Traumatic Strictures Research Articles

Surgical strategies for the management of traumatic benign stricture of high bile duct

Iatrogenic bile duct injuries (BDIs) and subsequent benign biliary stricture is a medical catastrophe which is associated with significant perioperative morbidity and mortality,reduced long-term survival rate and poor quality of life.For most major BDIs (Strasberg classification E1-E4),the recommended method of repair is hepaticojejunostomy (HJ).We conducted a retrospective review aiming to examine the surgical technique of high HJ at our institution.This review highlights 4 aspects in the operation which include the hepatoduodenal ligament exposure,hepatic artery and its branches protection,exposing the intrahepatic bile duct above the stricture plane,and HJ techniques.Overall,the optimal long-term result of surgical management depends on the availability of experienced hepatobiliary surgeons and a considerable large HJ anastomosis above the stricture. Key words: Biliary stricture, benign; Bile duct injuries, iatrogenic; Hepaticojejunostomy

Value of transrectal ultrasonography in the diagnosis of female traumatic urethral stricture

Objective To investigate the diagnostic value of transrectal ultrasonography (TRUS)for female traumatic urethral stricture.Methods Fifteen female patients with traumatic urethral stricture were examined by using TRUS and urethrography and the examination results were compared with op-eration findings.Results The ultrasonography results of all patients were in consistency with their operation findings,while the urethrography results of six patients were different from their operation findings.Conclusion TRUS is of great value in the diagnosis of female traumatic urethral stricture. Key words: Urethral stricture,female; Ultrasonography; Transrectal

240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2012240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY Andre Cavalcanti and Mauricio Rubinstein Andre CavalcantiAndre Cavalcanti Rio de Janeiro, Brazil More articles by this author and Mauricio RubinsteinMauricio Rubinstein Rio de Janeiro, Brazil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.295AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The artificial urinary sphincter(AUS) is the gold standard procedure to a definitive treatment of urinary incontinence associated with sphincter deficiency in male. The aim of this study is to describe our experience with the AUS implantation in a particular group: patients submitted to previously urethroplasties. METHODS The charts of 22 patients submitted to a AUS implantation after a urethroplasty were observed. The mean follow-up was 23.3 months (range from 6 to 48 months) and the mean patients age was 63 years (range from 25 to 81 years). The majority of the patients were submitted to a urethroplasty to treat an anastomotic stricture after radical prostatectomy (16 patients). 4 patients were submitted to a urethroplasty to treat a posterior stricture after a BPH surgery and 2 to treat a posterior traumatic stricture. The AUS surgical approach was transcorporal in all patients. In 7 patiens we performed a modified transcorporal approach, from the original Webester‘s technique (using two lateral tunica albugínea flaps to cover the urethra and a pericardium bovine graft to close the corporal defect). RESULTS In our initial 6 cases we used a early AUS implantation (3 months after the urethroplasty) and we observed a high urethral erosion rate (50%). In the other 16 cases we performed a late implantation (at least 6 months after the urethroplasty) and we observed an erosion rate decline to 6,2% (1 patient). 2/4 patients with AUS erosion were submitted to a suprapubic continent diversion and 2/4 patients were submitted to a AUS re-implantation with success. The final success rate of the AUS implantation (use of 1 pad per day or less), at least 6 months after the implantation was 75% (16/20 patients) with 65% complete dry (13/20). In 3/20 patients (15%) an improvement of the incontinence was observed with a reduction on the number of pads per day. 10/20 (50%) patients with AUS implanted were submitted to penile prosthesis implantation: 7 semirigid, 1 inflatable (3-pieces) e 2 inflatable (2-pieces). A delay cuff erosion was observed in all (2/2) patients after the implantation of a inflatable (2-pieces) penile prosthesis. CONCLUSIONS The AUS implantation after an urethroplasty is possible with acceptable rates of success. In our opinion the delay transcorporal implantation and the correct penile prosthesis choice (when necessary) are the best approaches to prevent complications. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e98-e99 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andre Cavalcanti Rio de Janeiro, Brazil More articles by this author Mauricio Rubinstein Rio de Janeiro, Brazil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Role of Dilation and Internal Urethrotomy as a Risk Factor of Failure in Patients Who Undergoing One-Stage Bulbar Oral Graft Urethroplasty

