- To describe the complications of transperineal end-to-end anastomotic urethroplasty in patients with posterior urethral strictures resulting from pelvic fracture.
posterior pelvic fracture urethral distraction defect
Posterior pelvic fracture urethral distraction defect (PFUDD) is a challenging problem in urology that can lead to disabling complications, including urinary incontinence and the inability to void . Although the worldwide incidence of PFUDD has recently decreased, a greater number of PFUDD cases are reported in developing countries where agricultural activities are still prevalent, the prevention of accidents in the workplace has not greatly increased, and bicycles and motorcycles are the most popularly used vehicles . Moreover, emergency treatment of patients with PFUDD in these regions is not currently codified, and the majority are treated with incorrect procedures that add iatrogenic damage to the trauma . The appropriate management of PFUDD is crucial for reducing the risk of disability.
Although multiple strategies are currently available for managing PFUDD, anastomotic urethroplasty remains the cornerstone. Numerous clinical studies have shown that anastomotic urethroplasty has excellent success rates in cases of posterior urethral strictures ; however, surgery for posterior urethral strictures has inherent problems related to difficult access, limited urethral length, surrounding fibrosis, and the small calibre of the bulbar urethra that makes it susceptible to ischaemic insults . As a result, reported complications associated with anastomotic urethroplasty include urinary incontinence, erectile dysfunction (ED), rectal injury, and false passage. Postoperative recurrence of stricture is also a problem with this procedure. Although recurrence and complications after transperineal bulboprostatic anastomosis for PFUDD have been discussed in broader reports of operative outcomes, however, they have not yet been systematically described.
In the present study, we systematically describe recurrence and complications after transperineal bulboprostatic anastomosis in 573 patients with posterior urethral strictures. In addition, we analyse the aetiologies of these complications and offer precautionary measures to avoid or reduce their occurrence.
This was a retrospective observational study of recurrence and complications after transperineal bulboprostatic anastomosis in patients with posterior urethral strictures. From January 1999 to June 2010, 573 male patients underwent bulboprostatic anastomosis for posterior urethral strictures in our department. Their mean (range) age was 36 (7–71) years. In all patients the aetiology of the stricture was pelvic fracture. The patients enrolled were expected not to have urethral rectal fistula, bladder neck injury or false passage. Patients treated using a combined abdominal–perineal approach were excluded because this approach is associated with the aforementioned complications. Preoperative evaluation included clinical history, physical examination, urine culture, uroflowmetry, and retrograde and voiding cysto-urethrography. MRI and CT were used only in complex cases . Distraction defects were measured using retrograde urethrography combined with voiding cysto-urethrography. Before referral to our centre, 537 (93.7%) of the patients had received previous treatments: 274 (51%) received dilation after previously undergoing an early urethral realignment with endo- or open surgery, 134 (25%) an internal urethrotomy, and 129 (24%) had undergone urethroplasty. Transperineal bulboprostatic anastomosis was performed at a mean (range) of 10 (6–24) months after pelvic trauma or previously failed urethroplasties (Table 1).
|No. of patients||573|
|Mean (range) age, years||36 (7–71)|
|Previous treatment, n (%)|
|Dilatation after previously undergoing an early urethral realignment with endo- or open surgery||274 (51)|
|Internal urethrotomy||134 (25)|
|Interval between pelvic trauma or previously failed urethroplasty to urethroplasty this time, months||6–24|
After providing written informed consent, all patients underwent perineal excision and primary anastomotic urethroplasty. The patients were placed in the lithotomy position. A stepwise approach for urethral mobilization was used, consisting of complete mobilization of the bulbar urethra, separation of the cavernous bodies, and inferior pubectomy in patients who had a urethral defect >3 cm in length (n = 183) with removal of the bone tissue at the bottom side of the pubis (size scope: 3 × 1.5 cm) to accomplish tension-free bulboprostatic urethral reanastomosis. By incising the cavernosa septum, the distal urethra was inserted through the septum. Both sides of the urethral stump were anastomosed with 6–8 interrupted sutures, using 4/0 polyglactin sutures, and 16–18-F silicone Foley catheters were placed in the urethra. The bulbocavernosus muscle or surrounding adipose tissue was used to fill in the gaps left by the excised pubic synchondrosis, to prevent the formation of a dead cavity. The local wound surface was sprayed with antibiotic powder, a negative pressure drain was placed behind the pubis, and a latex strip drain was placed for the perineal wound. Thus, the suprapubic ostomy was retained. A drain was placed in the perineal wound area for draining postoperative bleeding related to the surgical dissection and to prevent the formation of haematoncus which can lead to infection. The drain was removed 2– 3 days after surgery.
