British Jowrial o/' Urology (1976). 48, 83-88
0
Badenoch's Pull-through Operation for Urethral Stricture C;.
H. TILAK, H. C. D H A Y A G U D E
and
S. S. JOSH1
J.J . Hospital, Bombay, India
Techniques of urethral reconstruction as described by various authqrs (Solovov, 1935; Badenoch, 1950; Swinney, 1952; Johanson, 1953; Turner Warwick, 1960; Blandy, Singh and Tresidder, 1968) are available for the treatment of a urethral stricture partly depending upon its site. Strictures of the membranous and bulbomembranous urethra call for techniques described by Solovov (1939, Badenoch (1950) and Turner Warwick (1960). This series presents 14 cases of stricture of membranous urethra, I2 cases treated by Badenoch's method, with a modification of the technique in 2 cases.
Material From 1962 to 1974, 14 cases of stricture of the membranous urethra were treated at the J. J. Hospital, Bombay. The mean age of the patients was 32, the youngest being 13 years of age and the oldest 50 years of age. Symptomatology
The symptoms niost frequently encountered were dysuria and poor urinary stream. 9 patients presented with acute retention of urine and had to have a suprapubic cystostomy. ( 6 of these were referred to us after they had had an initial suprapubic cystostomy done elsewhere.) All these patients had a history of trauma to the perineum 5 patients having been involved in road traffic accidents. All these 5 patients had fracture of the ischio-pubic rami, 2 patients having slight disruption of the symphysis pubis. It is interesting to note that 8 patients had a history of trauma to the perineum from 4 months to 15 years prior to the first appearance of symptoms of dysuria. Urinary incontinence was encountered in 3 patients, I of these having chronic retention with overflow incontinence; he was admitted in uraeniia and was jaundiced. Impotence was encountered in all but 3 patients; one of them was only 13 years of age, the other 2 having had perineal traunia without any evidence of pelvic fracture or disruption of the symphysis pubis. Diagnosis and Investigations
The diagnosis of stricture of the urethra is itsiially cvident from a detailed history. The stream of micturition is observed and the investigations are then carried out. I t is our routine, in all cases, to perform a retrograde urethrogram before instrumenting the urethra. The urethrogram is an excellent guide to define the site and extent of the stricture; and the state of the urethra proximal to the stricture. Urine culture and sensitivity revealed almost 50": of cases with urinary infection, with the majority of the patients having E. coli, Proteus viilgaris and Pseiidomotzas aeuriginasa, as the causative organisms. An intravenous pyelogram and subsequently a micturating cystourethrograni are done to confirm the state 01' the renal function and the presence or absence of vesicoureteric reflux. The state of the bladder neck and the urethra proximal to the site of stricture can also be assessed. A cystogram and proximal urethrograni are done in cases having had an initial suprapubic cystostomy. The extent of the stricture and its site is a guide in selecting the procedure; whether a formal Badenoch's operation or its modification (vide irrfia).
Technique of Operative Procedure Our preference is for a 2-stage procedure. I f the patient has an associated bladder neckobstruction, this is resected through a suprapubic approach via a midline subumbilical incision and the bladder 48/ 1-F*
83
84
BRITISH JOURNAL OF IJROI-OGY
Fig. I . Modified Badenoch’s procedure. (a) Urethra cut across at, or jupt distal to, the perineal membrane; (b) urethra partially telescoped; ( c ) urethral ends fixed with catgut.
