Transpubic surgery: a new approach to difficult pelvic operations

Rare traumatic aorto-iliac dissection injury in a child with pelvic fracture and urethral rupture: a case report

This is a case report of polytrauma in a 4-year-old boy who sustained a rare aorto-iliac dissection injury along with pelvic fracture and rupture of posterior urethra. This child was initially treated for the rupture of posterior urethra and extravasation of urine with suprapubic cystostomy and drainage. Lower limb ischemia developed later. Exploration showed aorto-iliac dissection injury for which aorto-iliac replacement grafting was carried out. Subsequently delayed repair of posterior urethral rupture by transpubic urethroplasty was carried out.

The transpuboperineal approach for repair of traumatic strictures of the posterior urethra in children

Strictures of the posterior urethra resulting from pelvic fractures in children pose a formidable challenge due to the limitations of perineal exposure. With the transpubic approach, direct access to the involved anatomy is obtained. This technique, combined with perineal mobilization of the distal urethra, allows the performance of a tension-free anastomosis. The use of an omental pedicle wrap graft seems to add safety to the procedure. It is particularly suited for long strictures and after failure of the transperineal approaches. The results reported in the literature are remarkably good. There are no reports of orthopedic sequelae in children. Sexual potency and continence do not seem to be adversely affected. We present two cases successfully operated upon by this technique.

Effect of patient positioning on urethral mobility: implications for radical pelvic surgery

Patient positioning is of critical importance in the successful performance of several radical pelvic operations. Adequate exposure of the prostatic apex is vital in ligating the dorsal vein complex and performing vesicourethral anastomosis. To test the effect of different patient positions on urethral mobility, we conducted a prospective controlled study measuring the relative cephalad displacement of the prostatic apex in 3 positions, that is the supine, frog-leg and dorsal lithotomy positions. A combination of radiographic and cystoscopic techniques was used to mark the position of the prostatic apex. Each patient served as his own control. Of the 24 patients studied for a variety of urological complaints 19 (79%) had an increased cephalad displacement of the prostatic apex while in the frog-leg position compared with the dorsal lithotomy position. The mean gain was 0.5 cm. (p greater than 0.5). A total of 16 patients showed improvement while in the frog-leg position over the supine position with a mean advantage of 0.39 cm. (p greater than 0.05). Patient age, pelvic depth, pelvic circumference and prostatic urethral length had no predictive value in selecting an optimal position.

Transpubic approach for lower urinary tract surgery: a 15-year experience

Surgery on lower urinary tract organs sometimes is hindered by the symphysis pubis, which by its position and bulk could severely restrict maneuverability. Since 1972 we used a transpubic approach to improve surgical exposure in 287 patients operated on for prostate, bladder or urethral cancer, post-traumatic strictures and other conditions. The type of pubectomy performed (total, partial superior or partial inferior) depended upon whether a suprapelvic or infrapelvic diaphragm organ was the primary target of the approach. Total pubectomy was used in 137 patients, partial superior bone resection in 140 and partial inferior resection in 10 patients. Technical details for each type of pubectomy are illustrated. The transpubic approach was particularly useful for repair of posterior urethral strictures or removal of bulky tumors. Among the 3 types of approaches used, total pubectomy was associated with a high complication rate including bleeding, pelvic instability, urinary incontinence and stricture of the vesicourethral anastomosis. Therefore, we have abandoned the technique since 1978. Partial pubectomy provides exposure comparable to that of total pubectomy but with minimal complications, making it an alternative to the standard approach in difficult cases.

Technical nuances and surgical results of radical retropubic prostatectomy in 150 patients

We reviewed the surgical results of radical retropubic prostatectomy in 150 patients, of whom 37 had undergone transurethral resection of the prostate. The number and type of complications in our series compared favorably to those reported in other series: only 15 of our last 100 patients had complications, most of which were minor. Incontinence occurred in 2 of our last 100 patients and there were no symptomatic urethral strictures. Complications were similar between patients who had and those who had not undergone transurethral resection of the prostate. Several technical considerations that contribute to these results are discussed, especially the use of perineal pressure to facilitate hemostasis and the technique of vesicourethral anastomosis. Radical retropubic prostatectomy is a relatively well tolerated procedure with low morbidity.

