BERKELEY, CA (UroToday Inc.) - Posterior urethral disruption and resultant stricture formation occurs in approximately 10% of patients with pelvic fractures. Delayed excision and primary anastomosis is considered the reference standard of treatment for these strictures, with long-term success rates of 85% to 97%. Greater failure rates can be expected in patients who undergo staged scrotal inlay procedures or endoscopic realignment or urethrotomy.

The best treatment for any recurrent strictures has yet to be defined. Many urologists recommend repeated internal incisions or dilations over the fear of their ability to adequately perform a successful second operation. This hesitancy could be due to extensive fibrosis that may limit urethral mobilization and the ability to achieve a tension-free anastomosis.

A retrospective review by O.Z. Shenfeld et al., from Jerusalem was performed to determine whether delayed excision and primary anastomosis is appropriate after failed previous therapeutic attempts for post-traumatic membranous urethral strictures. Their results were reported in the May, 2004 issue of Urology. Over a three year period, thirteen patients underwent treatment for failed previous attempts at posterior urethral stricture repair. The previous treatments in these patients included urethroplasty in 8 patients, of which four were anastomotic urethroplasties and four were staged scrotal skin inlays. Primary catheter realignment of the ruptured urethra had previously failed in 5 patients, 3 of whom underwent additional endoscopic laser urethrotomy for stricture following these procedures. Mean patient age was 29 years, mean stricture length was 2.8 cm and mean follow-up was 27 months.

All patients subsequently underwent excision and primary bulboprostatic anastomosis using a perineal incision. A stepwise approach of urethral mobilization was performed including complete mobilization of the bulbar urethra and separation of the cavernous bodies, with inferior pubectomy and corporal rerouting of the urethra as needed to accomplish a tension-free urethral reanastomosis. All patients had stenting urethral catheters for 21 to 28 days, and all underwent voiding urethrography at catheter removal. They then had follow-up that included flow rates and post-void residual determinations every three months and flexible urethroscopy at 1 year.

Results showed an objective success in 12, or 92%. One patient required a single incisonal urethrotomy for an anastomotic stricture, which occurred three months post-operatively. All patients were successfully repaired during a single stage procedure that encompassed extensive urethral mobilization and separation of the cavernous bodies. Partial inferior pubectomy was required in four patients and corporal rerouting was required in an additional patient. Post-operative complications were minimal with one patient having a significant urinary tract infection. One patient also complained of decreased erectile function after surgery. Two patients reported postoperative mild urinary incontinence that did not require the use of pads.

The authors stress the importance of adherence to a progressive, stepwise approach for the achievement of urethral length in order to foreshorten the distance that the bulbar urethra must span to reach the proximal urethral stump. They found that sufficient urethral length could be recruited for tension-free anastomoses in all patients despite the history of failed previous repair. They postulated that the steps for mobilization had not been optimally performed in the previous procedure, and thus it was possible to gain additional urethral length by continuing where the previous surgeon had stopped.

Urology 2004;63:837-40