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United States alone, approximately 1.2 million patients sought medical care for this
pathology between 2007 and 2012, which equals to an annual consultation of
240,000 patients [5].
31 Treatment ofUrethral Injury. I: ThePosterior Urethra
31.1 Principles ofPosterior Urethral Injury Treatment
The key points of a successful repair of an injured urethra, be it posterior or anterior,
include control of local infections, correct epithelial apposition, ensuring healthy
and well-vascularized urethral ends, and the use of strong but resorbable sutures.
For direct anastomosis, both ends should be spatulated and approximated without
tension. In addition, for PFUIs, bladder neck competence should be preserved to
palliate possible distal sphincter damage [1].
In general, the acute clinical context of patients presenting with pelvic fractures
leaves a very narrow window for any direct repair of the urethral injury and all that
is required is to ensure urine drainage, generally through a suprapubic catheter,
while dealing with other life-threatening organ damages and endeavoring to stabilize the pelvis. Even when the patient is stable and the urologist is offered a chance
to operate on these patients, it is important to remember that immediate open repair
of posterior urethral injuries is not advisable for low-volume surgeons and institutions as it is hindered by great difculties in the identication and realignment* of
the anatomical planes because of hematoma and edema. These obstacles are associated with an increased incidence of bleeding, immediate failures, and delayed complications such as strictures, incontinence, and impotence. As a rule of thumb, in
the majority of cases, it is advised to defer the repair for 3–6months and refer
the patient to expert surgeons.
*This is an open realignment and should not be confused with the so-called railroading procedure, which is a closed or endoscopic realignment.
In a review of 538 patients from 19 reported series, Webster etal. compared the
results of SPC alone with those of early urethral surgical realignment and revealed
signicantly favorable outcomes in patients who had an SPC with delayed surgery:
For SPC and delayed repair, the rates of impotence and incontinence were 11.6%
and 1.7%, respectively, while these rates were 44% and 20%, respectively, for
immediate repair, which had also a high rate of strictures (69%) [6]. Nevertheless,
the dogma of “nothing other than SPC” has been revisited by Koraitim, who compared the outcome of SPC (with delayed or deferred repair) with primary
realignment and primary suturing. He found that SPC alone exposed to stricture
in almost all the cases (97%), that primary realignment decreased the incidence of
stricture to 53%, but exposed to a high impotence rate of 36% and that primary
suturing similarly decreased the incidence of stricture (49%) but has the drawback
to expose to an unacceptably high rate of impotence (56%) and incontinence (21%)
[7]. This review suggested to consider SPC alone only for incomplete urethral ruptures or complete ruptures with slight distraction, for critically unstable patients, or
when there is no sufcient surgical expertise available in the operating team. It
results from this study that primary realignment was advised whenever there is a
31.1 Principles ofPosterior Urethral Injury Treatment
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wide separation between the urethral ends, or associated bladder neck or rectal injuries. Nonetheless, this study remains consistent with the old ones as it strongly
disapproved of the primary suturing of the urethra [7].
Realignment of the injured posterior urethra can be achieved using railroading
techniques, also referred to as primary endoscopic realignment (PER). This
closed approach has also been suggested by other investigators in stable patients to
be the preferred option as it reduced by over 50% the risk of subsequent stricture
urethra inherent to SPC placement and delayed or deferred repair, and yielded an
acceptable rate of impotence and incontinence [8]. Despite the primary endoscopic
realignment can reduce the risk of developing urethra stenosis, it harbors the risk of
aggravating it when performed in poorly selected patients or by inexperienced surgeons, or in centers where facilities for endoscopy/uoroscopy are lacking [9].