Purpose: To test the hypothesis if dilation or direct visual internal urethrotomy (DVIU) are predictive of urethroplasty failure. Retrospective study, from 1999 to 2010, including184 patients (median age 37 years) who underwent ventral onlay oral graft urethroplasty for bulbar strictures. Exclusion criteria were traumatic strictures, lichen sclerosus, failed hypospadias repair, failed urethroplasty, panurethral strictures, and incomplete medical charts. Pre-operative evaluation included clinical history, physical examination, urine culture, residual urine measurement, uroflowmetry, urethrography, ultrasound and urethroscopy. Surgery was considered a failure when any post-operative instrumentation was needed. Median follow-up was 48 months. Out of 184 patients, 38 (20.7%) had not undergone previous treatment, 7 (3.8%) had undergone dilation, 81 (44%) DVIU and 58 (31.5%) DVIU associated with dilation. Out of 184 patients, 157 (85.3%) were successful and 27 (14.7%) failures. Out of 38 patients who had not undergone previous treatment, 33 (86.8%) were successful; out of 7 patients who had undergone dilation, 6 (85.7%) were successful; out of 81 patients who had undergone DVIU, 72 (88.9%) were successful; out of 58 patients who had undergone DVIU and dilation, 46 (79.3%) were successful. According to the number of previous DVIU, ventral graft urethroplasty for bulbar strictures showed high failure rate in patients who had undergone more than four DVIU associated or not with dilation.

Editorial Comment

In 1950, Badenoch 1 Badenoch A.W. A pull-through operation for impassable traumatic stricture of the urethra. Br J Urol. 1950; 22: 404-409 Crossref PubMed Scopus (77) Google Scholar described his pull-through operation for “impassable traumatic stricture of the urethra.” The Badenoch operation is not an operation that I have any experience with, nor have I ever felt the need to become facile with that technique. However, with that said, I am constantly amazed at the number of places that I have been, where surgeons do practice the Badenoch procedure and find it to be most useful for the reconstruction of pelvic fracture urethral distraction defects. The authors describe a series of 76 patients. They discuss excellent results and have good follow-up criteria. Using the operation for patients with complex conditions, as well as those with failed urethroplasty and those with failed urethrotomy, they report an overall success rate of 89%. Although this is slightly less than that from contemporary series using primary anastomotic techniques, it is not far below those success rates. They have a very acceptable rate of erectile dysfunction after urethral reconstruction, and they do not report any patients who complained of penile shortening or new onset of curvature. Although I have not seen the need to learn how to do this operation, it certainly would appear that it could represent an alternative method of dealing with pelvic fracture urethral injury. Urethral Pull-through Operation for the Management of Pelvic Fracture Urethral Distraction DefectsUrologyVol. 78Issue 4PreviewTo present our institutional experience in the management of pelvic fracture urethral distraction defects with urethral pull-through operation. Full-Text PDF ReplyUrologyVol. 78Issue 4PreviewThe management of pelvic fracture urethral distraction defect (PFUDD) is a difficult problem in urology. At present, it is widely accepted that the optimal procedure for the management of PFUDD is urethral anastomosis after excision of the intervening scarred segment through the perineum.1 A tension-free anastomosis is essential for a successful repair; however, in some cases, it is difficult to distinctly expose the proximal urethral stump because of its deep location after the excision of the stricture segment. Full-Text PDF

A Study on Sexual Function of Men with Anterior Urethral Stricture before and after Treatment

Introduction: Male urethral reconstruction for anterior urethral stricture has become increasingly popular and effective. Little is known about its potential impact on subsequent sexual performance. Patients and Methods: Thirty-four patients of anterior urethral stricture disease were studied from January 2008 to November 2009. The data were collected before surgery and at a follow-up of 3 months after completing the treatment. Evaluation of sexual function was done using O’Leary’s Brief Male Sexual Function Inventory. Results: Patients were divided into two categories: <40 and >40 years of age. Younger patients had more improvement in ejaculatory function and overall satisfaction after surgery than elderly. Elderly males had lower sexual drive scores. Patients with traumatic stricture had significant improvement in ejaculation and overall satisfaction. Patients without history of prior optical internal urethrotomy or dilatations reported a significant improvement in their ejaculatory function and overall satisfaction. Conclusion: Erectile dysfunction is not significant after anterior urethral reconstruction. The improvement is most pronounced in ejaculation and overall satisfaction, which was mostly appreciated by younger men. A successful urethral reconstructive procedure leads to rehabilitation of the patient back into a healthy sexual life. Dorsomedial dissection of bulbar urethra should be limited and cautery use should be minimized in that area.

