The effectiveness of early primary realignment in children with posterior urethral injury

Treatment and prognosis of pelvic-related urethral injuries in children: a 20-year single-center study and systematic review

BACKGROUND

Management of pelvic fracture-related urethral injury (PFUI) in children remains debated due to various complications. Patients typically receive either primary realignment (PR) or suprapubic cystostomy with delayed urethroplasty (SCDU), but optimal outcomes are unclear. This study evaluates these two surgical techniques by reviewing 20 years of case data and existing literature.

METHODS

We retrospectively analyzed patients treated for PFUI from 2004 to 2023, with a median follow-up of 2 years (1-15 years). Additionally, we performed a meta-analysis of relevant literature, searching PubMed, Web of Science, and Cochrane databases. Eight studies, including ours, were included in the analysis.

RESULTS

Sixty-eight boys with PFUI (median age: 7.3 years; range: 4.8-10.8) underwent PR (39) or SCDU (29). Postoperative complications-urethral strictures, urinary incontinence, calculus, infections, and erectile dysfunction-occurred in PR vs. SCDU groups as follows: 38.5% vs. 51.7% (p = 0.276); 12.8% vs. 3.45% (p = 0.360); 7.7% vs. 13.8% (p = 0.678); 56.4% vs. 93.1% (p < 0.001); and15.4% vs. 3.5% (p = 0.231), respectively. PR was associated with lower costs and higher quality of life. The meta-analysis of eight studies involving 432 patients showed no significant differences between PR and SCDU in urethral stricture rates (OR = 0.60, 95% CI 0.33-1.10, p = 0.10), urinary incontinence (OR = 0.94, 95% CI 0.52-1.70, p = 0.84), and erectile dysfunction (OR = 0.85, 95% CI 0.41-1.76, p = 0.65).

CONCLUSION

There was no difference in complications between the two surgical modalities at long-term follow-up, however, PR presents more advantages in reduce operative times, frequency of postoperative infections, cost, and long-term quality of life.

CLINICAL TRIAL NUMBER

Not applicable.

Management of Catheter-Related Urethral Injuries in Male Children

INTRODUCTION

Management of urethral trauma lacks clarity in the paediatric population. There is no clear guidance for management and follow-up of these patients which can lead to missing the long-term sequelae of the primary injury. Catheter-associated urethral injuries are less likely to cause a complete transaction of the urethra. This is due to the mechanism, typically caused by creating a false passage or inflating the balloon in the urethra. In partial urethral injuries, the European Association of Urology (EAU) guidelines suggest follow-up after one-two weeks of bladder drainage or a urethrogram.  The purpose of this study was to review literature related to the management and follow-up of catheter-induced urethral injuries, subsequently comparing this to a case series in a single paediatric tertiary centre. The aim was to propose a unique algorithm to safely and effectively guide clinicians for this presentation.

RESULTS

In our case series, 11 of 12 required initial bladder drainage. The data demonstrated an inconsistent approach to investigations throughout their admissions. Most cases had a successful trial without catheter (TWOC) or ability to resume continuous intermittent catheterisation. One patient needed a vesicostomy. We had a single bulbar urethral stricture, which wouldn't permit an 8fr catheter. This was managed using cystoscopy and serial urethral dilations. Our cohort is likely an underrepresentation of the actual number of catheter-related injuries in our institute. Some injuries are managed by the parent team without referring to paediatric urologists if spontaneous micturition occurs or if they manage to catheterise after an initial traumatic attempt.  Conclusion: Catheter-related urethral injuries are common but underreported. They are less likely to have long-term sequelae than other mechanisms of trauma. The majority of cases do well following a period of initial bladder drainage. Current practise varies even in one institute as there are no clear management and follow-up guidance in current literature. Our proposed algorithm is a useful tool and decreases the incidence of missing long-term sequelae. Management algorithm: Post urethral injury, a child who is passing urine with conservative management is likely to have good long-term function. They would require re-assessment after discharge. In clinic they would require urinary flow assessment and post-void residuals. If not toilet trained, parental impression of whether their child's stream is interrupted or if they strain during urination would be assessed. Back-pressure changes would be considered on ultrasound scan (USS). If the assessment indicates concern, then a micturating cystourethrogram (MCUG) assessment for children younger than one or a cystoscopic assessment for children older than one would be recommended. Post urethral injury, if a child is unable to pass urine conservatively, then an urgent urological assessment would be appropriate. An attempt at catheterisation would be made. If unsuccessful, the patient would be assessed for theatre. If unfit for it, an ultrasound-guided suprapubic (SP) catheter would be advised. If the patient is fit, then a cystoscopic and wire-guided catheter would be preferred. Later, if they passed a TWOC, they would be managed as per the algorithm described above. If they failed the TWOC, MCUG would be proceeded to. Catheter management and regular follow-up, or for a definitive intervention would be planned for.

