Post-traumatic Posterior Urethral Strictures Research Articles

Lower partial pubicectomy for postoperative complicated posterior urethral stricture

ObjectiveTo report the experience of partial inferior pubicectomy in the treatment of complex posterior urethral stricture after trauma.MethodsA total of 46 patients with post-traumatic posterior urethral stricture admitted to the Department of Urology of our Hospital from January 2013 to September 2021 were selected as the research objects and underwent urethroplasty (including nine patients who had failed previous perineal repair surgery and adopted partial inferior pubicectomy approach). Retrograde urethrograph (RUG) and urine flow measurement were performed at 1, 3, 12 and 18 months after operation, and follow-up was performed when necessary. The clinical data during treatment were statistically analyzed.ResultsAll 46 patients underwent urethroplasty successfully, of which nine were treated with partial pubicectomy, accounting for 19.57% of the total. The causes of the disease were motor vehicle accident in 4 cases, falling collision injury in 2 cases, and rolling injury of military exercise tank in 3 cases. Among the 9 patients, 2 were children (22.22%), aged 8 and 12 years, and 7 were adults (77.78%), aged 19–44 (28.42 ± 1.56) years. Among the 9 patients, 6 had erectile dysfunction, accounting for 66.67%. The length of posterior urinary tract stenosis was (5.12 ± 0.57) cm. The operation time was (290.34 ± 12.35) min from anesthesia induction to skin closure. Five patients received 2 U blood transfusion during operation and three patients received 3 U blood transfusion after operation. The average hospital stay was 12–16 (14.24 ± 1.25) days, and the follow-up was 12–24 (18.24 ± 1.35) months. After surgery, one patient developed HIP abscess, which was successfully treated conservatively. One patient had dysuria 1 month after operation and was successfully treated by transurethral dilatation. One case had postoperative infection and recovered after intravenous administration of potent antibiotics. Cystourethrography was performed 3 months after operation, and there was no difference between patients with wide, long or short anastomotic stretch defects. All patients met the criteria for surgical success.ConclusionPartial inferior pubicectomy is a good surgical procedure for the repair of complicated posterior urethral stricture after operation. It is safe and reliable, can better display the prostatic apex and surgical field, shorten the length of reconstructed urethra, and has good postoperative effect. It has no direct or long-term effect on the stability of pelvis or bladder. However, further studies in a larger cohort of patients with complex posterior urethral strictures after repair are needed to demonstrate the specific indications for partial pubicectomy.

Можливості використання ендоскопічного обладнання в лікуванні коротких посттравматичних стриктур уретри в дітей

Актуальність. Пошкодження уретри при пошкодженні кісток таза в дітей відмічається рідше, ніж у дорослих (менше 1 %) (Tarman G.J. et al., 2002). Посттравматична стриктура уретри в дітей є досить рідкісною та складною урологічною патологією. З урахуванням анатомічних особливостей лікування стриктури уретри в дітей відрізняється від її лікування в дорослих (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). М.М. Koraitim (2012) описав досвід лікування 20 хворих з ускладненнями після трансперинеальної пластики уретри. Автор відмітив, що у разі відсутності необхідності реконструкції шийки сечового міхура достатньо ефективним є ендоскопічне розсічення стриктури уретри. Т.Е. Helmy, А.Т. Hafez (2013) теж описали результати успішного застосування ендоскопічного обладнання (пряма візуальна уретротомія) після відкритих уретропластик. Важливим моментом, що спонукає до пошуку ефективних малоінвазивних методів лікування посттравматичних стриктур уретри в дітей, є розвиток еректильної дисфункції у подальшому, що, за даними деяких авторів (Koraitim M.M., 2014), становить до 47 %. Мета дослідження: на основі доступних літературних даних і власних результатів лікування дітей із стриктурами задньої уретри установити роль ендоскопічного лікування вказаної складної патології як методу профілактики та лікування нервово-м’язової дисфункції сечового міхура. Матеріали та методи. На базі хірургічних відділень Житомирської обласної дитячої клінічної лікарні широко впроваджені малоінвазивні ендоскопічні методи діагностики та лікування патології нижніх сечових шляхів. Наявне обладнання дає можливість проводити діагностичні процедури, починаючи з місячного віку. Виконується цілий ряд ендоскопічних оперативних втручань на нижніх сечових шляхах, а саме: видалення конкрементів, розсічення клапанів та стриктур задньої уретри, розсічення кіст уретри та ектопічних уретероцеле тощо. Також у 2010 році вперше виконано спробу за допомогою черезшкірної трипортової цистоскопії видалити вклинений у рубцево-змінену задню уретру конкремент. З 2013 року розпочато лікування посттравматичних стриктур задньої уретри під ендоскопічним контролем. Результати. Подано результати успішного малоінвазивного лікування із застосуванням сучасного ендоскопічного обладнання у двох хворих із посттравматичними стриктурами задньої уретри. Особливо наголошено на ефективності методу в діагностиці та лікуванні нервово-м’язової дисфункції сечового міхура в даної категорії хворих. Висновки. Отже, застосування сучасного малоінвазивного обладнання не лише дає можливість ефективно діагностувати пошкодження нижніх сечових шляхів, а й може бути дієвим механізмом малотравматичного хірургічного лікування при коротких посттравматичних стриктурах уретри в дитячому віці. Своєчасне якісне лікування рубцевих стриктур уретри в дітей зведе до мінімуму розвиток інфравезикальної обструкції та порушення евакуаторної функції сечового міхура із розвитком його нервово-м’язової дисфункції.