Comprehensive analysis of etiology on the prognosis of urethral strictures

Urethral strictures remain a reconstructive dilemma, due to high incidence of recurrence and less than satisfactory outcomes. Even experienced surgeons following strict surgical principles have not achieved optimal results, leading us to think whether the etiology of strictures dictate the outcome . We evaluated this "cause-effect" relationship highlighting the significance of the etiology on the overall prognosis of urethral strictures. A total of 302 males with urethral strictures were assessed (both retrospectively and prospectively) over a period of ten years. The preoperative evaluation was performed by retrograde urethrogram, urethrosonogram, and uroflowmetry and categorized, based on etiology: a) as post traumatic, b) post infective, c) iatrogenic or d) unknown. Traumatic strictures were subjected to pelvic X-ray and sub-categorized into grades A, B and C, following the TILE classification. Patients were operated; with tunica albuginea urethroplasty for anterior strictures and U shape prostato-bulbar anastomosis for posterior strictures. Traumatic strictures accounted for 54% of cases. 127 of the 302 patients were treated using Tunica Albuginea Urethroplasty, while U shaped Prostatobulbar Anastomosis was performed on others. Post traumatic strictures had best outcome whereas post infective strictures had the worse outcome. Among strictures following pelvic fractures, TILE grades A and B had a better post operative course as compared to TILE C. Overall complication rate was 13.24%. Our study demonstrated that etiology of urethral strictures may play a vital role for the overall prognosis of urethral strictures.

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

Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures

Purpose We report 18 years’ experience of traumatic urethral strictures in boys with emphasis on recurrent strictures. Materials and Methods Thirty-four boys with pelvic fracture urethral strictures underwent 35 repairs: 23 in the primary group (initial suprapubic cystostomy, but no urethral repair) and 12 in the re-do group (previously failed attempt(s) at urethroplasty elsewhere). The median age at operation and stricture length was 8.4 years and 3 cm in the primary and 9 years and 5.4 cm in the re-do group, respectively. Anastomotic urethroplasty was performed wherever possible, or failing this a substitution urethroplasty. Median follow up was 9 years for primary group and 8 years for re-do group. Results Primary group: urethroplasty was successful in 22/23, with 10 by perineal and 13 by additional transpubic approach. Two have stress incontinence. Erectile function is unchanged in all and upper tracts are maintained. One had recurrent stricture. Re-do group (12 including 1 recurrence from primary group): anastomotic urethroplasty was done in 5 and substitution urethroplasty in 7. Patients needing substitution had long stricture (>5 cm), stricture extending to distal bulb, or high riding bladder neck. All patients are voiding urethrally. Two patients with substitution required dilatation for early re-stenosis. One appendix substitution required delayed revision. Two have stress incontinence. Erectile function was unaffected. Upper tracts are maintained. Conclusions Anastomotic urethroplasty was successful in over 95% of primary cases. In re-do cases it was viable in only 41% of cases; the rest required substitution urethroplasty. Urethral substitution also gave acceptable results.

Clean Intermittent Catheterization (CIC) in Children Through Continent Catheterizable Channel: A Developing Country Experience