The cost-effectiveness of these procedures has been studied showing that pri-
mary endoscopic realignment (PER) costs a total average of $11,043 while a
suprapubic tube with elective bulbomembranous urethroplasty costs $9743,
allowing saving $1300 per patient. The same study showed that the cost- effectiveness
of primary endoscopic realignment would be better only in the hypothesis of having
a success rate of 40% or higher while having at the same time a success rate of SPC
with elective bulbomembranous urethroplasty inferior to 78% [10]. When considering the costs for a 2-year period or longer, PER was proved the most cost-effective
method being preferred over supra-pubic tube placement. It was shown that PER
followed by a single direct vision internal urethrotomy (DVIU) if needed, then
eventually urethroplasty if the rst two have failed had the best average costeffectiveness with the value of $17,493 per unobstructed voider. Delaying ure-
throplasty and preferring multiple repeated DVIU after PER greatly increased the
costs reaching $86,280 per unobstructed voider after a second DVIU and as high as
$172,205 after a third DVIU [11].
It should be understood here that the mere DVIU is not per se that costly, but
rather exposes to an increased risk of failure of a subsequent urethroplasty. This
study suggested considering PER as the rst-line management of PFUIs. And
when PER fails, a single DVIU may be attempted provided the presumed success rate is >32%. Otherwise, urethroplasty should be immediately considered
after any PER failure to improve cost-effectiveness.
This algorithm is supported by a large United Kingdom study which showed the
following costs [12]:
– urethrotomy/urethral dilation: 2250 pounds sterling (3375 dollars),
– simple 1-stage urethroplasty: 5015 pounds sterling (7522.50 dollars),
– complex 1-stage urethroplasty: 5335 pounds sterling (8002.50 dollars), and
– two-stage urethroplasty: 10,370 pounds sterling (15,555 dollars).
However, when considering that 47.6% of patients treated by endoscopic measures required a mean of 3.13 times of endoscopic retreatment, while also needing
a biweekly clean self-dilatation, the total cost per patient jumped to 6113 pounds
sterling (9170 dollars), exceeding the cost of a simple or complex 1-stage
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urethroplasty. This further supported the strategy of urethrotomy or urethral dilation
as rst-line treatment, followed directly by urethroplasty for any recurrence, yielding an average total cost per patient of 5866 pounds sterling (8799 dollars) [5, 12].
For female PFUIs (remember: females have no anterior urethra), a systematic
review and metanalysis showed that 53% of cases were managed with immediate
repair, a minority of whom (20%) underwent primary realignment while the majority (80%) were treated with an anastomotic repair. The remaining 47% were offered
a delayed repair [13]. This review showed the highest rates of urethral stenosis and
stula after primary realignment, and despite the urethral integrity appeared to be
similar after both primary and delayed anastomosis, the latter approach yielded a
signicantly higher rate of incontinence and vaginal stenosis, as patients were likely
to undergo more extensive reconstructive surgery than those operated primarily.
With the reservation of dealing with a very low-quality available literature, this
study concluded that female PFUIs should be managed with a primary anastomotic repair of urethral distraction defect via a vaginal approach in hemodynamically stable patients.
Flaps have also been successfully used to correct female urethral stricture, either
a pedicled ap from the labia minora [14], or pedicled ap from the vaginal vestibule [15], or free graft from the vaginal wall or the buccal mucosa [16].
31 Treatment ofUrethral Injury. I: ThePosterior Urethra
31.2 Surgical Approaches
Repair of posterior urethral injury is one of the most challenging enterprises of
the whole urological surgery due to the “underground” anatomical position
and delicacy of the involved structures with extensive surrounding brosis, the
propensity of bleeding, the risk of failure, the risk of functional complications
(urinary incontinence and sexual impotence), either from the injury itself or
from the procedure, the risk of lower limbs deep venous thrombosis and neurapraxia due to prolonged exaggerated lithotripsy position.
