Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome.

OBJECTIVE: To determine perioperative factors that may optimize the outcome after delayed perineal repair of a pelvic fracture urethral injury (PFUI). PATIENTS AND METHODS: In all, 86 consecutive patients who underwent perineal repair of a PFUI between 2004 and 2011 were prospectively enrolled in this study. The mean (range) patient age was 23 (5-50) years. The mean (range) follow-up was 5.5 (2-8) years. We examined seven perioperative variables that might influence the outcome including: prior failed treatment, condition of the bulbar urethra, displacement of the prostate, excision of scarred tissues, fixation of the mucosae of the two urethral ends, and the number and size of sutures used for urethral anastomosis. Univariate and multivariate analyses were used to identify factors that influence postoperative outcome. RESULTS: Of the patients, 76 (88%) had successful outcomes and 10 (12%) were considered treatment failures. On univariate analysis, four variables were significant factors influencing the outcome: excision of scarred tissues, prostatic displacement, condition of the bulbar urethra and fixation of the mucosae. On multivariate analysis only two remained strong and independent factors namely complete excision of scarred tissues and prostatic displacement in a lateral direction. CONCLUSIONS: Meticulous and complete excision of scar tissue is critically important to optimise the outcome after perineal urethroplasty. This is particularly emphasised in cases associated with lateral prostatic displacement. Six sutures of 3/0 or 4/0 polyglactin 910 are usually sufficient to create a sound urethral anastomosis. Prior treatment and scarring of the anterior urethra do not affect the outcome.

Predicting risk of erectile dysfunction after pelvic fracture urethral injury in children.

PURPOSE: We sought to determine the incidence of erectile dysfunction following pelvic fracture urethral injuries in children, and to identify the related causes and risk factors. MATERIALS AND METHODS: All consecutive children who had undergone repair of a pelvic fracture urethral injury between 1980 and 2010 were invited to participate in the study. All responders were queried after a median of 13 years (range 3 to 28) following trauma to assess erectile function using the erectile function domain of the International Index of Erectile Function. Patients who had erectile dysfunction underwent penile duplex ultrasonography. Medical records and imaging studies were reviewed with a focus on 4 variables, ie pattern of pelvic fracture, pubic diastasis, prostatic displacement and urethral gap length. Univariate and multivariate analyses were used to identify parameters predictive of erectile dysfunction at puberty. RESULTS: A total of 60 patients participated in the study, of whom 28 (47%) had erectile dysfunction. On univariate analysis all 4 parameters were significant predictors of erectile dysfunction, while on multivariate analysis only 2 parameters remained strong and independent predictors, namely urethral gap length 2.5 cm or greater and prostatic displacement in a lateral direction. Duplex ultrasound revealed the cause of erectile dysfunction as arteriogenic in 19 patients (76%), arteriovenogenic in 2 (8%) and likely neurogenic in 4 (16%). CONCLUSIONS: For every 2 children sustaining a pelvic fracture urethral injury 1 will exhibit erectile dysfunction at puberty. The risk of erectile dysfunction is appreciably increased in the presence of a long urethral gap and/or lateral prostatic displacement. The cause of erectile dysfunction is most commonly primarily arteriogenic and less commonly neurogenic.

Predictors of surgical approach to repair pelvic fracture urethral distraction defects.

