39 URETHRAL RECONSTRUCTION OF INTRACTABLE POSTERIOR URETHRAL STRICTURES

Abstract

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery I1 Apr 201039 URETHRAL RECONSTRUCTION OF INTRACTABLE POSTERIOR URETHRAL STRICTURES Polina Reyblat and Stuart D. Boyd Polina ReyblatPolina Reyblat More articles by this author and Stuart D. BoydStuart D. Boyd More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.084AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES An innovative reconstructive technique was introduced in 1984 to address intractable posterior urethral/bladder neck strictures that can potentially develop following difficult prostate cancer treatments. The reconstruction plan employs a safe and relatively simple urethral pull-through procedure to correct the stricture with subsequent placement of an artificial urinary sphincter (Americal Medical System, Minnetonka, MN) to resolve the associated incontinence. METHODS The procedure is performed totally perineally. The urethra is mobilized from the penoscrotal junction to the point of the obstruction in the urogenital diaphragm and transected. This type of mobilization makes 3-4cm of elastic urethra available for reconstruction. The stricture zone is typically 1.5-2.5cm in length, and it is incised and dilated to a 14 Hegar up into the bladder. The urethra is fixed with chromic suture to 20F Red Robinson catheter that has been pulled through the bladder suprapubically into the perineum. The urethra is then advanced up to just inside the opened bladder neck and the catheter is fixed to the abdominal wall. An AUS cuff is placed as a space holder. The urethra is well vascularized and is allowed to heal in place secondarily. The pull-through catheter is removed in 3 weeks. An AUS is placed 6 weeks after the initial surgery and activated 12 weeks after reconstruction. RESULTS 56 patients underwent the procedure between 1984 and 2008. Mean age at the time of surgery 64.5 (ranging 47-84). Mean follow up 12 years (1 –18 years). Eight patients (14%) had history of salvage prostatectomy, 15 (27%) patients with disrupted vesico-urethral anastomosis, 15 (27%) patients with history of radiation followed by transurethral resections of obstructive tissue and 18 patients (32%) underwent radical prostatectomy followed by adjuvant radiation. Mean number of transurethral attempts to dilate or incise the original stricture prior to reconstruction was 7 (range 3-12). Refractory stricturing of the pulled-through urethra affected 5 patients (9%) and was successfully managed by Urolume stent. Twelve patients (21%) underwent cuff downsizing or reservoir up-“grading”. 93% are highly satisfied with the outcome and would recommend this to others. CONCLUSIONS The long-term results in 56 patients have been uniformly excellent. No patient has had to be diverted. Many of these patients had previously been told that they would never urinate, and now can expect to void with a good stream and good control. Definitive treatment for these seemingly irreparable patients can now be offered in a more timely manner. Los Angeles, CA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e16-e17 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Polina Reyblat More articles by this author Stuart D. Boyd More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...