is closed leaving a Malecot catheter, as high in the suprapubic wound as possible. The staged procedure reduces the operating time at the second stage and also facilitates insertion of a catheter which acts as a splint at the pull-through operation. The second stage is undertaken about 3 weeks after the first operation (by which time the suprapubic incision has healed completely). Both the stages are done preferably under spinal anaesthesia, with long-acting anaesthetic agent, e. g. , Nupercaine. We have not come across any untoward side-effects after such an anaesthetic agent. On the contrary, this type of anaesthesia gives full relaxation and provides a relatively bloodless field, which is certainly an added ad vantage. The approach to the bulbomembranous urethra is through an inverted V incision (Blandy ct al., 1968) as against the original vertical incision employed by Badenoch (1950). I t prevents soiling of the incision by faecal matter, which may occur if the posterior limit of the vertical incision is carried too far. It also gives a better exposure for the posterior urethra, which enables one to excise the periurethral scarred tissue. This step is essential for a successful reconstruction. We always mobilise at least 4-5 cm of the urethra distally. The stricture site is identifed by passing a urethral bougie. The urethra is divided just distal to the stricture. Periurethral scarring over the membranous urethra is excised as much as possible. A Hey Grove’s curved bougie is projected into the proximal urethra through a suprapubic route, and the midline incision is made over the tip of the bougie. If it is found that the opening is small, then the incisions are made in 3 and 9 o’clock positions, so that the incision will appear to be cruciate. The edges of the incision are trimmed, after which a 12/15 (approx 21/25 Fr.) Lister’s bougie can easily be passed from below. The excess of spongy tissue of the distal urethra is excised so as to get the urethra in the shape of a pencil for facilitating the procedure of telescoping the urethra. In cases where disruption of the puboprostatic ligament has occurred at the original injury (usually with pelvic fracture), a formal Badenoch’s pull-through operation is undertaken. A Portex Nelaton’s catheter size 21Fr. is used to act as a splint. This catheter is passed through the suprapubic opening and is brought into the perineal wound. The catheter is then passed into the distal urethra, which has already been “tailored”. The distal urethra is then anchored to the catheter by a 4(0) chromic catgut stitch. This stitch passes through the wall of the urethra and the wall of the catheter, The ends of this catgut stitch are left long enough to encircle t h e catheter over the urethra where a firm knot is tied. The catheter and with it the urethra is pulled up till the distal urethra telescopes into the proximal urethra. Optimum tension is maintained to prevent
HADENOCH’SPULL-THROUGH OPERATION FOR URETHRAL STRICTURE
85
Fig. 2. (a) Preoperative urethrogram with membranous urethral stricuture; (b) Postoperative urethrogram after classical Ba denoch’s operation.
the urethra slipping out of position by applying a strong haemostat flush with the abdominal wall. The periurethral tissue is then approximated with 4(0) chromic catgut interrupted sutures. The bladder is drained with a Malecot’s catheter which lies by the side of the catheter splint. The inverted “V” incision is closed in layers after leaving two corrugated drains, one over the periurethral area, the other subcutaneously. The drains are left in for 48 to 72 hours. A modified Badenoch’s procedure was done in patients with strictures up to 1 cm long just distal to the perineal membrane without much periurethral scarring. In these 2, the distal urethra was partially telescoped into the dilated proximal urethra. This is facilitated by means of 4 interrupted 4(0) chromic catgut sutures on an atraumatic needle. The sutures are taken at the 3, 6 , 9 and 12 o’clock positions and tied firmly once all the stitches are taken. Further reinforcing stitches are then taken to take the tension off the initial sutures. These stitches are taken at the 3, 6 and 9 o’clock positions, picking up the periurethral tissue proximally and periurethral with minimal spongy tissue distally (Fig. 1). When all the sutures are in position, a Foley catheter ( F 18 or F 16 gauge) is passed per urethram. A small size catheter is preferred to allow the urethral discharge to find its way out around the catheter. Such an indwelling catheter is left in the bladder for about 3 weeks, during which time the suprapubic catheter can easily be dispensed with. Early Postoperative Follow-up The splint is removed on the 14th day and a Foley catheter is passed per urethram by ordinary or by a railroad method. The suprapubic Malecot catheter is then removed. The urethral catheter is removed after the suprapubic fistulous opening and the wound have completely healed. A retrograde urethrogram is done the day the catheter is removed (Figs. 2b and 3b). Calibration is performed (usually under local anaesthesia) and repeated at about monthly intervals, until the stream is satisfactory and stable; this has usually been between 4 and 6 months. Complications 1. Wound Infection. Three patients had local wound infection in the suprapubic region. These cases initially had urinary infection. Incidentally, 2 of these initially received treatment at other centres. The wound infection, however, was easily controlled with antibiotics.
86
Fig. 3. (a1 Preoperative urethrogram ; ( b ) Postopcrativc urethrogram of modified Badcnoch’s operation.