Transpubic cystectomy and ileocecal bladder replacement after preoperative radiotherapy for bladder cancer

Radical cystectomy was modified by leaving the apical prostatic capsule to facilitate anastomosis of the isolated ileocecal segment to the urethra and to preserve erectile potency. The transpubic approach was used to increase the exposure, and to facilitate dissection and anastomosis. A total of 15 patients with stages T1 to T4 bladder tumors underwent the operation: 13 after preoperative radiotherapy with 4,000 rad and 2 had salvage cystectomy after 6,000 rad. One patient died postoperatively. The remaining 14 patients underwent urodynamic evaluation 3 to 6 months postoperatively. The maximum urine flow rates were almost normal and none of the patients had significant residual urine. Daytime urinary continence was satisfactory in 13 patients and 1 was moderately incontinent. All of the patients were incontinent at night, probably owing to peristaltic contractions in the intestinal bladder and relaxation of the pelvic floor muscles. Preoperatively, 8 patients experienced erections and 7 had intercourse. Postoperatively, erectile potency was preserved in 4 patients and 3 had sexual function. No orthopedic disability occurred postoperatively. The median followup was 20 months, with a range of 3 to 30 months. There have been no local recurrences. A year postoperatively 6 of 9 patients had sterile urine. This technique makes it possible to avoid a urinary stoma, to obtain satisfactory voiding and urinary continence in almost all cases, and to preserve sexual function in some patients after cystectomy.

Pubectomy in urological surgery

Pubectomy has been useful, particularly for the treatment of traumatic disruption of the deep urethra after a preliminary cystostomy. This procedure provides unparalleled exposure for mobilization of the apex of the prostate and distal urethral segment, and the accomplishment of an end-to-end anastomosis. Results have been good. Pubectomy has been helpful in selected cases of chronic osteitis pubis. Experience with the technique was helpful during radical pubectomy in 2 patients with chondrosarcoma of the pubis.

Radical transpubic prostatectomy

Removal of an adequate wedge of symphysis pubis provides considerably improved exposure for radical prostatectomy. It is safer to remove the symphysis subperiosteally and to transect the bone with an oscillating bone saw or osteotome. The transpubic approach to radical prostatectomy affords the urologist the advantages of 1) early direct ligation of the dorsal vein, 2) reduced incidence of injury to the external urethral sphincter and subsequent urinary incontinence owing to visualization of the urogenital diaphragm, 3) simplified urethrovesical anastomosis and 4) increased opportunity for maintenance of potency by protecting the pelvic nerve plexus as they course in the lateral vascular pedicles.

Anatomical basis of the surgical approach to the membranous urethra

The pars membranacea is the short segment of the urethra traversing the floor of the perineum. The main anatomical obstacles encountered in the approach to the membranous urethra are the perineal body posteriorly, and the deep dorsal vein of the penis and preprostatic venous plexus, anteriorly. These obstacles must be borne in mind when performing a surgical approach to the membranous urethra. The perineal body is the main obstacle to the perineal approach and can be avoided by incision of the sagittal raphes (anobulbar and rectourethral raphes) posterior to it and up to the apex of the prostate. When the trans-symphysial or transpubic approach is used, detachment of the suspensory ligament and roots of the penis allows exposure of the preprostatic venous plexus whose inferior part lies over the membranous urethra.

Use of the transpubic approach for urethroplasty in children

The management of traumatic strictures of the posterior urethra in children poses several problems owing to the limitations of perineal exposure, and the small size and delicacy of the structures involved. We have used a transpubic approach in the repair of strictures of the posterior urethra in 5 children, 4 of whom had previously undergone unsuccessful attempts at repair by other routes. In 2 of the transpubic repairs a patch graft technique was used, and 3 consisted of excision and primary reanastomosis. Two repairs were accompanied by concomitant closure of a failed first-stage Turner-Warwick scrotal inlay. The transpubic approach offered excellent exposure and visualization of the involved anatomy, and facilitated accurate suture placement and tissue realignment in all 5 patients. Final results have been satisfactory in 4 patients. There have been no clinically detectable effects on gait and there have been no significant complications or morbidity associated with this approach.

Pubectomy for repair of membranous urethral strictures

We treated 7 patients with membranous urethral strictures secondary to fractures of the pelvis with pubectomy and termino-terminal anastomosis of the urethra. All patients are free of catheters and urinary tract infection. The surgical technique provided good exposure of the membranous urethra because the incision of the pubis was wide. None of the patients has had orthopedic problems secondary to the operation. Postoperative sexual function has been good.

