0022-534 7/78/1203-0373$02. 00/0 Vol. 120, September Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
AN UNUSUAL SOLUTION TO COMPLICATED PROSTATIC URETHRAL STRICTURE: MODIFIED PULL-THROUGH URETHROPLASTYURETHRONEOCYSTOSTOMY ROOHOLLAH SHARIFI
AND
SAMUEL S. CLARK
From the Division of Urology, Department of Surgery, University of Illinois Hospital, Abraham Lincoln School of Medicine, Chicago, Illinois
ABSTRACT
A modified transpubic pull-through procedure was used in a failed Solovov-Badenoch pullthrough repair of a traumatic prostatomembranous urethral stricture. The modification consisted of an incision of the intracrural septum through which the mobilized bulbous urethra was then passed and anastomosed to the most available dependent portion of the anterior bladder wall. The outcome was an unexpectedly good result that has persisted for more than 30 months. A review of the literature revealed no absolutely similar procedure. During the last few years technical advances in urethral operations have improved greatly the outlook for urethral strictures resulting from pelvic fractures. However, it is necessary to adopt a variety of surgical procedures to treat the wide assortment of conditions encountered. The successful procedures that are used for repair of a posterior urethral stricture include 1) a direct approach-scrotal inlay procedures of Johanson, Turner-Warwick or Leadbetter; 1• 2 2) an indirect approach-the classic Solovov-Badenoch-Wiggishoff3 • 4 pull-through or push-in modification; 3) a formal transperineal spatulated bulboprostatic direct suture anastomosis2 and 4) a patch graft urethroplasty originally described in 1953 by Presman and Greenfield. 5 The first series of cases in which grafts were used was published in 1963 by Devine and associates. 6 The success rate of this procedure in treating the urethral stricture varies from 50 to 100 per cent. 7 • 8 Tube-graft urethroplasty has demonstrated better results in the treatment of membranous urethral stricture compared to patch graft urethroplasty. 9 Finally, the transpubic approach to the posterior urethra has been used by resection of the pubic bone with mobilization of the bulbous urethra to bypass the dense fibrous tissue, allowing for a long oblique anastomosis between the spatulated ends of the urethra. 10• 11 The anastomosis may be wrapped with an omental graft to contribute more to its reliability. 2 The transpubic approach, used earlier by Pierce, 12 has been used recently by Waterhouse and associates, 13 • 14 Turner-Warwick 15 and others 16 with excellent results. We were unsuccessful with the transpubic procedure in 1 of our patients with a traumatic prostatomembranous urethral stricture and were unable to isolate the proximal urethra at the bladder neck owing to severe cement-like scar tissue and bony callous obstruction of the pelvic outlet. Therefore, an anterior transposition of the urethra was done with urethroneocystostomy at the most available dependent portion of the anterior bladder wall.
tially with primary alignment over a urethral catheter without success and, therefore, the patient was placed on suprapubic cystostomy drainage. A plaster spica was used to keep the catheter in place and to prevent the patient from removing it. The patient was transferred to our care 5½ months later and, after resection of the pubic bone, a SolovovBadenoch-Wiggishoff pull-through urethroplasty was done. This procedure failed owing to extensive callous formation in the pelvic outlet (fig. 1). Again a suprapubic catheter was inserted. A transpubic end-to-end urethral anastomosis was considered. Preoperative evaluation revealed normal renal function, vesicourethral reflux, persistent urinary tract infection and a long impassable prostatomembranous stricture. TECHNIQUE
The bulbous urethra was mobilized satisfactorily through a transverse perinea! incision. The prostatomembranous urethra was approached through a lower midline abdominal incision (the pubic bone was resected previously) and it was impossible to dissect the proximal urethra even at the level of the bladder neck from the cement-like scar tissue and rectum, which was disrupted previously. Therefore, we abandoned the end-to-end urethral anastomosis and embarked on an anterior urethral transposition after incision of the intercrural septum. The urethrovesical anastomosis was fashioned at the most dependent part of the anterior bladder wall over a 14F Foley catheter. Temporary drainage was continued with a suprapubic cystostomy catheter and Penrose drainage. Convalescence was uneventful. The urethral and suprapubic catheters were removed 14 and 21 days postoperatively, respectively. The patient is ambulatory, free of a tube and off all medication 30 months postoperatively. The urine is sterile, kidney function is normal, the upper urinary tract is normal radiologically (fig. 2) and there is no vesicoureteral reflux. The patient voids involuntarily as he did before the accident and the urinary stream is good without residual urine. At the present time he is undergoing puberty and appears to be impotent. He will, of course, have no ejaculation.
