Posterior Urethral Distraction Defects Research Articles

End to End Anastomotic Urethroplasty in the Management of Posterior Urethral Distraction Defect

Posterior urethral distraction deficits are a difficult and complex clinical condition that necessitates specialized care in urological therapy. End-to-end anastomotic urethroplasty has emerged as a critical procedure for treating posterior urethral distraction abnormalities, providing a thorough and successful approach for restoring normal urethral function. Objective: To assess the outcome of end-to-end urethroplasty in posterior urethral distraction defects. Methods: This study was conducted at the departments of Urology, MTI LRH, and Peshawar from 1st November 2017 to 31st December 2021. It was a descriptive case-series study by design. Patients included were having blind urethral strictures. End to end urethroplasty was performed. Patients were followed for one year. Depending upon symptoms relief, uro-flowmetery studies, and radiographic findings at the end of one year, success was defined as good, fair, or poor. Results: The study included a total of 110 patients, with a majority being male (80%) and the remaining 20% being female. The mean age of the patients was 35 years, with the majority falling in the age group of 30-39 years (50.9%). Good outcomes were recorded in 79 patients (71.8%). 11 (10.0%) participants had poor outcomes. Conclusions: Urethroplasty is a gold standard treatment modality in terms of outcome for patients with posterior urethral distraction defects.

Surgical Repair of Posterior Urethral Distraction Defects and its Outcome : Initial Experience in a Tertiary Level Hospital

Purpose: Management of posterior urethral distraction defects are challenging for urologists and need very careful and meticulous dissection for getting a good outcome. Dhaka medical college hospital is a tertiary referral hospital where we receive a lot of cases from different districts. The study was done to observe the outcome of anastomotic urethroplasty for posterior urethral distraction defects. Methods : This was a prospective experimental study. This study was done in a single unit of DMCH urology department by a single surgeon . Those who were suffering from posterior urethral distraction defects with suprapubic catheter in situ were included and underwent anastomotic urethroplasty from the period of January, 2018 to october, 2019. After proper evaluation and counseling all patients underwent perineal anastomotic urethroplasty under spinal anesthesia with 6-8 interrupted suture, using 4/0 vicryl. A 14 Fr Foley catheter was placed in urethral lumen and 16 Fr catheter in SPC site. A latex strip drain was placed for perineal wound. Drain was removed after 48 hours of operation . Patients were usually discharged in between 5th to 7th POD with definite follow up protocol and medications with supra pubic catheters (SPC) and per urethral catheters in situ. On 21 POD urethral catheter was removed. SPC was removed after 7 days if patient can void normally. 1st and 2nd follow up were done at the completion of 3rd and 6th month respectively. The prevalence of post-operative sexual disorders was investigated using the International Index of Erectile Function-5 (IIEF-5) questionnaire during follow-up. If the patient can able to void per urethra in a well manner and Qmax>15 mL/s then repair was defined successful.
 Result : Success rate of perineal anastomotic urethroplasty for posterior urethral distraction defect was 83.33.%. 18 patients were included in the study. The mean age was 28.27 years. 17 patients were able to void successfully after surgical procedure but among those 2 patients had urinary flow rate < 15 ml/sec and one patient didn’t able to void. 3 patients had developed wound infection, 3 patients developed erectile dysfunction.
 Conclusion : Perineal anastomotic urethroplasty is gold standard for treatment of posterior urethral distraction defects. Long term follow up is needed to give a opinion regarding the ultimate outcome of the surgical procedure and that have give a good idea for future management.
 Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.193-198

Outcome of Laser Urethrotomy in Comparison with Optical Internal Urethrotomy in Recurrent Stricture Urethra Following Perineal Anastomotic Urethroplasty for PUDD

