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31 Treatment ofUrethral Injury. I: ThePosterior Urethra
adult population with occurrences of 31% and 9%, respectively, conrming
Koraitim’s predictions based on G/U index (see reference [20]). Overall, the success
rates of Kulkarni’s series were 81% and 77% for primary and repeat cases, respectively [29].
References
1. Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoro V, McAninch
JW. Consensus statement on urethral trauma. BJU Int. 2004;93(9):1195–202. https://doi.
org/10.1111/j.1464- 410x.2004.04805.x. PMID: 15180604.
2. Turner-Warwick R. Complex traumatic posterior urethral strictures. J Urol.
1977;118(4):564–74. https://doi.org/10.1016/s0022- 5347(17)58109- 4. PMID: 916051.
3. Elbakry A. Classication of pelvic fracture urethral injuries: is there an effect on the
type of delayed urethroplasty? Arab J Urol. 2011;9(3):191–5. https://doi.org/10.1016/j.
aju.2011.06.001. Epub 2011 Aug 15. PMID: 26579295; PMCID: PMC4150576.
4. Iselin CE, Webster GD.The signicance of the open bladder neck associated with pelvic fracture urethral distraction defects. J Urol. 1999;162(2):347–51. PMID: 10411036.
5. Osterberg EC, Murphy G, Harris CR, Breyer BN.Cost-effective strategies for the management
and treatment of urethral stricture disease. Urol Clin North Am. 2017;44(1):11–7. https://doi.
org/10.1016/j.ucl.2016.08.002. PMID: 27908365.
6. Webster GD, Mathes GL, Selli C.Prostatomembranous urethral injuries. A review of the literature and a rational approach to their management. J Urol. 1983;130:898–902.
7. Koraitim MM.Pelvic fracture urethral injuries. Evaluation of various methods of management.
J Urol. 1996;156:1288–91.
8. Shrinivas RP, Dubey D.Primary urethral realignment should be the preferred option for the
initial management of posterior urethral injuries. Indian J Urol. 2010;26(2):310–3. https://doi.
org/10.4103/0970- 1591.65416. PMID: 20877620; PMCID: PMC2938566.
9. Horiguchi A.Management of male pelvic fracture urethral injuries: review and current topics.
Int J Urol. 2019;26(6):596–607. https://doi.org/10.1111/iju.13947. Epub 2019 Mar 20. PMID:
30895658.
10. Tausch TJ, Lotan Y, Zhao L, Morey AF.Decision analysis model comparing cost of management strategies for pelvic fracture urethral injuries. Urol Pract. 2016;4:285. https://doi.
org/10.1016/j.urpr.2016.07.004.
11. Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR. Costeffective management of pelvic fracture urethral injuries. World J Urol. 2017;35(10):1617–23.
https://doi.org/10.1007/s00345- 017- 2022- 8. Epub 2017 Feb 22. PMID: 28229209.
12. Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL, Mundy AR.Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor costeffective. J Urol. 2004;172(1):275–7. https://doi.org/10.1097/01.ju.0000132156.76403.8f.
PMID: 15201793.
13. Patel DN, Fok CS, Webster GD, Anger JT.Female urethral injuries associated with pelvic
fracture: a systematic review of the literature. BJU Int. 2017;120(6):766–73. https://doi.
org/10.1111/bju.13989. Epub 2017 Sep 7. PMID: 28805298.
14. Tanello M, Frego E, Simeone C, Cosciani CS. Use of pedicle ap from the labia minora
for the repair of female urethral strictures. Urol Int. 2002;69(2):95–8. https://doi.
org/10.1159/000065554. PMID: 12187036.
15. Montorsi F, Salonia A, Centemero A, Guazzoni G, Nava L, Da Pozzo LF, Cestari A,
Colombo R, Barbagli G, Rigatti P. Vestibular ap urethroplasty for strictures of the female
urethra. Impact on symptoms and ow patterns. Urol Int. 2002;69(1):12–6. https://doi.
org/10.1159/000064353. PMID: 12119432.
References
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16. Tsivian A, Sidi AA. Dorsal graft urethroplasty for female urethral stricture. J Urol.
2006;176(2):611–3; discussion 613. PMID: 16813901. https://doi.org/10.1016/j.
juro.2006.03.055.