CASE REPORT
An 11-year-old mentally retarded, incontinent black boy was involved in an accident in which a truck ran over the pelvis, causing complete transection of the prostatomembranous urethra, disruption of the rectum, fracture of the left acetabulum, epiphyseal displacement of the left femur, fracture of the left inferosuperior pubic rami and dislocation of the left sacroiliac joint. The urological problem was treated iniAccepted for publication January 27, 1978.
DISCUSSION
A life without a drainage bag and tube, restoration of urinary tract continuity with protection of function, and freedom of obstruction and infection are always the goals of any urological operation. Unfortunately, it is not always possible to achieve all of these goals. We did sacrifice reproduction which, of course, was not a major problem in this special case and we cannot say if we affected the urinary 373
374
SHARIFI AND CLARK
FIG. 1. Preoperative x-ray study. A, excretory urogram (IVP) demonstrates deformity of pelvis and excessive callous formation, bilateral hydroureter and calicectasis. B, cystogram done via suprapubic cystostomy with attempt to void shows vesicoureteral reflux on right side.
FIG. 2. X-ray study 30 months postoperatively. A, IVP reveals resolution of calicectasis and ureterectasis as well as severe distortion of pelvic bones. B, voiding cystourethrogram shows lack of reflux and widely patent urethra. C, post-voiding film demonstrates lack of reflux and residual urine.
continence, since the patient was incontinent before the accident. We did restore the continuity of the lower urinary tract, without infection and obstruction, and also preserved normal renal function. This procedure is only recommended for similar situations when there is no better alternative in restoring the continuity of the lower urinary tract. REFERENCES
1. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, 1953. 2. Turner-Warwick, R.: Urethral strictures. In: Urologic Surgery, 2nd ed. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, Inc., p. 718, 1975. 3. Badenoch, A. W.: Pull-through operation for impassable traumatic stricture of urethra. Brit. J. Urol., 22: 404, 1950. 4. Wiggishoff, C. C. and Keifer, J. H.: Pull-through reconstruction
of the posterior urethra. J. Urol., 93: 233, 1965. 5. Presman, D. and Greenfield, D. L.: Reconstruction of the perinea! urethra with a free full-thickness skin graft from the prepuce. J. Urol., 69: 677, 1953. 6. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J.E.: Use of full thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1973. 7. Berger, B., Sykes, Z. and Freedman, M.: Patch graft urethroplasty for urethral stricture disease. J. Urol., 115: 681, 1976. 8. McKinney, D. E. and Chenault, 0. W., Jr.: Experiences with Devine inlay graft urethroplasty. Urology, 5: 487, 1975. 9. Brannan, W., Ochsner, M. G., Fuselier, H. and Goodlet, J. S.: Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J. Urol., 115: 677, 1976. 10. Morales, P., Littman, R. and Golimbu, M.: Transpubic surgery: a new approach to difficult pelvic operations. J. Urol., 110: 564, 1973. 11. Paine, D. and Coombes, W.: Transpubic reconstruction of the
MODIFIED PULL-THROUGH URETHROPLASTY-URETHRONEOCYSTOSTOMY
urethra. Brit. J. Urol., 40: 78, 1968. 12. Pierce, J. M., Jr.: Exposure of the membranous and posterior urethra by total pubectomy. J. Urol., 88: 256, 1962. 13. Waterhouse, K., Abrahams, J. I., Gruber, H., Hackett, R. E., Patil, U. B. and Peng, B. K.: The transpubic approach to the lower urinary tract. J. Urol., 109: 486, 1973.
