Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty

PURPOSE: We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. MATERIALS AND METHODS: From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram. RESULTS: There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence. CONCLUSIONS: Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.     

MANAGEMENT OF OBLITERATIVE POSTTRAUMATIC POSTERIOR URETHRAL STRICTURES AFTER FAILED INITIAL URETHROPLASTY

Purpose

We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture.

Materials and Methods

Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage.

Results

At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status.

Conclusions

Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.     

Operative techniques of anastomotic posterior urethroplasty for traumatic posterior urethral strictures

Objective： To elucidate the details of operative technique of anastomotic posterior urethroplasty for traumatic posterior urethral strictures in attempt to offer a successful result. Methods： We reviewed the clinical data of 106 patients who had undergone anastomotic repair for posterior urethral strictures following traumatic pelvic fracture between 1979 and 2004. Patients＇ age ranged from 8 to 53 years （mean 27 years ）. Surgical repair was performed via perinea in 72 patients, modified transperineal repair in 5 and perineoabdominal repair in 29. Follow-up ranged from 1 to 23 years （ mean 8 years ）. Results： Among the 77 patients treated by perineal approaches, 69 （95.8 % ） were successfully repaired and 27 out of the 29 patients （93. 1% ） who were repaired by perineoabdominal protocols were successful. The successful results have sustained as long as 23 years in some cases.Urinary incontinence did not happen in any patients while impotence occurred as a result of the anastomotic surgery. Conclusions： Three important skills or principles will ensure a successful outcome, namely complete excision of scar tissues, a completely normal mucnsa ready for anastomosis at both ends of the urethra, and a tension-free anastomosis. When the urethral stricture is below 2. 5 cm long, restoration of urethral continuity can be accomplished by a perineal procedure. If the stricture is over 2. 5 cm long, a modified perineal or transpubic perineoabdominal procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely （5.7 % ） to urethroplasty.     

复杂性尿道狭窄的诊断和外科治疗

目的：提高复杂性尿道狭窄的诊断水平和治疗效果。方法：诊断采用膀胱尿道造影，经直肠尿道超声。治疗采用经会阴耻骨联合途径的尿道端端吻合术，游离颊粘膜，膀胱粘膜及带蒂包皮内板，纵隔阴囊皮瓣代尿道一期尿道成形术，女性尿道闭锁采用双阴唇带蒂皮瓣尿道成形术。结果：32例患者，术后25例排尿通畅，5例排尿不畅，2例失败。结论：膀胱尿道造影结合经直肠尿道B超是确诊尿道狭窄或闭锁严重程度的重要手段。根据不同病情选用不同的手术方法有利于复杂性尿道狭窄的治疗。     

复杂尿道狭窄合并尿道直肠瘘的手术径路选择

目的 探讨复杂尿道狭窄合并尿道直肠瘘的手术径路选择及疗效.方法 后尿道狭窄合并尿道直肠瘘患者34例.其中医原性6例,骨盆骨折尿道损伤所致26例,坠落伤所致2例.34例均采用尿道端端吻合同时行直肠瘘修补.4例尿道狭窄段1.5～2.5 cm采用单纯性经会阴途径;30例尿道狭窄段3.0～7.0 em者采用经会阴切除耻骨下缘途径21例,经会阴与经耻骨联合途径9例. 结果 单纯经会阴途径手术4例均获成功;经会阴切除耻骨下缘途径21例中成功19例(90%),经会阴加经耻骨联合途径9例中成功7例(78%).术后仍有尿道狭窄2例,发生直肠瘘2例. 结论 复杂尿道狭窄合并尿道直肠瘘的手术径路选择应根据尿道狭窄长度、瘘道部位与大小、病因及既往手术史决定.经会阴切除耻骨下缘途径手术效果好.     

The management of strictures of the membranous urethra

We present 40 cases of posterior urethral stricture resulting from pelvic fracture injury or prostatectomy. The strictures were managed according to various factors but most important were stricture length and the absence of pathological conditions in the anterior urethra. Post-traumatic obliterative strictures less than 2 cm. long can be managed with excellent success via a 1-stage perineal bulboprostatic anastomotic repair. Combined abdominoperineal procedures are equally successful but are reserved for patients in whom the stricture is more than 2 cm. long or who have an associated bladder neck pathological condition. When associated anterior urethral disease mitigates against mobilization and extension of the urethra to accomplish an anastomotic repair, the vascularized island flap or 2-stage scrotal inlay procedure appears to be the optimal choice. Of 3 failures with full thickness skin grafts 2 may have been owing to suboptimal graft beds in the scarred pelvic floor and perineum. Direct vision urethrotomy is advocated for nonobliterative posttraumatic strictures, and the rationale for dilation rather than urethroplasty management of postprostatectomy strictures is presented.     