A systematic review and meta-analysis of surgical approaches in pelvic fracture-associated urethral injury in children: Primary endoscopic realignment versus delayed urethroplasty

BACKGROUND

The management of pediatric patients afflicted with pelvic fracture urethral injury (PFUI) remains a topic of ongoing debate and controversy within the realm of urology. There is persistent discourse concerning the optimal timing for intervention, specifically between immediate primary realignment (PR) and delayed urethroplasty via suprapubic cystostomy (SCDU). This study was undertaken with the objective of conducting a systematic review of the existing body of evidence, with a focus on comparing the outcomes associated with PR and SCDU as interventions for PFUI among pediatric population.

METHODS

A systematic search across databases (PubMed, ScienceDirect, Web of Science and Cochrane Library) was conducted without time or language limitations. Both medical subject heading and free text terms as well as variations of keywords were searched. Randomized controlled trials (RCTs), nonrandomized comparative studies and single-arm case series were included. Data were narratively synthesized considering methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

RESULTS

From 1,776 identified articles, 5 studies encompassing 95 PR and 180 SCDU pediatric patients met our eligibility criteria. All studies were non-randomized comparative studies. In general, included studies were of moderately quality. Follow-up durations ranged from 3 to 204 months. Meta-analysis demonstrated that PR and SCDU had similar stricture rates (OR = 0.63, [95 %CI 0.29-1.36], p = 0.24), similar rates of urinary incontinence (OR = 0.65, [95 %CI 0.28-1.48], p = 0.3), and similar rates of ED (OR = 0.59, [95 %CI 0.23-1.53], p = 0.28).

CONCLUSION

This study demonstrated that primary realignment procedure did not yield superior outcomes in terms of stricture formation, urinary incontinence, and rates of erectile dysfunction compared to SCDU in pediatric populations with PFUI. It is noteworthy that the predominant inclusion of non-randomized retrospective studies in this analysis introduces a potential for bias. Consequently, there is a pressing requirement for further high-quality research, notably prospective studies and randomized controlled trials, to bolster the robustness of the existing evidence base.

Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial

OBJECTIVE

To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children.

METHODS

This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding the development of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding.

RESULTS

Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002).

CONCLUSION

Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

Pelvic Fracture Urethral Distraction Defects in Preschool Boys: How to Recognize and Manage?

OBJECTIVE

To share the cases of pelvic fracture urethral distraction defect (PFUDD) in preschool boys and evaluate the transperineal anastomotic urethroplasty strategy for the treatment of these cases.

MATERIALS AND METHODS

Between January 2010 and May 2021, 8 preschool boys (<6 years) with PFUDD underwent the transperineal anastomotic urethroplasty in our center were retrospectively reviewed. Etiology was traumatic pelvic fracture in all boys. The type of trauma included: fall injury in 1 and vehicle crush injury in 7. Urethroplasty was performed at least 3 months after initial trauma or the last failed intervention. One of them suffered from PFUDD associated with urethrorectal fistula received urethroplasty combined with fistula repair. A successful urethroplasty was defined as restoring the patency and continuity of urethra and no further interventions were needed.

RESULTS

Follow-up was obtained in all the 8 preschool boys for 3-135 (median: 65) months. The average age was 4.1 years old (range 1-5). After operation, the final success rate was 100%. Neither stenosis recurrence nor urinary fistulas were reported during follow-up. Of the 8 boys, 1 developed urinary incontinence, only occurring after high-intensity exercise such as running. Potency state could not be evaluated for all boys due to the young age. One boy reported having normal morning erection after a follow-up of 135 months.

CONCLUSION

PFUDD in preschool boys is a challenge for both the urologist and parent. Our study preliminarily confirmed that the progressive anastomotic urethroplasty strategy can ensure a high success rate.

Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis

Objective

Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU.

Methods

PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9).

Results

From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82).

Conclusion

For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Traumatic lesions of the posterior urethra

INTRODUCTION

The posterior urethral lesions are associated with pelvis fractures in 5-10% of cases. The posterior urethra is attached to the pelvis bone by puboprostatic ligaments and the perineal membrane, which explains why disruption of the pelvic ring can injure the urethra at this level.

OBJECTIVES

To identify suspected cases of posterior urethral trauma and to perform the diagnosis and its immediate or deferred management.

ACQUISITION OF EVIDENCE

Search in PubMed of articles related to traumatic posterior urethral lesions, written in English or Spanish. We reviewed the relevant publications including literature reviews and chapters from books related to the topic.