Objective: To compare the outcome of laser urethrotomy and optical internal urethrotomy(OIU) for the treatment of recurrent stricture urethra following perineal anastomotic urethroplasty for posterior urethral distraction defect.
 Materials and methods: The study was conducted in Dhaka Medical College Hospital from January 2013 to December 2014.Male patients presented with obstructed voiding symptoms following perineal anastomotic urethroplasty were evaluated by their history, physical findings and investigations (urinalysis, uroflowmetry, retrograde urethrogram and micturiting cystourethrogram ) & primarily 64 patients are selected by purposive sampling. Patients are divieded again by random allocation into group A and group B and underwent for OIU and laser urethrotomy respectively.
 Results: Comparison was made to find out the better method between optical urethrotomy and laser urethrotomy. Overall per-operative complications (bleeding, extravasations of irrigating fluid, false passage and broken knife) in the former group were 31.3% compared to none in the latter group. Post-operative complications like bleeding, haematoma, penile oedema and erectile dysfunction were found only in Group-A (p=0.002). The mean duration of postoperative catheterization and average hospital stay were observed to be much higher in Group-A than that in Group-B (p=0.000008; p=0.0006). Comparison of final outcome (development of stricture) between groups at 1 year of evaluation in Group-A and Group-B was not significant (p= 0.320).
 Conclusion: Laser urethrotomy is better than optical urethrotmy in regards of peroperative and post-operative complications.
 Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.181-187

Outcome of Anastomotic Urethroplasty in Posterior Urethral Distraction Defect With or Without Mucosal Fixation- a Randomized Clinical Trial

Introduction: Anastomotic urethroplasty is the treatment of choice for posterior urethral distraction defect. To notice the high failure rate of anastomotic urethroplasty, several peri-operative factors are identified. Among the per-operative factors, mucosal fixation of the both urethral ends is one of the outcome influencing factor that is recently identified. So, this randomized clinical trial has been designed to compare the outcome of anastomotic urethroplasty in posterior urethral distraction defects with or without mucosal fixation.
 Objective: To compare the outcome of anastomotic urethroplasty of PUDD patient groups with or without mucosal fixation in terms of post-operative IPSS, maximum urine flow rate and post void residual urine.
 Patients and Methods: The present study was conducted in the department of Urology, BSMMU between January’16 - November’17. Posterior urethral distraction defects with length of gap between two urethral segments upto 3 cm. were included in the study. The patients in whom anastomotic urethroplasty were done with mucosal fixation were enrolled as study group(n=21) and patients in whom anastomotic urethroplasty were done without mucosal fixation were included as control group(n=21). All the patients were followed upto 6 months of anstomotic urethroplasty and failure of anastomotic urethroplasty (by RGU and MCU), PVR and maximum urine flow rate (Qmax) in between two groups were compared.
 Result: The failure rate was found significantly higher in control group than in the study group (p=0.043). The control group showed highly significant (0.001) increase in postoperative PVR than the study group and the study group showed significant (0.007) increase in post operative maximum urine flow rate than the control group as was assumed in the hypothesis.
 Conclusion: In conclusion, it can be said that anastomotic urethroplasty with mucosal fixation is a better option than anstomotic urethroplasty without mucosal fixation. But multicentric trial is needed to further comment.
 Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p.31-34

Comparative Study Between Outcomes of Early Primary Endoscopic Realignment Versus Suprapubic Cystostomy With Delayed Reconstruction in the Management of Posterior Urethral Injury