PURPOSE: We identified preoperative factors predictive of the appropriate surgical approach to anastomotic repair of pelvic fracture urethral distraction defects. MATERIALS AND METHODS: We reviewed the medical records and imaging studies of 121 patients who had undergone anastomotic repair of a pelvic fracture urethral distraction defect. The review was focused on 10 preoperative clinicoradiological variables that may influence or predict the surgical repair. The patients were categorized as having undergone a simple perineal operation (78 patients, group 1), or an elaborated perineal or a combined perineo-abdominal procedure (43 patients, group 2). Univariate and multivariate analyses were used to identify preoperative parameters predictive of the type of anastomotic repair. In addition, ROC analysis was used to assess prediction results of the multivariate analysis. RESULTS: On univariate analysis 5 parameters were significant predictors of the type of repair, while on multivariate analysis only 3 parameters remained strong and independent predictors including the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index was a proxy for all other parameters. At a cutoff index of 0.35 the appropriate surgical repair was predicted with 91% specificity and a 95% positive predictive value. When ROC analysis was performed the AUC was 0.979. CONCLUSIONS: The type of anastomotic repair of pelvic fracture urethral distraction defect can be predicted by 3 preoperative factors, namely the gapometry/urethrometry index, urethral gap length and prostatic displacement. The gapometry/urethrometry index has the highest predictive accuracy and is a proxy for all other factors. An index less than 0.35 indicates a simple perineal operation and an index greater than 0.35 indicates an elaborated perineal or a transpubic procedure.

The male urethral sphincter complex revisited: an anatomical concept and its physiological correlate.

PURPOSE: The anatomy of the male urethral sphincter has not been stable since it was first described more than 150 years ago. Although 18th and 19th century historical descriptions of the urethral sphincter are most accurate and comprehensive, modern textbooks lack details and include inaccuracies and misleading illustrations. This is an attempt to achieve a revised concept of the male urethral sphincter complex. MATERIALS AND METHODS: A thorough review of the English literature in the last 100 years, and of pertinent Germinal publications and textbooks of the 19th and 20th centuries was done. Also, we reviewed urodynamic findings in male patients in whom the urethral sphincters had been expectedly damaged in the proximal or distal part by surgery during the last 20 years. RESULTS: The current concept of urethral sphincter anatomy does not differ much from that described and illustrated in the 19th century. The disagreement between the historical and recent descriptions is primarily concerned with the cranial extension of the skeletal muscle component and the caudal extension of the smooth muscle component in the urethral wall. CONCLUSIONS: The male urethral sphincter complex is composed of an inner lissosphincter of smooth muscle and an outer rhabdosphincter of skeletal muscle. It extends in the form of a cylinder around the urethra from the vesical orifice to the perineal membrane. While the rhabdosphincter is most marked around the membranous urethra and becomes gradually less distinct toward the bladder, the lissosphincter has its main part at the vesical orifice and is thinner in its further course in the urethra. The lissosphincter is primarily concerned with the function of continence at rest. On the other hand, the rhabdosphincter has a dual genitourinary function, namely active continence during stress conditions and antegrade semen propulsion.

Gapometry and anterior urethrometry in the repair of posterior urethral defects.

PURPOSE: We determined the influence of bulbar urethral length on the anastomotic repair approach to bulboprostatic urethral distraction defects. MATERIALS AND METHODS: We reviewed the medical records and radiographic studies of 120 patients 6 to 52 years old who had undergone anastomotic repair of bulboprostatic urethral gaps. Repair was accomplished by a simple perineal operation in 84 patients (group 1) and an elaborated perineal or a transpubic procedure in 36 (group 2). The length of the urethral gap and bulbar urethra was measured on preoperative urethrogram. Also, the length of the urethral gap as a fraction of bulbar urethral length (index of elastic lengthening) was calculated. RESULTS: Mean length of the urethral gap was 1.5 cm in group 1 vs 4.2 cm in group 2 (p <0.001). Mean bulbar urethral length was 7.3 cm in group 1 vs 6.6 cm in group 2 (p >0.05). The mean index of elastic lengthening was 0.21 (range 0.06 to 0.34) in group 1 vs 0.64 (range 0.38 to 0.88) in group 2 (p <0.001). The difference in the mean length of the urethral gap between children and adults in the 2 groups was not statistically significant (2.4 vs 2.5 cm, p >0.05), while the difference in the mean length of the bulbar urethra was highly significant (5.6 vs 7.7 cm, p <0.001). CONCLUSIONS: Bulboprostatic urethral gaps shorter than a third of bulbar urethral length are usually corrected by a simple perineal operation. For longer gaps an elaborated perineal or transpubic procedure is usually done. Also, the latter 2 procedures are more commonly performed in children than in adults because of the shorter bulbar urethra.

