Bulboprostatic Anastomosis Research Articles

Outcome of anastomotic urethroplasty in traumatic stricture (distraction defect) of posterior urethra in boys

ABSTRACT Objective To report the outcomes of operative management of traumatic posterior urethral distraction defect in boys at our Centre, as traumatic posterior urethral stricture in children is a rare condition that presents a major surgical challenge to the paediatric urologist and consensus on the optimal treatment of these strictures in children has not been reached. Patients and methods We retrospectively analysed our data from July 2013 to June 2018. All boys aged ≤16 years with traumatic posterior bulbo-prostatic obliteration (distraction defect) were included. Initial suprapubic cystostomy and delayed definite anastomotic urethroplasty was done in all the boys. The boys were evaluated preoperatively with a retrograde urethrogram and simultaneous voiding cystourethrogram, as well as cystourethroscopy. Results A total of 38 boys, with posterior urethral distraction defect, were divided into primary and redo surgery groups. The primary group comprised 34 boys who were operated upon for the first time. A perineal approach with development of an inter-crural space was done in 12 boys and along with an inferior pubectomy in 19 boys. Three boys in the primary group needed a transpubic approach due to a longer defect. In the redo group, there were six boys, of which four were operated initially outside our hospital, while two were our own unsuccessful urethroplasties. In the redo group, a perineal approach with inferior pubectomy was done in two boys and a transpubic urethroplasty in the remaining four boys. The success rate of anastomotic urethroplasty without any ancillary procedures was 81.5% (strict criterion), while the overall success rate was 94.7% (permissible criterion, which included boys who were managed later with direct vision internal urethrotomy and dilatation). Conclusion The ideal treatment of post-traumatic posterior urethral defect/strictures in boys is tension-free bulbo-prostatic anastomosis. This was done using a transperineal approach in most of the boys, but a few required a transpubic approach, with good results. Abbreviations DVIU: direct vision internal urethrotomy; SPC: suprapubic cystostomy; SUI: stress urinary incontinence

Stricture of Urethra: Patterns and Outcomes of Management from a Single Centre in Pakistan Over 7 Years.

To determine the outcomes of urethroplasty and its complications from a large cohort of patients managed in a single centre. Descriptive study. Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2010 to December 2016. A total of 546 patients with stricture urethra at different locations underwent urethroplasty from January 2010 to December 2016 were included. All patients had an ascending urethrogram followed by retrograde ± antegrade urethroscopy to assess the location and length of the stricture. Technique of urethroplasty was chosen according to the site, length and etiology. Following appropriate procedure, patients were followed up in the dedicated urethral stricture clinic. Procedure was considered successful if either no further therapeutic intervention was required and the maximum flow rate (Qmax) was >20 ml/sec with a voided volume of at least 200 mls. The procedure was regarded as unsuccessful, if further treatment was required or Qmax was <10ml/sec. A total of 546 patients with mean age of 32.3 +13.1 years (range: 12-74) involving anterior (n=323, 59.2%) or posterior (n=223, 40.8%) urethra were treated. Mean follow-up was 43.6 months (range: 3-84). The success rates of bulbar urethral strictures after excision and primary anastomosis (EPA) was 93. 3%, non-transecting urethroplasty 84.6% and oral mucosal graft (OMG), 81.8%. In penile urethral strictures, OMG, Orandi procedure and Johanson's techniques yielded success rates of 88.4%, 66.6% and 57.1%, respectively. In posterior urethral strictures, after excision and bulboprostatic anastomosis, good results were seen in 88.3%. In pan-urethral strictures, abdominal skin graft repair, combined tissue transfer and OMG urethroplasty yielded success rates of 74%, 78.5% and 75%, respectively. The complications/ adverse events were encountered in 251 / 546 (45.9%) patients in this series. Anastomotic urethroplasty yielded best outcomes followed by OMG urethroplasty. In the long-term follow-up, erectile dysfunction (ED), infertility and recurrence of stricture are the main complications which need individualised management.