375
14. Waterhouse, K.: The surgical repair of membranous urethral stricture in children. J. Urol., 116: 363, 1976. 15. Turner-Warwick, R.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968. 16. Khan, A. U. and Furlow, W. L.: Transpubic urethroplasty. J. Urol., 116: 447, 1976.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
AN UNUSUAL SOLUTION TO COMPLICATED PROSTATIC URETHRAL STRICTURE: MODIFIED PULL-THROUGH URETHROPLASTYURETHRONEOCYSTOSTOMY ROOHOLLAH SHARIFI
AND
SAMUEL S. CLARK
From the Division of Urology, Department of Surgery, University of Illinois Hospital, Abraham Lincoln School of Medicine, Chicago, Illinois
ABSTRACT
A modified transpubic pull-through procedure was used in a failed Solovov-Badenoch pullthrough repair of a traumatic prostatomembranous urethral stricture. The modification consisted of an incision of the intracrural septum through which the mobilized bulbous urethra was then passed and anastomosed to the most available dependent portion of the anterior bladder wall. The outcome was an unexpectedly good result that has persisted for more than 30 months. A review of the literature revealed no absolutely similar procedure. During the last few years technical advances in urethral operations have improved greatly the outlook for urethral strictures resulting from pelvic fractures. However, it is necessary to adopt a variety of surgical procedures to treat the wide assortment of conditions encountered. The successful procedures that are used for repair of a posterior urethral stricture include 1) a direct approach-scrotal inlay procedures of Johanson, Turner-Warwick or Leadbetter; 1• 2 2) an indirect approach-the classic Solovov-Badenoch-Wiggishoff3 • 4 pull-through or push-in modification; 3) a formal transperineal spatulated bulboprostatic direct suture anastomosis2 and 4) a patch graft urethroplasty originally described in 1953 by Presman and Greenfield. 5 The first series of cases in which grafts were used was published in 1963 by Devine and associates. 6 The success rate of this procedure in treating the urethral stricture varies from 50 to 100 per cent. 7 • 8 Tube-graft urethroplasty has demonstrated better results in the treatment of membranous urethral stricture compared to patch graft urethroplasty. 9 Finally, the transpubic approach to the posterior urethra has been used by resection of the pubic bone with mobilization of the bulbous urethra to bypass the dense fibrous tissue, allowing for a long oblique anastomosis between the spatulated ends of the urethra. 10• 11 The anastomosis may be wrapped with an omental graft to contribute more to its reliability. 2 The transpubic approach, used earlier by Pierce, 12 has been used recently by Waterhouse and associates, 13 • 14 Turner-Warwick 15 and others 16 with excellent results. We were unsuccessful with the transpubic procedure in 1 of our patients with a traumatic prostatomembranous urethral stricture and were unable to isolate the proximal urethra at the bladder neck owing to severe cement-like scar tissue and bony callous obstruction of the pelvic outlet. Therefore, an anterior transposition of the urethra was done with urethroneocystostomy at the most available dependent portion of the anterior bladder wall.
tially with primary alignment over a urethral catheter without success and, therefore, the patient was placed on suprapubic cystostomy drainage. A plaster spica was used to keep the catheter in place and to prevent the patient from removing it. The patient was transferred to our care 5½ months later and, after resection of the pubic bone, a SolovovBadenoch-Wiggishoff pull-through urethroplasty was done. This procedure failed owing to extensive callous formation in the pelvic outlet (fig. 1). Again a suprapubic catheter was inserted. A transpubic end-to-end urethral anastomosis was considered. Preoperative evaluation revealed normal renal function, vesicourethral reflux, persistent urinary tract infection and a long impassable prostatomembranous stricture. TECHNIQUE
The bulbous urethra was mobilized satisfactorily through a transverse perinea! incision. The prostatomembranous urethra was approached through a lower midline abdominal incision (the pubic bone was resected previously) and it was impossible to dissect the proximal urethra even at the level of the bladder neck from the cement-like scar tissue and rectum, which was disrupted previously. Therefore, we abandoned the end-to-end urethral anastomosis and embarked on an anterior urethral transposition after incision of the intercrural septum. The urethrovesical anastomosis was fashioned at the most dependent part of the anterior bladder wall over a 14F Foley catheter. Temporary drainage was continued with a suprapubic cystostomy catheter and Penrose drainage. Convalescence was uneventful. The urethral and suprapubic catheters were removed 14 and 21 days postoperatively, respectively. The patient is ambulatory, free of a tube and off all medication 30 months postoperatively. The urine is sterile, kidney function is normal, the upper urinary tract is normal radiologically (fig. 2) and there is no vesicoureteral reflux. The patient voids involuntarily as he did before the accident and the urinary stream is good without residual urine. At the present time he is undergoing puberty and appears to be impotent. He will, of course, have no ejaculation.