Patients were discharged from the hospital 7 days after surgery. Urethral catheters were removed 3 weeks after surgery. Uroflowmetry and retrograde and voiding cysto-urethrography were performed 1 week after removal of the catheter. The suprapubic catheter was removed after the patients voided smoothly for 2–3 days. If the repair was considered failed, the catheter was left in place until another repair could be performed.
The urethroplasty was defined as successful if the patient was free of stricture-related obstruction and did not require any further intervention. The repair was considered a failure if the stricture remained, recurrent stenosis developed and required repeated urethral dilatation or other definitive therapy, or the patient required self-catheterization.
The mean (range) follow-up was 36 (18–47) months. After catheter removal, the patients were followed at 3, 6 and 12 months, and every 6 months thereafter. Uroflowmetry was performed during the follow-up period. Retrograde and voiding cysto-urethrography or cystoscopy were performed if the patient complained of symptoms of obstruction. The prevalence of postoperative sexual disorders was investigated using the International Index of Erectile Function-5 questionnaire during follow-up. Evaluations were performed at three timepoints: pre-injury, post-injury, and 2 weeks after catheter removal. For evaluation of pre-injury erectile function, the patients were asked to recall their erectile function before trauma.
The degree of stress incontinence was assessed daily by pad testing. Incontinence was graded as follows: ‘mild’ when no incontinence occurred with general activities or at night, occasional incontinence occurred with increased abdominal pressure and there was no need to wear a pad; ‘moderate’ when frequent incontinence occurred with increased abdominal pressure or standing-up activities and there was no need to wear a pad; and ‘severe’ when incontinence occurred with standing-up activities or body position changes and the patient's life and social activities were badly affected. Stress incontinence was defined as a condition involving an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing or exercise. Urge incontinence was defined as a condition that involves a strong, sudden need to urinate immediately followed by a bladder contraction, which results in an involuntary loss of urine.
Statistical analyses were performed using SPSS 13.0 software (SPSS, Chicago, IL, USA). The chi-squared test was used to compare the differences in success rates and factors affecting preoperative and postoperative ED. A P value < 0.05 was considered to indicate statistical significance.
Of the 573 delayed transperineal bulboprostatic anastomosis procedures performed, 504 (88%) were successful and 69 (12%) were unsuccessful. The mean (sd) maximum urinary flow rate, assessed by uroflowmetry 4 weeks after the procedure, was 20.52 (5.1) mL/s.
Intra-operative rectal injury occurred as a complication in 28 patients (4.9%) and was repaired primarily using a two-layer interrupted closure. Seven of these patients required a colostomy with delayed repair and colostomy closure. In the 28 patients, 22 urethral reconstructions were primarily successful, giving an overall success rate of 79%.
Urethral strictures recurred in 55 patients (9.6%), including 10 (1.7%) cases recurring within the first 6 months after surgery and 45 (7.9%) cases recurring between 6 months and 1 year after surgery. All of these patients underwent re-operation by excision and anastomosis, which was successful for 33 patients (60%), including 26 who were managed using a perineal approach, and seven who had a short incomplete stricture that was treated with internal urethrotomy.
One month after surgery, 510 (89%) patients voided normally and were continent. Sixty-three patients had incontinence, of whom 24 (38.1%) had mild urge incontinence, 28 (44.5%) had mild stress incontinence when the bladder was full, which did not require treatment or protection from leakage, and 11 (17.5%) had severe incontinence, including nine patients with false passage who were treated by re-anastomosis.
