Traumatic Posterior Urethral Strictures 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

Is combined topical-local anesthesia technique adequate for visual internal urethrotomy in the treatment of traumatic posterior urethral strictures and prostatic urethral stenoses?

To compare the effectiveness of spinal anesthesia (SA) and the combination of intraurethral topical instillation of 2% lidocaine + intraurethral local visual injection anesthesia (T + LIA) for visual internal urethrotomy (VIU) in the treatment of traumatic posterior urethral strictures and prostatic urethral stenoses. In this study, the results of 178 patients who underwent visual internal urethrotomy for posterior urethral strictures and prostatic urethral stenoses secondary to trauma in our clinic between October 2018 and January 2020 were analyzed retrospectively. Patients were divided into two groups as combined T + LIA (n=146, 82.08%) group and SA (n=32, 17.97%) group according to the type of anesthesia used. The preoperative clinical data and postoperative results of the patients were analyzed and compared between the groups. The mean age of the patients was 67.99±10.87 years and the mean follow-up was 5.32±3.27 months. The median age of the patients in the T + LIA group was significantly higher than that of the patients in the SA group (p=0.033). There was no statistically significant difference between the groups regarding preoperative Q-max value (p=0.931). Similarly, the rate of postoperative improvement in the Q-max values of the patients was similar between the groups (p=0.572). The presence of postoperative complications and recurrence rates were similar between the groups (p=0.879 and p=0.904, respectively). Compared to spinal anesthesia, T + LIA anesthesia is a safe and effective technique for visual internal urethrotomy in treating traumatic posterior urethral strictures and prostatic urethral stenoses, with a high rate of success and acceptable rate of complications.

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

Radiographic gapometry score: A simple predictor for surgical approach in pediatric traumatic posterior urethral strictures

Post-traumatic posterior urethral injuries in children are rare events. Their management algorithms are extrapolations from adult literature and they continue to pose a difficult challenge for pediatric urologists. Not much data for age-related feasibility of an end-to-end urethroplasty are available. This study was designed to validate a simple preoperative radiographic score to predict the type of surgical repair for traumatic posterior urethral strictures in children. This retrospective study was conducted in a tertiary care center in northern India between 2000 and 2015. All patients under 15 years with traumatic bulboprostatic stricture disease were included. Preoperative voiding cystourethrogam (VCUG) and retrograde urethrogram (RGU) films were used to calculate the gapometry index (G/U index), defined as the length of urethral gap divided by the bulbar urethral length. This index was then analyzed for two patient groups based on the anatomical approach employed for achieving an end-to-end urethroplasty: group 1, who underwent a simple perineal approach, and group 2, who needed a more elaborate procedure. Statistical analysis was performed with the two-tailed t-test with SPSS version 18. A total of 38 patients met the inclusion criteria. The age distribution and G/U index for both groups are detailed in the table. The difference in mean length of the urethral gap for both groups was statistically significant (2.1cm in group 1 vs. 3.6cm in group 2). There was a direct correlation between the complexity of surgical procedure required to bridge the urethral gap and the G/U index. The overall success for urethroplasty in either group was between 92.3% and 94.6%. Urethral extensibility is more suitable for younger children. This challenges the traditional viewpoint that the transpubic approach for urethroplasty is more favorable in children. No previous study has been cited in literature correlating the gapometry index with the surgical approach for posterior urethral defects. Our results reflect that a preoperative G/U index of 0.44 correlate with a simple perineal repair, whereas an index of above 0.87 indicates the likelihood of needing a more elaborate transpubic approach. Preoperative assessment of G/U index in children with traumatic posterior urethral injuries can successfully predict the operative approach and may therefore aid in better management of these patients.

Preliminary clinical study on non-transecting anastomotic bulbomembranous urethroplasty.

This study aims to investigate the effect of non-transecting anastomotic urethroplasty for treatment of posterior urethral stricture. A total of 23 patients with traumatic posterior urethral stricture were enrolled and then divided into two groups. In one group, 12 patients underwent non-transecting anastomotic urethroplasty. In the other group, 11 patients underwent conventional posterior urethra end-to-end anastomosis. The effect of operation was evaluated using the following parameters: the bleeding amount during operation, operation time, IIEF-5 scores after operation, maximum flow rate (Qmax), and rating scale of quality of life (QoL). The comparison between the conventional posterior urethra end-to-end anastomosis group and the non-transecting anastomotic urethroplasty group showed no significant difference with regard to average operation time. However, a significant difference was observed between the groups with regard to the bleeding amount during operation. The patients in the group of non-transecting anastomotic urethroplasty urinated smoothly after the removal of catheter. Meanwhile, one patient from the group of conventional posterior urethra end-to-end anastomosis had difficulty urinating after the removal of catheter. Furthermore, significant differences in the operation time, bleeding amount during operation, IIEF-5 scores after operation, and rating scale of QoL were observed, whereas no significant difference was observed between urine flow rates of the two groups after operation. Overall, nontransecting anastomotic urethroplasty is effective for posterior urethra reconstruction, and it can reduce the occurrence rate of erectile dysfunction after operation.

