Two7 82B Brandes Posterior Urethra Urethra

• The posterior urethra is subdivided into 
• - bladder neck 
• - prostatic urethra 
• - membranous urethra 

• Uncommon strictures 
• - Bladder neck strictures and strictures of the prostatic urethra are largely a consequence of the treatment of carcinoma of the prostate and of benign prostatic hyperplasia with the use of the “new technology”
• - Membranous segment - most commonly caused by instrumentation of the urethra and by transurethral resection of the prostate.  Treatment is largely directed toward the preservation of urethral sphincter mechanism, and these
• so-called “sphincter strictures” are best treated by urethral dilation for this reason.

• Common strictures 
• - PFUI

Urethral stricture - anterior urethral disease, or a scarring process involving the urethral epithelium or spongy erectile tissue of the corpus spongiosum (spongiofibrosis). 

In contrast, posterior urethral “strictures” are not included in the common definition of urethral stricture. Posterior urethral stricture is an obliterative process in the posterior urethra that has resulted in fibrosis and is generally the effect of distraction in that area caused by either trauma or radical prostatectomy. The term stricture is limited to anerior urethra. 


The distraction of two ends of membranous urethra and bulbar urethra. BMJ is the most common site of urethral injury and not the prostato-membranous junction. The comparison with poucking an apple (prostate) off its stem (membranous urethra) is not correct, since it is distraction of BMJ. 

Other narrowing of posterior urethra are termed urethral contractures or stenosis.

• There is no corpus spongiosum, so dont use term stricture. 
• We usually call stricture, but there is no spongiosal tissue 

• Meatal stenosis 
• Urethral stricture - we use term like this 

Till date, all ICD classification is for male urethral disease

• 1986 - Webster - Simple Progressive perineal Urethroplasty 
• 1991 - Webster ? Turner Warwick included re-routing and called the Progressive Perineal or elaborative perineal approach 

Abdominoperineal apporach

• Total distraction of the entire circumference of the urethra appears not to occur with many injuries. Instead, a strip of epithelium is left intact.
• In these patients, the placement of an aligning catheter may allow the urethra to heal virtually unscarred or with an easily managed stenosis.
• Aligning catheters also seem to act as a drain as the pelvic hematoma liquefies, and perhaps the presence of the catheter may allow more rapid and complete resolution of the process. 
• Close follow-up after a voiding trial is essential because many of these patients experience stricture formation after removal of the aligning catheter and require definitive repair.

RGU/MCUG after 3 months, repair within 4-6 months after trauma.  Repair at least after 3 months. (EAU 2020) 

Long gap doesn’t always mean that the stricture extends all the way up to the bladder neck. It 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.

It is also quite common to see an apparently incompetent bladder neck (so-called“beaked” bladder neck) in association with a complete obstruction but this is usually misleading. 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.

Role of MRI - unclear 

A flexible cystoscopy may be helpful in determining the nature of an apparently obstructed or incompetent bladder neck and indeed might be helpful in the overall assessment of the urethra on either side of the obstruction.

Document  whether the patient has normal erections or erectile dysfunction, for obvious medicolegal reasons and also because those patients with complete erectile dysfunction, particularly if associated with a cold numb penis, are likely to have a more profound disruption of the local blood supply and may therefore be more prone to recurrent structuring after urethroplasty.

Check if the patient can abduct his hips to allow access to the perineum.

Urethral gaps shorter than a third of the bulbar urethra, as measured from its proximal blind end to the bulbopendulous junction, are usually corrected by a simple perineal operation. For longer gaps an elaborated perineal or a transpubic procedure is usually indicated.


Now we do not call PFUDD because it is not distraction, it is not named PFUI - urethral injury

Midline perineal incision. 

Anterior perineal triangle for PPU, posterior anal triangle (posterior to transverse perineal musculature) for perineal prostatectomy. 

• Incision deepened to bulbospongiosus muscle 
• At the anterior margin of the bulbospongiosus, there is a layer of fascia called Gallaudet’s fascia.
• Incising Gallaudet’s fascia puts you into a plane between that  fascia and Buck’s fascia as you dissect distally and allows you to get into the plane between bulbospongiosus and Buck’s fascia more proximally. 

