PFUDD

DR R SRIVATHSAN

PFUDD

• Following a pelvic bone fracture with the destruction of posterior urethral continuity, a surrounding hematoma-fibrosis complex willbe formed between the two urethral ends.

• Therefore, instead of “stricture,” the term of “defect” is usually used for the posterior urethra

• 3% and 25%

Multimodality Management • Last of the multimodality management by – Orthopedic– Vascular– General surgeon– Thoracic

MCU + RGU

• Characteristic S-bend deformity at the site of

injury.

• an apparently long gap between the distal

limit of a complete obliteration on ascending

(retrograde) urethrogram and the bladder

neck on a cystogram (through a suprapubic

catheter).

• only that the detrusor is unable to contract

and open the bladder neck and so allow

contrast down to the upper end of the

obliteration

Beaked BN

• It is also quite common to see an apparently incompetent bladder neck in association with a complete obstruction but this is usually misleading.

• The reason for this appearance (of a so-called “beaked” bladder neck) is not clear, but the vast majority of such patients have a perfectly competent bladder neck postoperatively.

• When the bladder neck has been damaged, it produces an altogether different appearance; indeed, it looks as thought it has been damaged rather than simply being beaked open.

Bladder neck – filling phase

• Incompetent• Fixed neck

• Not seen in voiding phase– ? Obliteration due to fibrosis or callus– Inability of detrusor to open the neck

BUT

• “The appearance of the bladder neck on contrast studies or on antegrade endoscopy does not accurately predict the ultimate function of the bladder neck after urethral reconstruction”

Imaging Modalities

• MRI can provide additional information on the lateral displacement of the prostate and the severity of the posterior urethral defect.

• Can detect bone fragments between the 2 ends of the urethra after pelvic fracture.

• MRI should be used in conjunction with RGU and VCUG and not as a sole method of evaluation.

• ? not of much utility Role of Flexible Cystoscopy

• Can Lithotomy be Put? (Xrays / ortho)• ? VASCULARITY – ED / IIEF– COLD CLAMMY PENIS– Need for angiography and prior revascularisation

Rostral / ? lateral displacement

Instrumentation

History • 1962 – Pierce - the ‘‘splendid’’ exposure of the posterior urethra by total

abdominal pubectomy, but he later abandoned this approach because of postoperative problems and several failures.

• 1968 - Paine and Coombes - direct transpubic excision of the stricture associated with primary end-to-end anastomosis of the urethral ends, using a single abdominal incision.

• 1973 – Waterhouse - perineal incision for mobilization of the anterior urethra and an abdominal incision for transpubic anastomosis between the bulbar urethra and the prostatic apex.

• 1976 - Turner-Warwick omental wrap to provide vascular and trophic support to

the transpubic bulboprostatic anastomosis.

• In the 1970s and into the 1980s, the perineal-abdominal transpubic urethroplasty was considered the gold standard in the majority of adults and children suffering from PFUDDs showing traumatic strictures that Turner-Warwick described as complex.

Membranous vs Bulbar

• Mundy showed that the disorder is accompanied by – avulsion of the bulbomembranous junction in two-

thirds of the cases – avulsion of the proximal bulbar urethra in one-

third.

Timing

• best left ≥3 months from the time of injury. • If performed earlier the tissues are often still

insufficiently recovered to be able to hold sutures. • severe stenoses or obliterations- an augmented

anastomotic repair is necessary. • two ends are spatulated dorsally, sutured to each

other over their ventral hemi- circumference and then the dorsal hemi- circumference is reconstituted with a graft, generally of buccal mucosa

Railroading

• Most of these alternatives are a variation on the theme of ‘retrograde catheterisation’ devised by Verguin.

• This was ‘rediscovered’ and popularised in the 1890s and became standard treatment during the 1920s and 1930s, particularly after Banks and subsequently Davis described the technique of combined antegrade/ retrograde passage of specially modified urethral sounds and thus of a urethral catheter, without the need for perineal exploration

Primary repair

• Main indications for primary repair are penetrating injuries, injuries of the bladder neck and prostate, injuries associated with perineal degloving and injuries associated with a rectal tear’

• Early intervention for severe dislocation of the bladder and prostate, the so-called ‘pie-in-the-sky’ bladder, and in female patients may be helpful but less urgent

• the first problem being that it does not actually realign the urethra, it simply retains luminal continuity.