Objectives: To compare the outcomes of early primary endoscopic realignment and suprapubic cystostomy with the outcomes of delayed reconstruction in the management of posterior urethral injury.
 Methods: This is a quasi-experimental prospective study Conducted in the Urology department Dhaka medical college and hospital from January 2009 to December 2010. Atotal of 60 consecutive patients were selected for this study and inclusion criteria, male patients and age 18years and above. Posterior urethral injury resulting in distraction defect and urethral injury with pelvic fracture. Group-A, 28 patients underwent early primary endoscopic realignment after initial suprapubic urinary diversion and Group-B, 32 patients underwent primary suprapubic urinary diversion and delayed urethral reconstruction after 3 months of injury.
 Results: After procedure 21(75%) out of 28 patients in Group-A developed stricture 12(42.9%) had simple and short segment stricture and 7(32.1%) had simple and long segment stricture, while in Group-B 12(37.5%) patients developed simple and short segment stricture. All of the patients in Group-A had minimum blood loss during operation. While, majority (81.3%) of patients in Group-B had a history of maximum blood loss. None of the patients in Group-A developed incontinence throughout the observations period (from removal of catheter to 9 months), while 15.6% of the patients in Group-B had incontinence at removal of catheter after anastomotic urethroplasty and at 3 month. The incontinence further increased to 18.8% at 6 and 9 months. Complaints of impotence were significantly less in Group-A than that in Group-B throughout the period of observation (14.3% vs. 37.5%, p = 0.042; 14.3% vs. 37.5%, p = 0.042 and 14.3% vs. 37.5%, p = 0.042). At removal of urethral catheter, stricture formation was observed and statistically there was no difference in Group-A and Group-B (14.3% vs. 21.9% in Group-B, p = 0.448). At month 3, stricture formation was significantly higher in Group-A than that in Group-B (42.9% vs. 15.6%, p = 0.020). At month 6, about 18% of patients in Group-A had stricture, but none of patients in Group-B was found so (p = 0.018).
 Conclusions: Early primary endoscopic realignment of traumatic posterior urethral disruption is a simple, less traumatic, safe, and rapid technique. It provides a low morbidity and less postoperative complications. Though recurrent stricture formation is higher but the strictures are simple and short and amenable to be corrected endoscopically. It may be considered as initial therapy in the management of posterior urethral distraction defect over suprapubic cystostomy with delayed reconstruction.
 Bangladesh Journal of Urology, Vol. 16, No. 1, Jan 2014 p.29-35

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

PT023 - The sexual and continence outcome of patients with post anastomotic (end to end) urethroplasty for pelvic fracture posterior urethral distraction defects

PT023 - The sexual and continence outcome of patients with post anastomotic (end to end) urethroplasty for pelvic fracture posterior urethral distraction defects

Traumatic Posterior Urethral Strictures in Children and Adolescents.

Background: Management of partial or complete traumatic urethral disruptions of the posterior urethra in children and adolescents, secondary to pelvic fracture poses a challenge. Controversy exists as to the correct acute treatment of posterior urethral injuries and delayed management of PFPUDDs. We reviewed the urological literature related to the treatment of traumatic posterior urethral injuries and delayed repair of these distraction defects in children and adolescents.Material and Methods: There are few long-term outcomes studies of patients who underwent PFPUDDs repairs in childhood; most reports included few cases with short follow up. We excluded studies in which the cohort of patients was heterogeneous in terms of stricture disease, etiology and location.Results: Primary cystostomy and delayed urethroplasty is the traditional management for PFPUIs. Immediate repair is rarely possible to perform. Realignment of posterior urethral rupture in children is indicated in special situations: (a) concomitant bladder neck tears, (b) associated rectal lacerations, (c) long disruptions of the urethral ends. Before delayed reconstruction ascending urethrography and micturating cystourethrogram along with retrograde and antegrade urethroscopy define site and length of the urethral gap. However, the most accurate evaluation of the characteristics of the distraction defect is made when surgical exposure reveals the complexity of the ruptured urethra. Partial ruptures may be managed with urethral stenting or suprapubic cystostomy, which may result in a patent urethra or a short stricture treated by optical urethrotomy. The gold standard treatment for PFPUDDs in children is deferred excision of pelvic fibrosis and bulbo-prostatic tension-free anastomosis, provided a healthy anterior urethra is present. Timing of delayed repair is at 3 to 4 months after trauma. Some urologists prefer either the perineal access or the transpubic approach to restore urethral continuity in children with PFPUDDs. Substitution urethroplasties are used in children with PFPUDDs, when anastomotic repair can't be achieved due to severe damage of the bulbar urethra.Conclusion: As evidenced in this review the progressive perineo-abdominal partial transpubic anastomotic repair has advantages over the isolated perineal anastomotic approach in patients with “complex” PFPUDD. This approach provides wider exposure and facilitates reconstruction of long or complicated posterior urethral distraction defects

