Visual Urethrotomy in the Management of the Obliterated Membranous Urethra

Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease

Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.

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.

Treatment of posterior urethral distractions defects following pelvic fracture

Posterior urethral injuries typically arise in the context of a pelvic fracture. Retrograde urethrography is the preferred diagnostic test in trauma patients with pelvic fracture where a posterior urethral rupture is suspected. Pelvic fractures however preclude the adequate positioning of the patient on the X-ray table on admission and computed tomography scan with intravenous contrast and delayed films generally performed first. Suprapubic bladder catheter placement under ultrasound guidance should be performed whenever a posterior urethral disruption is suspected. Early diagnosis and proper acute management decrease the associated complications, such as strictures, urinary incontinence and erectile dysfunction. The correct and appropriate initial treatment of associated urethral rupture is critical to the proper healing of the injury. Placing of a suprapubic cystostomy on admission and delayed anastomotic urethroplasty after 3–6 months continues to be the gold standard of treatment. In this paper, we provide a comprehensive review of the literature with a special emphasis on the various treatments available: Open or endoscopic primary realignment, immediate or delayed urethroplasty after suprapubic cystostomy, and delayed optical urethrotomy.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures

PURPOSE

We report 18 years' experience of traumatic urethral strictures in boys with emphasis on recurrent strictures.

MATERIALS AND METHODS

Thirty-four boys with pelvic fracture urethral strictures underwent 35 repairs: 23 in the primary group (initial suprapubic cystostomy, but no urethral repair) and 12 in the re-do group (previously failed attempt(s) at urethroplasty elsewhere). The median age at operation and stricture length was 8.4 years and 3 cm in the primary and 9 years and 5.4 cm in the re-do group, respectively. Anastomotic urethroplasty was performed wherever possible, or failing this a substitution urethroplasty. Median follow up was 9 years for primary group and 8 years for re-do group.

RESULTS

Primary group: urethroplasty was successful in 22/23, with 10 by perineal and 13 by additional transpubic approach. Two have stress incontinence. Erectile function is unchanged in all and upper tracts are maintained. One had recurrent stricture. Re-do group (12 including 1 recurrence from primary group): anastomotic urethroplasty was done in 5 and substitution urethroplasty in 7. Patients needing substitution had long stricture (>5 cm), stricture extending to distal bulb, or high riding bladder neck. All patients are voiding urethrally. Two patients with substitution required dilatation for early re-stenosis. One appendix substitution required delayed revision. Two have stress incontinence. Erectile function was unaffected. Upper tracts are maintained.

CONCLUSIONS

Anastomotic urethroplasty was successful in over 95% of primary cases. In re-do cases it was viable in only 41% of cases; the rest required substitution urethroplasty. Urethral substitution also gave acceptable results.

Core through urethrotomy with the neodymium:YAG laser for posttraumatic obliterative strictures of the bulbomembranous urethra

PURPOSE

We studied the safety and efficacy of core through urethrotomy with the neodymium (Nd):YAG laser for posttraumatic obliterative strictures of the bulbomembranous urethra.

MATERIALS AND METHODS

Eight patients a mean of 27.5 years old with posttraumatic (motor vehicle accidents) obliterative strictures of the bulbomembranous urethra were treated from May to December 1997. Laser treatment selection criteria were stricture length 2.0 cm. or less, good alignment between the urethral ends and no history of rectal injury or erectile dysfunction. All patients underwent core through urethrotomy with the Nd:YAG contact laser delivered with the 600 micro bare fiber at 15 to 25 W. The urethrotomy was guided only by a metal sound introduced through the suprapubic tract.

RESULTS

Blood loss was negligible and excellent visualization was maintained throughout the procedure. Operating time ranged from 45 to 70 minutes. There were no perioperative complications. Hospital stay was 24 hours in the first case and 6 to 8 hours in subsequent cases. All patients returned to work within 5 days. Urethroscopy was performed 4 and 12 weeks after catheter removal in all patients. Only 1 patient required repeat internal urethrotomy. Voiding cystourethrography revealed a stricture-free urethra in 7 cases. At last followup 7 to 14 months (mean 10.25) after the procedure mean maximum flow rate was 18.6 ml. per second (range 16.5 to 22.4) in the patients who were stricture-free and 11.8 ml. per second in 1 with recurrent stricture.

CONCLUSIONS

Core through urethrotomy with the contact Nd:YAG laser seems to be a safe and effective treatment option for select strictures. The hospital stay is remarkably short and complications are negligible. Re-stricture rates are likely to be low but more experience and longer follow-up are needed.