An unusual solution to complicated prostatic urethral stricture: modified pull-through urethroplasty-urethroneocystostomy

A modified transpubic pull-through procedure was used in a failed Solovov-Badenoch pull-through repair of a traumatic prostatomembranous urethral stricture. The modification consisted of an incision of the intracrural septum through which the mobilized bulbous urethra was then passed and anastomosed to the most available dependent portion of the anterior bladder wall. The outcome was an unexpectedly good result that has persisted for more than 30 months. A review of the literature revealed no absolutely similar procedure.

En bloc transpubic urethrectomy in conjunction with radical cystectomy for bladder carcinoma in males

A technique for en bloc transpubic urethrectomy and radical cystectomy in the male is described and compared with commonly employed means of urethrectomy. Although this technique has been performed in a limited number of cases, this report is warranted because of the following advantages: en bloc resection is achieved at one operation without compromised positioning or need to reposition; the risk of transecting tumor in the urethra or leaving tumor behind in the urethra is avoided; the contamination inherent with a perineal incision and the resulting increase in morbidity are avoided, yet the mobilization of the urethra and prostate is comparable to that achieved transperineally; the exposure with this technique equals or excels that achieved by other approaches; although thirty minutes are required to perform pubectomy and urethrectomy, this is comparable to the time required to expose and close the perineum; and usually time is saved because of the improved exposure.

Penetrating high-velocity genitourinary injuries. Part II: Ureteral, lower tract, and genital wounds

Penetrating ureteral wounds appear to occur at a constant low rate and demand internal splinting without ureterotomy drainage in the multiple-injured patient. Concomitant upper urinary tract and colonic or pancreatic injury absolutely requires the use of nephrostomy drainage. Most prostatic or prostatomembranous rupture can be approached retropubically, or if extensive tissue damage and uncontrollable hemorrhage are present, by transpubic methods. Intravesical fixation of the prostatomembranous rupture provides the best anchorage and approximation. Rectoprostatic-bladder wounds should be approached suprapubically and may be drained transcoccygeally also. Section of the obturator nerve may provide postoperative pain relief in severe pubic ramus fractures. Small high-velocity entrance wounds in the external genitalia warrant exploration because of great internal disruption. The skin of the external genitalia should be closed primarily.

A comparison of the morbidity associated with radical retropubic prostatectomy with and without pubectomy

Radical retropubic prostatectomy with bilateral pelvic lymphadenectomy for prostatic carcinoma was done with pubectomy in 8 patients and without pubectomy in 8 other patients. A comparison of the postoperative courses reveals an excess morbidity in patients who had pubectomy, with severe protracted pelvic girdle pain in 75 per cent, lower extremity thrombophlebitis in 37 per cent (one of which resulted in a non-fatal pulmonary embolus) and varying degrees of urinary incontinence persisting for 6 months or more in 75 per cent. In contrast, in patients who did not have a pubectomy mild transient pelvic girdle pain was noted in only 25 per cent of the cases, late lower extremity thrombophlebitis in 12 per cent and no late urinary incontinence. Pubectomy should not be used routinely with radical retropubic prostatectomy.

Transpubic urethroplasty for membranous urethral strictures

Six patients with traumatic membranous urethral strictures have undergone urethroplasty utilizing the traspubic approach with resection of a wedge of the symphysis pubis. Three patients are free of stricture, 2 required urethral dilatation in the early postoperative period only, and 1 patient requires dilation every three months. Four patients are completely continent of urine, 1 has mild stress incontinence, and 1 is incontinent because of a neurogenic bladder. This approach provides excellent exposure with minimal morbidity and allows an easy under-vision anastomosis.

The transpubic approach for strictures of the membranous urethra

Strictures of the membranous urethra following pelvic fractures pose a challenge in management because of their relatively inaccessible position above the urogenital diaphragm and behind the pubic symphysis. The corrective procedures the pass up from the perineum through the urogenital diaphragm to reach the stricture have the real or theoretical disadvantage of defunctionalizing the external urethral sphincter and leaving continence dependent solely upon the competency of the bladder neck. On the other hand, transpubic surgery allows a direct attack upon the stricture without violating the sphincter. Our experience with 4 such cases has convinced us of the superiority of this approach.

Transpubic repair of vesicourethrovaginal fistula

A patient with recurrent urinary vaginal fistula involving bladder, bladder neck, and urethra was treated by transpubic approach. This afforded excellent exposure for careful repair of the urologic defects. Difficulty with ambulation during the first few weeks postoperatively may be related to removal of larger segment of pubic bone than is usually reported.