Before trauma, two patients (<0.1%) had ED, and after trauma 487 (85%) had ED. There was no statistical difference between the number of patients with preoperative (post-trauma) ED (487/573 patients, 85%) and those with postoperative ED (492/573 patients, 86%; P > 0.05 [Table 2]).
|Rectal injury||28 (4.9)|
|Urinary incontinence||52 (9.1)|
|False passage||9 (1)|
False passage refers to an abnormal communication between the urethra and bladder and is a rare complication of surgery for posterior urethral strictures. In our study, nine patients (1%) were found to have anastomosis between the posterior urethra and bladder neck. All of these patients underwent repeated urethral dilatation postoperatively, but all developed dysuria and required re-operation.
Bulboprostatic anastomotic urethroplasty is the ‘gold standard’ treatment for pelvic fracture urethral injuries and generally has a high success rate; however, results reported for posterior urethral repair have varied greatly owing to differences among studies in the definition of success, duration of follow-up and patients' conditions . In addition to the influence of these factors, various complications also adversely affect surgical outcomes. Analysing the cause of these complications and taking precautionary measures can help prevent their occurrence and contribute to surgical success.
Rectal injury is a rare complication of posterior urethroplasty. Hosam et al.  reported that 3% of patients who underwent posterior anastomotic urethroplasties developed rectal injury. Corriere  reported a rectal injury rate of 3% in a study of one-stage bulboprostatic anastomotic urethroplasty for posterior urethral ruptures. Compared with previous reports, the incidence of rectal injury (4.9%) in the present study was remarkably high. We speculate that this was attributable to the fact that 93.7% of our patients had undergone previous treatments including endo- or open urethral surgery, which could cause extensive local scar formation and serious tissue adhesions and make patients vulnerable to rectal injury during urethroplasty.
Cutting open the urogenital diaphragm to mobilize and remove the urethral scar is the most difficult step of the surgery. A slight misjudgment may result in damage to the rectal wall, especially in patients who have previously undergone posterior urethral surgery and have extensive local scar formation and serious tissue adhesions. To avoid rectal injury, a suprapubic sound can be placed via the bladder to guide the excision of scar tissue around the urethra. In addition, during the procedure, the surgeon can insert an index finger into the rectum to feel the distance between the urethral sound and rectal wall to avoid unnecessary rectal injury.
Hosam et al.  reported a 100% success rate for posterior anastomotic urethroplasties over the observation period; however, Flynn et al.  reported a recurrence rate of 5% in 109 patients who underwent posterior urethroplasty via a perineal approach. The major cause of recurrent strictures is scar tissue around the urethra not having been excised completely during surgery, which results in contracture of postoperative scars. Other causes include severe local infection leading to urethral tissue necrosis, and false passage leading to scar formation at the anastomosis site. Another cause of postoperative strictures is the incomplete mobilization of the distal urethra, which results in high tension on the anastomosis. Scar tissue must be excised completely to ensure a tensionless, complete and healthy mucosal anastomosis .
Urinary incontinence is one of the most common complications of posterior urethroplasty. The incidence of urinary incontinence is ∼10% in some reports [9, 10] while in others the incidence was much lower [11, 12]. Several studies showed that opening the bladder neck in static cystography before surgery resulted in a higher incidence of urinary incontinence [13, 14]. The manipulation might injure the neurovascular bundles travelling to the corpus cavernosum along the apex dorsolaterally, and the striated urethral sphincter surrounding the membranous urethra and prostatic apex, resulting in incontinence or ED.
In the present study, 52 (9.1%) cases reported postoperative incontinence, but 28 (44.5%) of these had mild stress incontinence only. In fact, the majority of urinary incontinence complications can resolve spontaneously with time [9, 10]. Clinically, urinary incontinence associated with a serious pelvic fracture is usually caused by improper management of the urethral disruption. For example, urethral realignment results in high tension, or the time devoted to realignment during surgery is too long. For posterior urethral surgeries, especially those for repairing the membranous urethra near the prostate apex, if there is extensive scar formation around the urethra, scar tissues (especially those at the proximal end) must be thoroughly removed to ensure tension-free anastomosis of the healthy urethra stumps, which have a rich blood supply. Excision of scar tissues will inevitably injure the external sphincter at the apex of the prostate and lead to postoperative urinary incontinence.