Surgical selection and outcome for treating the post-traumatic posterior urethral strictures via transperineal approach

Objective To evaluate the outcome of various operative selection for treating posterior urethral stricture via transperineal approach. Methods The clinical data of 5 000 patients with posterior urethral stricture or obstruction from January 1990 to January 2017 were analyzed retrospectively. All patients were male. The age of those patients ranged from 18 months to 77 years old, mean 36.6 years old. Pelvic crush injury caused by car accident occurred in 2010 cases. Falling injury occurred in 1680 cases. Pelvic compressed injury occurred in 1 310 cases. Accompanied visceral damage occurred in 2 590 cases, including the liver and spleen rupture in 920 cases, lower limb fracture in 1 200 cases. 2 200 cases accepted urethral realignment under emergency. 2 800 cases were treated with pubic cystostomy. All patients were undergone a retrograde and voiding urethrogram. 562 patients accepted urethral ultrasongraphy, and 2 448 patients accepted urethroscopy. 204 patients accepted MRI examination. The mean stricture length was 4.3 cm, ranged from 1.8 to 8.6 cm. Posterior urethral stricture was found in 810(16.2%)cases. The complete obstruction of posterior urethra was found in 4 190(83.8%)cases, of which the length of the distraction defects≤3 cm was found in 2 650(53.0%)cases and the length of the distraction defects>3 cm was found in 1 540(30.8%)cases. Bladder calculi was found in 2 300 cases. The perineal fistula or abscess was noticed in 290 cases. False passage was found in 460 cases. Urethra rectum fistula was found in 160 cases. Bladder neck open was noticed in 89 cases. Repairing was performed via a simple anastomosis after urethral mobilization in 1 700 patients, via separation of the corporeal bodies in 1 302 patients, via separation of the corporeal bodies and inferior pubectomy in 1 910 patients and via scrotal skin flap urethroplasty in 68 patients. Pull-through operation was performed in 20 patients. Results Postoperative follow-up were conducted from 6 to 72 months with average duration of 23 months. The overall successive results after operation was 92.2%(4 608/5 000), which the Qmax was more than 15 ml/s .The successive rate of urethroplasty were 97%(1 649/1 700 )in simple anastomosis; 93%(1 211/1 302 )in separation of the corporeal bodies; 88% (1 680/1 910) in separation of the corporeal bodies and inferior puberctomy; 78%(53/68) in scrotal skin flap urethroplasty and 83%(15/18) in pull-through operation. The successive rate were 96%(778/810)in posterior urethral stricture; 95%(2 517/2 650)in distraction with the length of obstruction less than 3 cm and 86%(1 324/1 540)in distraction with the length of obstruction more than 3 cm. Conclusions The transperineal end to end anastomotic urethroplasty has become the first-line therapy for posterior urethral atresia. The length of the strictures or distraction defect which is lower than 3 cm is much more successfully corrected. Key words: Urethral stricture; Urological surgical procedure; Transperineal; Wound and injuiry

