COMPLEX POSTERIOR URETHRAL DISTRACTION DEFECTS -ABDOMINO PERINEAL REPAIR AVOIDING TRANSPUBIC APPROACH

THE JOURNAL OF UROLOGY®

Vol. 181, No. 4, Supplement, Saturday, April 25, 2009

CONCLUSIONS: The management of complex anterior urethral stricture disease continues to be a challenging clinical problem. In this series, buccal mucosal graft staged urethroplasty provides excellent short-term results with low complication rates. Objective urethral patency is 94%. Our success rate shows that this procedure is an excellent treatment modality when other reconstructive options have been exhausted. Source of Funding: None

79 PREOPERATIVE VASCULAR EVALUATION OF PATIENTS WITH PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS (PFUDD) Timothy O Davies*, Lawrence B Colen, Nicholas Cowan, Gerald H Jordan, Norfolk, VA INTRODUCTION AND OBJECTIVE: Distraction injuries of the urethra occur in approximately 15-20% of patients who have a pelvic fracture. In many of these cases, comcomitant injuries to the internal pudendal arteries can cause erectile dysfunction(ED) and abnormality of the deep penile vasculature. Those patients without adequate vascularity to the corpus spongiosum may suffer the complication of ischemic necrosis following reconstruction with primary anastomotic techniques. At our center, those patients with any degree of ED are evaluated with penile duplex, and if abnormal, pudendal angiography prior to urethral reconstruction. We reviewed our experience with this algorithm for preoperative evaluation. METHODS: A retrospective review of PFUDD repairs performed at our institution since 1999 - the time of our current algorithm. Patients without ED were excluded. Selected patient characteristics and vascular evaluation are reviewed. RESULTS: 56 patients were identified who had preoperative vascular evaluation. All 56 patients underwent duplex ultrasonography, 26 patients were found to have abnormal findings on duplex (either a systolic velocity 80ms, or both). 27 cases underwent angiography and all were found to have abnormal arterial anatomy. 21 showed reconstitution of 1 or both pudendal arteries and the remaining 6 did not show reconstitution. All 6 patients showed improvement in duplex parameters and 5 of 6 patients showed improvement in erectile function post revascularization. All 6 went on to have successful urethral reconstruction. CONCLUSIONS: Patients with PFUDD injuries are at risk for ischemic necrosis. Penile duplex is an excellent screening tool to identify those patients with potential arterial insufficiency that may result in ischemic necrosis. Angiography will discover those patients with bilateral injury without reconstitution who appear to be at risk for ischemic necrosis. We believe we have identified the patient subset with PFUDD injury who are at risk for ischemic necrosis. Angiography also identifies those with reconstitution, all of whom appear to be reconstructable without vascular complicating sequelae. We thus continue to utilize this algorithm in this patient subset. Source of Funding: None

80 RECONSTRUCTION OF PELVIC FRACTURE-RELATED URETHRAL INJURIES Daniela E Andrich, Anthony R Mundy*, London, United Kingdom INTRODUCTION AND OBJECTIVE: There have been a number of recent presentations and publications on this subject - principally concerned with the technical aspects of “steps in reconstruction”. The implications are that there are three steps - mobilisation (step1), crural separation (step2) and inferior pubectomy (step3); and that by some sort of “gapometry” the exact procedure can be defined preoperatively with predictable results. This presentation reviews our recent experience. METHODS: From the period October 1996 and October 2006 we have follow-up data on 234 patients we reconstructed for pelvic

