036) or whether they had suffered a pelvic bone injury (p=0.012). Multivariate logistic regression analyses revealed that a previous urethroplasty was the only preoperative clinical factor that significantly affected the surgical outcome in PUA with a GMF (odds ratio, 0.218; 95% confidence interval, 0.050 to 0.947; p=0.042).

Conclusions

A history of previous urethroplasty is a preoperative clinical factor that significantly affects the surgical outcome in PUA with a GMF; the procedure is more likely to be successful in patients who have not previously undergone urethroplasty.

Transpubic posterior urethroplasty via perineal approach in children: a new technique

OBJECTIVE

To evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children.

METHODS

Of 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median = 8.5 years). The median distraction defect length was 4.8 cm (range 3.7-6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter.

RESULTS

Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9-3.2 h) with a mean blood loss of 200 ml (range 50-640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis.

CONCLUSIONS

Transpubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes.

Post-traumatic urethral strictures in children: what have we learned over the years?

BACKGROUND

Urethral stricture presents an uncommon but difficult urological problem in the pediatric population. Treatment protocols are different from in adults due to anatomical considerations.

MATERIAL AND METHODS

A thorough manual and Medline search was conducted to review the existing literature on post-traumatic pediatric urethral strictures, with key words: stricture, children, post-traumatic, urethroplasty, pediatric.

RESULTS

Opinion early on was that, due to the confined perineum, high incidence of supramembranous injury resulting in less predictable distraction defects of the posterior urethra and a high incidence of prostatic displacement, transperineal urethroplasty is technically more difficult than in adults and thus the transpubic approach is more feasible. Recent reports revealed that both approaches resulted in almost the same clinical outcomes for children with post-traumatic posterior urethral strictures.

CONCLUSION

The ideal reconstruction for the treatment of post-traumatic posterior urethral strictures in children is bulboprostatic anastomosis. This procedure should be initially attempted through the perineum in every case. A transpubic procedure should be done only when tension-free anastomosis cannot be accomplished through the perineum.

Construction of neourethra using flipped anterior bladder wall tube in a prepubertal girl with complete disruption of urethra

A rare case of urethral construction using flipped anterior bladder wall tube in an 8-year-old girl with complete disruption of the urethra and vagina accompanying pelvic fracture was reported. Following a split of the pubic symphysis, the vagina was reconstructed with end-to-end anastomosis. The neourethra was constructed tubularizing and flipping anterior bladder wall flap caudally to proximal site of the original urethra after fascial sling procedure. After catheter removal, this girl has been continent and voided normally. In conclusion, flipped anterior bladder wall tube technique for urethral construction is suitable in prepubertal girls with complete disruption of the urethra.

Factors Contributing to a Successful Outcome of Combined Abdominal Transpubic Perineal Urethroplasty for Complex Posterior Urethral Disruptions

PURPOSE

We present our results of and operative principles essential for a successful outcome of complex posterior urethral disruption management.

MATERIALS AND METHODS

A total of 25 patients underwent abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic and radiological assessment.

RESULTS

Patient age was 22 to 57 years. Average followup was 24 months (range 11 to 39). Four patients had previously undergone failed perineal urethroplasty. A rectourethral fistula was present in 8 patients, of whom 2 required colonic diversion, while there were false passages in 3, a periurethral cavity with abscess in 6 and bladder neck laceration in 20. Mean stricture length +/- SD was 6.5 +/- 2.5 cm (range 4 to 9). Four of the 25 patients had previously undergone failed perineal urethroplasty. The mean period between original trauma/failed repair and definitive repair was 11.5 +/- 4.4 months. Urethroplasty could be achieved through the normal subpubic route in 19 patients, while 6 required supracrural rerouting. A total of 20 patients underwent simultaneous bladder neck repair. In 24 of 25 patients (96%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperatively incontinence developed in 1 of 25 patients (4%). Ten of the 25 patients (40%) were impotent after the primary injury. Potency status in our patients did not change after urethroplasty. The overall urethroplasty success rate was 92%.

CONCLUSIONS

Hostile conditions in the perineum of patients with complex posterior urethral disruption mitigate against a good result. However, the safety and success of combined abdominal transpubic perineal urethroplasty make it the procedure of choice for these difficult strictures.

Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty

PURPOSE

We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption.

MATERIALS AND METHODS

From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram.

RESULTS

There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence.

CONCLUSIONS

Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.

Symphysiotomy: a viable approach for delayed management of posterior urethral injuries in children

PURPOSE

The outcome of symphysiotomy for accessing pelvic fracture related, obliterative urethral strictures is described.

MATERIALS AND METHOD

In 7 boys and 3 girls 4 to 13 years old (mean age 6) surgical correction of a pelvic fracture related, obliterative urethral stricture was achieved through symphysiotomy. The stricture involved a prostatomembranous location in boys and complete vesicourethral distraction in girls. Patients were followed an average of 2.5 years (range 6 months to 4 years) by physical examination, urethrography and endoscopy.

RESULTS

The stricture was successfully corrected in all patients and all void with a normal flow. All boys are continent but 2 of the 3 girls had early incontinence, which resolved with time in 1. In 2 of the 10 cases a previous attempt at perineal repair had already failed. No patient required urethrotomy or dilation and none had significant hemorrhage, fistulization, bladder hernia, chronic pain or secondary gait disturbance.

CONCLUSIONS

Symphysiotomy is hereby revisited as a simple and effective approach for repairing traumatic posterior urethral injuries in the pediatric population. It can be performed instead of transpubic urethroplasty to manage long or otherwise complicated strictures.