Purpose To evaluate the role of CISC through continent cathetrizable channel (mitrofanoff) in an augmented bladder in children with bladder dysfunction/outlet obstruction managed in a public sector hospital of a developing country. Material and Methods This is a retrospective analysis of 126 patients managed between 2001 and 2008. Patients belong to urban, periurban and rural areas of various part of whole country with diverse ethnic, cultural, linguistic, poor socioeconomic and low educational backgrounds. Results We present our data of 126 patients, age ranged between 21/2 to 15 years, male female ratio of 1.5:1.0, with various congenital and acquired causes of bladder dysfunction/ outlet obstruction including Neurogenic bladder, Non Neurogenic Neurogenic bladder, Posterior Urethral Valve, Exstrophy Epispadias complex, traumatic stricture urethra and Genitourinary Tuberculosis. These patients had augmentation cystoplasty using different bowel segments. The continent catheterizable channel “mitrofanoff channel” was made using appendix in 108 cases while in 18 “spiral Montii” method was used. A stoma was created by VQZ technique in 116 patients while concealed umbilical stoma was made in 10. Complications included superficial wound infection in 9 patients, subacute intestinal obstruction in 6 patients which was resolved by conservative treatment, acute intestinal obstruction, bladder calculus and stomal stenosis in 6, 10 and 3 patients respectively. More than 90% patients showed good compliance and are under regular follow up as per advice of treating team. Conclusions In a developing country setting with low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of paediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance. To evaluate the role of CISC through continent cathetrizable channel (mitrofanoff) in an augmented bladder in children with bladder dysfunction/outlet obstruction managed in a public sector hospital of a developing country. This is a retrospective analysis of 126 patients managed between 2001 and 2008. Patients belong to urban, periurban and rural areas of various part of whole country with diverse ethnic, cultural, linguistic, poor socioeconomic and low educational backgrounds. We present our data of 126 patients, age ranged between 21/2 to 15 years, male female ratio of 1.5:1.0, with various congenital and acquired causes of bladder dysfunction/ outlet obstruction including Neurogenic bladder, Non Neurogenic Neurogenic bladder, Posterior Urethral Valve, Exstrophy Epispadias complex, traumatic stricture urethra and Genitourinary Tuberculosis. These patients had augmentation cystoplasty using different bowel segments. The continent catheterizable channel “mitrofanoff channel” was made using appendix in 108 cases while in 18 “spiral Montii” method was used. A stoma was created by VQZ technique in 116 patients while concealed umbilical stoma was made in 10. Complications included superficial wound infection in 9 patients, subacute intestinal obstruction in 6 patients which was resolved by conservative treatment, acute intestinal obstruction, bladder calculus and stomal stenosis in 6, 10 and 3 patients respectively. More than 90% patients showed good compliance and are under regular follow up as per advice of treating team. In a developing country setting with low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of paediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance.

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

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

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

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.

Aetilogy and Treatment Outcomes of Symptomatic Congenital Cobb's Collar

Purpose “Genuine” paediatric posterior urethral strictures are uncommon and their true existence as distinct from posterior urethral valves is questioned. We report on the treatment and outcome of such strictures. Material and Methods Eleven cases over a 9 year period were identified from departmental records and case notes were analysed retrospectively. Results Eleven strictures were identified in a nine year period. The age at presentation had a bimodal distribution, with 6/11 presenting in the first year of life, of which 4 had observed antenatal hydronephrosis. 4/11 presented after the age of 11 years. 1 patient presented aged 3 years. 7 patients underwent optical urethrotomy as the primary treatment which was curative in 42 % and 58% required further intervention with 1 requiring anastomotic urethroplasty, which was considered indicative of failed primary treatment. 3 children were treated by urethral dilatation, of which 66 % required further intervention, and 1 was referred for anastomotic urethroplasty. 1 patient was treated by primary anastomotic urethroplasty with a durable result. Conclusions All patients who underwent, or were referred for anastomotic urethroplasty were older than 13 years. This outcome, in conjunction with the bimodal age distribution at presentation would suggest a different aetiology in older children. Consequently, we would urge caution in classifying strictures in ambulant children as genuinely congenital, as strictures in this population may represent the long term manifestation of unrecorded bulbar urethral trauma received in infancy. We believe that there exists an uncommon group of patients who develop a congenital bulbar stricture which is distinct from posterior urethral valves or post traumatic strictures, which may be a remnant of the cloacal membrane. Optical urethrotomy or dilatation is durable when treated in infancy but older patients do not experience prolonged resolution and we would recommend treatment along adult lines.

