Posterior Urethral Strictures

Abstract

Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty.

Figure 1

(a) Laterally placed suprapubic tube. (b) Small “pigtail” catheter of inadequate caliber. (c) Suprapubic tube placed below the ideal location. (d) Suprapubic tube repositioned midline 2-finger breadth above the midline pubic symphysis.

Figure 2

(a) After the bladder is filled with contrast through the suprapubic tube, a RUG is performed as the patient is asked to attempt to void. If the bladder neck opens, contrast fills the prostatic urethra, and the membranous urethral defect is seen. (b) When the bladder neck does not open, the length of the defect cannot be determined accurately.

Figure 3

(a) A RUG is performed as contrast is simultaneously injected into the posterior urethra through the flexible cystoscope, with the tip in the distal prostatic urethra. (b) Imaging accurately demonstrating the length and location of the defect.

Figure 4

(a) Catheter balloon inflation with only 1–3 cc of air or fluid is associated with balloon inflation well beyond the normal caliber of the normal fossa navicularis. (b) Repeat RUG demonstrating, in addition to the previously seen bulbar stricture, a new fossa navicularis stricture that developed after a RUG was performed using fossa balloon inflation technique.

Figure 5

Simultaneous antegrade and retrograde urethral imaging demonstrating a bulbar urethral obliteration, further confirmed with antegrade cystoscopy.

Figure 6

Inferior epigastric artery to dorsal artery penile revascularization, shown subsequent to skin marking (a) and during surgery (b).

Figure 7

(a) Modified Skytron Custom 6000 Surgical Table with pelvic tilt mechanism (highlighted in yellow). (b) Patient positioned in exaggerated lithotomy.

Figure 8

(a) Lambda incision with the patient in the exaggerated lithotomy position. (b) Jordan-Simpson perineal retractor is used to facilitate exposure of the corpus spongiosum. (c) The corpus spongiosum is circumferentially mobilized along the bulbar urethra.

Figure 9

(a) Solid Haygrove sound. (b) After dissection of the obliterative scar, the tip of the sound (placed through the suprapubic tract) can then be advanced through the patent proximal urethra into the perineum. (c) Temporary vesicostomy in a patient with a laterally placed suprapubic tube. (d) Gelman visualizing posterior urethral sound. (e) Flexible scope advanced through the hollow visualizing sound.