Symphysiotomy: a viable approach for delayed management of posterior urethral injuries in children

PURPOSE: The outcome of symphysiotomy for accessing pelvic fracture related, obliterative urethral strictures is described. MATERIALS AND METHOD: In 7 boys and 3 girls 4 to 13 years old (mean age 6) surgical correction of a pelvic fracture related, obliterative urethral stricture was achieved through symphysiotomy. The stricture involved a prostatomembranous location in boys and complete vesicourethral distraction in girls. Patients were followed an average of 2.5 years (range 6 months to 4 years) by physical examination, urethrography and endoscopy. RESULTS: The stricture was successfully corrected in all patients and all void with a normal flow. All boys are continent but 2 of the 3 girls had early incontinence, which resolved with time in 1. In 2 of the 10 cases a previous attempt at perineal repair had already failed. No patient required urethrotomy or dilation and none had significant hemorrhage, fistulization, bladder hernia, chronic pain or secondary gait disturbance. CONCLUSIONS: Symphysiotomy is hereby revisited as a simple and effective approach for repairing traumatic posterior urethral injuries in the pediatric population. It can be performed instead of transpubic urethroplasty to manage long or otherwise complicated strictures.     

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES: We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures. METHODS: From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty. RESULTS: The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction. CONCLUSIONS: Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.     

Posterior sagittal approach for repair of rectourethral fistula occurring after perineal surgery for imperforated anus at birth

PURPOSE: Posterior sagittal approach was used for the repair of 11 cases of rectourethral fistula between 1992 and 1998. METHODS: All these patients had rectourethral fistula as a result of perineal procedure performed for imperforate anus at the time of birth. In addition to the fistula repair, an associated anorectal stenosis (3 cases) and urethral stricture 11 case) also were corrected with this approach. All the patients underwent surgery under cover of a protective colostomy. RESULTS: Successful repair was achieved in all patients, and the follow-up period ranged from 10 months to 7 years. As far as bladder and bowel control, urinary control was normal in all 11 patients, whereas bowel control was normal in 10 cases. One patient who had severe scarring of anal sphincters caused by infection in the previous surgery still suffers occasional perianal soiling after 18 months of follow-up. CONCLUSIONS: Posterior sagittal approach not only gives adequate exposure but also suits the basic principles of fistula repair, namely, completely separating the rectum from urethra and leaving normal rectal wall behind the urethral sutures thus eliminating the possibility of recurrence. In addition to fistula repair, one can also correct associated problems like anorectal stenosis or urethral stricture, and a mislocated rectum can be relocated within the sphincter complex.     

On the art of anastomotic posterior urethroplasty: a 27-year experience

PURPOSE: We determined the various operative details of anastomotic posterior urethroplasty that are essential for a successful result. MATERIALS AND METHODS: We reviewed the medical records of 155 patients who had undergone anastomotic repair of posterior urethral strictures or distraction defects between 1977 and 2003. Patient age ranged from 3 to 58 years (mean 21) and all except 1 had sustained a pelvic fracture urethral injury as the initial causative trauma. Repair was performed with a perineal procedure in 113 patients, elaborated perineal in 2 and perineo-abdominal in 40. Followup ranged from 1 to 22 years. RESULTS: The results were successful in 104 (90%) cases after perineal (including 2 elaborated perineal) and in 39 (98%) after perineo-abdominal repair. Successful results were sustained for up to 22 years after surgery. Urinary incontinence did not develop in any patients while 2 lost potency as a direct result of anastomotic surgery. CONCLUSIONS: Of the operative details 3 constitute the gold triad that assures a successful outcome, namely complete excision of scarred tissues, fixation of healthy mucosa of the 2 urethral ends and creation of a tension-free anastomosis. When the bulboprostatic urethral gap is 2.5 cm or less, restoration of urethral continuity may be accomplished with a perineal procedure after liberal mobilization of the bulbar urethra. For defects of 2.5 cm or greater the elaborated perineal or perineo-abdominal transpubic procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely (2%) to urethroplasty itself.     