In a review of 145 cases of PFUI, Koraitim reported the following technical
options: optical (internal) urethrotomy in 8%, urethroscrotal inlay in 16%, perineal
anastomotic urethroplasty in 54%, and transpubic urethroplasty in 22% of cases
[17]. In another review of 121 PFUI patients, the same author found three independent predictive factors to guide the choice of the appropriate surgical approach: the
ratio urethral gap/ bulbar urethral length (the so-called gapometryurethrometry or G/U index), the urethral gap length, and the prostatic displacement (lateral vs. upward diastasis) [18]. Based on these factors, a decision
can be made to perform either a simple perineal operation or a complex perineal, or
a combined perineo-abdominal procedure. A G/U index inferior to 0.35 was associated with a 50 times greater likelihood to undergo correction with a simple perineal
operation compared to a G/U index superior to 0.35. A urethral gap inferior to
2.5cm was associated with a simple approach. However, this factor was not always
a reliable predictor. A lateral displacement of the prostate, despite generally limited
to several mm only, was invariably associated with dense adhesions and xation of
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the prostate in the abnormal position, calling for a tedious retropubic dissection and
the need for omental wrapping through a peritoneo-abdominal transpubic approach.
These ndings were endorsed by the joint “Société Internationale d’Urologie—
International Consultation on Urological Diseases” (SIU-ICUD) in their recommendations [19]. Children are more likely to undergo more complex procedures
than adults because they have almost equal urethral gaps while having signicantly
shorter bulbar urethral length than adults, resulting therefore in a higher G/U
index [20].
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31.3 Direct Vision Internal Urethrotomy (DVIU) or
Optical Urethrotomy
This is the simplest initial technique in cases of partial injury of the urethra and
preservation of the continuity, where there is dense short brosis uniting the two
ends and a persistent opening in the lumen. This procedure is performed using a
cold knife and incising the stricture at 12 o’clock and an antegrade suprapubic
approach can be necessary to complete it. The success rate in well-selected patients
varies from 58 to 92% after a 3-year follow-up, with a 10-month median time to
recurrence [17, 21].
Urethrotomy performed for urethral trauma generally has only short-term results
and should be combined with intermittent self-dilatation; therefore, its role remains
very limited as a denitive treatment [1]. Moreover, it should be borne in mind that
when this procedure is repeated, not only does its failure rate increase but also the
brotic segment becomes longer complicating further denitive treatment (urethroplasty) [9].
31.4 Urethroscrotal Inlay Procedure
This technique yields a high failure rate reaching 57% in one series [17]. It involves
the use of substitution tissues (scrotal skin grafts) to cover the brotic urethral segment without completely removing it, and may prove very useful in patients with
excessively long gaps [9].
31.5 Excision oftheFibrotic Segment
andEnd- to-End Reanastomosis
Before developing this topic, let us remember the advice of R.Turner-Warwick
which is more valid than ever 45years later: “Posterior urethroplasty should be
regarded as a specialist procedure. It can be made to appear beguilingly simple
but it cannot be recommended for occasional or general use” [2]. This is particu-
larly true in low-volume centers or in low and middle-income countries where an
international partnership is highly recommended to improve the outcome [22].
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Table 31.1 Postoperative results in 145 posterior urethral strictures
Optical urethrotomy 7 (58) 5 (42) 12
Urethroscrotal inlay 10 (43) 13 (57) 23
Perineal anastomosis 74 (95) 4 (5) 78
Transpubic anastomosis 31 (97) 1 (3) 32
From Koraitim MM [17], with permission from Wolters Kluwer Health
31 Treatment ofUrethral Injury. I: ThePosterior Urethra
Number (%)
Successful Failure Totals
Only after heeding this caveat can we safely state that excision-anastomosis is
the gold standard of posterior urethral rupture with distraction, accomplishing
a success rate ranging between 90 and 98% either with the perineal or with the
transpubic approach [17, 23, 24] (Table31.1).
The technique of posterior urethral reconstruction in PFUIs was pioneered by
Turner-Warwick who preconized three key principles to ensure a successful outcome of the repair: complete excision of scarred tissues, lateral xation of
healthy mucosa of the two urethral ends, and creation of a tension-free anastomosis [2, 9]. This approach was validated, reemphasized, and developed by subse-
quent surgeons and investigators [23–25]. However, Mundy and Andrich proposed
to use the term bulbomembranous anastomosis (BMA) rather than bulbo-
prostatic anastomosis (BPA) because, contrary to the old belief, the injury is not a
prostatic avulsion from the membranous urethra, but is rather located at the bulbomembranous junction in most of the patients [26].