The combined perineo-abdominal transpubic urethroplasty.

Research pertaining to transpubic urethral surgery is described. The operative technique of the perineo-abdominal transpubic approach for pelvic fracture urethral injury (PFUI) is reported in detail. Under all circumstances the operation should be started by a perineal exposure and liberal circumferential mobilisation of the bulbar urethra. The operation proceeds to an abdominal exposure only when a tension-free urethral anastomosis cannot be made from the perineal approach. An omental wrap of the urethral anastomosis is mandatory to guard against the surrounding fibrosis and callus formation. The operation might be indicated for PFUI with a long urethral gap when the urethral anastomosis cannot be made from the perineal approach, and in complex PFUI associated with an intra-abdominal complication. The combined perineo-abdominal transpubic procedure provides a wide and excellent exposure for an easy and neat bulboprostatic urethral anastomosis. Success rates are usually 98-100% and are sustained in the long term.

Optimising the outcome after anastomotic posterior urethroplasty.

OBJECTIVES: To develop a plan that would optimise the outcome after an anastomotic repair of a pelvic fracture urethral injury (PFUI). METHODS: Data on the delayed repair of PFUI from reports in English were critically reviewed. The search criteria included reports by high-volume surgeons and those from tertiary centres of reconstructive urethral surgery. RESULTS: The delayed repair of a PFUI should not be attempted within 4-6 months of the initial trauma. A tension-free, scar-free and mucosa-to-mucosa urethral anastomosis is critically important for a successful outcome. Urethral defects shorter than a third of the bulbar urethral length can usually be repaired by a simple perineal operation, while longer defects usually need an elaborated perineal or perineo-abdominal transpubic procedure. The finest suture that provides adequate strength should always be used for a urethral anastomosis, generally 3/0 polyglactin 910 for adult patients and 4/0 for children. In transpubic urethroplasty, an omental wrapping of the intra-abdominal segment of the bulbar urethra and the site of anastomosis is mandatory. CONCLUSIONS: Anastomotic repair of a PFUI entails various surgical components, and the importance of each of these should not be underestimated. Careful attention to these surgical components is mandatory for a successful outcome after repair.

Bladder neck incompetence at posterior urethroplasty.

The finding of an incompetent bladder neck (BN) at the time of posterior urethroplasty will necessarily exacerbate the already difficult situation. In such cases the aim of the treatment is not only to restore urethral continuity by end-to-end urethral anastomosis, but also to restore the function of the BN to maintain urinary continence. Fortunately, the incidence of incompetence of the BN at posterior urethroplasty is uncommon, usually ≈4.5%. It seems that pelvic fracture-related BN injuries, in contrast to urethral injuries which result from a shearing force, are due to direct injury by the sharp edge of the fractured and displaced pubic bone. The risk of injuries to the BN is greater in children, in patients with a fracture involving both superior and inferior pubic rami on the same side, and in those managed initially by primary realignment. An incompetent BN is suspected by finding an open rectangular BN on cystography, and a fixedly open BN on suprapubic cystoscopy. An incompetent BN can be treated either subsequent to or concomitant with the urethral repair, according to whether a perineal or a perineo-abdominal urethroplasty is used, respectively. Several options have been reported to treat pelvic fracture-related BN incompetence, including reconstructing the BN, forming a new sphincter by tubularisation of a rectangular flap of the anterior bladder wall, and mechanical occlusion by an artificial sphincter or collagen injection. Reconstruction of the BN by the Young-Dees-Leadbetter∗∗ procedure probably provides the most successful results.

Complex pelvic fracture urethral distraction defects revisited.