SYNTHESIS OF THE EVIDENCE

With patients with pelvis fractures, we must always rule out posterior urethral lesions. The diagnostic examination of choice is retrograde urethrography, which, along with the severity of the condition, will determine the management in the acute phase and whether the treatment will be performed immediately or deferred. Early diagnosis and proper acute management decrease the associated complications, such as strictures, urinary incontinence and erectile dysfunction.

CONCLUSIONS

Despite the classical association between posterior urethral lesions and pelvic fractures, the management of those lesions (whether immediate or deferred) remains controversial. Thanks to the growing interest in urethral disease, there are an increasing number of studies that help us achieve better management of these lesions.

Pro: endoscopic realignment for pelvic fracture urethral injuries

Patients with pelvic fracture urethral distraction injuries may benefit from early endoscopic realignment. Realignment is associated with a low risk of immediate complications and has a high success rate for achieving catheter placement. Review of over thirty studies assessing for subsequent urethral stenosis, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Furthermore, realignment may result in easier subsequent urethroplasty and possibly shorter stenoses.

The management of the acute setting of pelvic fracture urethral injury (realignment vs. suprapubic cystostomy alone)

Background

In patients with pelvic fracture urethral injury there are two options for management: First, to realign as an early primary realignment over a catheter; and second, to place a suprapubic tube with delayed urethroplasty of the inevitable stricture.

Methods

We reviewed previous reports from 1990 to the present, comparing early endoscopic realignment, early open realignment and suprapubic tube placement, to determine the rates of incontinence, erectile dysfunction and stricture formation.

Results

Twenty-nine articles were identified. The rates of erectile dysfunction, incontinence, and stricture formation, respectively, were: for early endoscopic realignment, 20.5%, 5.8% and 43.8%; for open realignment over a catheter, 16.7%, 4.7% and 48.9%; and for a suprapubic tube and delayed urethroplasty 13.7%, 5.0%, and 89.0%. A one-way anova showed no difference in the mean rate of erectile dysfunction (P = 0.53) or incontinence (P = 0.73), and only stricture formation was significantly different (P < 0.1).

Conclusion

The rates of incontinence and erectile dysfunction are similar between the groups. Only the rate of stricture formation was higher in the suprapubic tube and delayed urethroplasty group.

Urotrauma: AUA guideline

PURPOSE

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

CONCLUSIONS

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

Predictors for recurrence after urethroplasty in pediatric and adolescent stricture urethra

OBJECTIVE

This study aims at evaluating factors predicting recurrence of urethral stricture following urethroplasty in pediatric patients at a tertiary care center.

PATIENTS AND METHODS

Fifty-two patients of up to 18 years of age, who underwent urethroplasty, were reviewed. Duration of symptoms, etiology, previous intervention, and site of stricture, surgical modality, stricture length, and spongiofibrosis at stricture site, recurrence, and ancillary procedures required were recorded.

RESULTS

Forty-two (82.76%) patients (Group I) had recurrence-free course on follow-up. Of the 10 patients with recurrence (Group II), 9 had PTS and 1 had IS (p = 0.04). Most of the factors evaluated did not differ statistically between the groups; however, length of stricture (1.8 vs. 4.3 cm, p < 0.001) and degree of spongiofibrosis (61% vs. 90%, p = 0.003) were significantly different. Seven patients with recurrence were managed with single procedures, but three required multiple procedures because of multiple recurrences. History of incision and drainage for paraurethral abscess was significantly higher (28.6% vs. 100%, p = 0.002) in patients who had multiple recurrences.

CONCLUSIONS

Etiology, fibrosis at local site, and stricture length have significant impact on recurrence of pediatric urethral stricture disease. Associated paraurethral abscess may further compromise the outcome of urethroplasty.

Complications of primary realignment of posterior urethral disruption after pelvic trauma

Background:

There are two fundamental selections for the management of traumatic posterior urethral injury, delayed repair or early primary realignment.

Objectives:

The aim of this study was to assess the complications of primary realignment of posterior urethral disruption.

Patients and Methods:

This retrospective descriptive cross-sectional study was done at the Shohada-ye Ashayer University Hospital in Khorramabad. All male patients admitted to the hospital with posterior urethral disruption and had undergone primary realignment of the urinary tract between 2003 and 2010 were included. Primary realignment of the urinary tract was done up to 24 hours after injury. The patients underwent open cystostomy and then a nelaton catheter was inserted from the bladder neck to the distal urethra anterogradely. Upon voiding from the catheter, another nelaton catheter was fixed to it and was pulled into the bladder. The catheter was removed if the urethra was intact in the retrograde urethrography after three weeks. The patients were followed for six months. The data were presented as mean and percentage.

Results:

A total of 24 patients were evaluated while seven, eleven, four, and two patients were aged under 20, 20 to 39, 40 to 59, and over 60 years old, respectively. Thirteen patients (54.16%) had urinary tract stenosis after the primary realignment. Erectile dysfunction was reported in three of them. Urinary incontinence did not occur in patients without stenosis.

