Redo urethroplasty after multiple failure of surgical procedures for complex pelvic fracture urethral distraction defect

Redo urethroplasty after multiple failure of surgical procedures for complex pelvic fracture urethral distraction defect

Paksi Satyagraha^1,&, Ryan Akhmad Adhi Saputra¹

¹Department of Urology, Medical Faculty, Brawijaya University-Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

^&Corresponding author
Paksi Satyagraha, Department of Urology, Medical Faculty, Brawijaya University-Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

Introduction    

Injuries to the urinary tract occur in 10% of patients who present after blunt or penetrating trauma [1]. Of these injuries, a few involve the urethra, with 65% being complete and 35% partial tears [2]. Urethral injuries alone are never life-threatening except as a consequence of their close association with associated pelvic fractures and multiple organ injuries [1]. Urethral injuries range from a mild contusion with preservation of epithelial continuity to a partial tear of the urethral epithelium, or full urethral transection possibly combined with disruption [1]. Colapinto and McCallum classified posterior urethral injuries by their radiographic appearance into three types, depending on the integrity of the membranous urethra and extension of the disruption into the bulbar and membranous urethra [3]. Recently, urethral trauma classification has been proposed (Table 1), providing a means of comparing treatment strategies and outcomes [4]. Posterior urethral injuries classically occur in association with pelvic fractures and result from shearing of the prostate from its connection to the apex of the prostate and from the puboprostatic ligaments which are ruptured. Association of urethral injuries with pelvic fractures is reportedly 3 ± 25% in most studies [5]. As the forces involved in pelvic fractures have to be extreme, urethral injuries associated with pelvic fractures tend to be associated with multiple and life-threatening injuries. Attention to resuscitation tends to predominate in the early management of these patients [1]. Posterior urethral injuries are often given low priority in the management of patients with pelvic fracture injuries, as these individuals almost always have multiple injuries of more serious consequence. Most patients are best treated by a suprapubic catheter initially, followed 3 months later by an end-to-end anastomotic urethroplasty in those who have developed urethral occlusions. Although there are roles for delayed primary repair and for endourologic management in selected patients, these procedures require considerable technical expertise that may not be available in all centers. Their exact roles have yet to be defined [6].

Following trauma, the ruptured urethra is usually replaced by fibrosis, and in between, there is no lumen. Anastomotic urethroplasty is a well-established procedure to deal with posterior urethral strictures, and gives very good long-term results [7]. Pelvic fracture urethral distraction defect (PFUDD) may result in complications such as recurrent stricture, erectile dysfunction, and incontinence, which leading to a lifelong disabling condition [6]. Urethral reconstruction due to the failure of a previous surgical procedure poses a challenge. There is no established treatment protocol for the management of failed anastomotic urethroplasty. Treatment varies from endodilation to open reconstruction and is used arbitrarily. The majority of failed anastomotic urethroplasty patients can best be managed by redo urethroplasty [8]. In this article, we report our experience using redo posterior end-to-end anastomotic urethroplasty for a case with recurrent stricture after failures in previous surgical procedures which included insertion of a Memokath urethral stent.

Patient and observation     

A 28-year-old man came to the Urology Department at Saiful Anwar General Hospital with suprapubic cystostomy, complaining of urinary retention for 4 years since his last surgery. He had a history of an accident 8 years ago, with stable pelvic fracture, mild head injury, and urinary retention with the presence of bloody discharge. The history of surgical procedures in this patient was open cystostomy in December 2006, primary endoscopic realignment in March 2007, end-to-end anastomosis in July 2007, buccal mucosal graft urethroplasty in January 2008, and Memokath urethral stent insertion in February 2008. Panendoscopic evaluation and re-open cystostomy were done 2 years later because of urinary retention. On physical examination, a midline infraumbilical scar with 18 Fr cystostomy catheter (Figure 1A) and the perineal scar was found (Figure 1B). Micturition cystourethrography-retrograde urethrography (MCU-RGU) showed total membranoprostatic stricture with a Memokath urethral stent (Figure 2). On antegrade panendoscopic evaluation, we found multiple stones inside his Memokath urethral stent. The retrograde panendoscopic evaluation showed total posterior urethral obstruction (Figure 3).