Management of Post Traumatic Posterior Urethral Stricture; Internal Urethrotomy verses Perennial Urethroplasty

Objective: To compare the efficacy and cost effectiveness of cold knife optical internal urethrotomy with perineal urethroplasty (excision and end to end anastomosis) in the management of post traumatic short posterior urethral stricture. Design: an observational prospective study. Place and duration of study: the study was performed in the department of urology and kidney transplantation Services hospital/post graduate medical institute Lahore, from September 1997 to December 1999. Patients and methods: Forty male patients of post traumatic posterior urethral stricture revealed by their urethrogram were included in the study. Patients were divided in two groups randomly (group A & group B). After complete evaluation, patients of group A were managed by internal uretherotomy, while those of group B by perineal urethroplasty. Follow up was done at 1,3,6,9 & 12 months. Results: age range of the patients was 20 to 59 years with the mean age of 35.5 years. Road traffic accident was the main cause (82.5%). After facing the traumatic urethral injury, there was history of attempted Foley catheterization (47.5%), bouginage (15%) and intervention by rail road technique in 10% of the patients. All patients were with supra pubic catheter because of failure to void. The length of stricture varied from 0.5 to 2.0 cm (mean 1.4 cm). Clinical response at the end of the study in group A & B was "good" in 58.82% & 66.66%, "satisfactory" in 23.52% & 22.22% and "poor" in 17.64% &11.11% respectively. The mean cost of operation, hospital stay and loss of working hours were less in group A as compared to that of group B. Conclusion: The results of perineal urethroplasty are comparatively better than optical urethrotomy. The other differences of the two procedures lie in operative time cost of the operation and mean hospital stay. It is concluded that optical urethrotomy is an acceptable alternative to urethroplasty in patients with short post traumatic posterior urethral stricture.

Perineal Anastomotic Urethroplasty in a Pediatric Cohort With Posterior Urethral Strictures: Critical Analysis of Outcomes in a Contemporary Series

To evaluate the long-term outcomes of perineal anastomotic urethroplasty for post-traumatic pediatric posterior urethral strictures. We retrospectively reviewed the medical records of 65 boys who had a perineal anastomotic urethroplasty for post-traumatic posterior urethral strictures between 1991 and 2010. Patients were followed up for a mean (range) of 78 (13-210) months by a history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Regression analysis was done to assess the predictors of success after urethroplasty. The mean (range) age of the patients was 9.3 (3-16) years. The estimated radiographic stricture length before surgery was 2.4 (1-5) cm. All patients presented with a suprapubic cystostomy tube and scheduled for delayed or repeated correction of a urethral stricture. Twenty boys (30%) had failed previous attempts of repair elsewhere. Mean interval between the original trauma and repair in new cases, and since the last repair in recurrent cases, was 7 months. The perineal anastomotic repair was successful in 58 of 65 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in 5 patients and by repeat perineal anastomotic repair in the remaining 2. All boys are continent. There was no chordee or urethral diverticula during the follow-up. One-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is feasible with minimal morbidity. Denovo cases and surgeon experience are the predictors of success after urethroplasty.

Our experience, technique and long-term outcomes in the management of posterior urethral strictures

PurposeTo share our experience, technique and long-term outcomes in posterior urethral stricture management. Materials and methodsThirty-seven boys with post-traumatic posterior urethral stricture underwent resection and end-to-end anastomosis through pre-anal coronal approach or in combination with trans-pubic approach from January 2000 to December 2011. Follow up included symptomatic evaluation by micturating cystourethrogram and retrograde urethrogram in all patients, and urethroscopy in patients with voiding symptoms. ResultsPre-anal coronal approach was used in 29 (78%) cases and in 8 (21%) cases it was combined with trans-pubic approach. In 33 (89.1%) patients it was first attempt, while in 4 (10.9%) it was redo surgery. Two patients required buccal mucosal graft to bridge the deficient urethra. Patient age was 5–17 years (mean 10.8 years). Mean follow up was 48.5 months (range 6–132 months). Thirty-two (86%) patients were symptom free. Failed repairs were successfully managed by urethral dilation in 3 and by redo urethroplasty in the remaining 2. All patients were continent. There was no chordee, penile shortening or urethral diverticula. ConclusionsResection and end-to-end anastomosis of posterior urethral stricture is possible through pre-anal coronal incision; however, if slightest difficulty is envisaged in creating a satisfactory end-to-end anastomosis, extension to trans-pubic approach should be done.