Spectrum of management options for pediatric pelvic fracture urethral injury and outcome analysis: 12-year tertiary center experience

IntroductionPediatric pelvic fracture–associated urethral injuries (PFUIs) are relatively rare injuries that occur in secondary to high impact pelvic trauma. There is no consensus yet on the optimal management approach. ObjectivesIn this study, the authors reviewed their experience of pediatric PFUIs and discussed the current spectrum of potential management options. Study designThe authors retrospectively evaluated a cohort of 33 children (≤14 years) treated for PFUI between January 2005 and December 2017. ResultsThe mean age of presentation was 11.2 ± 2.1 years (range 6–14). All the subjects were male. Average stricture length was 2.5 + 1.4 cm. Transperineal anastomotic repair (TPAR) was done in 27 patients; Mitrofanoff procedure was done in three patients; Badenoch's procedure, preputial flap, and transpubic urethroplasty (TPU) was done in 1 patient each. Overall success rate for TPAR was 85%. Minor complications (Clavien grade I and II) were seen in eight cases (24.2%). Average hospital stay was 11.3 days (range 6–15). The mean follow-up duration was 13.8 months (range 9–18). DiscussionAs not many large overview studies were known, this retrospective study is small step for developing a protocol for patients with a pediatric PFUI that needs treatment. The goal of surgery in pediatric PFUI–associated posterior urethral strictures is to achieve a tension-free bulboprostatic anastomosis after excision of the distraction segment. Transperineal anastomotic repair is the best and most commonly performed surgery for pediatric PFUI with 85–98% success rates. The success rates for TPAR may be lower in children because of smaller pelvic cavity, small caliber urethra, and poorly formed elastic spongiosa. Hence, a TPAR should be attempted in every case of posterior urethral stricture post-PFUI. If a tension-free anastomosis is not possible, then procedures depending on local stricture characteristics such as TPU may be required. ConclusionMost pediatric posterior urethral strictures post-PFUI (≤2 cm) can be managed by delayed TPAR with reasonable success rates. Few selected patients may require procedures such as TPU based on local stricture characteristics.TableFactors affecting choice of surgery and outcomeTableSurgery groupNo.Previous interventionDefect siteMean defect length (cm)SuccessFailureTPAR274BMU-25BU-022234Badenoch procedure11BMU-01410Mitrofanoff30BMU extending upto BN-03630Preputial flap urethroplasty11BMU-01401TPU11BMU + Long BU segment-01510TPAR, transperineal anastomotic repair; TPU, transpubic urethroplasty; BMU, bulbomembranous; BU, bulbar urethra; BN, bladder neck.

Reconstruction of Membranous Urethral Strictures.

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. 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.

Risk factors associated with transperineal bulboprostatic anastomosis after pelvic fracture urethral injury: 10 years of experience from a urethroplasty center

Risk factors associated with transperineal bulboprostatic anastomosis after pelvic fracture urethral injury: 10 years of experience from a urethroplasty center

Mini-invasive reconstruction technique of the bulbomembranous urethra

The paper presents the technique of the reconstruction of the bulbar and membranous urethra in the occurrence of strictures and sphincter-stenosis. The method uses an autologous graft and has potential advantages over the bulboprostatic anastomosis. Objective. To develop a method of helping patients with existing urethral anastomoses, with a damaged neck of the bladder and a risk of subsequent incontinence, wishing to maintain the erectile function. Materials and methods. 35 patients underwent 36 reconstructions of the urethra from August 2013 to July 2017, 11 - after previous urethral plastics, 14 - after prostate surgery (4 - after radical prostatectomy), 7 - suffered from a urethral distraction defect. The age of the patients was 58.17 ± 12.2 years. The median follow-up period was 525 (341; 813) days. The average length of urethral strictures was 15 (10; 15) mm. The average diameter of the urethra in the stricture zone was 1.4 ± 0.56 mm. Reconstruction with the use of a buccal mucosa graft is performed intraurethrally through corpus spongiosum using magnifying optics. Results. The overall efficacy of the primary reconstruction in 35 patients was 94.2 %; the repeated reconstruction in two patients was successful. All patients underwent the comprehensive monitoring of the results, the average follow-up period was 654 days, the average relapse-free period was 447 days. All patients preserved continence and erectile function Conclusion. The proposed technique showed a high efficiency in reconstruction of the bulbar and membranous urethra.

