Urethral Reconstructive Surgery - part 6 doc

The urethral sphincter extends from the bladder neck to the perineal membrane diaphragma urogenitale The muscular lining and surrounding of the membranous urethra are directly continuous

Reconstruction of the Bulbar

and Membranous Urethra

F Schreiter, B Schönberger*, R Olianas

14.4.1 Reconstruction of the Bulbar Urethra – 110

14.4.1.1 Stricture Resection and Bulbar End-to-End Anastomosis – 110

14.4.2 Reconstructing the Membranous Urethra

(Bulboprostatic Anastomosis) – 114

14.4.2.1 Combined MCU Retrograde Urethrogram – 114

14.4.3 Surgical Approach – 114

14.4.4 Partial Resection of the Symphysis – 117

14.4.5 Finishing the Anastomosis – 117

14.4.6 Results and Risks of the Surgery – 117

14.4.6.1 Stricture Resection and Anastomotic Repair

in the Bulbar Stricture – 117

14.4.6.2 Stricture Resection and Anastomotic Repair

in Membranous Strictures – 117

14.4.6.3 Alternative Procedures in Bulboprostatic Anastomosis – 118

14.5 Buccal Mucosa Onlay Plasty – 118

References – 120

* Professor Schönberger has died since this chapter was completed.

14.1 Introduction

Destruction or rupture of the posterior urethra is caused

mainly by forces that occur during traumatic pelvic

rup-ture This trauma results in partial or complete rupture of

the urethra A complete rupture often results in

destruc-tion of the posterior urethra and may damage the

sphinc-teric structures, while always damaging the neurovascular

bundles, which results in impotence and incontinence

For a long time, conventional urological wisdom was

that the urethral rupture in men occurs at the

prosta-tomembranous junction by a shearing force that

avul-ses the prostatic apex from the urogenital diaphragma

Recent studies suggest that this traditional belief may be

a misconception The urethral sphincter extends from

the bladder neck to the perineal membrane (diaphragma

urogenitale) The muscular lining and surrounding of the

membranous urethra are directly continuous with similar

muscle fibers of the prostatic urethra and end abruptly at

the perineal membrane

Hence, the weakness may lie in the

bulbomembra-nous junction rather than the membranoprostatic

junc-tion at which the posterior urethra is liable to rupture

(⊡ Fig 14.1)

As the sphincteric component remains intact,

incon-tinence occurs only when the bladder neck is impaired

(post-TUR-P) or when the bladder neck is involved in the

traumatic rupture, which occurs mainly in children

14.2 Acute Management of Posterior Urethral

Trauma

Although the urethral injury is seldom the main problem

of these often severally and severely traumatized patients,

consequences of the urethral trauma such as urethral

strictures, erectile dysfunction, and (in some cases) nary incontinence may be problems with lifelong ramifi-cations for these patients

uri-In this connection, primary urological treatment should be directed at preventing early complications and minimizing the risk of the aforementioned potential pro-blems A satisfactory outcome is dependent on a correct diagnosis, along with thorough and well-planned urolo-gical therapy

Meanwhile, the controversy surrounding immediate

vs delayed treatment of urethral injuries is still solved The perfect treatment plan still remains to be developed; the value of the different approaches including recent evolution of innovative endourological techniques

unre-to achieve urethral continuity needs unre-to be determined.The following treatment strategies are available for acute management:

1 Primary open suturing of the disrupted urethra

2 Endoscopic or surgical realignment by insertion of a transurethral »railroad« catheter

3 Suprapubic cystostomy and delayed repair

4 Acute surgical intervention is indicated for the wing:

follo-▬ Concomitant rectal tear

▬ Bladder neck laceration

▬ Serious, life-threatening bleeding, mainly from the inferior or superior gluteal arteries

A large gap between the bladder neck and the disrupted urethra, also known as »pie in the sky bladder,« is a relati-

ve indication for open surgical exploration (⊡ Fig 14.2).Nevertheless, immediate surgical exploration does not necessarily indicate exploration of the urethral injury site Exploration of the urethral injury also involves release of the tamponade effect of the hematoma in the small pelvis and may compromise control of the venous bleeding

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⊡ Fig 14.1 Mechanism of membranous urethral disruption

Attempts to suture both ends of the urethra are

challen-ging – dissection of the periurethral and prostatic tissues

can cause additional damage to the neurovascular bundles

and the intrinsic urethral sphincter structures Due to the

increased risk of iatrogenic impotency and incontinence,

primary anastomotic repair is no longer recommended

Reconstructive procedures should be limited to open

sur-gical placement of the transurethral catheter and

suprapu-bic drainage of the bladder

Therefore, for primary therapy of posterior urethral

injury, we recommend urinary diversion using a

supra-pubic catheter and/or by endoscopically inserting a

trans-urethral catheter Several researchers have described a

number of different railroading techniques to manipulate

the catheter across the urethral gap into the bladder It may

be useful to railroad the prostate to the urethra by using a

suprapubic sound or an endoscope Sometimes it is also

useful to drain the pelvic hematoma via the endoscope

Additional traction obtained by applying additional

weight to the transurethral catheter has been shown to

produce pressure damage to the bladder neck and

sub-sequently increase the risk of urinary incontinence In

addition, the traction may pull the prostatic gland into an

abnormal position, causing misalignment or malrotation For these reasons, traction has been abandoned, as has