• This other premise is that ePR reduces the length of the fibrotic segment and thereby facilitates DU.

? Primary repair Primary realignment techniques described in the literature include

• simple passage of a catheter across the defect• catheter realignment using flexible/rigid endoscopes and

biplanar fluoroscopy• use of interlocking sounds (‘railroading’) or magnetic catheters

to place the catheter• catheter traction or perineal traction sutures to pull the prostate

back to its normal location• pelvic haematoma evacuation and dissection of the prostatic

apex (without suture anastomosis) over a catheter. • Open realignment techniques that include suture anastomosis

between the prostatic apex and the membranous urethra should be considered a form of immediate open urethroplasty.

Paediatric PFUDD

• Reconstruction of pediatric PFUDD represents a significant surgical challenge because of the – smaller pelvic confines, – smaller caliber of the urethra, – the less developed and therefore less elastic

nature of the preadolescent corpus spongiosum– Less developed vascularity – increased tissue fragility.

Delayed repair

• Webster • Turner warwick• Waterhouse

• Perineal approach• Progressive perineal• PAPA / Transpubic

? Approach

• Most posterior urethral distraction defects are short and usually resolved by a perineal approach anastomotic repair.

• However, a ‘perineal progressive approach’ is required when the prostatobulbar gap is longer than 2–3 cm due to a high dislocation of the prostate or when the mobilized urethra is too short because of damage during a previous surgical procedure.

• The progressive approach involves a series of manoeuvres to produce sufficient anterior urethral mobility to bridge up to 8 cm of separation

Caveat

• While there is no panacea for the management of posterior urethral strictures, it is generally agreed that the optimal procedure is a one-stage anastomotic repair, preferably performed through the perineum alone

• It is only uncommon, extremely complex strictures that should require an abdominoperineal approach or substitution ure- throplasty

Procedure

• perineal exposure of the bulbar and posterior urethra facilitated by a perineal Book-Walter re- tractor or perineal OmniTrac retractor.

• The first step of the procedure is circumferential mobilization of the bulbar urethra as far proximally as the obliterated segment

• The proximal urethra is transected at the point of obliteration, and the urethra is then mobilized distally to a few centimeters distal to the crus

• A descending urethral sound is passed through the suprapubic cystostomy and negotiated by ‘‘feel’’ through the bladder neck and into the proximal urethra.

• If the stricture is short and pelvic floor fibrosis minimal, the tip of the sound can be palpated easily in the dissection in the perineum.

• In these circumstances a one-stage perineal anastomosis can usually be assured.

? Haygrove dilator

• Hossieni et al. in their experience have described the role of flexible cystoscopy in the intraoperative localization of the proximal healthy urethra.

• In this technique, cystoscope is passed through the bladder neck from the prostatic urethra and the tip of the cystoscope is placed on the end of the stricture.

• The scar tissue is resected under the guidance of cystoscopic light. Then a needle is passed through the perineum into the proximal urethral end under the guidance of the flexible cystoscope light.

Use of haygrove dilator?

• This maneuver has eliminated the occurrence of false passages with use of a sound such as the Haygrove staff through the suprapubic site, and also has eliminated the occurrence of misanastomosis of the anterior urethra to sites other than the apical proximal urethra.

• The pelvic floor scar is incised perineally until the tip of the sound is exposed and the prostatomembranous urethra spatulated posteriorly.

• The verumontanum should be visible in the floor of the spatulated opening.

• At this point it will be apparent whether a simple anastomosis will be possible or if further maneu- vers will be necessary to achieve a tension-free anastomosis

Bulbar dissection

• Further circumferential mobilization of the distal urethra as far as the suspensory liga- ment of the penis.

• To prevent chordee, the dissection should not extend beyond the ligament, which can be incised to facilitate urethral elongation.

• After this mobilization, the healthy adult urethra can be stretched as much as 2 to 3 cm, which proves sufficient for anastomosis

corporal separation

• Separation of the proximal 4 to 5 cm of the corporal bodies beginning at the level of the crus distally, dissecting in the relatively blood- less plane between them

• The urethra can be laid between the separated corporal bodies, which can shorten the distance for anastomosis by 1 to 2 cm and is sufficient for anastomosis in 41% of cases

Inferior pubectomy.

• A 1.5 to 2 cm wide wedge of bone can be excised from the inferior surface of the pubis exposed by corporal separation

• Routing the mobilized urethra between the separated corpora and through the bony defect will further shorten the distance to the prostatic urethra by 1 to 2 cm and facilitates anastomosis in 28% of cases.