V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE Cristina Baeza, Reynaldo Gomez, Rodrigo Campos, and Laura Velarde Cristina BaezaCristina Baeza More articles by this author , Reynaldo GomezReynaldo Gomez More articles by this author , Rodrigo CamposRodrigo Campos More articles by this author , and Laura VelardeLaura Velarde More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.236AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-membranous urethral stenosis after surgery for benign prostate hyperplasia (BPH) are challenging because the internal sphincter has been removed and continence depends on the function of the external sphincter, which is located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches RESULTS The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up CONCLUSIONS Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e68-e69 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Cristina Baeza More articles by this author Reynaldo Gomez More articles by this author Rodrigo Campos More articles by this author Laura Velarde More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP91-18 THE ROLE OF VACUUM ERECTION DEVICES IN PENILE REHABILITATION AFTER POSTERIOR URETHRAL ANASTOMOTIC URETHROPLASTY:A PILOT STUDY

You have accessJournal of UrologySexual Function/Dysfunction: Medical, Hormonal & Non-surgical Therapy I1 Apr 2017MP91-18 THE ROLE OF VACUUM ERECTION DEVICES IN PENILE REHABILITATION AFTER POSTERIOR URETHRAL ANASTOMOTIC URETHROPLASTY:A PILOT STUDY Lujie Song and Qiang Fu Lujie SongLujie Song More articles by this author and Qiang FuQiang Fu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2858AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess the efficacy and safety of vacuum erection devices(VED) for the penile rehabilitation in patients with pelvic fracture urethral distraction defects (PFUDD) who underwent posterior urethral anastomotic urethroplasty. METHODS This prospective study consisted of 60 patients who underwent successfully primary bulboprostatic anastomosis with a perineal approach and developed erectile dysfunction following surgery between Jan 2012 and Jun 2015. The patients were randomized to VED combined with Tadalafil (10mg) once every two days (Group 1, n=28) or Tadalafil (10mg) once every two days (Group 2, N=32) for 6 months. The International Index of Erectile Function-5(IIEF-5), nocturnal penile tumescence (NPT) testing and dynamic color-duplex Doppler ultrasonography (D-CDDU) was used as the evaluation tools. Assessments were made at 2 time points: 1 month and 7 months after urethroplasty. RESULTS The mean patient age was 31.4±7.0 years (Group 1) and 33.3±7.2 years (Group 2) repectively (p>0.05). No patients ended the penile rehabilitation program because of treatment-related adverse events in both groups. In Group 1, 57.1% (16/28) patients have erections sufficient to finish the vaginal intercourse compared to 46.9% (14/32) in Group 2 at 7 months after urethroplasty. At 7 months after urethroplasty, the IIEF-5 score is (16.5±4.0) and (13.6±4.3) respectively in Group 1 and Group 2 (p<0.05). According to D-CDDU, the cavernosal artery peak systolic velocity (PSV) is (37.1±7.4) cm/second and (31.6±9.7) cm/second (p<0.05), the cavernosal artery end diastolic velocity(EDV) is (4.1±0.9) cm/second and (4.2±1.2) cm/second (p>0.05), and the penile length change is (3.1±0.9) cm and (2.4±0.9) cm(p<0.05) respectively in Group 1 and Group 2 after drug injection. NPT testing shows that the number of erectile events is (2.4±2.0) and (2.8 ±1.7) (p>0.05), the duration of erectile events is (12.1 ±4.1) min and (11.5±4.7)min (p>0.05), and the penile Avg Event Rigidity is (26.9±10.2) cm and (26.4±11.6) cm (p>0.05)respectively in Group 1 and Group 2. CONCLUSIONS This short term study showed that early use of VED is useful and well-tolerated in the penile rehabilitation for the patients after posterior urethral anastomotic urethroplasty because of PFUDD. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1224-e1225 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Lujie Song More articles by this author Qiang Fu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD44-01 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRICTURES AFTER SURGERY FOR BENIGN PROSTATIC HIPERPLASIA WITH PRESERVATION OF CONTINENCE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2016PD44-01 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRICTURES AFTER SURGERY FOR BENIGN PROSTATIC HIPERPLASIA WITH PRESERVATION OF CONTINENCE Reynaldo Gomez, Juan Carlos Castaño, Laura Velarde, and Rodrigo Campos Reynaldo GomezReynaldo Gomez More articles by this author , Juan Carlos CastañoJuan Carlos Castaño More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Rodrigo CamposRodrigo Campos More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1793AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-membranous urethral strictures (BMUS) after surgery for BPH are challenging because the internal sphincter has been removed and continence relay on the external sphincter, which is located just at the site of the stricture; any attempt to reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue [1]. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS Patients with BMUS after TURP or open prostatectomy (OP) who failed dilation and/or internal urethrotomy were reconstructed with a BPA with preservation of the external sphincter. The bulbo-membranous junction is approached dorsally and the bulb is mobilized only from one side, without detachment from the perineal body. The bulbo-membranous junction is isolated with a vessel loop and the bulbar vessels retracted posteriorly. The sheath of the membranous urethra is opened circumferentially, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained. Gentle blunt proximal dissection along this connective tissue plane allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis RESULTS From January 2010 to October 2015 we operated 23 patients, 14 after TURP and 9 after OP. All had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. Mean age was 68 years (57 – 81). Except 4 patients, all have been treated with either dilation and or one or more DVIUs; seven were with a suprapubic tube. Mean length of stricture was 3 cm (1 - 4.5), mean time from surgery to reconstruction was 30 months (2 - 153). At a mean follow-up of 34 months (1 - 68) 19/23 patients were completely dry or using only one security pad (83% success). There were two Clavien I and one Clavien III complications and no stricture recurrence. CONCLUSIONS Excision and bulbo-prostatic anastomosis with sphincter sparing for BMUS after BPH surgery is feasible and safe. Our technique allows preserving continence in most patients and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate our results. 1. Dalpiaz O et al. Anatomical approach for surgery of the male posterior urethra. BJU Int 2008; 102: 1448-1451. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e998 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Reynaldo Gomez More articles by this author Juan Carlos Castaño More articles by this author Laura Velarde More articles by this author Rodrigo Campos More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