Trans-symphyseal urethroplasty in children

Post traumatic posterior urethral strictures were managed by trans-symphyseal urethroplasty in 11 male patients of pediatric age group. The aim of the study was to evaluate the results of the technique in patients who underwent multiple unsuccessful procedures in the past. Two(18.2%) patients were 3-5 years old, 3 (27.3%) were between 6 and 8 years, 1 (9.1 %)was 10 years old whereas 5(45.5%) were 12-14 years of age. The length of the strictures varied from 1-3cm. Repair was performed after excising the stricture and anastomosing the spatulated urethral ends with interrupted sutures of 5/0 vicryl over a Foley`s catheter. Post operative follow up showed incontinence in 1(9.1%) case and prolonged urinary tract infection in 4(36.4%) cases. Postoperative stricture was not noted in only one of them at I year follow up. The authors recommend that trans-symphyseal urethroplasty is a satisfactory procedure for the treatment of posterior urethral strictures in children as it provides excellent approach and visualization with minimal post operative complications.

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.

Outcome of end-to-end urethroplasty in post-traumatic stricture of posterior urethra.

To determine the outcome of delayed end-to-end anastomotic urethroplasty in blind post-traumatic stricture of posterior urethra at our setup. Case series. Department of Urology and Renal Transplantation, Quaid-e-Azam Medical College/Bahawal Victoria Hospital, Bahawalpur, from January 2009 to June 2011. Adult patients with completely obliterated post-traumatic stricture of posterior urethra ≤ 2 cm were included in the study. Patients with post-prostatectomy (TUR-P, TVP) stricture, stricture more than 2 cm in size or patients of stricture with neurogenic bladder and patients with any perineal disease were excluded from the study. Retrograde urethrogram and voiding cysto-urethrogram was done in every patient to assess stricture length and location. Stricture excision and delayed end-to-end anastomosis of urethra with spatulation was performed in every patient. Minimum followup period was 6 months and maximum 18 months. There were 26 cases with road traffic accident (indirect) and 14 had history of fall/direct trauma to perineum or urethra. Majority of the patients (57.5%) were between 16 to 30 years of age. Twelve (30.0%) patients developed complications postoperatively. Early complications of wound infection occurred in 01 (2.5%) patient. Late complications were seen in 11 (27.5%) patients i.e. stricture recurrence in 7 (17.5%), erectile dysfunction in 2 (5.0%), urethrocutaneous fistula and urinary incontinence in one patient (2.5%) each. Success rate was 70.0% initially and 87.5% overall. Delayed end-to-end anastomotic urethroplasty is an effective procedure for traumatic posterior urethral strictures with success rate of about 87.5%.

Clinical research on treatment of 25 cases of urethral stricture with a guide-wire-leading balloon dilatation catheter

Objective To observe the effect and safety of the treatment of urethral stricture with guide wires leading a balloon dilatation catheter.Methods The clinical date of 25 cases of male patients suffering traumatic posterior urethral stricture were analyzed retrospectively,was treated with a balloon dilation catheter led by guide wires.Results All our patients were cured successfully with a guide-wire-leading balloon dilatation catheter expanding only once and there were no complications such as urethral perforation,rectal injury etc.Although 2 cases had not been ohviously improved risht after dilatation,but improved furtherly six months later.The follow-up was six to twelve months.23 cases were cured.2 osses were improved.The recovery rate was 92%.The effective rate was 100%.Conclusion It was safe and effective to treat urethral stricture with balloon dilation catheter led by guide wires. Key words: Urethral stricture; Dilatation

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 ...