17. Koraitim MM. The lessons of 145 posttraumatic posterior urethral strictures treated in 17
years. J Urol. 1995;153(1):63–6. https://doi.org/10.1097/00005392- 199501000- 00024. PMID:
7966793.
18. Koraitim MM.Predictors of surgical approach to repair pelvic fracture urethral distraction
defects. J Urol. 2009;182:1435–9.
19. Gómez RG, Mundy T, Dubey D, El-Kassaby AW, Firdaoessaleh KR, Santucci R.SIU/ICUD
consultation on urethral strictures: pelvic fracture urethral injuries. Urology. 2014;83(3
Suppl):S48–58. https://doi.org/10.1016/j.urology.2013.09.023. Epub 2013 Nov 8. PMID:
24210734.
20. Koraitim MM.Gapometry and anterior urethrometry in the repair of posterior urethral defects.
J Urol. 2008;179:1879–81.
21. Al Taweel W, Seyam R.Visual internal urethrotomy for adult male urethral stricture has poor
long-term results. Adv Urol. 2015;2015:656459. https://doi.org/10.1155/2015/656459. Epub
2015 Oct 1. PMID: 26494995; PMCID: PMC4606400.
22. Haider M, Jalloh M, Yin J, Diallo A, Puttkammer N, Gueye S, Niang L, Wessells H, McCammon
K. The role of international partnerships in improving urethral reconstruction in low- and
middle-income countries. World J Urol. 2020;38(12):3003–11. https://doi.org/10.1007/
s00345- 019- 02819- 2. Epub 2019 Jun 8. PMID: 31177304; PMCID: PMC7716901.
23. Webster GD, Ramon J.Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145(4):744–8. https://doi.
org/10.1016/s0022- 5347(17)38442- 2. PMID: 2005693.
24. Koraitim MM.On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol.
2005;173(1):135–9. https://doi.org/10.1097/01.ju.0000146683.31101.ff. PMID: 15592055.
25. Koraitim MM.Failed posterior urethroplasty: lessons learned. Urology. 2003;62(4):719–22.
https://doi.org/10.1016/s0090- 4295(03)00573- 9. PMID: 14550450.
26. Mundy AR, Andrich DE. Urethral trauma. Part II: types of injury and their management.
BJU Int. 2011;108(5):630–50. https://doi.org/10.1111/j.1464- 410X.2011.10340.x. PMID:
21854524.
27. Andrich DE, O’Malley KJ, Summerton DJ, Greenwell TJ, Mundy AR.The type of urethroplasty for a pelvic fracture urethral distraction defect cannot be predicted preoperatively. J
Urol. 2003;170:464–7.
28. Barratt RC, Bernard J, Mundy AR, Greenwell TJ.Pelvic fracture urethral injury in malesmechanisms of injury, management options and outcomes. Transl Androl Urol. 2018;7(Suppl
1):S29–62. https://doi.org/10.21037/tau.2017.12.35. PMID: 29644168; PMCID:
PMC5881191.
29. Kulkarni SB, Joshi PM, Hunter C, Surana S, Shahrour W, Alhajeri F.Complex posterior urethral injury. Arab J Urol. 2015;13(1):43–52. https://doi.org/10.1016/j.aju.2014.11.008. Epub
2015 Jan 20. PMID: 26019978; PMCID: PMC4435922.
30. Kulkarni SB, Surana S, Desai DJ, Orabi H, Iyer S, Kulkarni J, Dumawat A, Joshi
PM. Management of complex and redo cases of pelvic fracture urethral injuries. Asian J
Urol. 2018;5(2):107–17. https://doi.org/10.1016/j.ajur.2018.02.005. Epub 2018 Mar 2. PMID:
29736373; PMCID: PMC5934510.
31. Gomez RG, Campos RA, Velarde LG. Reconstruction of pelvic fracture urethral injuries
with sparing of the bulbar arteries. Urology. 2016;88:207–12. https://doi.org/10.1016/j.urol-
ogy.2015.09.032. Epub 2015 Nov 23. PMID: 26616094.