One-stage Anastomotic Urethroplasty for Traumatic Urethral Strictures. January 2004-January 2013.

Purpose:One-stage anastomotic urethroplasty is an attractive procedure for reconstructing the urethra following trauma. This prospective study highlights the advantages of the procedure and outcome of treatment.Materials and Methods:A total of 87 patients, age range 11–68 years with a mean of 35.4 years were included in the study. These patients were seen at two tertiary Institutions in South East Nigeria. The stricture lengths varied between 0.8 cm and 3.2 cm. All had suprapubic cystostomy initially followed by an end to end perineal anastomosis after thorough work up. Preoperatively 9 (10.3%) patients had impotence from the trauma. Postoperatively the patients were assessed with peri-catheter retrograde urethrogram, micturating cystourethrogram, and uroflowmetery.Results:All the patients were males. At 6 months, 13 out of 21 (62%) patients who had bulbo-prostatic anastomosis and 62 out of 66 (94%) patients that had bulbo-membranous, bulbo-bulbar anastomosis had satisfactory micturition with urine flow rate >15 ml/s. Totally, 12 (13.8%) patients had urine flow rate of <12 ml/s. At 1-year, there were 12 re-strictures, no urinary incontinence and four cases of a decrease in the strength of penile erection that needed no treatment.Conclusion:Delayed one-stage anastomotic urethroplasty provides for decreased incidence of postoperative morbidity, re-stricture, impotence and urinary incontinence for most short segment posttraumatic urethral strictures.