»vest sutures,« which are introduced through the prostatic apex and brought out through the perineum

The purpose of the realignment is to reduce the number of secondary urethral strictures, and to decrease the stricture length in comparison to both suprapubic cystostomy and delayed repair Although the ultimate value of this procedure is still under discussion, there is clear evidence that realignment can significantly decrease the incidence of strictures (Koraitim 1985, 53% vs 97%)

On the other hand, this procedure may be associated with

an increased risk of erectile dysfunction (Koraitim 1996, 36% vs 19%) In another study (McAnninch 1997), the incidence of erectile dysfunction was reported at up to 55% after immediate realignment

There is a widespread acceptance of a hands-off-policy

in the acute management of posterior urethral injury, i.e., limiting initial treatment to placing a suprapubic cystosto-

my, which necessitates later stricture repair in most cases Spontaneous healing after 2–3 weeks can be expected only if the urethral rupture is incomplete

Thus end-to-end anastomosis remains the gold dard in repairing obliterated membranous urethral stric-tures Experts are divided on the other treatment options Endosurgical procedures such as »cutting to the light« have very limited indications and value In most cases, they do not cure the stricture

stan-14.3.1 Indications

1 Partial or incomplete rupture of the bulbar urethra following a primary straddle trauma or a secondary development of a stricture

2 Rupture (distraction) of the membranous urethra, usually as a result of pelvic fracture

3 Short strictures (e.g., iatrogenic or inflammatory) the bulbar and membranous urethra

⊡ Fig 14.2 Pie in the sky bladder

14.3.3 Instruments and Suture Material

1 Special retractor (Scott retractor or Buckwalter

re-tractor)

2 Curved metal probes and flexible cystoscope

3 Extended nose speculum (see ⊡ Fig 14.18)

4 Microcoagulation

5 Magnifying glasses and headlight

6 Monofilic, absorbable suture material 3–0 to 5–0

14.4 Surgical Technique

14.4.1 Reconstruction of the Bulbar Urethra

Post-traumatic strictures of the posterior urethra are

bro-ken down into bulbar strictures (anterior strictures) and

membranous strictures (posterior strictures)

Bulbar strictures are usually caused by straddle

trau-ma, while membranous strictures are typically the result

of urethral disruption due to a pelvic fracture

The anterior and posterior strictures are usually short,

which makes them ideally suited for a stricture resection

by means of spatulated end-to-end anastomosis

If a stricture is longer than 3 cm, penile curvature or

penile shortening usually results This should be taken

into account when choosing this surgical procedure, and

the patient should be informed of the repercussions

The literature (Webster et al 1999) describes satisfactory

results up to a stricture length of 7 cm; but in our

expe-rience, the resultant penile curvatures and penile injuries

cause patients to be dissatisfied with the results of the

surgery (Kessler et al 2002)

14.4.1.1 Stricture Resection and Bulbar

End-to-End Anastomosis Lithotomy Position

Slightly hyperextended lithotomy position In our ence, a hyperextended lithotomy position is not necessary (⊡ Fig 14.3)

experi-Perineal Approach

We prefer a median perineal incision extending close to the anus However, a lambdoid cut or perianal incision with extension in the midline of the perineum is also possible (⊡ Fig 14.4)

Incising the Bulbocavernosus Muscle

The bulbocavernosus muscle is split down the middle and the urethral bulbus is laid open in the area of the stricture Although the urethral injury is rarely the main problem

of these often multiple and severely traumatized patients, consequences of the urethral trauma such as urethral stric-tures, erectile dysfunction, and sometimes urinary incon-tinence are potential problems with lifelong ramifications The stricture may be localized using a 20-Fr curved metal probe or with a flexible cystoscope (⊡ Fig 14.5)

The urethra is mobilized from the cavernous corpora (⊡ Fig 14.6)

Resecting the Stricture

The stricture is resected into the healthy corpus osum, i.e., when blood begins to drip from the urethral stumps Note that the spongiofibrosis may extend beyond the actual stricture itself, in which case it must also be resected (⊡ Fig 14.7)

spongi-14

⊡ Fig 14.3 Lithotomy position

⊡ Fig 14.7 Resecting the stricture

⊡ Fig 14.5 Incising the bulbocavernosus muscle

⊡ Fig 14.4 Perineal approach ⊡ Fig 14.6 Mobilizing the stricture

Spatulating the Urethral Stumps

The adequately mobilized urethral stumps are spatulated

at 6 and 12 o’clock, to arrive at a sufficiently wide

ana-stomosis later Please consider that the anaana-stomosis will

shrink by roughly 20% (⊡ Fig 14.8)

