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  • Posterior Urethroplasty After Pelvic Fracture (Male)

    About the Surgeon

    Jill Buckley MD (LINK)

    Dr. Jill Buckley, MD

    Jill Buckley MD on Urologybook.com

    “Posterior” urethral strictures, refer to strictures located in the most proximal portion of the urethra (closest to the bladder). Their etiology often is the result of blunt trauma generally associated with a pelvic fracture. It is estimated that ~10% of pelvic trauma fractures are associated with urethral injuries. These traumatic fractures may have enough force to completely separate the two ends of the urethra causing a distraction defect at the prostatomembranous junction in men. (1) Injuries may result in impotence, stricture disease, and incontinence. Strictures may also be iatrogenic in nature (caused by prior medical intervention. ie radiation therapy), related to prior surgeries such as radical prostatectomy for cancer or transurethral resection of the prostate for enlarged prostates. (2)

    Stretch injuries of the posterior urethra leading to contusion, may be managed with temporary catheterization. Cases with complete disruption (such as the case presented) will require surgical intervention. The timing of surgery has been a point of controversy in the past. Some have advocated for an attempt at endoscopic realignment with catheterization.(3) Other authors have argued that a significant percentage of patients will go on to develop stricture disease needing a more definitive repair.(4) In cases where the trauma is managed at a center without urethral repair surgical expertise, it is common to place a suprapubic catheter and delay repair for several months

    Dr. Jill Buckley’s Surgical Pearls for the management of Posterior Urethral Strictures

    • Extensive mobilization of the urethra promotes tension free anastomosis and is critical to a successful repair.
    • Extreme care is required during placement of the male sound via the SPT tract site to locate the bladder neck and proximal posterior urethra.
    • Cystoscopy via a retrograde approach (through the perineum) ensures proper anastomosis of the two ends of the urethra.
    • All the radial anastomotic sutures should be placed first prior to tying down

    Excellent free review of topic By Ying-Long Sa and Yue-Min Xu (Link).

    Urologybook.com is grateful for Dr. Jill Buckley‘s second submission.

    REFERENCES:

    1.            Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999;161(5):1433-41.

    2.            Msezane LP, Reynolds WS, Gofrit ON, Shalhav AL, Zagaja GP, Zorn KC. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol 2008;22(2):377-83.

    3.            Maheshwari PN, Shah HN. Immediate endoscopic management of complete iatrogenic anterior urethral injuries: a case series with long-term results. BMC Urol 2005;5:13.

    4.            Singh BP, Andankar MG, Swain SK, Das K, Dassi V, Kaswan HK, et al. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology 2010;75(1):179-82.

    Write up by Urologybook.com