• The bulbo spongiosus muscle can be divided along the line of its raphe all the way back to the perineal body and can then be reflected off the surface of the corpus spongiosum on both sides. 
• By dividing Buck’s fascia and deepening this towards the midline on each side the corpus spongiosum can be freed up from the corpora cavernosa as far distally as necessary and as far proximally as the site of the obliteration. 
• Anteriorly on the surface of the urethra as the bulbar segment becomes the membranous segment there is a  urethral artery on each side at 11 o’clock and 1 o’clock, which may bleed irritatingly if it is not secured by diathermy first.

Verumontanum should be clearly visible within the posterior urethra

Divide triangular ligament and develop the intercrural space down to the pubis. If dorsal veinis encountered, it is ligated and divided. 

While doing inferior pubectomy, always use vertical incision to open periosteum. Never give inverted U shaped incision - chance of vessel injury. Use Kerrison rongeur to remove as much of bone as necessary. 

If adequate length is not obtained, itis necessary to bring the urethra lateral to one of the crura to make up this length. 

The urethra is then transected through the site of obliteration to free it. It is then trimmed back to healthy tissue and spatulated on its dorsal aspect, then lightly clamped with an atraumatic vascular clamp and retracted out of the way. 

Identification of the proximal urethra when the lumen is obliterated, and incision onto a sound passed antegrade (Haygrove). 

Six 5-0 polyglactin sutures

• - described by Turner-Warwick
• - If the prostatic urethra not reachable even after inferior pubectomy, abdomen was opened through a lower midline incision to get a transpubic approach by partial pubectomy, as described by Waterhouse et al.
• - Urethral re-routing lateral to the corporal bodies was not tried.
• - All fibrosis behind the pubic bone was excised to reveal the anterior surface of the posterior urethra.
• - End-to-end anastomosis was performed under direct vision

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.

It is said that up to 9cm length can be gained, by all four combined approaches.


When rerouting the urethra is necessary during an abdomino-perineal repair, it is usually easier to reroute it through a superior wedge pubectomy rather than an inferior wedge.

Identification of apex of membranous urethra by passing needle and viewing with flexible cystoscope from SPC site, then passing guidewire.

• Vessel sparing 
• Muscle and nerve sparing
• Non-transecting

Most common site of recurrence after augmentation urethroplasty is - proximal anastomotic site  - Apul sir

Concommittent bladder neck injury

• Urine is diverted via the suprapubic cystostomy, and the urethral catheter is plugged and serves as a stent only.
• Bed rest for 24 to 48 hours and then ambulated and discharged with the suprapubic catheter and stenting urethral catheter in place.
• Discharge with oxybutynin and a suppressive antibiotic only if the preoperative urine culture was positive.
• The drains are removed as drainage allows.
• Voiding trial with contrast material is performed between 21and 28 days postoperatively.
• Patients are directed to stop taking oxybutynin 24 hours before the voiding trial.

• The patient is allowed to void through the urethra for 5 to 7 days, and the suprapubic catheter is then removed. 
• Approximately 6 months postoperatively and again 1 year later, patients are evaluated with flexible endoscopy. 
• AUA urotrauma guideline - follow up be continued for at least 1 year after the repair. 

In general, failure is indicative of ischemia of the proximal corpus spongiosum and, not due to technical problem.

Open-book pelvic fracture - any fracture that significantly disrupts the pelvic ring. These injuries combine an anterior pelvic injury causing a widening (opening) of the pubic symphysis, and a posterior pelvic fracture or ligamentous injury

fd

• Bladder injury is more common in children. 
• Typical
• Type 1 Anterior midline rupture of the prostate, prostatic urethra and bladder neck

• Atypical
• Type 2 Transverse rupture of the bladder neck and of the membranous urethra with  sequestration of the prostate
• Type 3 Avulsion of the anterior aspect of the prostate (‘blow out’ injury)

BJUI - 2009, Anthony R. Mundy and Daniela E. Andrich

https://sci-hub.tw/10.1111/j.1464-410x.2009.08970.x

Bladder neck injuries never heal spontaneously. 

• Bladder neck injuries are associated with 
• - severe injuries to the urinary tract
• - injury to the bulbomembranous urethra
• - infected cavities and fistulation of those cavities through to the perineum or into the adductor compartment to the leg.