2. Haematoma and Gaping of the Perineal Wound. One case developed a perineal haematoma. The wound gaped and had to be resutured and later skingrafting had to be done. Fortunately. the bulbospongiosus muscle apposition prevented the urethra from being exposed. 3. Perineal Leak. One patient had a perineal urinary leak, probably from the site of repair ;IS revealed by the urethrogram (Fig. 4). The leak lasted for about 2 weeks and then stopped completely. 4. Secondary Haemorrhage. Mild secondary haemorrliage was encountered in I patient on the 8th postoperative day. This lasted for about 24 hours and was easily controlled by continuous irrigation through a suprapubic catheter. 5. Restricture with Periurethral Abscesses, One patient had an impassable stricture at the site o f reconstruction, with periurethral abscesses. He had undergone a formal pull-through procedure 2 years prior to the development of the stricture. He, however, had failed to report for regular post operative follow-up.
Results 14 patients have been treated for stricture of the membranous urethra over a period of 13 years. At the follow-up, urine culture, blood urea and if necessary a retrograde urethrograni are done. This series shows that 10 of the 14 patients had a good result, 2 of these having undergone the modified procedure. Their stream is excellent, as is the urinary control. They do not require urethral dilatations and have a normal blood urea with no urinary infection. These patients had their operations from 6 months to 13 years ago. Fair results were obtained in 3 patients where intermittent dilatation at an interval of 1 to 2. months is necessary. One of these has granulations at the site of repair (Fig. 5) and is being
87
RADENOCH‘S PULL-THROUGH OPERATION FOR URETHRAL STRICTURE
Fig. 4. Classical Badenoch’s with postoperative urinary fistula.
Fig. 5. Postoperative urethrograrn of classical Badenoch’s operation with granulation tissue.
considered for endoscopic fulguration. Nevertheless, they still have a satisfactory urinary stream. The operation was a failure i n 1 patient whose urethra has stenosed completely at the site of reconstruction, with periurethral abscesses. This occurred 2 years after the initial procedure. A t present he has a suprapubic cystostomy; the periurethral abscesses have subsided. A Turner Warwick procedure is being considered to tackle the stricture.
Discussion Strictures of the membranous urethra pose special problems owing to their inaccessible site for ordinary procedures. Badenoch’s ( I950), Turner Warwick’s ( 1 960) and Waterhouse’s ( 1974) procedures have all been tried. Of these the first 2 have stood the test of time. The Badenoch’s
Table I incidence of Stricture of Membranous Urethra, as Related to Fractured Pelvis
Table ll Stricture of the Membranous Urethra and its Association with Bladder Neck Obstruction
Stricture of membranous urethra
Stricture of membranous urethra Cases with B.N.O. Cases without B.N.O.
.
~
No. of patients -
~~~~~~~
~
~~
5 9
Table 111 Type of Procedure employed in 14 Cases Type of procedure _
_
~
~
~
_
No. of patients _
_ ~~~~~
~-
~~
~~~
Patients with fracture of ischio-pubic rami Patients without fracture of ischio-pubic rami
No. of patients
~
“Formal” Badenoch’s pull-through operation “Modified” Badenoch’s procedure
_
_
12. 2.
~
_
.
~
5 9
XX
BRITISH JOURNAL O F UROL.OCiY
‘Table IV Follow-up in Years and Number of Patients Years
No. of patient5 ~
Up to
I to 7 to 0 io 10 to
I year 2 3 years 3 6 years 4 10 years 3 13 years 2 Total 14
Table V Results in Patients Treated for Membranous Urethral Stricture Results
No. of patients
Good Fair Failure Total
10
3 I 14
procedure and its modification, however, can be done as a one-stage procedure, which is advantageous to patients who object to repeated or multi-staged procedures. The morbidity by using a skin flap for urethral reconstruction can be completely eliminated. It has been observed ( G . H. T.) in the past 15 years that in the East patients have profuse sweating and burning sensations in the perineal urethra in the hot and humid weather, when a skin flap is used for urethral reconstruction. In addition, formation of hypertrophic scar and growth of hair in the urethra cannot be completely eliminated. Last but not least is the feasibility of the Badenoch’s and its modified procedure which can be done at centres where special equipment for reconstructive urethral surgery is not available.