The spectrum of pelvic fracture urethral injuries and posterior urethroplasty in an Italian high-volume centre, from 1980 to 2013

ObjectiveTo describe the emergency and delayed treatment of patients with pelvic fracture urethral injuries (PFUI) presenting to an Italian high-volume centre. Patients and methodsIn a retrospective, observational study we evaluated the spectrum of PFUI and posterior urethroplasty in an Italian high-volume centre, from 1980 to 2013. Patients requiring emergency treatment for PFUI and delayed treatment for pelvic fracture urethral defects (PFUD) were included. Patients with incomplete clinical records were excluded from the study. Descriptive statistical methods were applied. ResultsIn all, 159 male patients (median age 35years) were included in the study. A traffic accident was the most frequent (42.8%) cause of PFUI, and accidents at work were reported as the cause of trauma in 34% of patients. Agricultural accidents decreased from 24.4% to 6.2% over the course of the survey. A suprapubic cystostomy was the most frequent (49%) emergency treatment in patients with PFUI. The use of surgical realignment decreased from 31.7% to 6.2%, and endoscopic realignment increased from 9.7% to 35.3%. A bulbo-prostatic anastomosis was the most frequent (62.9%) delayed treatment in patients with PFUD. The use of the Badenoch pull-through decreased from 19.5% to 2.6%, and endoscopic holmium laser urethrotomy increased from 4.9% to 32.7%. ConclusionsThe spectrum of PFUI and subsequent treatment of PFUD has changed greatly over the last 10years at our centre. These changes involved patient age, aetiology, emergency and delayed treatments, and were found to be related to changes in the economy and lifestyle of the Italian patients.

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

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

Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and role of ancillary maneuver: A retrospective study in 172 patients

Objective:We present our experience with transperineal bulboprostatic anastomosis procedure and compare the results with age of patients, length of urethral stricture, effect of previous treatment and need for ancillary procedures.Materials and Methods:We retrospectively reviewed the outcome of 172 patients who underwent perineal urethroplasty procedure for traumatic stricture in our institute. Simple perineal anastomosis was done in 92 patients. Perineal anastomosis and corporal separation were done in 52 patients. Perineal anastomosis with inferior pubectomy was done in 25 patients. Perineal anastomosis with rerouting was done in three patients. Age, prior treatment, length of stricture, and ancillary techniques required during reconstruction were compiled. The clinical outcome was considered as failure when any postoperative instrumentation was needed.Results:Out of 172 cases that underwent transperineal urethroplasty procedure, 157 (91.28%) were successful. Simple perineal urethroplasty procedure showed a success rate of 93.4%, perineal anastomosis with separation of corporal bodies had a success rate of 90.4%, perineal anastomosis with inferior pubectomy had a success rate of 88% and perineal anastomosis with rerouting of urethra around the corpora had a success rate of 66.7%.Conclusion:The success rate of delayed progressive perineal urethroplasty procedure for post-traumatic stricture urethra is excellent and majority of the failures occurs in prepubescent boys and in those undergoing secondary repair.

Editorial Comment

This is a stunningly large series of urethral distraction injuries repaired at 1 referral center. It is a welcome analysis, and provides insight into several important questions. (1) The success rate of redo perineal urethroplasty: the success rate of second urethroplasty is 83% compared with 90% in unoperated cases. (2) Timing of failures: most failures occur before 6 months. (3) Complication rate: in this series, there was new impotence in 12% of cases (not reported in other series). (4) Higher failures in children: this series confirms that children have a 7% higher failure rate than adults. There are some other conclusions, however, that are less robust, and deserving of some unwincing examination. Transperineal Bulboprostatic Anastomosis in Patients With Simple Traumatic Posterior Urethral Strictures: A Retrospective Study from a Referral Urethral CenterUrologyVol. 74Issue 5PreviewTo evaluate the results of ancillary procedures for posterior urethroplasty and compare them with the severity of urethral stricture. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewThis is an interesting issue for discussion. First, we will discuss urethral lengthening. It may be unusual for specialists to require maneuvers such as corporeal rerouting or pubectomy. We also suggest distal mobilization of the bulbar urethra from the external sphincter to the penoscrotal junction, because this is known to provide 4-5 cm of the urethral length. This step alone should be sufficient to allow tension-free anastomosis in most patients, because in 76%-78% of patients the defect was < 3 cm. Full-Text PDF

Transperineal Bulboprostatic Anastomosis in Patients With Simple Traumatic Posterior Urethral Strictures: A Retrospective Study from a Referral Urethral Center