CASE REPORT
An 11-year-old mentally retarded, incontinent black boy was involved in an accident in which a truck ran over the pelvis, causing complete transection of the prostatomembranous urethra, disruption of the rectum, fracture of the left acetabulum, epiphyseal displacement of the left femur, fracture of the left inferosuperior pubic rami and dislocation of the left sacroiliac joint. The urological problem was treated iniAccepted for publication January 27, 1978.
DISCUSSION
A life without a drainage bag and tube, restoration of urinary tract continuity with protection of function, and freedom of obstruction and infection are always the goals of any urological operation. Unfortunately, it is not always possible to achieve all of these goals. We did sacrifice reproduction which, of course, was not a major problem in this special case and we cannot say if we affected the urinary 373
374
SHARIFI AND CLARK
FIG. 1. Preoperative x-ray study. A, excretory urogram (IVP) demonstrates deformity of pelvis and excessive callous formation, bilateral hydroureter and calicectasis. B, cystogram done via suprapubic cystostomy with attempt to void shows vesicoureteral reflux on right side.
FIG. 2. X-ray study 30 months postoperatively. A, IVP reveals resolution of calicectasis and ureterectasis as well as severe distortion of pelvic bones. B, voiding cystourethrogram shows lack of reflux and widely patent urethra. C, post-voiding film demonstrates lack of reflux and residual urine.
continence, since the patient was incontinent before the accident. We did restore the continuity of the lower urinary tract, without infection and obstruction, and also preserved normal renal function. This procedure is only recommended for similar situations when there is no better alternative in restoring the continuity of the lower urinary tract. REFERENCES
1. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, 1953. 2. Turner-Warwick, R.: Urethral strictures. In: Urologic Surgery, 2nd ed. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, Inc., p. 718, 1975. 3. Badenoch, A. W.: Pull-through operation for impassable traumatic stricture of urethra. Brit. J. Urol., 22: 404, 1950. 4. Wiggishoff, C. C. and Keifer, J. H.: Pull-through reconstruction
of the posterior urethra. J. Urol., 93: 233, 1965. 5. Presman, D. and Greenfield, D. L.: Reconstruction of the perinea! urethra with a free full-thickness skin graft from the prepuce. J. Urol., 69: 677, 1953. 6. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J.E.: Use of full thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1973. 7. Berger, B., Sykes, Z. and Freedman, M.: Patch graft urethroplasty for urethral stricture disease. J. Urol., 115: 681, 1976. 8. McKinney, D. E. and Chenault, 0. W., Jr.: Experiences with Devine inlay graft urethroplasty. Urology, 5: 487, 1975. 9. Brannan, W., Ochsner, M. G., Fuselier, H. and Goodlet, J. S.: Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J. Urol., 115: 677, 1976. 10. Morales, P., Littman, R. and Golimbu, M.: Transpubic surgery: a new approach to difficult pelvic operations. J. Urol., 110: 564, 1973. 11. Paine, D. and Coombes, W.: Transpubic reconstruction of the
MODIFIED PULL-THROUGH URETHROPLASTY-URETHRONEOCYSTOSTOMY
urethra. Brit. J. Urol., 40: 78, 1968. 12. Pierce, J. M., Jr.: Exposure of the membranous and posterior urethra by total pubectomy. J. Urol., 88: 256, 1962. 13. Waterhouse, K., Abrahams, J. I., Gruber, H., Hackett, R. E., Patil, U. B. and Peng, B. K.: The transpubic approach to the lower urinary tract. J. Urol., 109: 486, 1973.
375
14. Waterhouse, K.: The surgical repair of membranous urethral stricture in children. J. Urol., 116: 363, 1976. 15. Turner-Warwick, R.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968. 16. Khan, A. U. and Furlow, W. L.: Transpubic urethroplasty. J. Urol., 116: 447, 1976.
