Prostatomembranous Disruption Research Articles

Traumatic posterior urethral disruptions in boys: experience with the perineal/perineal-transpubic approach in ten cases.

The management of traumatic posterior urethral disruption in children has ranged from primary realignment/repair to delayed urethroplasty. The operative approach may be perineal or transpubic; the advocates of either cite comparable outcome. The anatomic considerations in a child differ from the adult and the management is individualized. We present our experience with the perineal/perineal-transpubic approach in the management of traumatic posterior urethral disruptions in ten boys. A preliminary suprapubic cystostomy was followed by a delayed urethroplasty after comprehensive investigations to delineate the pathoanatomy of the disruption. The urethroplasty began with a perineal exposure and progressed to varying extents to achieve a satisfactory urethral anastomosis. Four cases of bulbomembranous disruption were repaired by perineal approach, whereas six cases of prostatomembranous disruption required a perineal-transpubic approach. Permutations of operative techniques (circumurethral mobilization, corporeal separation/urethral rerouting, pubectomy and omentoplasty) were used. The follow-up assessed micturition patterns, urinary continence and penile erections. At a mean follow-up of 5 years (1.5-12 years), all ten boys void in a good stream and are continent. All have normal penile erections, posture and gait. The paper discusses the rationale and outcome of our management.

Immediate Management of Prostatomembranous Urethral Disruptions

We present 33 patients with complete prostatomembranous urethral disruptions: 20 were managed by immediate realignment, while 13 were managed by initial cystotomy and delayed urethroplasty. Techniques for immediate realignment are described. Immediate realignment of complete prostatomembranous disruptions resulted in an overall potency rate of 80% compared to only 50% in patients who underwent delayed repair. In addition, there was an increased need for a secondary operation when the repair was delayed. Continence rates were excellent and similar in both groups. Immediate urethral realignment as described results in impotence and incontinence rates that are comparable to or better than delayed repair techniques without the need for multiple surgical procedures.

Management of Posterior Urethral Strictures Secondary to Pelvic Fractures in Children

Bulboprostatic anastomotic urethroplasty was performed in 20 children with posterior urethral strictures secondary to bony pelvic fractures. The approach was perineal in 4 children and transpubic abdominoperineal in 16, with good postoperative results in 100 and 62.5%, respectively. In some children the urethral disruption occurred within the prostate itself and not at the prostatomembranous junction. In such cases the proximal sphincteric mechanism may be at risk and immediate repair of the injury is advisable.In the case of common prostatomembranous disruption displacement of the urethra may be significant. In such cases a transpubic approach is preferable. If the proximal sphincteric mechanism is deranged, it can be managed at the same time.

Penile Arteriography in Impotence After Pelvic Trauma

A patient who was impotent following pelvic trauma was evaluated by penile arteriography. The study revealed bilateral disruption of the internal pudendal artery at the level of the urogenital diaphragm. It is concluded that impotence in this case is vasculogenic, although it is not possible to eliminate conclusively the possibility of neurogenic factors. Evaluation of more patients with this new technique of penile arteriography is necessary to establish the frequency of vasculogenic impotence in pelvic trauma.A review of the current literature revealed that impotence is approximately 10 times more common after conventional retropubic urethral realignment for acute prostatomembranous disruption compared to treatment by cystostomy tube alone. Analysis of the pertinent neurovascular anatomy suggests that when impotence is caused by surgical dissection of the periprostatic region the pathogenesis probably is neurogenic because of injury to the prostatic plexus and/or cavernous nerves, and it may be irreversible.

Traumatic Injuries to the Urethra

Major urethral injuries from external trauma are complex problems of diagnosis and treatment. Complications resulting from injury, failed diagnosis, and inappropriate therapy include stricture, impotent, and incontinence. Opinions differ as to whether immediate suprapubic cystostomy followed by later reconstruction is preferable to immediate direct urethral realignment. A review of 30 patients with urethral injuries is presented, 27 male and three female, 29 from blunt trauma and one gunshot. Initial suprapubic cystostomy alone was used in 26 male patients, 21 with prostatomembranous disruption and five with straddle injury. Prostatomembranous reconstruction in 14 complete urethral transections resulted in one residual stricture, two impotent patients, and no incontinence. Partial prostatomembranous disruption and straddle injuries had insignificant residual stricture, none requiring dilation or reconstruction. The results of this management approach appear superior to those of immediate urethral realignment. Advantages of immediate suprapubic cystostomy are: 1) simplified early approach in management, and 2) successful elective reconstruction of major prostatomembranous injuries with low incidence of stricture, impotence, and incontinence.

Urologic Injuries

We have reviewed our experience in 311 cases of urologic trauma seen at Detroit General Hospital. A properly organized emergency surgery team is necessary to handle these types of injures effectively. We feel that, whenever possible, evaluation of any patient suspected of genitourinary trauma should be accomplished by a urologist before the patient enters the operating room. We approach renal injuries with a conservative viewpoint, trying to preserve as much renal tissue as possible, yet realizing that at time an aggressive approach to renal injuries is necessary to accomplish this and to save the patient's life. The injuries of the renal pelvis and ureter should be treated by debridement and a water-tight anastomosis with a fine absorbable material. It is our impression that patients suffering from gunshot wounds, because an ideal anastomosis is not possible, do better with a stented anastomosis. Ruptures of the bladder are simple to repair and attention is focused on the diagnosis and exploration of associated ureteral injuries. The prostatomembranous disruptions are without question one of the most difficult injuries in urology. Although we attempt to stent the urethra in order to align the ends, we condemn a vigorous attempt with interlocking sounds or other instruments since they may lead to iatrogenic injuries of the urogenital diaphragm. In these cases suprapubic cystostomy drainage and secondary repair is indicated. Our results with a group of patients with injuries of the anterior urethra showed that the overwhelming majority of these patients did well with a suprapubic cystostomy and drainage with no immediate repair.