To evaluate the results of ancillary procedures for posterior urethroplasty and compare them with the severity of urethral stricture. A total of 301 patients (average age: 36 years) with posterior urethral strictures due to pelvic fracture urethral distraction defects were included in the study. Delayed transperineal bulboprostatic anastomosis was performed 6-24 months (mean 10 months) after pelvic fracture urethral distraction defects. Simple perineal anastomosis: 103 (34.2%) patients (group 1); perineal anastomosis with separation of the corporeal bodies: 89 (29.6%) patients (group 2); perineal anastomosis with inferior pubectomy: 95 (31.6%) patients (group 3); perineal anastomosis with rerouting of the urethra around the corpora cavernosum: 14 (4.7%) patients (group 4). The clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the total success rate of the procedures. The secondary outcome examined the success rate of the procedures according to the ancillary surgical steps. Of the 301 delayed transperineal bulboprostatic anastomosis procedures, 263 (87.4%) were successful and 38 (12.6%) were unsuccessful. Simple perineal anastomosis without ancillary procedures reflected an 89.3% success rate, perineal anastomosis with separation of the corporeal body had an 86.5% success rate, perineal anastomosis with inferior pubectomy had an 84.2% success rate, and perineal anastomosis with urethral rerouting had an 85.7% success rate. Corporal splitting, inferior pubectomy, and urethral rerouting are beneficial and useful ancillary procedures in transperineal posterior urethroplasty to achieve tension-free anastomosis.

Combined Endoscopic and Surgical Technique for the Repair of Posterior Traumatic Urethral Stricture

The aim of this study is to show and evaluate the combined procedure, which uses an endoscopic suprapubic access and a surgical perineal access to repair posterior urethral stricture secondary to traumatic pelvis fracture. Material and Methods In the period from January 1989 to December 2007 eighty-nine patients underwent urethral surgery for post-traumatic posterior urethral stricture. From January 2003 all patients underwent combined endoscopic and surgical technique. According to this technique, the patient is placed in simple lithotomic position with the calves carefully placed in Allen stirrups. Two surgical teams work simultaneously. A middle-line perineal incision is made and the bulbar urethra is isolated proximally and the membranous urethra is transected at the strictured site. At the same time the second surgical team performs an endoscopic suprapubic access placing the “Amplatz” sheath, previous progressive dilation to 20/22 Ch. By using a rigid or flexible cystoscope the operator follows endoscopically the bladder neck and reaches the stenotic site performing an anterograde urethroscopy. At this point the perineum is transilluminated by the endoscope and the surgeon can easily identify the proximal urethral end. A soft guide wire is inserted at this point into the urethra through the endoscope to facilitate the dilation till a nose speculum can be inserted. At this point an end-to-end anastomosis is performed. A Foley 18 Fr catheter and a suprapubic cystostomy are left in place for 1 month; a voiding cystourethrography is then performed. Results The bulboprostatic anastomosis shows better results (65% of success) if compared with the other techniques (Badenoch, two stage urethroplasty, perineal urethrostomy). A definite increase in the success rate (10%) has been evident in the last five years, simultaneously to the use of combined technique. Conclusions The combined perineal and suprapubic access, in post-traumatic posterior urethral strictures repair, allows achieving a better and easy location and a better preparation of the proximal urethra. The final target is to obtain a better bulboprostatic anastomosis, with better results confirmed by long-term follow-up. In particular, the endoscopic management of the suprapubic access is possible and of minor invasiveness to the patient.

The Use oF Flexible Cystoscope in Posterior Urethroplasty

We present our experience with a simplified anastomotic posterior urethroplasty to highlight the necessity and usefulness of ancillary reconstructive maneuvers. We reviewed the records of 46 patients who had undergone anastomotic repair of posterior urethral strictures due to pelvic trauma between 2000 and 2007. Mean patient age at surgery was 43 years. Average stricture length was 2.3 cm. Repair was performed with a progressive perineal anastomotic procedure using flexible cystoscope by means of transcystostomic approach: after mobilization of the bulbo-membranous urethra and the corporal splitting, the prostatic apex is well visualized and the membranous urethra is sectioned proximally; the flexible cystoscope by means of transcystostomic approach facilitates to find the proximal urethral lumen and to perform the bulbo-prostatic anastomosis. Mean follow-up was 32 months. Of 46 cases, 40 (87 %) were successful and 6 (13 %) failed with recurrence of the stricture. Urinary incontinence did not develop in any patients. The operative details and maneuvers facilitate the preparation of the bulbo-membranous urethral tract and prostatic apex, and simplify the performance of the anastomotic repair.