To Study the Role of Magnetic Resonance Imaging in Posterior Urethral Distraction Defects

To Study the Role of Magnetic Resonance Imaging in Posterior Urethral Distraction Defects

Delayed surgical repair of posttraumatic posterior urethral distraction defects in children and adolescents: Long-term results

Various surgical techniques have been proposed to treat pelvic fracture urethral distraction defects (PFUDDs) in children (Figure): primary alignment of the acute transected urethra, substitution procedures and delayed anastomosis urethroplasties (DAU) by perineal, elaborated perineal, transpubic or perineo-abdominal/partial transpubic access. However, long-term follow-up of surgical correction for PFUDDS with DAU is infrequently reported in the literature. Long-term efficacy of DAU in children and adolescents with PFUDDs was evaluated. Other surgical methods used to accomplish tension-free DAU were also described. We reviewed records of 49 male children aged 3.5-17.5 years (median 9.6) with PFUDDS who underwent DAU from 1980 to 2006. Median PFUDDs length was 3 cm (range 2-6). Six patients had prior failed treatments: anastomotic urethroplasties (5) and internal urethrotomy (1). Surgical access was transperineal in 28 cases and perineal/partial pubectomy in 21. Urethral rerouting was performed in 8 cases. Median follow-up was 6.5 years (range 5-22). On review median PFUDDS length in patients treated with primary cystostomy was 3 cm compared to those initially managed with urethral alignment (4 cm). Five patients treated with perineal DAU developed recurrent strictures at the anastomosis site, successfully managed with additional perineal/partial pubectomy anastomosis (4 cases) and internal urethrotomy (1). Primary and overall success rate was 89, 7% and 100%, respectively. Urinary incontinence occurred in 9 cases. Two had overflow incontinence and performed self-catheterization; 1 developed sphincter incontinence and required AUS placement, while 4 of 6 cases with mild stress incontinence achieved dryness at pubertal age. Retrospectively, associated bladder neck lesions at trauma time were noted in 5 patients. Three patients with erectile dysfunction before DAU remained impotent. In children, several factors make management of PFUDDs more difficult than in adults: 1) restricted surgical access to reach a high lying proximal urethral end, 2) long distraction defects, 3) simultaneous bladder neck and membranous urethral lesions and 4) small urethral caliber. In our experience and that of others (Turner Warwick, 1989 and Ranjan, 2012), radiographic and endoscopic findings provide information on stricture features; however, the final choice of surgical exposure to restore urethral continuity is made at operative time based on PFUDD complexity. Perineal exposure usually allows performing DAU in 2 cm long PFUDDs. Ten percent of our patients treated with perineal DAU developed recurrent strictures attributed to inappropriate access selection or unrecognized PFUDD complexity. Failures were treated endoscopically (1) and by perineal/partial pubectomy anastomotic urethroplasty (4) with 100% final success. We used perineal/partial pubectomy DAU in 43% of the cases to excise pelvic scarring and bridge long urethral gaps, with urethral rerouting in 8 cases. Success rate of initial perineal and perineal/partial pubectomy anastomotic procedures was 82% and 100%, respectively. Koraitim (1997), Orabi (2008) and Ranjan (2012) reported excellent outcomes in children with either transperineal or transpubic anastomotic repair, as opposed to poor results in those undergoing substitution urethroplaties. Most reports rarely evaluate urinary incontinence after successful DAU. At the end of follow-up only 2 of our 9 initial incontinent cases remain with acceptable stress incontinence. Retrospectively, in 5 cases the original trauma comprised the bladder neck and the membranous sphincter mechanism. In our series erectile dysfunction after trauma did not change after DAU except in 1 patient who regained potency 1 year after repair. All patients were referred after initial treatment was done elsewhere, thus they may represent the most severe PFUDDs cases. Additionally, erection dysfunction was not investigated in the kind of detail required due to patients' age. DAU has durable success rate for PFUDDs treatment in children with a healthy bulbar urethra. In childhood, additional surgical steps are frequently needed to achieve direct anastomotic repair.