Management of urinary incontinence after bulboprostatic anastomotic urethroplasty for posterior urethral obstruction secondary to pelvic fracture

OBJECTIVE: To present our experience of the management of urinary incontinence after bulboprostatic anastomotic urethroplasty for post-traumatic posterior urethral obstruction secondary to pelvic fracture. MATERIAL AND METHODS: Between 1979 and 1998, we managed 13 patients with postoperative incontinence after bulboprostatic anastomotic urethroplasty. Of these patients, nine had undergone a transpubic approach and four a perineal approach. The causes of urinary incontinence in the 13 patients were as follows. Ten patients had derangement of the proximal sphincteric mechanism (the distal sphincteric mechanism is usually destroyed as a result of trauma and/or during urethroplasty). These 10 patients were managed by placement of an anterior bladder tube, after the failure of pharmacological manipulations. Two patients who had been managed by transpubic urethroplasty experienced complications due to vesicourethral fistulae. They were managed by excision of the tract and repair of the bladder and the urethral defects. One patient, who was managed additionally by visual urethrotomy (for postoperative obstruction after perineal bulboprostatic anastomosis), experienced complications due to a false tract between the bladder and urethra. He was managed by bulboprostatic anastomosis and excision of the false tract. RESULTS: After 1-6 years follow-up, the outcome of the 10 patients who underwent placement of a bladder tube was good in four (40%), fair in three (30%) and poor in two (20%). The two patients who presented with vesicourethral fistulae regained continence after excision of the fistulae. The patient who had a false tract between the bladder and urethra regained continence after revision of the bulboprostatic anastomosis and excision of the fistulous tract. CONCLUSIONS: The proximal sphincteric mechanism should be fully evaluated before performing bulboprostatic anastomosis. Placement of a bladder tube is a good option for managing urinary incontinence. Vesicourethral fistulae are an unrecognized cause of urinary incontinence following transpubic urethroplasty. Visual urethrotomy should only be used in short, passable strictures.     

Management of traumatic urethral disruption in children: Oman experience, 1988-2000

Background: Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options. Methods: This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation. Results: In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations. Conclusions: Primary repairs required less hopitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions. J Pediatr Surg 37:1451-1455.     

Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: the long-term outcome

OBJECTIVE

To evaluate the long‐term results of one‐stage perineal anastomotic urethroplasty for post‐traumatic paediatric urethral strictures.

PATIENTS AND METHODS

Thirty‐five boys who had a perineal anastomotic urethroplasty for post‐traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6–132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto‐urethrography.

RESULTS

The mean (range) age of the patients was 11.9 (6–18) years. The estimated radiographic stricture length before surgery was 2.6 (1–5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow‐up.

CONCLUSIONS

The overall success of a one‐stage perineal anastomotic repair of post‐traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino‐perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

     

小儿尿道损伤的诊断与治疗

目的：探讨小儿尿道外伤及外伤后尿道狭窄的诊治经验。方法：在8例新鲜完全性后尿道断裂患儿中,3例行经耻骨上与会阴入路的尿道修复术,2例行尿道会师术,2例行膀胱造瘘术,1例女童行经耻骨后尿道吻合术。在18例陈旧性后尿道外伤患儿中,10例行经尿道内切开（TUR）术,4例行经耻骨、会阴联合入路修复术,4例行经会阴修复术。结果：8例新鲜后尿道断裂患儿中,术后出现尿道狭窄5例,不完全尿失禁1例。18例陈旧性尿道蛱雅患儿中,行TUR的成功率为60．0％,经会阴及经耻骨、会阴联合入路行尿道修复术的成功率为91．7％,有不完全尿失禁5例,会阴尿道造瘘尚未修复1例。结论：后尿道外伤的急症处理非常重要,如患儿情况允许,应尽量行经耻骨、会阴联合入路尿道修复术。经尿道内切开适用于绝大多数单纯性后尿道狭窄,经耻骨、会阴联合入路或经会阴修复尿道适用于复杂性后尿道狭窄或TUR失败者。     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Mechanism of continence after transpubic urethroplasty

Urethral profilmetry was performed in seven continent patients with transpubic urethroplasty. The studies were repeated in the supine and upright positions, both at rest and under the stresses of cough, bearing down, and hold maneuvers. The urethral pressure tracing of these patients is characteristically bihumped in shape. The proximal hump with a mean height of 18 cm water at rest corresponds to the prostatic plateau of normal subjects. The distal hump with a mean height of 32 cm water represents the pressure inside that segment of the bulbar urethra which had been brought into the abdomen by the transpubic operation. The average functional urethral length is 4.6 cm and on standing increased to 6.7 cm, mainly due to elongation of the distal hump. Changes in intra-abdominal pressure by cough or bearing down are transmitted along the whole functional urethral length with augmented urethral closure pressure of 57 to 61 cm water in the proximal hump and 44 to 48 cm water in the distal hump. However, contraction of the perineal musculature by hold maneuvers has no effect on the urethra of these patients. We conclude that after transpubic urethroplasty, although the distal urethral mechanism is destroyed and excluded, the new intra-abdominal position of the transposed bulbar urethra provides a new factor that supplements the bladder neck in maintaining urinary continence.     