Supra-crural re-routing

• If the urethra still appears to be too short after the three previous maneuvers, the urethra can be re-routed around the lateral surface of a corporal body

• It is necessary to create a tunnel in the bone beneath the corporal body and communicate this with the tunnel created by inferior pubectomy.

• The urethra is then laid in this pathway, re-routing it around the corporal body, which shortens the distance to the anastomosis by 1 to 2 cm.

• This is usually sufficient for the final 23% of cases

Pubectomy • changed from total to partial

• complications, such as – profuse bleeding and – problems arising out of the large dead space including the

cosmetic deformity of an externally visible depression in the prepubic region.

• Partial pubectomy may be in the form of a superior or inferior pubectomy.

Pubectomy

• pubectomy can be associated with long-term sequelae that include – shortening of the penis, – destabilization of erection, and – destabilization of the pelvis, – resulting in a chronic pain syndrome with exercise

Partial sup pubectomy• Koraitim et al - perineoabdominal partial superior pubectomy

complex posterior urethral distraction defects. • In superior pubectomy, about 1.5 × 0.5 inch of bone is resected along

with the arcuate ligament. • superior pubectomy greatly facilitates exposure of the normal

urethra proximal to the injury site and thereby downward mobilization of the superiorly displaced prostate.

• fistulous communication to the surrounding organs and bladder neck incompetence at the same time.

• pedicled omental graft can be brought down to obliterate the perianastomotic dead space

• This is also helpful in managing the defects in prepubescent boys who may have a narrow body habitus and in whom the distal urethral mobilization may be limited by the insufficient blood supply to the glans

PERINEAL REPAIR(Webster)

PERINEAL REPAIR(Webster)

Urethral mobilisation upto thesuspensory ligament

Corporal splitting

PERINEAL REPAIR(Webster)

Inferior pubectomy Corporal re-routing

Urethrourethral anastomosis

PAPA

• majority of posterior urethroplasties can be performed through the perineum alone

• The abdominoperineal approach involves both perineal and retropubic exposure of the urethra and prostate with removal of a segment of pubic bone to facilitate exposure.

• The main indication for this approach is to improve visualization and to facilitate the removal of fistulous tracts and periurethral epithelialized cavities, the excision of scar tissue at the prostatic apex, and the performance of a tension-free anastomosis

• The patient is positioned in the lithotomy position but prepped for a possible abdominal exploration.

• The initial dissection is perineal and the urethra is transected at the level of obliteration.

• The first three steps of the progressive perineal approach are performed, including inferior wedge pubectomy.

• If retropubic exposure is needed, a lower midline abdominal incision is made down to the base of the penis.

• The prevesical or retropubic space is dissected down to the level of the prostatic apex, staying close to the periosteum of the retropubis, until communication is made with the perineal dissection.

• It is helpful to open the bladder high on the anterior wall so a finger can be used to help direct the retropubic dissection and avoid the bladder neck

• Excising an entire anterior wedge of pubis using a Gigli saw • however, equally good access is achieved by partial removal of

the posterior surface of the pubis using a Capener’s gouge• Inferior wedge pubectomy will have been completed perineally,

and this—combined with retropubic bone removal—will provide wide anterior access, which facilitates anastomosis and access to the pelvic floor to manage the complicating features that were the indication for this approach.

• At the completion of the procedure the bladder neck and anastomosis should be wrapped with an omental flap to preserve functional mobility as well as facilitate future re-exposure if needed.

• This approach is very successful (greater than 85% success rate) in expert hands with few complications.

• A re-stricture rate of ~50% has been reported by some surgeons using a trans- pubic approach, which emphasizes the importance of surgeon experience and proper patient selection.

• The technique has been criticized for causing excessive blood loss as well although McAninch did not find this to be the case in 30 patients who underwent the procedure

Combined Abdominoperineal Transpubic Approach for More Complex Injuries

• Indications for this approachFistulous tractsInability to achieve the lithotomy positionPelvic floor cavitiesLong posterior urethral strictures

Waterhouse procedure

Waterhouse procedure

Waterhouse procedure

Waterhouse procedure

Waterhouse procedure

• Postoperative Problems• Incontinence • Anastomotic stenosis• Impotence• Nerve injury• Rhabdomyolysis