Internal Urethrotomy for Recurrence After Perineal Anastomotic Urethroplasty for Posttraumatic Pediatric Posterior Urethral Stricture: Could It Be Sufficient?

To evaluate the long-term outcome of visual internal urethrotomy (VIU) after perineal anastomotic urethroplasty for posttraumatic pediatric posterior urethral strictures. Data of 22 boys who had undergone internal urethrotomy for recurrent stricture after perineal anastomotic urethroplasty for posttraumatic posterior urethral strictures between 1998 and 2008 were analyzed retrospectively regarding patient age, interval between anastomotic urethroplasty and internal urethrotomy, stricture length, surgical technique, and postoperative complications. VIU was performed in patients in whom a guidewire could be passed beyond the stricture segment. The eventual surgical success was defined as asymptomatic voiding without clinical evidence of residual stricture (good flow rate and absence of residual urine). The mean (range) age of patients was 12.2 (3-17) years. All patients had a road traffic accident with associated pelvic fracture. The perineal approach for anastomotic urethroplasty was adopted in all. The estimated stricture length was 0.5 cm or less in 15 patients and was 0.5 to 1 cm in 7 patients. The interval between anastomotic urethroplasty and internal urethrotomy was early-after 12 weeks or less-in 13 children or late-beyond 12 weeks-in the remaining 9. The overall mean interval was 18 (5-63) weeks. In all patients, a guidewire could be passed through the strictured area. One VIU was performed in 17 patients, 2 VIU in 3 patients, while 3 VIU were performed in 2 patients. There was no extravasation reported. The mean follow-up duration was 98 (38-210) months. VIU was successful in 20 of 22 (90%) patients. All patients voided with no symptoms and were continent. VIU offers high success rate and can be sufficient in recurrent strictures of less than 1 cm length after anastomotic urethroplasty in children whenever a guidewire can be passed through the stricture area.

Three-dimensional spiral computed tomographic cysto-urethrography for post-traumatic complex posterior urethral strictures associated with urethral-rectal fistula

To evaluate the value of three-dimensional spiral computed tomography/cysto-urethrography (CTCUG) in diagnosing posterior urethral strictures associated with urethrorectal fistulas (URF). Between June 2008 and March 2012, 38 patients with posterior urethral strictures associated with URFs were examined by CTCUG, retrograde urethrography (RUG) and cysto-urethrography (CUG). Urethral reconstruction was undertaken and URFs were surgically repaired in all patients. The length of the urethral defect, location and size of URFs were recorded. Data from radiological examinations were compared with surgical findings. No statistically significant difference was found in the length of stricture measured using CTCUG (4.31 ± 2.28 cm) or conventional urethrography (4.02 ± 3.12 cm; p > 0.05), However, the accuracy in determining the location of the stricture was higher with CTCUG (93.12%) than with conventional urethrography (70.59%; p < 0.05). CTCUG identified URFs in all 38 patients (100%), whereas URFs were only observed in 27 patients (71%) using conventional urethrography. In conclusion, CTCUG was more accurate, safer and provided more details of URFs and urethral defects than conventional urethrography in patients with posterior urethral strictures associated with URFs.

Effect of modified Badenoch operation on the treatment of posterior urethral stricture