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fracture-related urethral injuries - 186 first time repairs and 48 revisions after previous surgery elsewhere. Of the 186 first time procedures 8% required step 1, 48% steps 1 and 2 and 16% underwent steps 1, 2 and 3. In addition, 14% underwent supra crural rerouting as a fourth step, 8% underwent abdomino-perineal reconstruction, 2% underwent bladder neck reconstruction as well as posterior urethroplasty; 2% underwent patch urethroplasty and 2% underwent entero-urethroplasty. In the revision group there was a similar spread of procedures but a generally more advanced stage of reconstruction. Overall only 149/234 (64%) were dealt with by the ‘three steps’. RESULTS: Most of these are not distraction defects as is commonly described, hence the term pelvic fracture-related urethral injury; only a minority are distracted. Preoperative “gapometry” or other imaging was not helpful in determining the operative procedure. The surgical procedure was more complicated than just mobilisation and development of the inter crural plane and inferior pubectomy, although 64% of patients fell into one or other of these three categories. The best means of monitoring outcome was by means of retrograde urethrogram and voiding cystogram; symptom scores, flow rates and flexible endoscopy are more unreliable.The restricture rates are 4-9% after primary repair and 11-16% after revision surgery according to complexity. De novo post-operative organic erectile dysfunction is rare, although erectile dysfunction overall is a common associated problem. CONCLUSIONS: ‘Complex’ surgical problems other than those readily dealt with by simple repairs are rarely reported in the recent literature. Most reports in the recent literature come from small series or amalgamations of small series, and do not address these issues. Source of Funding: None

81 COMPLEX POSTERIOR URETHRAL DISTRACTION DEFECTS -ABDOMINO -PERINEAL REPAIR AVOIDING TRANSPUBIC APPROACH Rajagopal V Vallivayai*, Venkat A Gite, H Girish, Rahul Reddy, D Sharma, Hyderabad, India INTRODUCTION AND OBJECTIVE: We present our results of abdomino perineal urethroplasty for complex posterior urethral distraction defects without pubectomy(transpubic repair). The complex strictures are best managed by variety of maneuvers suitable for each case. We review our experience of 28 cases of complex posterior urethral distraction defects out of which 6 cases were managed by abdominoperineal repair without resorting to transpubic approach. METHODS: From Jan2005-Mar2008, 28 patients with complex posterior urethral disruption underwent anastamotic urethroplasty, consisting of stricture exceeding 3cm, associated fistulae, rectourethral fistulas, periurethral cavities, false passages and previous failed repairs. Preoperative cystourethrograms and cystourethroscopy were done to evaluate the stricture and bladder neck. PROCEDURE: After performing the progressive perineal approach, when further perineal approach appeared difficult-the urethral transection and trimming was done: 6 anastamotic sutures were placed : abdominal exploration to open the retropubic space was done: posterior urethra was dissected to reach prostatic apex : the prepared urethra with sutures was transferred to abdominal wound after excising all the scar tissue beneath the pubic arch. Anastamosis was completed by taking the sutures appropriately through posterior urethra with omental wrap. Followup consisted of symptomatic assessment ,Uroflowmetry,voiding cystourethrogram and endoscopic urethral assessment. RESULTS: There were 22 adults and 6 boys with average age of 34 years (range11-46). Mean followup of 20 months (range 8-36). Mean stricture length was 3 cms (range 2cms-5.5cms). 8 had previous urethroplasty. Urethroplasty was achieved through the retropubic abdomino-perineal route without pubectomy with abdominal anastomosis in 6 patients, while 2 required transpubic approach and 20 had perineal repair. In 24 of 28 patients postoperative cystourethrography and endoscopy showed a wide, patent anastomosis.3 patients had postoperative anastomotic narrowing needing Optical urethrotomy. 1

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needed redo urethroplasty. CONCLUSIONS: Combined abdomino -perineal urethroplasty without pubectomy with abdominal anastomosis allows wide exposure to create a tension-free urethral anastomosis preserving continence and potency: avoiding all morbidity and complications of transpubic urethroplasty. It is safe in children and adults: provides easy and direct access to anastomotic area and gives excellent results. Source of Funding: None