Use of anastomotic urethroplasty with partial pubectomy for posterior urethral obliteration injuries: 10 years experience

Management of pelvic trauma-induced posterior urethral disruption due can be quite controversial and challenging. Posterior urethral obliteration cases at the membranous urethra (n = 154) were analyzed from January 1997 to December 2006. The mean length of the urethral obliteration was 4.82 +/- 1.1 cm (range 3.5-6 cm). All patients underwent excision and primary bulboprostatic anastomosis with a perineal approach partial pubectomy. The percentage of overall successful surgeries (defined by Qmax values > 15 ml/s) was 85.1%, and the mean Qmax value was 22.94 +/- 5.7 cm/s without post-operative incontinence. Short anastomotic strictures developed 1-3 months post-operatively in 23 cases with persistent voiding difficulties. Partial pubectomy is a feasible therapeutic option in patients with long urethral obliteration and may provide effective surgical results for post-traumatic posterior urethral strictures.

Surgical repair of posterior urethral defects: review of literature and presentation of experiences.

The main objective of the present review article was to study the different aspects of reconstructive surgery for posterior urethral defects by reviewing the published articles and presentation of our experiences in the reconstructive urology division at Shohada-e-Tajrish hospital. The Medline was searched with the keywords of posterior urethroplasty, end-to-end anastomosis, excisional urethroplasty, anastomotic urethroplasty, pelvic fracture, bulboprostatic anastomosis, and urethral repair. The search was limited to papers published from 1980 to September 2008. We selected the relevant published articles in this database and also presented our experience at our reconstructive urology division. Of over 5000 search results, we selected 38 relevant articles with substantial contribution to the subject. Pelvic fracture due to accidents was the most common etiology of pelvic fracture urethral distraction defect that usually involved the membranous urethra. Surgical treatment of this disorder with perineal anastomotic urethroplasty was accompanied by a success rate of 82% to 95% in different studies. The most important complications of this surgery include urinary incontinence and impotence; however, the incidence of these complications has been reduced by using new surgical techniques. Complete preoperative assessment, the use of suitable reconstructive techniques, and in particular, the use of flexible cystoscopy can lead to acceptable outcomes of the surgical repair of pelvic fracture urethral distraction defects.

U-SHAPED PROSTATOBULBAR ANASTOMOSIS FOR URETHRAL INJURY AFTER PELVIC TRAUMA

We describe a technique of U-shaped bulboprostatic anastomosis for urethral injury after pelvic trauma. Sixty-eight male patients were included in our study. Suprapubic cystostomy was carried out initially, followed by U-shaped prostatobulbar anastomosis after 6-12 weeks. Follow ups were carried out at 6, 12 and 18 months by assessing patient satisfaction rates along with preoperative and postoperative urethrogram, uroflowmetry and labelled as good, fair and poor. The surgical technique used was as follows: after an inverted Y-shaped skin incision, subcutaneous tissue and Colle's fascia was opened. Bulbospongiosum was mobilized to gain access to the stricture membranous urethra, which was excised and the bulbar urethra freed. A sound was passed through the suprapubic cystostomy and complete resection of the scar over the tip of the sound was carried out. A silicon catheter was then passed into the bladder and the anastomosis was completed in a 'U' shape; that is, there were no stitches from the 10 to the 2 o'clock position. Good and fair results were considered as successful. Overall success rate was 97.05% immediately and after 6 months, but decreased to 95.6% at 12 months and 93.6% at 18 months. U-shaped end-to-end prostatobulbar anastomosis markedly decreases the chance of restenosis and impotence.