To determine the effects of modified pull-through operation (Badenoch operation) on the treatment of posterior urethral stricture. From September 2001 to December 2010 traditional pull-through operation was Modified for two times in our center. A total of 129 patients with posttraumatic posterior urethral stricture resulting from pelvic fracture injury underwent the modified urethral pull-through operation. Stricture length was 1.5 to 5.3 cm (mean 2.9 cm). Of the patients 43 had undergone at least 1 previous failed management for stricture. In phase 1 (from September 2001 to January 2008), the improving items include: (1) The distal urethral end was stitched and tied to the catheter. (2) As catheter was inserted into bladder and 20 ml water was injected into catheter balloon, the distal urethral end was fixed in the proximal urethra and an overlaying of 1.5 cm was formed between the two ends. (3) Three weeks later, it was tried to insert the catheter to bladder. After the urethral stump necrosis and the catheter separating from the urethra, the catheter was removed. In phase 2 (from February 2008 to December 2010), based on the above, irrigating catheter was used. After the surgery, urethra was irrigated with 0.02% furacillin solution through the catheter 3 times a day. All patients were followed up for at least 6 months. If patients had no conscious dysuria and maximum urinary flow rate (Qmax) > 15 ml/s, the treatment was considered successful. All complications were recorded. In phase 1, the 96 patients (101 times) underwent the procedure. The treatment was successful in 88 patients (success rate 92%). Within 1 to 13 days after removal of the catheter, urethral stricture was recurred in 8 patients. They had to undergo cystostomy once more for 3 to 11 months before reoperation (the 3 patients' reoperation was in phase 2). The 8 cases were treated successfully. In phase 2, 33 patients (total 36 times) underwent the procedure. One patient was failed (success rate 97%). The actual follow-up time is 7 to 93 months (An average of 37.6 months). Qmax is (22 ± 5) ml/s. No complications such as urinary incontinence, erectile pain, urinary shortening happened. The modified urethral pull-through operation is effective for the surgical treatment of posttraumatic posterior urethral stricture. It has a high success rate with durable long-term results. Complications are few. The procedure is simple, less demanding and especially suitable in patients who had previously undergone failed surgical treatments.

Surgical treatment of post-traumatic complex posterior urethral stricture in male patients

Objective To investigate the therapeutic effect of post-traumatic complex posterior urethral stricture in the male patients.Methods Clinical data of 479 male patients with post-traumatic complex posterior urethral stricture were reviewed.One-stage resection of the stenosis and end-to-end anastomosis was performed in 422 patients and scrotal flap with blood pedicle posterior urethroplasty in 57.Results The mean operation time was 115 minutes(range,90-140 minutes).The mean blood loss was 225 ml(range,100-300 ml).No intraoperative blood transfusion was needed.The mean follow-up time was 15 months(range,12-24 months).Among the 422 patients performed end-to-end anastomosis,386 patients had good voiding and 36 had dysuria because of the formation of anastomotic stoma valve(21 patients)or stricture ring(15 patients).The problem was resolved by transurethral valve/stricture ring resection.Among 57 patients undergone posterior urethroplasty,45 patients had good voiding nine patients were found with anterior urethra-skin tube anastomotic stoma stricture,of which four patients were treated by urethral dilatation and five by endourethrotomy; three patients were found with posterior urethra-skin tube anastomotic stoma stricture,of which one patient was treated by urethral dilation and two by endourethrotomy.Conclusions One-stage resection of the stenosis and end-to-end anastomosis is the main treatment for post-traumatic complex posterior urethral stricture.If the condition of the patients does not allow the end-to-end anastomosis,posterior urethroplasty can be an alternative. Key words: Male; Trauma; Posterior urethral stricture; Surgery

204 IMPACT OF PRIOR URETHRAL MANIPULATION ON OUTCOME OF ANASTOMOTIC URETHROPLASTY FOR POST-TRAUMATIC URETHRAL STRICTURE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 2011204 IMPACT OF PRIOR URETHRAL MANIPULATION ON OUTCOME OF ANASTOMOTIC URETHROPLASTY FOR POST-TRAUMATIC URETHRAL STRICTURE Aziz Abdullah Aziz AbdullahAziz Abdullah Karachi, Pakistan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.275AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. METHODS From Jan 2008 to Feb. 2010, a total of 42 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (5), endoscopic realignment (7), or open urethroplasty (6). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. RESULTS Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. CONCLUSIONS Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e84-e85 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aziz Abdullah Karachi, Pakistan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of Prior Urethral Manipulation on Outcome of Anastomotic Urethroplasty for Post-traumatic Urethral Stricture

To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. From October 1995 to March 2008, a total of 58 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (3), endoscopic realignment (7), or open urethroplasty (8). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise.

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.

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.