English

INTRODUCTION: Posterior pelvic fracture urethral distraction defect is a challenging urologic problem that may result in complications such as urinary incontinence and inability to void due to recurrent stricture leading to a lifelong disabling condition. AIMS AND OBJECTIVES: To evaluate the outcome of primary realignment after pelvic fracture urethral injury and the outcome of urethroplasty after development of urethral stricture. To study the outcome of simple trocar spc after pelvic fracture urethral injury and the results of stricture management. To compare the results of primary realignment versus simple trocar spc after pelvic fracture urethral injury. MATERIALS AND METHODS: 50 patients with pelvic fracture urethral injury who attended emergency department were included in the study. All patients were subjected to RGU, USG and CECT Abdomen with delayed films in selected cases with high probability of rectal, bladder neck injury. In our study subjects undergoing primary catheter realignment are included in group A. and those undergoing simple emergency SPC are included in group B. Both were followed up for the development of complications and managed accordingly. RESULTS: Out of 50 patients with pelvic fracture 26 (52%) were in in 20- 30 years age group. Trocar SPC was done in 40 patients (80%) and managed conservatively. They are grouped as Group B. All of them underwent RGU after three weeks. When there was no demonstrable stricture, suprapubic catheter was clamped and voiding trial given. If the patient was not voiding well, SPC catheter continued for 3-6 months until the healing of orthopedic injuries. If RGU shows stricture, SPC catheter is continued for 3-6 months. Patients with total block underwent combined RGU and VCUG (up and downogram) before planning for delayed urethroplasty. The remaining 10 patients (20%) were included in Group A who underwent primary catheter realignment simultaneously when laparotomy is done for other indications like rectal injury, bladder neck injury or internal fixation for pelvic fracture.In group A after primary realignment, 70% developed posterior urethral structure. All of them underwent progressive perineal urethroplasty. In group B after Trocar SPC, 95% developed post urethral stricture out of which 82.5% underwent progressive perineal urethroplasty and 12.5% needed perineoabdominal urethroplasty. CONCLUSION: Trocar SPC followed by delayed urethroplasty is the choice of treatment for PFUDD except in few selected cases

Proximal hypospadias repair with principles of progressive perineal urethroplasty

Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. Significant variability exists for preferred approaches of repair. Often combinations of procedures are required in staged manner. Here, we have combined steps of pelvic fracture urethral distraction defects (PFUDD) repair with tubularized incised plate procedure in a single stage. Materials and Methods: A total of 8 patients consisting of 5 adults (mean age 20 years) and 3 children less than 3 years old that presented with proximal hyposphadias were included. All patients underwent degloving and progressive perineal approach as described by Webster for repair of PFUDD including mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra with division of lateral attachments, division of attachment from perineal body and corporal separation. Mobilization of the urethral plate from the corpora cavernosa to the glans was carried out. The urethral plate was tubularized with a dorsal incision. Results: The neomeatus was advanced by a distance of 2.5-3.8 cm in all eight patients. Dartos fascia was used in 5 adults and 1 child for cover. Two patients required a tunica vaginalis flap as dartos was tethered during the harvesting. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All the patients were voiding normally and satisfied in terms of cosmetic appearance. None of the patients had wound infection or total disruption, residual chordee, meatal stenosis or any erectile difficulties. Conclusion: The steps of progressive perineal approach for repair of posterior urethral distraction defects if followed aids in achieving the goals of proximal hypospadias surgery in a single stage.

