Endoscopic Realignment of Prostatomembranous Urethral Disruptions

Abstract

Prior to discussing the endoscopic approach to realignment of prostatomembranous urethral disruptions, some discussion of the general approach to management of prostatomembranous urethral disruptions is appropriate. There have been advocates of both immediate and delayed repair of prostatomembranous urethral disruptions. Proponents of delayed repair of these injuries have suggested that immediate repair results in further damage to the delicate neurovascular structures in the urogenital diaphragm which have been injured. They have suggested that it is better to allow these acute injuries to subside prior to urethral reconstruction. However, advocates of immediate repair of these injuries have argued that impotence and incontinence in these patients are the result of the injury itself and not the method of management. Furthermore, they believe that urethral realignment over a urethral catheter is no more traumatic or less anatomic than a delayed urethroplasty through the fibrotic urogenital bed that results from the injury. The controversy between early versus delayed repair of prostatomembranous urethral disruptions originated in 1972 when Morehouse reported that early repair of these injuries resulted in excess incontinence and impotence compared with initial suprapubic tube placement alone followed by a delayed ~rethrop1asty.l~ In a follow-up study published in 1980, they reported on 58 consecutive patients treated with complete prostatomembranous urethral disruptions managed by initial suprapubic tube placement alone and delayed urethral reconstr~ction.'~ They reported remarkably good results, including a 0% incidence of stricture, a 2% incidence of mild stress incontinence, and only 10% impotence. They compared these results with those of another group of patients who were referred to their medical center after unsuccessful attempts at immediate repair. Not unexpectedly, the patients who underwent unsuccessful attempts at immediate repair had worse results. This report has been appropriately criticized because, in essence, they are comparing those patients who underwent successful management with initial suprapubic tube placement followed by delayed urethroplasty with those patients who were failures of immediate realignment.