Lithotripsy and Memokath urethral stent removal were done in the first stage, followed by radiologic evaluation with MCU-RGU which showed total membranoprostatic urethral stricture (Figure 4). He underwent a redo posterior end-to-end anastomotic urethroplasty a week later. Under general anesthesia in a lithotomy position, endoscopic evaluation was performed by both retrograde and antegrade routes. The posterior urethra was exposed through a midline perineal incision. The posterior urethra was mobilized circumferentially and proximally up to the obliterated segment, and distally up to the penoscrotal junction. The distal urethra was divided just beyond the obliterated segment. A sound was passed through the cystostomy catheter. If the sound could be palpated, then the strictured segment and all the fibrotic tissue was excised completely till the tip of the sound was seen. The proximal prostatic urethra was spatulated posteriorly while the bulbomembranous urethra was spatulated anteriorly. End-to-end anastomosis between the healthy membranoprostatic urethra was performed over a 14 Fr silicone catheter using interrupted 4-0 vicryl. Finally, a cystostomy catheter tube was inserted. This patient had spontaneous micturition after urethral catheter removal; the MCU-RGU result was patent urethral caliber (Figure 5). Uroflowmetry examination showed a Qmax of 21.4ml/s; voided volume was 83 cc, and residual urine was 22 cc.

Discussion     

Complete or partial rupture of the posterior urethra occurs by shearing forces during pelvic fractures. The initial treatment options for these cases are: 1) primary open suturing of the disrupted urethra, 2) primary realignment by inserting a urethral catheter either endoscopically or surgically, and 3) suprapubic cystostomy and delayed repair. Delayed repair is the preferred option. The best results are achieved with end-to-end urethroplasty with a perineal or transpubic approach [4]. The success rate of end-to-end anastomosis varies from 77% to 95% as described by different series. There are very few reports regarding urethroplasty for previously failed posterior urethral strictures [6]. The most common causes of urethroplasty failure are inadequate excision of the strictured segment and surrounding fibrosis, improper case selection, and ischemia [9]. Koraitim reported the predictors of failure for anastomotic urethroplasty; the most important was incomplete excision of the sclerosed prostatic apex, inadequate lateral fixation of the prostatic mucosa, and failure to achieve tension-free anastomosis [10]. Previous intervention, stricture length, and urinary tract infection were not associated with a negative outcome. There are no clear guidelines for the management of these failed cases. Procedures vary from endodilation to repeat open reconstruction and are used arbitrarily [6]. The success rate of repeat surgery for failed urethroplasty is reported to be less than that for primary urethroplasty. Jakse et al. reported a 71% failure rate following end-to-end urethroplasty with a history of prior urethroplasty [11]. Roehrborn and McConnell reported the success rate of preoperative urethroplasty to be just 58% [9]. Endoscopic urethrotomy has a poor long-term outcome for primary post-traumatic posterior urethral strictures so there is no reason to suggest that it should provide good results in failed urethroplasty patients, except in short segment strictures where it can be attempted once or twice [6].

In longer strictures with significant spongiofibrosis, the natural history is of stricture recurrence. Further endoscopic procedures will result in worsening of the underlying spongiofibrosis, and cure is seldom achieved [12]. Several studies about stents report results on lumen patency but understate the side effects such as perineal pain, sexual discomfort, erectile disorders, stent encrustations, stones, recurrent urinary tract infections, dysuria, postvoiding dribbling, and incontinence [12]. The principal stent-related problems are hyperplastic overgrowth with intraluminal stricture or new stricture development at the distal or proximal end of the prosthesis. These problems may be managed by repeated optical urethrotomy and dilatations, but they carry high failure rates [12]. In this patient, the important factors for gaining successful outcome were complete removal of fibrotic tissue, and anastomose between healthy urethral tissues. The pitfall of previously failed urethroplasty was found to be the incomplete excision of fibrosis around the proximal urethra intraoperatively, so we thought that one should be very careful during the excision of fibrosis, especially around the proximal urethra.

Conclusion     

Proper anastomotic urethroplasty remains essential in the management of PFUDD, even in previously failed urethral repairs. Buccal mucosal graft urethroplasty and urethral stent have no place in the definitive procedure in posterior urethral stricture due to its complications.

Competing interests     

The authors declare no competing interests.

Authors´ contributions     

Paksi Satyagraha performed the study design and conception and Ryan Akhmad Adhi Saputra contributed to the editing and final approval of the article. All authors read and approved the final manuscript.

Table and figures     

Table 1: urethral trauma classification according to the American Association of Trauma Surgery

Figure 1: (A) clinical presentation showed cystostomy catheter with post-operative suprapubic scar; (B) perineal post-operative scar

Figure 2: MCU-RGU showed total membranoprostatic stricture with Memokath urethral stent

Figure 3: retrograde panendoscopic evaluation showed total membranoprostatic urethral stricture

Figure 4: MCU-RGU showed total membranoprostatic urethral stricture after lithotripsy procedure and Memokath stent removal

Figure 5: MCU-RGU showed patent urethral caliber after silicone catheter removal

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