Summary 14 patients with strictures in the region of the membranous urethra were treated by Badenoch’a urethral pull-through operation or a slight modification of this. The results were good in 10 of the cases. This procedure has advantages over those using scrotal flaps in hot climates.
References BADENOCH, A . W. (1950). A pull-through operation for impassable traumatic stricture of the urethra. British Journal of Urology, 22, 404-409. -- (1956). Discussion on urethral injuries. Proceedings of the Royal Society of Medicine, 49, 685-695. - (1968). Traumatic stricture of the urethra. British Journal of Urologjl, 40, 671-676. BLANDY,J. P., SINGH,M. and TRESIDDER, G. C. (1968). Urethroplasty by scrotal flap for long urethral Strictures. British Journal of Urology, 40, 261-267. JOHANSON, B. (1953). In Modern Trends in Urology, ed. E. Riches, London: Butterworths, pp. 344-351. LEADBETTER, G . W. (1960). A simplified urethroplasty for strictures of the bulbous urethra. Journal of Urology, 83, 54-59. SOLOVOV, P. D. (1935). Fracture of pelvis with injury of bladder and ureter. Vestnik Khirurgii, 37, 36-48. SWINNEY, J. (1952). Reconstruction of the urethra in the male. British Journal of Urology, 24, 229-235. __ (1957). Urethroplasty : an assessment after seven years’ experiences. British Journal of Urology, 29, 293-297. TURNERWARWICK, R. T. (1960). A technique for posterior urethroplasty. Journal of Urology, 83, 416-419. ~(1968). The repair of urethral strictures in the region of the membranous urethra. Joitrrial of Urolog),, 100, 303-31 4. WAI‘ERHOUSE, K., AHRAHAMS, J. I., CAPONEGRO, P., HACKETT,R. E., PATIL,U. B. and PENO, B. K . (1974). The transpubic repair of membranous urethral strictures. Journal of Urology, 111, 188-190.
The Authors G . H . Tilak, MS, FRCSE, Honorary Urologist.
H. C. Dhayagude, MS, FRCS, FRCSE, Pool Officer in Urology. S.S. Joshi, MS, FRCS, Pool Officer in Urology (now Surgeon, Jaslok Hospital, Bombay).
0
Badenoch's Pull-through Operation for Urethral Stricture C;.
H. TILAK, H. C. D H A Y A G U D E
and
S. S. JOSH1
J.J . Hospital, Bombay, India
Techniques of urethral reconstruction as described by various authqrs (Solovov, 1935; Badenoch, 1950; Swinney, 1952; Johanson, 1953; Turner Warwick, 1960; Blandy, Singh and Tresidder, 1968) are available for the treatment of a urethral stricture partly depending upon its site. Strictures of the membranous and bulbomembranous urethra call for techniques described by Solovov (1939, Badenoch (1950) and Turner Warwick (1960). This series presents 14 cases of stricture of membranous urethra, I2 cases treated by Badenoch's method, with a modification of the technique in 2 cases.
Material From 1962 to 1974, 14 cases of stricture of the membranous urethra were treated at the J. J. Hospital, Bombay. The mean age of the patients was 32, the youngest being 13 years of age and the oldest 50 years of age. Symptomatology
The symptoms niost frequently encountered were dysuria and poor urinary stream. 9 patients presented with acute retention of urine and had to have a suprapubic cystostomy. ( 6 of these were referred to us after they had had an initial suprapubic cystostomy done elsewhere.) All these patients had a history of trauma to the perineum 5 patients having been involved in road traffic accidents. All these 5 patients had fracture of the ischio-pubic rami, 2 patients having slight disruption of the symphysis pubis. It is interesting to note that 8 patients had a history of trauma to the perineum from 4 months to 15 years prior to the first appearance of symptoms of dysuria. Urinary incontinence was encountered in 3 patients, I of these having chronic retention with overflow incontinence; he was admitted in uraeniia and was jaundiced. Impotence was encountered in all but 3 patients; one of them was only 13 years of age, the other 2 having had perineal traunia without any evidence of pelvic fracture or disruption of the symphysis pubis. Diagnosis and Investigations
The diagnosis of stricture of the urethra is itsiially cvident from a detailed history. The stream of micturition is observed and the investigations are then carried out. I t is our routine, in all cases, to perform a retrograde urethrogram before instrumenting the urethra. The urethrogram is an excellent guide to define the site and extent of the stricture; and the state of the urethra proximal to the stricture. Urine culture and sensitivity revealed almost 50": of cases with urinary infection, with the majority of the patients having E. coli, Proteus viilgaris and Pseiidomotzas aeuriginasa, as the causative organisms. An intravenous pyelogram and subsequently a micturating cystourethrograni are done to confirm the state 01' the renal function and the presence or absence of vesicoureteric reflux. The state of the bladder neck and the urethra proximal to the site of stricture can also be assessed. A cystogram and proximal urethrograni are done in cases having had an initial suprapubic cystostomy. The extent of the stricture and its site is a guide in selecting the procedure; whether a formal Badenoch's operation or its modification (vide irrfia).