Modified Urethral Pull-Through Operation for Posterior Urethral Stricture and Long-Term Outcome

We present our experience, technique and long-term results of the modified urethral pull-through operation for posttraumatic posterior urethral stricture. A total of 113 patients with posttraumatic posterior urethral stricture resulting from pelvic fracture injury underwent the modified urethral pull-through operation at our department from August 1999 to March 2007. Patient age was 17 to 69 years (mean 35.2). Stricture length was 1.5 to 4.7 cm (mean 2.6). Of the patients 52 (46.0%) had undergone at least 1 previous failed management for stricture, including urethroplasty in 29 (25.7%). Followup included symptomatic and urinary flow rate evaluation, which was performed 6 and 12 months after the modified urethral pull-through operation in all patients and thereafter when needed, and urethrography and/or urethroscopy in patients with voiding symptoms. Clinical outcomes were considered a success when no postoperative procedure was needed. Patients were followed for 12 to 86 months (mean 48.5). During that period 109 patients were symptom-free and required no further procedures. The maximal flow rate in each case was greater than 15 ml per second. Recurrent stricture developed in 4 patients. All treatment failures occurred within the first 8 months postoperatively. Failed repairs were successfully managed endoscopically in 1 patient by urethral dilation in 1 and by repeating the pull-through operation in the remaining 2 for a primary success rate of 96.5% and a final success rate of 100%. All patients were continent. Erectile dysfunction was noted postoperatively in 5 patients (3.7%). There was no chordee, penile shortening or urethral diverticula. The modified urethral pull-through operation is effective for the surgical treatment of posttraumatic posterior urethral stricture. It has a high success rate with durable long-term results. Complications are few. The procedure is simple, less demanding and especially suitable in patients who had previously undergone failed surgical treatments.

Does a previous end‐to‐end urethroplasty alter the results of redo end‐to‐end urethroplasty in patients with traumatic posterior urethral strictures?

To evaluate the success rate of redo anastomotic urethroplasty and to compare it with primary anastomotic urethroplasty. We compared 52 patients with post-traumatic posterior urethral strictures (group 1, mean age 24.6 years, range 10-62) who had undergone redo urethroplasty with 66 patients (group 2, mean age 22.6, range 6-71) who had undergone primary anastomotic urethroplasty. Mean stricture length was 2.0 cm (1-4.5) and 2.5 cm (1.5-6), respectively. All of the patients in group 1 had a stricture located at the bulboprostatic anastomotic site. In group 2, 43 (65.2%) had a bulbomembranous stricture and 23 (34.8%) had a prostatomembranous stricture. Mean operative time was 140 (100-240) and 90 min (75-200) in group 1 and 2, respectively. Mean blood loss was 180 (80-900) and 125 mL (50-700), respectively. Mean hospital stay was comparable (6.6 days vs 5.5 days) between the two groups. Mean follow up was 54 months (10-144) for group 1 and 62 months (12-122) for group 2. Corporal separation, inferior pubectomy, a transpubic approach and urethral rerouting were required in 22 (42.3%) and 12 (18.2%), 7 (13.5%) and 3 (4.5%), 12 (23%) and 5 (7.6%), 2 (3.8%) and nil patients in group 1 and 2, respectively. An excellent or acceptable outcome was achieved in 42 (80.8%) and 57 (86.4%), 8 (15.4%) and 7 (10.6%) patients, respectively. Two patients in each group failed. Previously failed end-to-end urethroplasty does not alter the success rate of redo end-to-end urethroplasty.

Posttraumatic Posterior Urethral Strictures in Children—Management and Intermediate-term Follow-up in Tertiary Care Center

To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children. From March 2000 to November 2006, the surgical records of 28 children (< or = 18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3-58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated. The mean age of the patients was 12.1 years (range 5-18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2-6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant. Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty.