Transperineal bulbo‐prostatic anastomosis for posterior urethral stricture associated with false passage: a single‐centre experience

• To evaluate the management of traumatic posterior urethral stricture associated with false passage, as this remains a challenge for urologists. • From January 2000 to February 2010, 19 patients (mean (range) age 34 [25-52] years) with traumatic posterior urethral obliteration associated with false passage were evaluated and treated at our centre. • All patients underwent perineal excision and primary anastomotic urethroplasty using cystoscopy by the suprapubic route to insert a guidewire into the original bladder neck, allowing exposure of the normal posterior urethra. • Patients underwent voiding cysto-urethrography 1 month after the procedure. When symptoms of decreased force of stream were present and uroflowmetry was <15 mL/s, urethrography and urethroscopy were repeated. • Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. • The mean (range) follow-up was 12 (9-14) months. The overall success rate was 84%. • Three patients (16%) with persistent voiding difficulty developed a short anastomotic stricture 1-3 months after surgery. • The mean maximum urinary flow rate after surgery was 20.01 mL/s and no patient had urinary incontinence. • The preoperative use of flexible cystoscopy via the suprapubic route represented a successful key point of urethroplasty for posterior urethral stricture associated with false passage.

Reply

In this study, it was clear that the patients who underwent urethroplasty for the first time showed good results. However, there has been evidence of poor results in patients undergoing urethroplasty after realignment or urethroplasty. In case of realignment, this could be either because of adverse effect of the procedure itself or severe primary urethral injury, which may explain the failure of realignment as well as subsequent urethroplasty. Realignment can worsen the injury in many ways. First, it may physically exaggerate the urethral injury. 1 Mundy A.R. Pelvic fracture injuries of the posterior urethra. World J Urol. 1999; 17: 90-95 Crossref Scopus (50) Google Scholar , 2 Mundy A.R. Reconstruction of the urethra after pelvic trauma. Acta Urol Belg. 1998; 66: 48 Google Scholar This may be especially true when realignment is done in suboptimal conditions (without flexible cystoscopy and expertise, overzealous multiple attempts) or in an early phase when traumatized urethral margins are edematous, friable, and ischemic. Second, putting the catheter across the urethral margins will prevent the free drainage of resolving hematoma and inflammatory exudate, which is present near traumatized urethral ends and would have otherwise gradually drained through either of the urethral ends. This will cause more inflammatory injury and fibrosis. Third, there is a risk of introducing an infection into the hematoma by realignment. Editorial CommentUrologyVol. 75Issue 1PreviewThis manuscript addresses the following question: “do prior urethral manipulations adversely affect the outcomes of urethral reconstruction, for traumatic posterior urethral strictures?” This question is of some importance as it relates to 2 issues, should these patients be treated in the acute phase with primary catheter realignment as has been suggested in recent years? And who should perform urethral reconstruction in these patients with posterior urethral traumatic strictures? The manuscript is based on a relatively small group of patients (58 patients during 13 years); thus, the study may not be robustly powered to make strong negative statements where statistical significance has not been reached. Full-Text PDF Impact of Prior Urethral Manipulation on Outcome of Anastomotic Urethroplasty for Post-traumatic Urethral StrictureUrologyVol. 75Issue 1PreviewTo determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. Full-Text PDF

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

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.

Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

BackgroundUrethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature. ObjectiveThe aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures. Design, setting, and participantsFrom January 1985 to December 2007, 31 patients (age: 6–61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic–perineal approach. InterventionsA simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic–perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic–perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients). MeasurementsSuprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk. Results and limitationsOne-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal–inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic–perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients. ConclusionsSurgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal–inferior pubic approach may be appropriate as a first-line procedure.

Editorial Comment on: Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Editorial Comment on: Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Editorial Comment on: Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Editorial Comment on: Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Supracrural rerouting as a technique for resolution of posterior urethral disruption defects.

Selection of an acceptable method for the treatment of posterior urethral disruption defects would be highly desirable. We determined the efficacy and success rate of some techniques including supracrural rerouting for removing of these defects among our patients. Records of 200 consecutive men treated with anastomotic urethroplasty for traumatic posterior urethral strictures were reviewed at our teaching hospital. Prior treatment, surgical approach, and ancillary techniques required during reconstruction were evaluated. Success rate due to posterior urethral reconstruction was achieved in 78.0% of cases. Supracrural urethral rerouting was performed in 11 patients (5.5%), of whom 7 sustained recurrent stricture requiring intervention. The highest success rate of defect resolving was reported by urethral mobilization (92.4%). Supracrural rerouting is not an acceptable technique and can result in postoperative complications such as recurrent stricture in most of the patients with posterior urethral disruption defects.

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.

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.