Management of postoperative obstruction after bulboprostatic anastomotic urethroplasty for membranous urethral defects secondary to pelvic fracture

OBJECTIVE: To present our experience in the management of postoperative obstruction after bulboprostatic anastomotic urethroplasty for post-traumatic membranous urethral defects secondary to pelvic fracture. MATERIAL AND METHODS: Between 1979 and 1998 we managed 25 patients with postoperative posterior urethral obstruction after bulboprostatic anastomotic urethroplasty. Of these patients, 17 had undergone one repair and 8 had undergone more than one repair. One case had multiple perineal fistulae. Visual urethrotomy was done in 3 patients, 1 had cross union at the site of the anastomosis, and the other 2 had short passable strictures. In cases of obliterated strictures, bulboprostatic anastomosis was done in 6 patients via the perineal route and in 10 patients via the transpubic route. In 6 patients the urethral obstruction was due to new bone formation (callus) in the pubic gap (after pubectomy) pressing on the anastomatic line, and these cases were treated by removal of the callus. RESULTS: After 1-6 years of follow up (mean 3.16 years) the outcome of the 3 patients who underwent visual urethrotomy was good. Eleven of the 16 patients who underwent anastomotic urethroplasty (68.7%) void well, 2 patients had fair results and the remaining 3 (18.7%) had restenosis. In the 6 patients who had new bone formation in the pubic gap, the obstruction was relieved by removal of the callus. CONCLUSIONS: Visual urethrotomy is limited to very short passable urethral strictures, we do not recommend cutting on the light. End-to-end anastomosis was performed in obliterated strictures. Removal of the new bone formation from the pubectomy gap relieved the urethral obstruction.     

Muscle- and nerve-sparing bulbar urethroplasty: a new technique

BACKGROUND: To describe a new surgical technique for the repair of bulbar urethral strictures to preserve the bulbospongiosum muscle and its perineal innervation. OBJECTIVE: Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are described. The outcome is provided regarding semen sequestration and postvoiding dribbling. DESIGN, SETTING, AND PARTICIPANTS: We performed the procedure in 12 patients (average age: 43.58 yr) with bulbar urethral strictures (average stricture length: 4.47cm). SURGICAL PROCEDURE: Six patients underwent urethroplasty using a ventral oral mucosal onlay graft, and six patients underwent urethroplasty using a dorsal oral mucosal onlay graft. In all patients, the surgical approach to the bulbar urethra was made avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact. MEASUREMENTS: Clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the technical feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The secondary outcome examined the presence or absence of postoperative postvoid dribbling and semen sequestration using a nonvalidated questionnaire (Appendix). RESULTS AND LIMITATIONS: In all patients, postoperative voiding cystourethrography was performed 3 wk after surgery and no urethral sacculation was evident. Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or semen sequestration was demonstrated in all patients at 6 mo and 12 mo after surgery. No patient showed stricture recurrence. The average follow-up was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo). CONCLUSIONS: Bulbar urethroplasty preserving the bulbospongiosum muscle, the central tendon of the perineum, and the perineal nerves is a safe, feasible, minimally invasive alternative to traditional bulbar urethroplasty.     

Johanson's staged urethroplasty revisited in the salvage treatment of 68 complex urethral stricture patients: presentation of total urethroplasty

BACKGROUND: To show our experience with the staged Johanson's urethroplasty as a salvage treatment of difficult and complicated groups of patients, and to present the total urethroplasty technique. MATERIAL AND METHODS: During a 12-year period, 68 men with urethral stricture underwent the staged Johanson's urethroplasty. 51 had war-related injuries (75%) resulting in an unhealthy perineal and genital skin with fistulae and/or scarring. 35 patients (52%) had other urethral or vesical problems. 60 patients (88%) had long (0.5-4 cm), multiple or impassable strictures. 58 patients (85%) had strictures of the pendulous urethra. The second stage was performed 2-3 months after the first. Both stages of Johanson's urethroplasty were protected by a stab suprapubic catheter for 3 weeks. Patients were followed up for 23-82 months (mean 52.5). RESULTS: All patients but 4 had improved urine flow (best Qmax ranged between 13.2 and 31.8 ml/s; mean 17.4). 4 patients (6%) needed a revision because of fistula formation or recurrence and 6 patients (9%) developed urinary tract infection postoperatively. CONCLUSIONS: The staged Johanson's urethroplasty is a good treatment for the difficult and complicated urethral strictures which are not suitable for optical urethrotomy, especially those in the pendulous part. In strictures involving all parts of the urethra total urethroplasty could be performed.