• Treatment
• - repair as early as possible to reduce the risk of the latter complications.
• - More minor bladder neck injuries may appear to heal in the first instance but they always give rise to problems later on: incontinence, persistent or recurrent bleeding, or recurrent cavitation and infection. The longer they are left, the more difficult they are to repair. 

After abdominoperineal reconstruction of the urethra, with our without bladder neck reconstruction, mobilization of the omentum to fill the dead space, line the raw bony areas, and wrap around the reconstruction seems sensible.

PFUDD can always be repaired with single stage with PPU. 

• Exceptions to this generalization is seen in exceptionally long defect between the obliterated ends of the urethra.
• - when there is concomitant injury to the membranous urethral along with loss of the bulbar urethra caused by penetrating injuries
• - ischemic loss of bulbar urethral tissue
• - when the bladder and prostate are markedly displaced into the upper pelvis and do not descend with resolution of the pelvic hematoma
• - when there is obliteration of the prostatic urethra due to
• laceration, crush injury or extensive bladder neck trauma.
• - tissue loss due to ongoing infection, abscess formation, calculus formation, severe pubic bone deformity or concommitent original rectal injury may cause alternation n the local environment so as to make primary anastomotic repair very difficult or potentially ill advised 

In such cases, transpubic urethroplasty may be considered with the anterior urethra being routed alongside the corpora and brought directly to the prostate or bladder neck anteriorly. It may, however, simply be impossible to bring the anterior urethra to an appropriate location with extensive displacement and tissue loss, necessitating a staged repair.

Blandy flap  staged urethroplasty - involves rotating an inverted V-shaped perineal flap into the proximal urethral segment and performing a local skin closure which amounts to partly tubularizing the perineal skin flap to create a perineal urethrostomy. 

Turner-Warwick urethroplasty - similar to the Blandy flap in principle but simply involves displacement of local skin into the opened urethra, rather than creation of the V-shaped flap.

Permanent perineal urethrostomy -  also an option for the refractory pendulous urethral stricture that has failed prior reconstructions. Complications include - stomal stenosis, stone formation in hear bearing area

• Johansen procedure 
• - first stage - marsupialization of the anterior urethra to the adjacent penile skin following full thickness longitudinal ventral incision as the first stage
• - second stage - tubularization of the neourethra, which consists of the dorsal urethral plate, in addition to a variable width of the adjacent penile skin which is incised longitudinally and included with the tissue tubularized into the neourethra.

Longitudinally placed buccal mucosal grafts on the ventral surface of penis, mobilized or tubularized in final stage of creation of neourethra. BMG is placed over the dartos fascia. If the graft is placed immediately onto the tunica albuginea or corpora cavernosa, the inability to mobilize the graft makes second-stage tubularization difficult.

• BMG 
• - urineleak 
• - fistula 
• - recurrence 
• - UTI 
• - erectile dysfunction 
• - post void dribbling - result of decreased urethral elasticity 
• - urethral sacculations

Ejaculatory dysfunction - upto 20% of cases, due to tortuous uretra and dysfunction of bulbocavernous muscles

Erectile dysfunction - temporary in up to 20% of cases, resolve within 6 months 

Penile curvature

• Patients treated with acute open realignment
• Lateral prostatic displacement at time of injury 
• Urethral gap >2.5 cm

• Fibrosis of the corpus spongiosum penis, caused by urethral manipulation and the resulting ventral penile deviations are known as the urethral manipulation  syndrome  (Kelâmi Syndrome). This condition is due to fibrosis and scarring of the corpus spongiosum penis after any kind of urethral manipulation. 
• OIU in penile urethra can lead to Kalamy syndrome

• Delayed imaging - 
• other injury heal 
• hematoma resolve 
•   at 3 months 
• - history - nocturnal erections 
• x-ray - orthopedic assessment, plain xray pelvis, 

MRI - in fistulas, false passages, severe imating 

• Intraoperative evaluation 
• General anesthesia 
• Social lithotomy 

• Bladder neck 
• closed - competent 
• Open - Neuropraxia, ? Normal 
• Open bladder neck with visible scarrin g- b neck injury 
• Tear drop deformity at 12 o clock - B neck injury

Penile urethra length - jQuery1124012148655774854045_1593015468611 in asian equal to penile length 

bulbar urethral artery  injury - suture ligation, avoid cautery 

• how far crural separation - 
• Infrapubectomy 

obtain pink, supple, mmbbile urethra 

Venral onlay -

?