Complicated urethroplasty: a guide for surgeons

Although straightforward male urethral stricture disease is commonly encountered in the scope of general urologic practice, complex urethral strictures are less common and require a more systematic approach. Complex urethral stricture surgery for long and panurethral strictures, after failed hypospadias repair, and for recurrent posterior urethral distraction defects requires a dynamic treatment paradigm. A multistaged urethral reconstruction is often necessary owing to hostile urethral tissue, especially after multiple previous procedures. A perineal urethrostomy sometimes offers improved quality of life for patients with complex urethral stricture disease, particularly if they have undergone previous failed repairs. Recurrent posterior urethral distraction defects are best treated with excision of the scarred urethral segment and re-anastomosis. Urethral stricture disease after treatment for prostate cancer requires multiple treatment approaches given the often poor tissue quality and likelihood of stricture recurrence.

Transpubic Urethroplasty Revisited: Total, Superior, or Inferior Pubectomy?

To describe research base pertaining to transpubic urethral surgery and present our experience with this approach to repair pelvic fracture urethral defects. A total of 64 patients, 5-40 years old, underwent repair of a pelvic fracture urethral defect via the partial transpubic approach between 1979 and 2008. The length of urethral gap varied from 2.5 to 8 cm (mean, 4.2 cm). A wedge-shaped piece of bone was subperiosteally resected from the medial portions of the pubic bones by an osteotome. The mobilized bulbar urethra was passed up through the subpubic tunnel or rerouted around the left penile crus to be anastomosed to the prostatic apex inside the pelvis. The site of anastomosis was wrapped by an omental pedicle. Follow-up ranged from 1 to 24 years. The results were successful in 63 (98.4%) patients. None of the patients experienced abnormal gait or pelvic girdle pain. Apart from 2 patients who developed stone bladder 6 and 14 years after surgery, no postoperative complications were encountered. Impotence as a direct result of transpubic surgery occurred in 2 patients. Partial transpubic approach provides an excellent exposure that greatly facilitates the creation of an undervision tension-free and scar-free bulboprostatic urethral anastomosis. It is the only way to go for complex cases associated with intra-abdominal pathologic conditions. For a long-gap posterior urethral distraction defect the excellent results of both the partial transpubic and elaborated perineal procedures compete rather than contradict each other for the best welfare of the patient.

Hinged transpubic approach to delayed repair of posterior urethral distraction defects complicating pelvic fractures — Preliminary experience

To present our experience with a transpubic approach to the management of one of the most challenging injuries of the lower urinary tract. Between January 2003 and December 2005, 7 patients presenting to our unit with complex urethral distraction defects due to type 2 or 3 posterior urethral disruption injuries complicating pelvic fracture were included in an ongoing evaluation of the transpubic approach to the repair of such defects. The patients had a mean age of 37.7 (range 22–56) years and were followed up for 1–4 years. After the follow-up period 4 patients had a very successful outcome with trouble-free voiding. Three developed strictures, two of which were successfully managed with regular dilatation, while the third patient became catheter-dependent following dilatation and inadvertent creation of a false passage. This patient underwent a successful re-operation with full recovery. The transpubic approach to delayed repair of urethral distraction defects complicating pelvic fracture is feasible. It allows an effective dissection of the dense hematoma-fibrosis that commonly complicates these injuries at a later stage. The approach is particularly useful in complex long-standing defects where such dissection is made relatively easy by the ample working space provided. The successful outcome of treatment by this approach in 4 and ultimately 5 out of 7 patients offers a reasonable degree of salvage for patients with an otherwise poor prognosis. Further studies are warranted to confirm our positive results.