Another common complication of posterior urethroplasty is ED, and traumatic injury to the pelvis is associated with both urethral disruption and ED. In several recent reports, the incidence of ED after end-to-end urethral anastomosis was as high as 69% . Kanishka et al.  performed end-to-end urethral anastomoses in 10 patients, including four procedures via the perineal approach and six via a perineal-transpubic approach, and found that, after 10 years of follow-up, all patients but two maintained good erectile function. These findings suggest that the initial injury, but not the method of surgical management, was responsible for the loss of potency. Our finding that there was no significant difference between the incidence of preoperative and postoperative ED supports this.
It has been speculated that the aetiology of ED associated with urethral strictures relates to neurovascular injury. Dissection of the periprostatic and peri-urethral tissues of the injured ends of the urethra during anastomosis may further damage neurovascular bundles and increase the risk of ED . Many studies have reported that nerve injury is a prominent risk factor for ED in patients with urethral injury. Majeed  found clinical evidence of neurological injury, confirmed by electromyogram, in 33% of patients with unstable fractures of the pelvis. Cavernous nerves close to the apex of the prostate are easily injured in cases of blunt perineal trauma . One study reported that patients with a posterior urethral disruption defect also had vascular and neurogenic disturbances . The cavernous nerves and pudendal artery branches are often injured by pelvic fractures and significant straddle injuries, because they are proximal to the pelvic bones and membranous urethra [21, 22].
Men with shorter urethral defects (<3 cm) usually have less neurological damage. In patients with longer defects, development of the intracorporal space is often required during posterior urethroplasty. This will result in an increased risk of neurovascular injury. In addition, ancillary manoeuvres (e.g. inferior or total pubectomy) for complex deformities may further increase the likelihood of impaired erectile function.
Most long-term sexual dysfunction is caused by the initial injury itself, not the repair surgery. The erectile function of patients who underwent suprapubic cystostomy with delayed urethroplasty for pelvic fracture urethral injuries was comparable to that of patients who underwent immediate primary urethral realignment . Similar pre- and postoperative ED rates (∼17%) were also reported in patients after urethral reconstruction for post-traumatic urethral stricture . Morey and McAninch  found a drop in the ED rate from 54% preoperatively to 38% postoperatively after follow-up (>1 year) of 82 men who underwent posterior urethroplasty for traumatic strictures. This finding indicates that young men often experience a delayed recovery of sexual function, which might occur several years after posterior urethral injury .
During the end-to-end anastomosis posterior urethroplasty procedure, variation in the direction of the curved sound when it is used as internal guidance will cause an anastomosis between the distal urethra and bladder wall near the orificium urethrae internum, thereby leading to surgical failure [26, 27]. Since the urethral sound is connected to the urethra and bladder, the device can enter the bladder during catheterization or urethral dilatation, but there is still difficulty in urinating after the expansion. False passage can lead to prolonged unhealed infections, promote scar formation around the urethra, and increase the severity of strictures. To reduce the occurrence of false passage, the position of the bladder neck and urethral orifice should be judged correctly. Thus, cystoscopy might be performed sometimes to check landmarks such as the verumontanum to prevent the occurrence of this complication.
The present study has several limitations. One is its retrospective nature may have introduced bias. There was a possible selection bias because the study did not include patients that were expected to have urethral rectal fistula, bladder neck injury or false passage. For example, patients treated using a combined abdominal–perineal approach were excluded because this approach was associated with these complications. Another limitation is its descriptive nature. The changes in the recurrence of urethral strictures over time or the degree of incontinence were not quantified. Finally, the timing of measurements was not optimized.
In conclusion, although transperineal bulboprostatic anastomosis is a highly effective method of repairing posterior urethral strictures, this procedure is associated with multiple complications. Nonetheless, a significant number of complications can be avoided with meticulous preoperative evaluation to define the anatomy, and with careful intraoperative manipulation.