OBJECTIVE: This study aimed to establish some guidelines for the definition, diagnosis and treatment of complex pelvic fracture urethral distraction defects (PFUDD). MATERIAL AND METHODS: A total of 40 patients with complex PFUDD was enrolled in this study. Urethral defects were associated with a paraurethral bladder base fistula (PBBF) (six patients), urethrorectal fistula (eight), urethrocutaneous fistula (nine), urinoma cavity (eight) or bladder neck incompetence (nine). In four patients the urethra had been wrongly reconstructed into a bladder base fistula (three) or urinoma cavity (one), elsewhere. Repair was performed by a perineal anastomotic urethroplasty in 15 patients and by a perineoabdominal transpubic procedure in 25. RESULTS: Repair was successful in nine out of 15 (60%) patients who received a perineal repair and in 23 out of 25 (92%) who underwent a perineoabdominal transpubic procedure. Of the eight patients with unsuccessful outcomes five were successfully recorrected by transpubic urethroplasty. CONCLUSIONS: A PFUDD may be considered as complex if it is associated with a PBBF, urethrorectal or urethrocutaneous fistula, urinoma cavity, or bladder neck incompetence. Complete excision of a PBBF usually requires a perineoretropubic approach. The initial trauma-related urethrorectal fistula usually opens into the prostatic urethra and its repair requires an abdominal approach, whereas an iatrogenic rectal fistula usually opens into the proximal bulbar urethra and can be resolved by a relatively simple perineal operation. Excision of a urinoma cavity or urethrocutaneous fistula can usually be accomplished from the perineum, while repair of a bladder neck incompetence requires an abdominal approach.

Lower genitourinary trauma in modern warfare: the experience from civil violence in Iraq.

BACKGROUND: Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war. PATIENTS AND METHODS: A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs. RESULTS: Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53-67% of cases and by individual firearms in 33-47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17-22% of cases and by firearms in 78-83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died. CONCLUSIONS: Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.

Urethral and penile war injuries: The experience from civil violence in Iraq.

OBJECTIVE: To determine the incidence, mechanism of injury, wounding pattern and surgical management of urethral and penile injuries sustained in civil violence during the Iraq war. PATIENTS AND METHODS: In all, 2800 casualties with penetrating trauma to the abdomen and pelvis were received at the Al-Yarmouk Hospital, Baghdad, from January 2004 to June 2008. Of these casualties 504 (18%) had genitourinary trauma, including 45 (8.9%) with urethral and/or penile injuries. RESULTS: Of 45 patients, 29 (64%) were civilians and 16 (36%) were Iraqi military personnel. The injury was caused by an improvised explosive device (IED) in 25 (56%) patients and by individual firearms in 20 (44%). Of the patients, 24 had penile injuries, 15 had an injury to the bulbar urethra and six had an injury to the posterior urethra. Anterior urethral injuries were managed by primary repair, while posterior urethral injuries were managed by primary realignment in five patients and by a suprapubic cystostomy alone in one. An associated injury to major blood vessels was the cause of death in eight of nine patients who died soon after surgery (P < 0.001). CONCLUSION: Urethral and penile injuries were caused by IEDs and individual firearms with a similar frequency. Most of the casualties were civilians and a minority were military personnel. Injuries to the anterior urethra can be managed by primary repair, while injuries to the posterior urethra can be managed by primary realignment. An associated trauma to major blood vessels was the leading cause of death in these casualties.

SIU/ICUD Consultation on Urethral Strictures: Urethral strictures in children.

A literature search was made through PubMed from 1990 to the present for articles on strictures in children. There were 32 articles that provided the data for this review. The studies were rated according to the level of evidence and the grade of recommendation using the International Consultations in Urologic Disease standards.

Predictors of erectile dysfunction post pelvic fracture urethral injuries: a multivariate analysis.