The Changing Pattern of Urethral Stricture Disease in Midwestern Nigeria

Sixty-eight new patients with Urethral Stricture presented at the University of Benin Teaching Hospital Benin City, Nigeria between January 1994 and December 2003, an average of seven patients per year. Forty-two (61.9%) of these patients were aged between 21 and 50 years, 38 (55.9%) of the strictures were traumatic in origin and of these 23 (60.5%) were of the bulbomembranous type and resulted from fractures of the pubic bones. Eight (21.2%) of the traumatic strictures were from iatrogenic causes. Thirty-three (48.5%) of the patients presented without any of the clinical complications of urethral stricture disease. Thirty-four (50.0%) of the patients had treatments other than urethral bouginage. This picture contrasts with the situation in the past when urethral strictures were predominantly post inflammatory in origin. The patients presented more with complications, involved almost entirely bulbar or penile urethral in location and were usually treated by periodic serial dilation. Keywords: Urethral stricture, changing patterns. Journal of Medicine and Biomedical Research Vol. 5 (2) 2006: pp. 50-54

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

Prospective study on the treatment of traumatic biliary stricture by balloon dilation.

Objective To investigate the efficacy of balloon dilatation in the treatment of traumatic biliary stricture(TBS).Methods Eighty-one patients with TBS who had been admitted into General Hospital of Chengdu Command from February 1997 to February 2007 were divided into 2 groups.In the control group,40 patients underwent choledoco-jeiunostomy with T tube stenting in the anastomotic stoma for 6 months.In the balloon dilatation group,41 patients received implantation of the balloon catheters along with the two arms of the T tube in the anastomotic stoma.The efficacy of different surgical procedures were analyzed by chi-square test.Results Seven patients in the control group were failed with a failure rate of 18%.Of the 7 palients,6 were transferred to receive balloon dilatation and 5 were cured.In the balloon dilatation group,only 1 patient was failed and the failure rate was 2%.The diameter of the anastomotic stoma ilq the balloon dilatation group was dilated gradually to 12 mm in 3 months.The difference upon the success rate of the operation between the 2 groups had statistical significance (x2=5.10,P＜0.05).Conclusions Balloon dilatation is effective in the treatment of TBS. Key words: Biliary stricture; Bile duct injury; Balloon dilatation

Editorial Comment

The authors report on a series of 28 children with pelvic fracture urethral distraction defects. They defined children as those <18 years of age (mean 12.1). It would be interesting to know the median age. I believe many would agree that from the standpoint of pelvic fracture urethral distraction in children, once individuals have reached adolescence, the anatomy is much more similar to the adult anatomy than to the child's anatomy. This nonetheless is a pure series of pelvic fracture urethral distraction defects; most series have tended to combine all traumatic strictures, thus proximal bulbous strictures due to straddle trauma have been included, making the interpretation of results difficult.

The Posterior Sagittal Approach for Recurrent Genitourinary Pathology

The posterior sagittal transanorectal approach offers the surgeon excellent exposure to the lower genitourinary system. The approach has been successfully used for revisional surgery involving the urinary tract and rectum. We have used this approach to treat müllerian remnants, acquired or congenital fistulas and acquired urethral strictures. In the setting of revisional surgery abdominal or perineal approaches may not provide the same level of exposure to the lower urinary tract. Of 911 males who underwent a posterior sagittal approach 12 were identified in whom this approach was used to manage lower urinary tract problems without associated anorectal malformation (group 1). An additional 58 patients with associated anorectal malformations were included in analysis (group 2). All cases were approached with a posterior sagittal incision to facilitate exposure after failed prior surgical attempts to treat traumatic strictures of the proximal urethra in 4 and müllerian remnants in 8 (group 1). In group 2 there were 19 urethral diverticula, 8 strictures and 31 persistent rectourethral fistulas. Followup was 6 months to 15 years. There were no recurrences identified in group 1. In group 2 there were 5 postoperative urethrocutaneous fistulas. Data on potency were available on 4 patients in group 1 and 14 in group 2. All 14 patients in group 2 reported intact potency after surgery. One patient in group 1 was impotent before and after surgery. The posterior sagittal approach is helpful for addressing lower urinary tract pathology when exposure is inadequate from a perineal or abdominal approach. We propose that better exposure with this approach may limit inadvertent injury to nerves and result in more complete treatment of the presenting pathological condition. This approach provides an alternative that warrants careful consideration when dealing with the lower genitourinary tract in pediatric patients, especially in the setting of revisional surgery.