Technique of Operative Procedure Our preference is for a 2-stage procedure. I f the patient has an associated bladder neckobstruction, this is resected through a suprapubic approach via a midline subumbilical incision and the bladder 48/ 1-F*
83
84
BRITISH JOURNAL OF IJROI-OGY
Fig. I . Modified Badenoch’s procedure. (a) Urethra cut across at, or jupt distal to, the perineal membrane; (b) urethra partially telescoped; ( c ) urethral ends fixed with catgut.
is closed leaving a Malecot catheter, as high in the suprapubic wound as possible. The staged procedure reduces the operating time at the second stage and also facilitates insertion of a catheter which acts as a splint at the pull-through operation. The second stage is undertaken about 3 weeks after the first operation (by which time the suprapubic incision has healed completely). Both the stages are done preferably under spinal anaesthesia, with long-acting anaesthetic agent, e. g. , Nupercaine. We have not come across any untoward side-effects after such an anaesthetic agent. On the contrary, this type of anaesthesia gives full relaxation and provides a relatively bloodless field, which is certainly an added ad vantage. The approach to the bulbomembranous urethra is through an inverted V incision (Blandy ct al., 1968) as against the original vertical incision employed by Badenoch (1950). I t prevents soiling of the incision by faecal matter, which may occur if the posterior limit of the vertical incision is carried too far. It also gives a better exposure for the posterior urethra, which enables one to excise the periurethral scarred tissue. This step is essential for a successful reconstruction. We always mobilise at least 4-5 cm of the urethra distally. The stricture site is identifed by passing a urethral bougie. The urethra is divided just distal to the stricture. Periurethral scarring over the membranous urethra is excised as much as possible. A Hey Grove’s curved bougie is projected into the proximal urethra through a suprapubic route, and the midline incision is made over the tip of the bougie. If it is found that the opening is small, then the incisions are made in 3 and 9 o’clock positions, so that the incision will appear to be cruciate. The edges of the incision are trimmed, after which a 12/15 (approx 21/25 Fr.) Lister’s bougie can easily be passed from below. The excess of spongy tissue of the distal urethra is excised so as to get the urethra in the shape of a pencil for facilitating the procedure of telescoping the urethra. In cases where disruption of the puboprostatic ligament has occurred at the original injury (usually with pelvic fracture), a formal Badenoch’s pull-through operation is undertaken. A Portex Nelaton’s catheter size 21Fr. is used to act as a splint. This catheter is passed through the suprapubic opening and is brought into the perineal wound. The catheter is then passed into the distal urethra, which has already been “tailored”. The distal urethra is then anchored to the catheter by a 4(0) chromic catgut stitch. This stitch passes through the wall of the urethra and the wall of the catheter, The ends of this catgut stitch are left long enough to encircle t h e catheter over the urethra where a firm knot is tied. The catheter and with it the urethra is pulled up till the distal urethra telescopes into the proximal urethra. Optimum tension is maintained to prevent
HADENOCH’SPULL-THROUGH OPERATION FOR URETHRAL STRICTURE
85
Fig. 2. (a) Preoperative urethrogram with membranous urethral stricuture; (b) Postoperative urethrogram after classical Ba denoch’s operation.