Conclusions:

Early primary realignment of posterior urethral disruption had significant complications. In this study we did not have a control group, thus we could not compare the complications of delayed repair and early primary realignment of the posterior urethra. We recommend further case-control studies with larger sample size.

Our experience, technique and long-term outcomes in the management of posterior urethral strictures

PURPOSE

To share our experience, technique and long-term outcomes in posterior urethral stricture management.

MATERIALS AND METHODS

Thirty-seven boys with post-traumatic posterior urethral stricture underwent resection and end-to-end anastomosis through pre-anal coronal approach or in combination with trans-pubic approach from January 2000 to December 2011. Follow up included symptomatic evaluation by micturating cystourethrogram and retrograde urethrogram in all patients, and urethroscopy in patients with voiding symptoms.

RESULTS

Pre-anal coronal approach was used in 29 (78%) cases and in 8 (21%) cases it was combined with trans-pubic approach. In 33 (89.1%) patients it was first attempt, while in 4 (10.9%) it was redo surgery. Two patients required buccal mucosal graft to bridge the deficient urethra. Patient age was 5-17 years (mean 10.8 years). Mean follow up was 48.5 months (range 6-132 months). Thirty-two (86%) patients were symptom free. Failed repairs were successfully managed by urethral dilation in 3 and by redo urethroplasty in the remaining 2. All patients were continent. There was no chordee, penile shortening or urethral diverticula.

CONCLUSIONS

Resection and end-to-end anastomosis of posterior urethral stricture is possible through pre-anal coronal incision; however, if slightest difficulty is envisaged in creating a satisfactory end-to-end anastomosis, extension to trans-pubic approach should be done.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

Posterior urethral injury in male children: long-term follow up

OBJECTIVE

Owing to the immature pelvis and the relative intra-abdominal position of the child's bladder, children with a posterior urethral injury differ from adults. We report our experience in the management of such injuries in male children.

PATIENTS AND METHODS

Children with suspected urethral injury underwent retrograde urethrography once their clinical condition was stable. Children with complete urethral injury underwent primary urethral realignment either endoscopically or by open surgical technique. Suprapubic cystostomy was performed in other children who were unfit to undergo primary realignment or in whom the management of other injuries took precedence over that of urethral injury. Children referred from elsewhere for further management of urethral injury and those with initial suprapubic cystostomy underwent delayed urethroplasty.

RESULTS

Twenty-two children with mean age of 11.3 years were treated at our centre for urethral injury. Seven children underwent primary endoscopic urethral realignment, five open surgical realignment and 10 initial suprapubic cystostomy followed by delayed urethroplasty. Six of the 12 children undergoing primary urethral realignment required additional endoscopic urethrotomy for managing the stricture, and three of these six children eventually underwent urethroplasty. Of the 10 children undergoing delayed urethroplasty, three required additional sessions of endoscopic urethrotomy and two of these required further correction graft urethroplasty.

CONCLUSION

Most male children with posterior urethral injuries need immediate realignment to prevent long-term complications.

Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting

PURPOSE

We present our combined experience with a simplified posterior urethroplasty technique to determine the necessity and usefulness of ancillary reconstructive maneuvers.

MATERIALS AND METHODS

We reviewed the records of 135 men and 7 boys who underwent reconstruction of traumatic posterior urethral defects with greater than 1 year of followup from 5 tertiary teaching hospitals. Prior treatments, surgical approach and ancillary techniques required during reconstruction were compiled.

RESULTS

Direct anastomosis following scar excision and urethral mobilization alone was performed in 95 of the 142 males (67%). Formal corporal splitting was performed in 24 patients (17%) and inferior pubectomy in was done in 14 (10%). Supracrural urethral rerouting was performed in only 4 patients (3%), of whom 3 (75%) experienced recurrent stenosis. Abdominoperineal reconstruction, which was reserved mainly for salvage and pediatric cases, was required to reconstruct complex defects in 5 of the 142 cases (4%) and it was successful in 4 (80%). Early urethral realignment was associated with successful subsequent reconstruction in all patients in whom this maneuver was achieved (17 of 17 or 100%). This maneuver tended to be straightforward. Overall successful posterior urethral reconstruction was achieved in 130 of 142 cases (92%). Eight failures were successfully salvaged by internal urethrotomy (3) or repeat urethroplasty (5).

CONCLUSIONS

Ancillary maneuvers such as corporal splitting or inferior pubectomy are seldom required for successful posterior urethral reconstruction. Urethral rerouting appears to be inferior to the abdominoperineal approach as a salvage maneuver for complex cases. Primary realignment appears to promote more simplified and successful surgical repair.