The techniques described below as well as the ancillary steps to help approximate the ureteral ends cannot be reliably predicted by pre-operative imaging, and
the decision to opt for one or another is mainly taken during the procedure once the
surgeon faces the “battleeld” reality [18, 27].
The procedure starts with the patient in a normal or exaggerated lithotomy position, disinfected, and draped. The surgical steps are [2, 9, 23, 24, 27–30]:
31.5.1 Perineal Approach
(a) Midline or curved perineal incision of the skin and the bulbospongiosus
muscles.
(b) Circumferential mobilization of the bulbar urethra from the penoscrotal junc-
tion proximally to the disrupted area distally. This step aims to use the elasticity of the healthy bulbar urethra and stretch it and is considered as the rst
ancillary technique to overcome the gap*.
(c) Detachment of the bulbar urethra from the perineal body and transection of the
strictured segment below the gap. The introduction of the non-dominant index
nger in the rectum might help guide this step [29]. This dissection generally
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sacrices the bulbar arteries with the risk of compromising the spongiosal
blood ow and healing of the anastomotic area. Herein a novel bulbar
artery- sparing technique has been proposed with excellent initial results in a
small series [31].
(d) Incision of the apex of the prostate over a sound (such as the Van Buren’s or the
Béniqué’s sound) antegradely pushed through the suprapubic tract and the
bladder neck indicating the site of the proximal urethral end*.
(e) Retrograde piecemeal resection of the sclerosed prostatic apex up to a
healthy mucosa.
(f) Spatulation of the two urethral ends and lateral mucosa xation using 4–6
sutures of 4/0 resorbable material (PDS).
(g) Distal mobilization of the bulbar urethra from the perineal membrane up to the
penoscrotal junction.
(h) Insertion of a Foley’s catheter (8–12Fr for children, 14–16Fr for adults).
(i) Tension-free end-to-end mucosa-to-mucosa bulboprostatic anastomosis per-
formed with 6–8 sutures of 4/0 resorbable material (PDS, Vicryl) over the
Foley’s catheter.
(j) Fixation of the bulbar urethra to the perineal fascia with resorbable materials to
further release the tension.
(k) Closure of the bulbospongiosus muscles over the bulbar urethra by resorbable
materials.
(l) Leaving a drain for 2–3days.
(m) Keeping the suprapubic catheter as a safety urinary drainage until removal of
the urethral catheter after 2–4weeks and ascertaining the patency of the ure-
thra. SPC shall then be clamped for 1–2days and removed if the patient passes
urine comfortably.
* There are four ancillary steps used to approximate the ureteral ends. These
steps were rst described by Webster and Ramon as transperineal progression
approach, with the idea to stop at the step which allows satisfactory results [9,
23, 28].
First step: bulbar urethra circumferential mobilization (see above).
After this step, there are three other ancillary techniques used to overcome difcult scenarios where the proximal urethral end cannot be found despite the use of
a sound, or an anastomotic tension is expected due to a very long urethral gap:
Second step: corporal splitting at the level of the triangular ligament and lateral
retraction to develop the intercrural space.
Third step: partial (wedge) resection of the inferior pubic arch.
Fourth step: rerouting the urethra around one penile crus.
A simple perineal approach is dened by the use of the rst two steps alone,
while an elaborated perineal approach includes steps 3 and 4 (Fig.31.1).