Suturing the Posterior Wall

It should be possible to adapt the mobilized urethral

stumps without any tension First, the posterior wall is

sutured with four to six single stitches; the stitches are

sewn in two layers (mucous layer and corpus

spongio-sum); however, a single-layer suture that catches all layers

of the wall is also possible (⊡ Fig 14.9)

Suturing the Anterior Wall

Finally, the same suture technique is used to suture the

anterior wall, to arrive at a wide, tension-free

anasto-mosis To take some of the tension off the anastomosis

suture, the urethral stumps may be fixed to the area

surrounding the urethra with several single-stitch sutures

(⊡ Figs 14.10, 14.11)

Suturing the Bulbocavernosus Muscle

Finally, the bulbocavernosus muscle is reconstructed

over the urethra If there is enough cavernous tissue, it

may be sutured across the anastomosis as a

Turner-War-wick plasty

The wound is drained with suction drainage, and the

perineal incision closed layer by layer (⊡ Figs 14.12, 14.13)

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⊡ Fig 14.9 Suturing the posterior wall

⊡ Fig 14.10 Suturing the anterior wall

⊡ Fig 14.8 Spatulating the urethral stumps

⊡ Fig 14.11 Suturing the anterior wall

⊡ Fig 14.12 Turner-Warwick roof plasty ⊡ Fig 14.13 Suturing the bulbocavernous muscle

14.4.2 Reconstructing the Membranous

Urethra (Bulboprostatic Anastomosis) 14.4.2.1 Combined MCU Retrograde

Urethrogram

A combined MCU-retrograde urethrogram, carried out

in a 45° Lauenstein position, is the best way to determine

the precise length Any additional spongiofibrosis is best

detected using a 10-MHz ultrasound probe

Counterindi-cations for bulboprostatic anastomosis are the same as for

bulbobulbar anastomosis The stricture length should not

exceed 2–3 cm (⊡ Fig 14.14)

14.4.3 Surgical Approach

A reconstruction of the membranous urethra is usually

also possible by perineal access The abdominal or

abdo-minoperineal access is reserved for cases that cannot

assume a lithotomy position because of extreme loss of

motion, and for rare 6- to 9-cm defects in the

memb-ranous and prostatic urethra including a demonstrably

severe injury to the bladder neck requiring bladder neck

reconstruction (⊡ Fig 14.15)

Preparing the Central Tendons

The central tendon is dissected to expose the prostatic

apex, taking care to completely remove all scar tissue

that surrounds the stricture The end of the stricture may

be located using a suprapubically inserted curved metal

probe or a flexible cystoscope The scar tissue must be

removed down to the healthy tissue of the prostatic apex,

which has sufficient blood supply, keeping as much as

possible of the intrinsic sphincter structures intact The

distal end of the stricture is easily determined by inserting

a transurethral probe, and is cut off in the healthy tissue

Mobilizing the Posterior Urethra

The posterior urethra is extensively dissected

proximal-ly Here, too, the bulbocavernosus muscle is split above

the urethra, taking advantage of the bulbar and anterior

urethra’s elasticity to suture a tension-free bulboprostatic

anastomosis later (⊡ Fig 14.17)

Nose Speculum

A special long nose speculum was designed, long enough

to open the apex of the prostate sufficiently in the depth

⊡ Fig 14.19 Using the speculum to open the prostatic apex

⊡ Fig 14.18 The special speculum

⊡ Fig 14.17 Mobilizing of the posterior urethra

⊡ Fig 14.16 Dissecting the central tendon

Stitching Technique Once the Prostatic Apex

Is Spread Open

A bent-open curved needle (e.g., CT 2) is inserted

lengthwise in the needle holder and used to pierce the

apex from the outside in, including the mucous tissue

Gripping the tip of the needle with the needle holder, the

needle is pushed into the bladder, where it may be easily

turned and led to the outside without traumatizing the

urethral tissue (⊡ Fig 14.20)

Procedure for Short Distal Urethra

The distal urethral stump is spatulated to approximate the

width of the prostatic apex

If the anastomosis cannot be adapted without tension because the urethral stump is too short or inelastic, the path to the apex may be shortened by splitting the cor-pora cavernosa down the midline This may shorten the distance to the apex by 1–2 cm (⊡ Fig 14.21)

Detaching One Crus of the Corpora Cavernosa

A similar result may be achieved by detaching one crus of the corpora cavernosa This too may help to reduce the tension on the anastomosis by reducing the distance bet-ween the apex and the urethral stump by another 1–2 cm (⊡ Fig 14.22)

⊡ Fig 14.20A–E Stitch technique using a curved and

straight needle