Pediatric and adolescent transperineal anastomotic urethroplasty

Purpose Pediatric urethral stricture disease represents a significant surgical challenge because of smaller pelvic confines, decreased caliber and increased tissue fragility. Operative series of pediatric urethral reconstruction usually involve small numbers. In this study, we examined the outcome of open reconstructive techniques for pediatric and adolescent patients with posterior urethral distraction injuries. Patients and methods Between February 2002 and September 2005, 15 patients from Kasr ElAini hospital presenting with posterior urethral distraction defects due to motor vehicle accidents were included in our study. Their age ranged between 5 and 17 years (mean 12.5). We used the progressive perineal approach to achieve a tension-free spatulated anastomosis. Results Mean follow-up was 28.4 months. Initial and ultimate success rates were 80 and 86.6%, respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No penile curvature, shortening or urethral diverticulae were noted during follow-up. Conclusion Using the appropriate modern guidelines of urethroplasty, consistent success can be achieved in pediatric and adolescent patients with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. Urethral reconstruction is strongly recommended as the primary treatment option, especially in the pediatric urethral stricture population, because of the repair durability.

TRANSPERINEAL ANASTOMOTIC URETHROPLASTY: EXPERIENCE IN PEDIATRIC & ADOLESCENT POPULATION VERSUS ADULT POPULATION

fragility. We compared outcome of urethral reconstruction in the pediatric population as opposed to adults. METHODS: Between February 2002 and September 2005, 32 consecutive patients presenting with posterior urethral distraction defects, all caused by motor vehicle accidents, were included in our study. 16 pediatric patients with age range 5 and 17 years (mean 12.5) and 16 adult patients with age range 21 and 65 years (mean 40.2). We used the progressive perineal anastomotic repair in 29 patients. Two patients (an adult and a child) had extensive strictures of the bulbar and posterior urethra and were managed by substitutional urethroplasty. Scrotal inlay procedure was done in one adult patient also with extensive stricture of the bulbar and posterior urethra. RESULTS: Mean follow up was 16 months in the pediatric versus 28.5 months in the adult population. Results in both cohorts were found to be comparable. The primary and ultimate success rates were 81% and 87.5% in the pediatric population versus 69% and 100% in adults respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No curvature, penile shortening or urethral diverticulae were noted during follow up. CONCLUSIONS: Comparable success could be achieved in pediatric and adult population with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results.

Role of Magnetic Resonance Imaging in Assessment of Posterior Urethral Distraction Defects

To determine the clinical usefulness of magnetic resonance imaging (MRI) in the assessment of posterior urethral distraction defects. A total of 21 male patients, 6 to 35 years old, with posterior urethral distraction defects underwent MRI of the pelvis and combined antegrade retrograde urethrography before surgical repair. Repair was performed with a bulboprostatic urethral anastomosis through the perineum in 13 patients and transpubically in 8. The MRI and urethrographic findings were compared and correlated with the operative findings. The MRI findings were also correlated with the incidence of posttraumatic impotence. On MRI, the length of urethral defect and type of prostatic displacement could be correctly determined in 86% and 89% of the patients, respectively. Also, MRI precisely delineated the extent of scar tissue, which varied according to the type and magnitude of the original trauma. Furthermore, MRI revealed the presence of paraurethral false tracks in 3 patients. In addition, MRI demonstrated avulsion of the corpus cavernosum, as well as lateral prostatic displacement in all 6 patients with posttraumatic impotence. Preoperative MRI can provide useful information that might help determine the appropriate surgical repair. It correctly estimates the length of the urethral defect, clearly demonstrates the type and degree of prostatic displacement, precisely delineates the site and density of scar tissue, and reveals the presence of paraurethral false tracks. Also, MRI can identify the cause of posttraumatic impotence such as avulsion of the corpus cavernosum and thus might predict the potency outcome in these cases.

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.

Harnröhrenplastik nach Urethraabriss und simultane perineale Prostatektomie

We present a case of post-traumatic posterior urethral stricture and localized prostate cancer, which could be treated successfully with simultaneous radical perineal prostatectomy and membranous urethral stricture excision. After 6 months follow-up, the patient is continent with no evidence of stricture recurrence. Post-traumatic posterior urethral strictures can be managed surgically through a perineal approach with high success rates. Prostate surgery after pelvic fracture with posterior urethral distraction defects does not necessarily lead to stress urinary incontinence.