Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

Objectives

To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI).

Methods

Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results.

Results

A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1-8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5-9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8-10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation.

Conclusions

The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Robotic Urethral Reconstruction Outcomes in Men with Posterior Urethral Stenosis

OBJECTIVE

To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction.

METHODS

A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed.

RESULTS

Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included BPH treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (BPH), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (p=0.52). Median length of stay after reconstruction was 2, 1, and 2 days (p=0.45). 30-day complications occurred in 0%, 20%, 40% (p =0.19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (p =0.004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (p=0.63), with functional success rates of 100%, 100%, 60% (p=0.035). Median postoperative pad/day usage was 0,0, 10.5 (p<0.001), and ultimately 0%, 30%, 80% (p=0.013) underwent artificial urinary sphincter placement.

CONCLUSION

Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence.

Frequency of Extravasation on Pericatheter Retrograde Urethrogram in Patients Who Undergo Posterior Urethroplasty

Introduction

Urethroplasty is the gold standard treatment for urethral stricture disease resulting from pelvic fractures, urethral manipulation, and straddle injuries. Post-operative morbidity depends on the presence of urethral catheterization with or without a suprapubic catheter (SPC). Urethral healing at the anastomotic site can be easily assessed using retrograde pericatheter urethrography (RPU). Post-operative removal of the catheter is traditionally performed on the 21^st day following urethroplasty. However, some controversy still exists regarding the best feasible time of proper urethral healing and its assessment utilizing simple techniques. The duration of anastomotic healing differs depending on the type of procedure performed, but whether there is any significant difference in duration of healing at the anastomotic site according to the etiology of short‐segment stricture urethra is still a dilemma.

Materials and methods

This was a descriptive case-series conducted for a duration of six months from September 2019 to February 2020 at the urology department of a tertiary care hospital in Karachi, Pakistan. A sample population of 135 patients aged 20-50 years with posterior urethral stricture who underwent posterior urethroplasty with disease duration of >12 months was included in the study. All patients were put on the next operation theater (OT) list for urethroplasty. After surgery, the patients were catheterized and were kept in the ward under observation for 48 hours and discharged on the 2^nd post-operative day. All patients were followed weekly and RPU was performed on the 21^st day following urethroplasty to assess the presence of extravasation and the collected data was entered into the proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0.

Results

The mean age of our participants was 32.8±6.02 years. The mean duration of the procedure was 26.3±7.14 months. Extravasation cases were observed in less than one-fifth (n=22 out of 135, 16.3%) of the posterior urethral stricture patients in our study.

Conclusions

It is to be concluded that extravasation is fairly common in patients who undergo posterior urethroplasty. The prevalence varies depending on the assessment method, likely reflecting the treatment of somatic symptoms.

Adding a vacuum erection device to regular use of Tadalafil improves penile rehabilitation after posterior urethroplasty

This study aimed to evaluate whether adding a vacuum erection device (VED) to regular use of Tadalafil could achieve better penile rehabilitation following posterior urethroplasty for pelvic fracture-related urethral injury (PFUI). Altogether, 78 PFUI patients with erectile dysfunction (ED) after primary posterior urethroplasty were enrolled and divided into two treatment groups: VED combined with Tadalafil (Group 1, n = 36) and Tadalafil only (Group 2, n = 42). Changes in penile length, testosterone level, International Index of Erectile Function-5 (IIEF-5) questionnaire, Quality of Erection Questionnaire (QEQ), and nocturnal penile tumescence (NPT) testing were used to assess erectile function before and after 6 months of ED treatment. Results showed that the addition of VED to regular use of Tadalafil preserved more penile length statistically (0.4 ± 0.9 vs −0.8 ± 0.7 cm, P < 0.01). IIEF-5 score and QEQ score in Group 1 were higher than Group 2 (both P < 0.05). After treatment, 21/36 (58.3%) Group 1 patients and 19/42 (45.2%) Group 2 patients could complete vaginal penetration. Group 1 patients also had markedly improved testosterone levels (P = 0.01). Unexpectedly, there was no significant difference in NPT testing between two therapies. For PFUI patients with ED after posterior urethroplasty, the addition of VED to regular use of Tadalafil could significantly improve their conditions – improving erection and increasing penile length – thus increasing patient satisfaction and confidence in penile rehabilitation.

Anatomy and techniques in posterior urethroplasty

Given its complex anatomy, injury to the posterior urethra may result in a number of reconstructive challenges. With the appropriate operative planning and experience, surgical repair can be very successful. This review discusses the applicable techniques for the perineal approach to posterior urethral stenosis, including bulbomembranous anastomosis for pelvic fracture urethral injury and repair of vesicourethral anastomotic stenosis (VUAS) following prostate surgery. The advanced techniques reviewed include an adaptation allowing a bulbar artery sparing approach to posterior urethroplasty and an intrasphincteric urethroplasty procedure which may allow continence preservation in patients with membranous urethral stenosis.

Recurrence and complications after transperineal bulboprostatic anastomosis for posterior urethral strictures resulting from pelvic fracture: a retrospective study from a urethral referral centre

OBJECTIVE

To describe the complications of transperineal end-to-end anastomotic urethroplasty in patients with posterior urethral strictures resulting from pelvic fracture.

MATERIALS AND METHODS

A total of 573 patients, who underwent bulboprostatic anastomosis for posterior urethral strictures, were enrolled in this study. Distraction defects were measured using retrograde urethrography combined with voiding cysto-urethrography. All patients underwent perineal excision and primary anastomotic urethroplasty. The urethroplasty was considered successful if the patient was free of stricture-related obstruction and did not require any further intervention. The degree of stress incontinence was assessed daily by pad testing. The prevalence of pre- and postoperative sexual disorders was investigated using the International Index of Erectile Function-5 questionnaire.

RESULTS

Of 573 bulboprostatic anastomosis procedures performed, 504 (88%) were successful and 69 (12%) were not successful. The mean (sd) maximum urinary flow rate, assessed by uroflowmetry 4 weeks after surgery, was 20.52 (5.1) mL/s. Intraoperative rectal injury was repaired primarily in 28 cases. Recurrence of urethral strictures was observed in 10 (1.7%) patients during the first 6 months after surgery, and in 45 patients from 6 months to 1 year. All of these patients underwent re-operation. Twenty-four (4.2%) patients had mild urge incontinence and 28 (4.9%) had mild stress incontinence. Erectile dysfunction (ED) was present in two (<0.1%) patients before trauma and in 487 (85%) patients after trauma. There was no statistical difference between the incidences of preoperative and postoperative ED (85 vs 86%, P > 0.05). Nine (1%) patients were found to have false passage between the posterior urethra and bladder neck.

CONCLUSION

The majority of complications associated with transperineal bulboprostatic anastomosis can be avoided as long as meticulous preoperative evaluation to define the anatomy and careful intra-operative manipulation are ensured.