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Treatment ofUrethral Injury. II:
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TheAnterior Urethra
32.1 Principles ofAnterior Urethra Repair
Alike the posterior urethral injury, SPC and delayed repair is preconized for anterior
injury with severe contusion and hematoma. The rationale is to allow an incomplete
injury to heal, then to assess the residual stricture after 3months with combined
antegrade and retrograde urethrography [1]. However, a greater room exists here for
immediate urethral repair when several conditions are present, namely a complete,
anterior, penetrating, or open injury, a stable patient, a minimal hematoma, an experienced surgeon, and non-involvement of other organs [1].
If the urethral disruption is found to be too extensive during an attempt for primary anastomosis, the surgeon should avoid any obstinacy and humbly proceed to
a mere debridement with marsupialization of the urethra to prepare for a delayed
nal repair that should be planned after a period not lesser than 3months [1].
Contrary to the posterior urethral stricture where the result depends on complete
excision of the brotic area with end-to-end anastomosis of the urethral healthy
ends while grafts are rarely used, the anterior urethroplasty often implies the use of
autologous grafts for long gaps with no need for complete excision of the strictured
area, while brous tissue excision with end-to-end anastomosis remains a valid
approach for short strictures (<2cm).
32
32.2 The Surgical Techniques
32.2.1 Direct Vision Internal Urethrotomy (DVIU)
The cost-effectiveness was assessed for the management of short anterior urethral
strictures (precisely 2-cm bulbar urethral strictures) by a model that included the
risks of a direct vision internal urethrotomy (DVIU), namely bleeding, urinary tract
infection, and the possibility of recurrence, on the one hand, and the drawbacks of a
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_32
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primary urethral reconstruction, namely wound infections or delayed healing, the
eventual complications of exaggerated lithotomy position, and the possibility of
treatment failure, on the other hand. This model demonstrated a greater average
total cost per patient treated with DVIU compared with immediate open urethral
reconstruction, with values of $17,747 and $16,444, respectively. It predicted a
favorable cost for DVIU only if the long-term risk of stricture recurrence was less
than 60% [2].
32 Treatment ofUrethral Injury. II: TheAnterior Urethra
32.3 Excision andEnd-to-End Anastomosis
A US study including approximately 3700 men who underwent urethroplasty over
a 10-year period (2000–2010) showed that excision with primary anastomosis
(EPA), the use of buccal graft, and the use of other graft or ap urethroplasty was
performed in 80.3%, 14.3%, and 5.4% of the procedures, respectively. However
only 1.6% of hospitals had a volume of 20 urethroplasties or greater per year, and
the popularity of buccal mucosa graft procedures was noticed to increase over time,
reecting the universal trend [3].
What is the best management of a short bulbar urethral stricture dened as
≤2cm long: resection of the brotic tissue with end-to-end anastomosis or buc-
cal mucosa graft?
Despite the tremendous efforts of the pioneers to propose the best approach to
≤2cm bulbar urethral stricture repair, there are still controversies, especially regarding the impact of urethral transection on the degree of erectile dysfunction and
penile complications. This subject was recently explored by a Scandinavian multicentric randomized study that showed an increased rate of penile complications
(reduced glans lling and a shortened penis) after transection than after buccal
mucosa graft, but none of the techniques exposed to an increased rate of erectile
dysfunction (IIEF-5 score). This study also revealed a similar recurrence rate in
both groups (12.9%) [4].
32.4 Non-transecting Bulbar Urethroplasty
In view of the concerns related to the urethral stricture excision and primary anastomosis (EPA), namely the fear of erectile dysfunction, a non-transecting anastomotic
technique was proposed for short strictures (<2cm) with the aim to preserve a wellvascularized underlying spongiosum [5].
32.5 Urethroplasty withAutologous Graft
In a thorough review, Barbagli etal. have raised many controversies in almost all the
steps of the reconstructive surgery of the anterior urethra, namely the nature of the
substitute material or ap (buccal mucosa vs penile skin), the technique itself
32.5 Urethroplasty withAutologous Graft
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267
(grafting versus apping, grafting vs end-to-end anastomosis), the variant (dorsal vs
ventral), the approach of complex injuries (denitive perineal urethrostomy vs onestage repair), etc. [6]. A historical review and summary of the most popular techniques are proposed in the following paragraphs.