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a
b
c
31 Treatment ofUrethral Injury. I: ThePosterior Urethra
d
Fig. 31.1 Images and scheme of operative procedures of delayed urethroplasty. (a) The bulbar
urethra is circumferentially mobilized from the penoscrotal junction distally and proximally. (b)
Corporal bodies are split and (c) the inferior pubis is resected in steps if the proximal urethral end
cannot be found or urethral tension is observed. (d) After complete removal of the covering brotic
scar, eight interrupted anastomotic sutures are placed to reapproximate the urethral mucosa. (From
Horiguchi A [9], with permission from John Wiley and Sons)
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31.5.2 Abdomino-perineal or Perineo-transpubic Approach
This approach is seldom needed but is necessary when adequate access to the proximal urethral end cannot be achieved despite the use of all the above four ancillary
steps. Statistically, this extreme scenario is mostly encountered in children, in re-do
cases after initial perineal urethroplasties, in complex cases associated with rectourethral stula, false passage, etc. [9, 24, 29, 30] (Figs.31.2 and 31.3).
The steps are:
(a) Extended sub-umbilical midline incision up to the root of the penis below the
symphysis pubis
(b) Dissection of the retropubic space
(c) Exposure of the posterior and lower surface of the symphysis as well as the
prostatic apex
(d) Disconnection of the attachments of the rectus abdominis muscles from the
outer surface of the pubis using a periosteal elevator
(e) Removal of a wedge-shaped piece of bone from the superior surface of the
pubis using an osteotome
(f) Exposure and dissection of the prostate from the extensive scar tissue
a
d
Fig. 31.2 Anastomotic posterior urethroplasty. (a) Bulbar urethra (yellow) and strictured segment
(grey) are dissected in continuity to the apex of the prostate (blue); (b) complete excision of scarred
tissue including prostatic apex to a level just short of verumontanum (red); (c) spatulation of two
urethral ends. (d) Fixation of the mucosa of the bulbar and prostatic urethral ends; (e) wide-caliber
bulboprostatic anastomosis. (From Koraitim MM [24], with permission from Wolters
Kluwer Health)
b
c
e
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31 Treatment ofUrethral Injury. I: ThePosterior Urethra
ab
Fig. 31.3 (a) Combined antegrade and retrograde urethrogram shows a long gap between two
distracted ends of the prostatic (short arrow) and bulbar (long arrow) urethra. Transpubic urethroplasty was performed on April 30, 1985. (b) Retrograde urethrogram of the same patient on March
16, 2002. Note the shorter course of the anterior urethra to the prostate and wide bulboprostatic
anastomosis (arrow). (From Koraitim MM [24], with permission from Wolters Kluwer Health)
(g) Re-routing the mobilized urethra around the left penile crus to take a shorter
transpubic path to the upwardly dislocated prostate.
(h) Anastomosing the urethra to the prostate and wrapping the site by an omen-
tal pedicle
(i) Insertion of a suprapubic catheter and closure of the abdomen after leaving a
drain in the Retzius space
During an abdominal approach, a posterior pubectomy might be required, espe-
cially in children [29] (Fig.31.4).
bc
31.7 Results ofPosterior Urethra Repair
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a
de
Fig. 31.4 (a) A transabdominal view of a posterior pubectomy (Z, posterior pubic bone; S, the
suprapubic catheter). (b) A transabdominal view of forceps highlighting the UVF (F) (∗, bladder).
(c) The anastomosis of the proximal (U) and distal urethra (d), showing a Babcock clamp on the
suprapubic tract. (d) The omental wrap (O) interposition. (e) The transpubic approach in a young
boy (∗ bladder, O omentum, P prostate). (From Kulkarni SB etal. [29], with permission from the
Arab Association of Urology (AAU) and Taylor & Francis Group)
31.6 Urethral Stenting
Stents are contraindicated in PFUI patients with stenosis as they yield the highest
risk of failure and stenosis aggravation [1, 9].
31.7 Results ofPosterior Urethra Repair
In a recent study from a high-volume center in India, Kulkarni etal. reported on a
series of 308 PFUIs, including 126 with earlier multiple failed surgeries [29]. They
found that the most frequent causes of initial failure were insufcient mobilization of the bulbar urethra, followed by inadequate excision of the scar and the
non-performance of inferior pubectomy which was required in >60% of patients
in their series, a greater rate than that from western series, probably due to anthropometric differences. They also found that young boys aged ≤12years were more
likely to require a perineal abdominal approach with posterior pubectomy than the
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