the urethra slipping out of position by applying a strong haemostat flush with the abdominal wall. The periurethral tissue is then approximated with 4(0) chromic catgut interrupted sutures. The bladder is drained with a Malecot’s catheter which lies by the side of the catheter splint. The inverted “V” incision is closed in layers after leaving two corrugated drains, one over the periurethral area, the other subcutaneously. The drains are left in for 48 to 72 hours. A modified Badenoch’s procedure was done in patients with strictures up to 1 cm long just distal to the perineal membrane without much periurethral scarring. In these 2, the distal urethra was partially telescoped into the dilated proximal urethra. This is facilitated by means of 4 interrupted 4(0) chromic catgut sutures on an atraumatic needle. The sutures are taken at the 3, 6 , 9 and 12 o’clock positions and tied firmly once all the stitches are taken. Further reinforcing stitches are then taken to take the tension off the initial sutures. These stitches are taken at the 3, 6 and 9 o’clock positions, picking up the periurethral tissue proximally and periurethral with minimal spongy tissue distally (Fig. 1). When all the sutures are in position, a Foley catheter ( F 18 or F 16 gauge) is passed per urethram. A small size catheter is preferred to allow the urethral discharge to find its way out around the catheter. Such an indwelling catheter is left in the bladder for about 3 weeks, during which time the suprapubic catheter can easily be dispensed with. Early Postoperative Follow-up The splint is removed on the 14th day and a Foley catheter is passed per urethram by ordinary or by a railroad method. The suprapubic Malecot catheter is then removed. The urethral catheter is removed after the suprapubic fistulous opening and the wound have completely healed. A retrograde urethrogram is done the day the catheter is removed (Figs. 2b and 3b). Calibration is performed (usually under local anaesthesia) and repeated at about monthly intervals, until the stream is satisfactory and stable; this has usually been between 4 and 6 months. Complications 1. Wound Infection. Three patients had local wound infection in the suprapubic region. These cases initially had urinary infection. Incidentally, 2 of these initially received treatment at other centres. The wound infection, however, was easily controlled with antibiotics.
86
Fig. 3. (a1 Preoperative urethrogram ; ( b ) Postopcrativc urethrogram of modified Badcnoch’s operation.
2. Haematoma and Gaping of the Perineal Wound. One case developed a perineal haematoma. The wound gaped and had to be resutured and later skingrafting had to be done. Fortunately. the bulbospongiosus muscle apposition prevented the urethra from being exposed. 3. Perineal Leak. One patient had a perineal urinary leak, probably from the site of repair ;IS revealed by the urethrogram (Fig. 4). The leak lasted for about 2 weeks and then stopped completely. 4. Secondary Haemorrhage. Mild secondary haemorrliage was encountered in I patient on the 8th postoperative day. This lasted for about 24 hours and was easily controlled by continuous irrigation through a suprapubic catheter. 5. Restricture with Periurethral Abscesses, One patient had an impassable stricture at the site o f reconstruction, with periurethral abscesses. He had undergone a formal pull-through procedure 2 years prior to the development of the stricture. He, however, had failed to report for regular post operative follow-up.
Results 14 patients have been treated for stricture of the membranous urethra over a period of 13 years. At the follow-up, urine culture, blood urea and if necessary a retrograde urethrograni are done. This series shows that 10 of the 14 patients had a good result, 2 of these having undergone the modified procedure. Their stream is excellent, as is the urinary control. They do not require urethral dilatations and have a normal blood urea with no urinary infection. These patients had their operations from 6 months to 13 years ago. Fair results were obtained in 3 patients where intermittent dilatation at an interval of 1 to 2. months is necessary. One of these has granulations at the site of repair (Fig. 5) and is being
87
RADENOCH‘S PULL-THROUGH OPERATION FOR URETHRAL STRICTURE
Fig. 4. Classical Badenoch’s with postoperative urinary fistula.
Fig. 5. Postoperative urethrograrn of classical Badenoch’s operation with granulation tissue.
considered for endoscopic fulguration. Nevertheless, they still have a satisfactory urinary stream. The operation was a failure i n 1 patient whose urethra has stenosed completely at the site of reconstruction, with periurethral abscesses. This occurred 2 years after the initial procedure. A t present he has a suprapubic cystostomy; the periurethral abscesses have subsided. A Turner Warwick procedure is being considered to tackle the stricture.