82 ENDOSCOPICALLY ASSISTED PERINEAL POSTERIOR URETHROPLSTY Mamdouh M Koraitim*, Mohamed M Koraitim, Jr, Alexandria, Egypt INTRODUCTION AND OBJECTIVE: A disastrous consequence of misdirected optical urethrotomy of a posterior urethral distraction defect (PUDD) is the creation of a paraurethral false passage into the bladder base. Repeated urethrotomy followed by dilation will result in its persistence and establishment of urethral voiding yet inefficient and only for a short time. Later, during surgical repair of these cases, the anterior urethra may be mistakenly anastomosed to the false tract, thus escalating the already complex situation. We describe an innovative technique to discriminate between the normal and false tracts during perineal repair and thus one can guarantee that urethral continuity has been correctly restored. METHODS: This study includes 5 male patients, 23 to 33 years old, with PUDD complicated by paraurethral false tracts opening into the bladder base. All patienta had undergone elsewhere failed attempts at endoscopic and surgical repair which varied from 6 to 21 procedures for each patient. On presentation all 5 patients had a suprapubic catheter in place. Through a midline perineaql incision, and after complete excision of the scarred segment and liberal mobilization of the bulbar urethra, antegrade cystourethroscopy was performed via the pre-existing suprapubic tract. The endoscope was then negotiated under vision through the prostatic urethra and guided by the verumontanum into its distal blind end. Then a cut was done on the light which was readily seen in the perineum until the tip of the endoscope appeared in the surgical feild. This cut was trimmed and spatulated before it was anastomosed into the mobilized bulbar urethra. RESULTS: Urethral continuity was successfully restored in all 5 patients and persisted through the follow up period that ranged between 4 and 12 years. Also, urinary continence was maintained in all patients. CONCLUSIONS: In perineal repair of PUDDs complicated by a paraurethral bladder base fistula, it is so difficult to discriminate the normal and false passages from the perineal incision. In such cases the prostatic urethra should be identified by visualization of the all-important landmark of the verumontanum by suprapubic urethroscopy. Cutting on the light will guarantee that the passage concerned is the prostatic urethra which can be securely anastomosed to the anterior urethra. Source of Funding: None

83 DIVERSITY OF SURGICAL APPROACH FOR POST-TRAUMATIC POSTERIOR URETHRAL STRICTURE --- A TWENTY-YEAR CLINICAL EXPERIENCE Jiong Zhang*, Yue Min Xu, San-Bao Jin, Yong Qiao, Shanghai, China INTRODUCTION AND OBJECTIVE: In developing countries, the number of patients for posterior urethral distraction defects (PUDD) is increasing constantly every year. On the terms of treatment of PUDD, a suitable surgical approach and precise surgical operation remains the crucial status for urethral reconstruction. Choosing surgical approach for post-traumatic posterior urethral stricture and distraction defects during the past twenty years remain controversial. We analyzed our experience with 426 patients to present the long-term results of the different approaches for posterior urethral stricture. METHODS: A total of 426 patients 7 to 69 years old with posterior urethral stricture and distraction defects were retrospectively analyzed between January 1987 and December 2007. The disease course ranged

Vol. 181, No. 4, Supplement, Saturday, April 25, 2009

from 3 months to 16 years with a mean of 23.5 months. The stricture length ranged from 0.5 to 7cm(mean 3.6cm). Of the 426 patients 270(63.4%) presented with associated complications, including 25 with urethral false passage, 9 with urethrocutaneous fistula, 23 with rectourethral fistula, 194 with posterior urethral or vesical stones and 19 with vesicoureteral reflux on 1 or both sides. Of the patients 112 were treated during the former decade and 314 were treated during the last decade. RESULTS: In the first period, 72 cases were operated with simple transperineal approach with success rate of 72.2 %; transperineal series of surgical methods, including separation of the corporeal bodies and inferior pubectomy, was adopted in 12 and the success rate was 83.3%; Combined transpubic-perineal approach in 28 with a successful rate of 60.7%. In the last period, 68 cases with transperineal simple approach were operated and 49(72.1%) cases were cured; 228 cases with transperineal series of surgical approach and 202 cases cured (88.6%); 18 cases with transpubic-perineal approach and 14 cases (77.8% )cured. It suggested that patients with transperineal series of surgical approach obtained higher success rate than those with other procedure (P