Many tissues have been used in the past for urethral grafting, including scrotal
or preputial skin. The bladder mucosa was also successfully used for this purpose
but its drawback is the necessity for a Pfannenstiel incision and a cystotomy for
graft harvesting [7]. The preputial ap is contra-indicated in balanitis xerotica obliterans and lichen sclerosus. Nowadays the use of buccal mucosa has supplanted
all other grafts [3, 8].
The use of buccal mucosa graft (BMG) was rst introduced in Ophthalmology
by the Austrian Stellwag von Carion in 1873 to cover conjunctival defects [9].
Sapezhko from Kyiv is credited with the rst use of BMG for urethral defects in
1894 [10], well before the English Humby described the same in 1941 [11]. The
popularity of this technique started in the 1990s [12, 13].
32.5.1 Buccal Mucosa Harvesting
The buccal mucosa length is proportionate to the length of the stricture and may be
as short as 3cm or as long as 17cm. To obtain such a long graft, the team may need
to harvest two or three different segments (right inner cheek, left inner cheek, inner
lower labial mucosa and even lingual mucosa) [13–16] (Figs.32.1, 32.2, 32.3, 32.4,
and 32.5). One of the best mouth retractors to provide a good exposure is the Kilner-
Doughty mouth gag.
a b
Fig. 32.1 (a, b) Marking of a 4-cm long and 2.5-cm wide graft, beginning 1.5 cm from the
Stensen’s duct and 1.5cm from the edge of the cheek. The Stensen’s duct, located at the level of
the second molar, is identied and the desired graft size is measured and marked in an ovoid shape.
(From Barbagli G etal. [15], with permission from Elsevier)
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Fig. 32.2 (a, b) The graft is lifted and removed, leaving the muscular bers intact. (From Barbagli
G etal. [15], with permission from Elsevier)
32 Treatment ofUrethral Injury. II: TheAnterior Urethra
Fig. 32.3 (a, b) Optionally, two stitches are placed at the apices of the harvesting site, and then
pulled, remarkably reducing the width of the wound. (From Barbagli G etal. [15], with permission
from Elsevier)
32.5 Urethroplasty withAutologous Graft
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Fig. 32.4 Optionally, the
donor site can be closed
with interrupted or running
4-0 polyglactin sutures.
When necessary, another
graft can be harvested from
the contralateral cheek
using the same technique.
(From Kulkarni SB etal.
[16], with permission from
the Indian Journal of
Urology)
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32.5.2 Buccal Graft Positioning
After harvesting the buccal mucosa, the question is now: How to position it (or any
other graft) over the urethral stricture?
Monseur described a one-stage dorsal inlay technique in 1968in patients with
long anterior urethral strictures yielding encouraging results. His technique consisted of a dorsal incision of the brotic segment followed by suturing of the incisional edges to the corpora cavernosa albuginea allowing a progressive regeneration
of the urothelium to completely line the urethral lumen [17]. However, this technique showed some limits when the urethral caliber was not sufcient; exposing it
to stenosis, some investigators proposed to adjunct the use of pedicled penile skin
graft dorsally onto the urethra [18].
Morey and McAninch proposed the ventral onlay technique in 1996 [13]. This
technique was very attractive by its simplicity and straightforwardness; however, it
was associated with a high risk of ballooning and pseudo-diverticulum formation of
the ventrally positioned unsupported graft, in addition to concerns about possible
vascular compromise at the ventral site [19].
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
a
b
c
Fig. 32.5 The graft is stabilized on a silicone board using insulin needles. Once all submucosal
tissue is carefully excised with iris scissors (a), the graft is tailored according to site, length, and
stricture characteristics. While removing all the submucosal tissue, it is paramount to not excessively thin the graft, as thin grafts are more likely to heal with contracture. If the preparation of the
graft is adequate, an average 4cm long graft will stretch up to 6cm due to the intrinsic elasticity
of the mucosa (b and c). Two 6cm long grafts (one from each cheek) are enough to repair the vast
majority of penile or bulbar strictures using one-stage techniques. (From Kulkarni SB etal. [16],
with permission from the Indian Journal of Urology)
Barbagli is credited for the rst use of the dorsal onlay technique in 1998 and
Asopa etal. for that of a dorsal inlay technique in 2001, both using penile skin
(inner prepuce) or buccal mucosal graft [20, 21].
32.5.2.1 Barbagli Dorsal Onlay Technique [19, 20, 22] (Fig.32.6)
– Complete mobilization of the corpus spongiosum and urethra from the cor-
pora cavernosa and 180° rotation.