Delayed management of posterior urethral disruption in children

OBJECTIVE

To review the results of delayed operative treatment of total disruption of the posterior urethra in children.

PATIENTS AND METHODS

Twelve boys (3-12 years, mean 7.5) with a suprapubic catheter were referred after primary management in other hospitals. All but one had been involved in road traffic accidents. In addition to their urethral injury, they all had pelvic fractures and the majority also had other major associated injuries. Six to 14 months after injury, abdominoperineal transpubic urethroplasty was performed in 11 patients according to Turner-Warwick. In one case a perineal anastomotic urethroplasty was performed.

RESULTS

After the operation, voiding cysto-urethrography showed a wide anastomosis in all cases. After 3 to 45 months follow-up, there were no strictures. Eight boys were continent, two were totally incontinent, two had stress incontinence and one nocturnal enuresis. All patients with confirmed erections after injury also had erections after their operation.

CONCLUSION

Primary suprapubic cystostomy and delayed repair can be used successfully for the treatment of posterior urethral disruption in children.

Alternative endoscopic management in the treatment of urethral strictures

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.

Antegrade-retrograde urethrotomy for treatment of severe strictures of the urethra: experience and literature review

In cases of urethral stricture that are nonpassable when using conventional internal urethrotomy, open urethroplasty can be avoided by performing combined antegrade-retrograde urethrotomy (ARUT). A rigid cystoscope is guided through a dilated suprapubic cystostomy channel toward the stricture in the membranous or bulbar urethra. A urethrotome is inserted in retrograde fashion, and the "cut to the light" procedure is performed. Using the ARUT method, realignment was achieved in nine patients; four of whom had strictures induced by trauma or urethritis and five of which were the result of previous transurethral management. Recurrent stricture in four of seven cases necessitated further urethrotomy. There was no recurrence in five of seven patients for at least 5 months subsequent to the last treatment. All patients were spared open surgery. The antegrade-retrograde technique was described in 1978, but to date, only 70 cases have been reported in the literature. The primary success rate is 25%. Successful retreatment following recurrence was observed in 65%. We recommend ARUT as a first-choice treatment for severe strictures of the bulbar and membranous urethra.

Endoscopic urethroplasty of posterior urethral avulsion

OBJECTIVES

Traumatic avulsion of the posterior urethra represents a challenging reconstructive problem that traditionally has been managed by the transpubic or transperineal approach. We report the advantages of endourologic techniques to reconstruct short posterior urethral disruptions based on the principles of establishing proximal urethral control and balloon dilation of the newly constructed urethra.

METHODS

Endourologic urethroplasty consists of: (1) antegrade flexible cystoscopy or antegrade passage of a Goodwin sound, (2) retrograde urethrotomy to light or to tip of Goodwin sound, facilitated by C-arm fluoroscopy, (3) establishment of urethral continuity by passage of a guide wire, (4) balloon dilation of the newly established urethra to 24 to 30 F over a length of 4 cm, and (5) long-term urethral stenting (4 to 8 weeks) with a silicone Foley catheter.

RESULTS

In four men initially managed by suprapubic cystostomy, endourologic reconstruction was performed. The mean blood loss was 250 mL, and mean length of hospitalization was 5.4 days. All patients were continent and three were potent over a mean follow-up of 10.5 months. Uroflowmetric monitoring showed satisfactory voiding patterns with subsequent minor endoscopic revisions required in three patients.

CONCLUSIONS

The technical advantages of this method include stabilization and identification of the proximal urethra, intraoperative shortening of the urethral gap to facilitate the urethrotomy, and radial distention of the urethra by balloon dilation. We conclude that endourologic methods provide a safe and effective initial treatment of urethral avulsion.

Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation

Five patients with complete posterior urethral obliteration (less than 3 cm.) underwent endoscopic reconstitution of the urethra followed by planned direct vision internal urethrotomy and temporary self-dilation. Of these patients 3 complied with the treatment regimen and are currently free of voiding complaints (average followup 31 months), while 2 failed to perform self-dilation and required repeat internal urethrotomy. Of the latter 2 patients 1 then performed self-dilation and has a stable urethra (followup 2 years). The youngest patient refused to perform self-dilation and underwent successful perineal urethroplasty. Major complications did not occur. The treatment regimen as described is a suitable alternative to surgical urethroplasty in select patients with short urethral defects (less than 3 cm.) who are willing to perform temporary urethral self-dilation.