Discussion Strictures of the membranous urethra pose special problems owing to their inaccessible site for ordinary procedures. Badenoch’s ( I950), Turner Warwick’s ( 1 960) and Waterhouse’s ( 1974) procedures have all been tried. Of these the first 2 have stood the test of time. The Badenoch’s
Table I incidence of Stricture of Membranous Urethra, as Related to Fractured Pelvis
Table ll Stricture of the Membranous Urethra and its Association with Bladder Neck Obstruction
Stricture of membranous urethra
Stricture of membranous urethra Cases with B.N.O. Cases without B.N.O.
.
~
No. of patients -
~~~~~~~
~
~~
5 9
Table 111 Type of Procedure employed in 14 Cases Type of procedure _
_
~
~
~
_
No. of patients _
_ ~~~~~
~-
~~
~~~
Patients with fracture of ischio-pubic rami Patients without fracture of ischio-pubic rami
No. of patients
~
“Formal” Badenoch’s pull-through operation “Modified” Badenoch’s procedure
_
_
12. 2.
~
_
.
~
5 9
XX
BRITISH JOURNAL O F UROL.OCiY
‘Table IV Follow-up in Years and Number of Patients Years
No. of patient5 ~
Up to
I to 7 to 0 io 10 to
I year 2 3 years 3 6 years 4 10 years 3 13 years 2 Total 14
Table V Results in Patients Treated for Membranous Urethral Stricture Results
No. of patients
Good Fair Failure Total
10
3 I 14
procedure and its modification, however, can be done as a one-stage procedure, which is advantageous to patients who object to repeated or multi-staged procedures. The morbidity by using a skin flap for urethral reconstruction can be completely eliminated. It has been observed ( G . H. T.) in the past 15 years that in the East patients have profuse sweating and burning sensations in the perineal urethra in the hot and humid weather, when a skin flap is used for urethral reconstruction. In addition, formation of hypertrophic scar and growth of hair in the urethra cannot be completely eliminated. Last but not least is the feasibility of the Badenoch’s and its modified procedure which can be done at centres where special equipment for reconstructive urethral surgery is not available.
Summary 14 patients with strictures in the region of the membranous urethra were treated by Badenoch’a urethral pull-through operation or a slight modification of this. The results were good in 10 of the cases. This procedure has advantages over those using scrotal flaps in hot climates.
References BADENOCH, A . W. (1950). A pull-through operation for impassable traumatic stricture of the urethra. British Journal of Urology, 22, 404-409. -- (1956). Discussion on urethral injuries. Proceedings of the Royal Society of Medicine, 49, 685-695. - (1968). Traumatic stricture of the urethra. British Journal of Urologjl, 40, 671-676. BLANDY,J. P., SINGH,M. and TRESIDDER, G. C. (1968). Urethroplasty by scrotal flap for long urethral Strictures. British Journal of Urology, 40, 261-267. JOHANSON, B. (1953). In Modern Trends in Urology, ed. E. Riches, London: Butterworths, pp. 344-351. LEADBETTER, G . W. (1960). A simplified urethroplasty for strictures of the bulbous urethra. Journal of Urology, 83, 54-59. SOLOVOV, P. D. (1935). Fracture of pelvis with injury of bladder and ureter. Vestnik Khirurgii, 37, 36-48. SWINNEY, J. (1952). Reconstruction of the urethra in the male. British Journal of Urology, 24, 229-235. __ (1957). Urethroplasty : an assessment after seven years’ experiences. British Journal of Urology, 29, 293-297. TURNERWARWICK, R. T. (1960). A technique for posterior urethroplasty. Journal of Urology, 83, 416-419. ~(1968). The repair of urethral strictures in the region of the membranous urethra. Joitrrial of Urolog),, 100, 303-31 4. WAI‘ERHOUSE, K., AHRAHAMS, J. I., CAPONEGRO, P., HACKETT,R. E., PATIL,U. B. and PENO, B. K . (1974). The transpubic repair of membranous urethral strictures. Journal of Urology, 111, 188-190.
The Authors G . H . Tilak, MS, FRCSE, Honorary Urologist.
H. C. Dhayagude, MS, FRCS, FRCSE, Pool Officer in Urology. S.S. Joshi, MS, FRCS, Pool Officer in Urology (now Surgeon, Jaslok Hospital, Bombay).