• Urethrorectal fistulas maybe
• - congenital (associated with imperforate anus & extremely rare) or
• - acquired (iatrogenic or non- iatrogenic)

• Iatrogenic causes of URFs include:
• 1. Radical Prostatectectomy (RP)
• - Incidence of Rectal injury during RP is less than 1 - 2%,
• - However, it is considered the most common cause due to increased number of radical prostatectomies done yearly.
• - Predisposing factors for post- prostatectomy urethrorectal fistulas are: radiation, previous rectal surgery, or TURP.

2. Local treatments for prostatic cancer: including Radiotherapy, Brachytherapy (0.4%), Cryotherapy (0.5 to 2%) or HIFU.

3. Open prostatectomy or TURP or overly aggressive TUR of bladder neck contracture.

4. Anorectal surgery: abdomino-perineal resect.

5. Urethral instrumentation is also a rare cause of urethrorecal fistula

• 7. Non-iatrogenic causes of URFs include:
• - Trauma: penetrating trauma.
• - Malignancy: prostatic or rectal malignancy.
• - Infection such as tuberculosis, Ruptured prostatic abscess.
• - Inflammatory diseases: such as Crohns disease (0.3%).

• Clinical presentation
• - Fecaluria
• - Hematuria
• - Recurrent UTI refractory to treatment
• - Peritonitis and sepsis.
• - Fever, Nausea and vomiting.
• - DRE - fistula track can be felt along the anterior rectal wall

• Investigations
• - Cystoscopy and sigmoidoscopy for visualization of the fistula track & biopsy for detection of malignancy
• - Upper tract imaging can be used to exclude a related ureteral injury
• - Diagnosis of rectourethral fistula can be confirmed with RUG or VCUG.

Pre-op assessment of continence and sphincteric function is important in rectourethral fistula after radical prostatectomy because most rectourethral fistulas lie at or near the vesicourethral anastomosis and membranous urethra. So, stress urinary incontinence can occur after repair.

• Management -
• - Conservative treatment can cure some cases of post- prostatectomy URFs (open or laparoscopic).
• - Conservative treatment include catheter drainage, NPO, IV Total parentral nutrition, anal dilatation and Antibiotics
• - Fecal diversion may be needed in urethrorectal fistulas after brachytherapy or cryosurgry - repair of such fistulas is quiet difficult because it is usually large with induration, fibrosis and ischemia.
• - Surgery is the main line of treatment in most of cases of urethrorectal fistulas. It can be performed as single stage or staged repair.
• - Staged repair is done with fecal diversionperformed before repair of the rectourethral fistula. Staged repair is indicated in:
• - large fistulas
• - post-radiation therapy
• - uncontrolled local or systemic infection
• - Immunocompromised
• - inadequate bowel preparation at initial oper

• Approaches of urethrorectal fistula -
• Transrectal approach
• - Without division of anal sphincter (Transanal) - Techniques include rectal advancement flap or Latzko method. The main limitation of this approach is the limited exposure and it is best suited for small distal fistulae.
• - With division of anal sphincter (York-Mason) - performed in the prone jackknife position. transrectal, transsphincteric approach that has been shown to be effective with low morbidity. The fistula track is excised, and the anterior rectal wall is mobilized circumferentially around the fistula margins. The urethra is closed. Anterior rectal wall is closed. Rectal mucosa is re- approximated. This provides 3-layer closure.
• Transperineal approach - Advantages of perineal approach include: being a familiar approach for many urologists and local accessability to a variety of potential interpositional flaps.
• Transabdominal approach - The principal advantage to this technique is the availability of greater omentum for an interpositional flap. Potential disadvantages include: morbidity and prolonged postoperative convalescence associated with a laparotomy incision the poor exposure of the operative field, limited maneuverability in the deep pelvis and risk of urinary and fecal incontinence.