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.