Gapometry and Anterior Urethrometry in the Repair of Posterior Urethral Defects

We determined the influence of bulbar urethral length on the anastomotic repair approach to bulboprostatic urethral distraction defects. We reviewed the medical records and radiographic studies of 120 patients 6 to 52 years old who had undergone anastomotic repair of bulboprostatic urethral gaps. Repair was accomplished by a simple perineal operation in 84 patients (group 1) and an elaborated perineal or a transpubic procedure in 36 (group 2). The length of the urethral gap and bulbar urethra was measured on preoperative urethrogram. Also, the length of the urethral gap as a fraction of bulbar urethral length (index of elastic lengthening) was calculated. Mean length of the urethral gap was 1.5 cm in group 1 vs 4.2 cm in group 2 (p <0.001). Mean bulbar urethral length was 7.3 cm in group 1 vs 6.6 cm in group 2 (p >0.05). The mean index of elastic lengthening was 0.21 (range 0.06 to 0.34) in group 1 vs 0.64 (range 0.38 to 0.88) in group 2 (p <0.001). The difference in the mean length of the urethral gap between children and adults in the 2 groups was not statistically significant (2.4 vs 2.5 cm, p >0.05), while the difference in the mean length of the bulbar urethra was highly significant (5.6 vs 7.7 cm, p <0.001). Bulboprostatic urethral gaps shorter than a third of bulbar urethral length are usually corrected by a simple perineal operation. For longer gaps an elaborated perineal or transpubic procedure is usually done. Also, the latter 2 procedures are more commonly performed in children than in adults because of the shorter bulbar urethra.

Post-traumatic posterior urethral stricture in children: How to achieve a successful repair

Objective Complex post-traumatic posterior urethral strictures in children constitute a major challenge to the pediatric urologist. Surgical repair depends primarily on the length of the urethral obliteration. Resection with end-to-end anastomosis is the usual procedure in the face of a short segment stricture. Transpubic urethroplasty and substitution urethroplasty are currently used to treat extensive and complex urethral strictures. We present our experience of the management of children presenting with post-traumatic posterior urethral stricture. Patients and methods Fifty boys with a mean age of 9 years (6–13) with obliterative urethral stricture were operated on during May 1999 to August 2006. Short posterior urethral stricture was treated by excision and end-to-end anastomotic urethroplasty in 40 boys. Long posterior urethral stricture was managed by combined inferior pubectomy in three, transpubic urethroplasty in four and tubed penile fasciocutaneous flap in three. Results With a mean follow-up of 4.5 years (6 months–7 years), all children who underwent perineal anastomotic urethroplasty were successfully repaired. Transpubic urethroplasty was associated with a re-stricture in one child 6 years following the repair. In the group repaired by tubed fasciocutaneous flap, we encountered a distal anastomotic stricture accompanied by a huge proximal diverticulum which needed revision in one child, and another diverticulum with multiple stones in another who was treated successfully. Conclusion Anastomotic urethroplasty in children is feasible with good results. Proper evaluation is needed to choose the best surgical technique for each patient. Tubed fasciocutaneous flap carries the highest complication rate.

Traumatic Obliterative Urethral Strictures in Pediatric Patients: Failure of the Cut to Light Technique at Long-Term Followup

The cut to light procedure or antegrade and retrograde urethroscopy with endoscopic incision of obliterative urethral strictures is an accepted method of treating posterior urethral distraction injuries. We report long-term followup on 22 pediatric patients treated with this technique. The records of all pediatric patients with a posterior urethral distraction injury treated from 1986 through 2006 were reviewed. The cut to light procedure was performed for obliterative strictures less than 1 cm via a cold knife or laser in 11 patients each. A urethral catheter was left in situ for 3 weeks. Patients were then followed a minimum of 2 years. A total of 22 patients at a median age of 11 years (range 3 to 16) were treated. Followup revealed stricture recurrence in all patients. Median time to recurrence was 3 months after catheter removal (range 5 days to 1 year). Although intermittent catheterization to maintain patency was attempted in all patients, the development of impassable urethral strictures in 16 (73%) and complaints of chronic pain with catheterization in 4 (18%) led to end-to-end urethroplasty. Successful reconstruction with open surgery was achieved in 19 of 20 patients (95%). Two patients (9%) maintained urethral patency with intermittent catheterization. In children with obliterative posterior urethral distraction injuries a cut to light procedure had a long-term success rate of 0%. All patients required daily intermittent catheterization (9%) or formal urethral reconstruction (91%) to maintain patency. We would strongly recommend against treating pediatric obliterative urethral strictures with a cut to light procedure.