– Opening of the strictured tract along its dorsal surface and extension of the inci-
sion beyond the stricture proximally and distally.
– Spreading of a fenestrated ovoid preputial free skin or buccal mucosa graft
which is sutured to the corpora cavernosa (tunica albuginea) using inter-
rupted stitches.
– Addition of several quilting sutures to optimize contact between the graft and
the corporeal bed and enhance the “take” of the graft.
– Making small incisions all over the graft to prevent hematoma or edema forma-
tion beneath it.
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ab
e
Fig. 32.6 Dorsal onlay augmentation (Barbagli technique) for bulbar urethral stricture. (a) The
bulbar urethral is rotated, and (b) the dorsal urethral surface is incised along the midline to expose
the entire stricture. (c) The oral mucosa graft is spread, xed over the corpora cavernosa. (d) The
bulbar urethra is rotated back, and the margin of the oral mucosa graft is sutured to the margin of
the urethral mucosal plate. (e) Cross-sectional view of the grafted urethral lumen. CC corpora
cavernosum, CS corpus spongiosum, OM oral mucosa, TA tunica albuginea, UMP urethral mucosal plate. (From Horiguchi A [22], with permission from John Wiley and Sons)
– Suturing of the left mucosal margin of the opened urethra to the left side of the
patch graft.
– Rotation of the urethra back to its original position.
– Insertion of a 16-Fr silicone catheter.
– Suturing the edges of the stricturotomy to the graft and to the corpora cavernosa:
the right urethral margin is sutured to the right side of the patch graft. This results
in the graft area being entirely covered by the urethral plate.
32.5.2.2 Asopa Inlay Technique [19, 21, 22] (Fig.32.7)
– Exposure of the urethra at the site of the stricture.
– No attempt to mobilize the urethra or dissect the bulbospongiosus muscle
and Buck’s fascia.
– Ventral urethrostomy carried out on the strictured area over a bougie upto 2cm
both proximally and distally into the healthy urethra.
– Incision of the full thickness of the dorsal urethra in the mid-line for about
1–2cm both proximally and distally into the healthy urethra.
– Sharp dissection of the margins of the incised dorsal urethra from the tunica
albuginea without lifting the two halves of the bisected urethra. This dissection
creates a 1.5–2cm-wide elliptical raw area between the bisected edges of the
urethra over the tunica albuginea.
– Anchoring of the incised dorsal free margins of the urethra to the tunica albu-
ginea with interrupted 5-0 polyglactin.
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
a
b
e
Fig. 32.7 Dorsal inlay (Asopa technique). (a) The urethra is left adherent to the corpora caver-
nosa, and is longitudinally opened ventrally extending to the distal and proximal healthy urethra.
(b) The strictured urethral plate is longitudinally opened dorsally. (c) The oral graft is sutured to
the margins of the urethral plate and xed to the corpora cavernosa. (d) The urethra is retubularized
over a urethral catheter. (e) Cross-sectional view of the grafted urethral lumen. CC corpora cavernosum, CS corpus spongiosum, OM oral mucosa, TA tunica albuginea, UMP urethral mucosal
plate. (From Horiguchi A [22], with permission from John Wiley and Sons)
– Placement of full-thickness free grafts (inner prepuce or buccal mucosa) over the
raw area of the incised dorsal urethra.
– Fixing the graft to the edges of the incised dorsal urethra with 5-0 resorbable
sutures, and adding several quilting sutures at the underlying tunica albuginea to
prevent dead space.
– Insertion of a 14- to 16-Fr silicon catheter and retubularization of the urethra by
closing the ventral urethrostomy with continuous 4-0 resorbable sutures.
– Drain in situ and compressive dressing.
At rst glance, it appears that the avoidance of urethral mobilization and dis-
section in the Asopa or inlay technique would preserve the urethral blood supply through circumex and perforating vessels, and simplify the procedure. Herein
a prospective randomized study comparing both techniques showed a similar success rate (86.4–88%), however, the Asopa technique (dorsal inlay) appeared to
be technically easier than the Barbagli one (dorsal onlay) with a shorter operative time (128 vs 205min) and less blood loss (105 vs 228mL) [19].
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