OBJECTIVE: To learn the incidence of erectile dysfunction (ED) after pelvic fracture urethral injury (PFUI) and to identify the related risk factors. METHODS: Patients who had sustained a PFUI from 1984 to 2010 were identified from database and invited to participate in the study. All responders were queried after a minimum of 2 years from the time of trauma to assess their erectile function (EF) using the EF domain of the International Index of Erectile Function (IIEF). Medical records and imaging studies were reviewed with a focus on 6 variables that may predict ED. Univariate and multivariate analyses were used to identify parameters predictive of ED. RESULTS: Overall, 90 patients participated in the study, among whom 40 (44%) had ED. On univariate analysis, 4 variables were significant factors for prediction of ED, whereas on multivariate analysis only 3 factors remained strong and independent predictors, namely diastasis of pubic symphysis, lateral displacement of prostate, and long urethral gap. The results of analyses showed that these 3 variables were significant at odds ratios (ORs) of 15.9, 6.9, and 2.0, respectively. CONCLUSION: The development of ED after PFUI can be predicted by 3 factors, namely diastasis of pubic symphysis, lateral prostatic displacement, and long urethral gap. Pubic diastasis has the highest predictive accuracy. A tendency for higher risk of ED could be observed after bilateral rami and Malgaigne's fractures, but they failed to reach the level of significant predictors on multivariate analysis. No relationship was evidenced between ED and age at traumatism.

Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury.

OBJECTIVE: To determine the effect of early realignment of posterior urethral injury on the length and delayed repair of ensuing urethral defect. METHODS: We reviewed the medical records of 120 patients with a pelvic fracture urethral defect who were referred for delayed repair from elsewhere from 1995 to 2009. The review was focused on 5 variables: initial management of urethral injury, length of urethral defect, type of delayed repair, continence, and erectile function. Of the patients, 26 were excluded from the study and 94 were categorized as having been initially treated by realignment (42 patients, group 1) or suprapubic cystostomy (52 patients, group 2). RESULTS: Urethral defects ≤ 2 cm in length were found in 28 patients (67%) in group 1 versus 22 (42%) in group 2. Defects >2 cm were found in 14 patients (33%) in group 1 versus 30 (58%) in group 2. The repair was accomplished by a simple perineal operation in 32 (76%) and 30 (58%) patients in groups 1 and 2, respectively. An elaborated perineal or perineo-abdominal procedure was required in 10 (24%) and 22 (42%) patients in groups 1 and 2, respectively (all P < .05). Incontinence occurred in 1 patient in group 1. Impotence developed in 10 (28%) of 36 realigned adults and in 2 (5%) of 38 adults with suprapubic cystostomy. CONCLUSION: Early realignment of posterior urethral injury decreases the length of the ensuing urethral defect and facilitates its delayed repair. Incontinence and impotence appear to result from the injury itself and not the treatment.

Unsuccessful outcomes after posterior urethroplasty: definition, diagnosis, and treatment.

OBJECTIVE: To establish some guidelines for the definition, diagnosis, and treatment of failed posterior urethroplasty. METHODS: We identified 20 successive patients who required a secondary endoscopic or surgical procedure after anastomotic repair of a postpelvic fracture urethral injury from 1979 to 2010. Of the 20 patients, 18 had undergone perineal repair and 2 a perineo-abdominal procedure. Their medical records were reviewed with a focus on 6 postoperative items: symptoms, onset of unsuccessful result, urethral calibration, urethrocystography, urethroscopy, and treatment. Follow-up ranged from 1 to 25 years (mean 14). RESULTS: Of the 20 patients, 11 (55%) presented shortly after removal of the urethral stent with failure to void (n = 9) or incontinence (n = 2), and 9 (45%) presented 1 month to 12 years after surgery with a weak stream. Early failures resulted from obstruction at the site of repair in 5 patients, retraction of the bulbar urethra in 3, wrong anastomosis to a false tract in 1, and an open bladder neck in 2. Correction was accomplished by salvage urethroplasty in 8 patients and bladder neck repair in 2. Late failures resulted from narrowing of the anastomosis and were corrected by direct visual internal urethrotomy in 7 patients and surgery in 2. CONCLUSION: Unsuccessful outcomes can be encountered shortly after removal of the urethral stent or delayed for several months or years after surgery. Early cases present by an inability to void or incontinence and usually require salvage urethroplasty or bladder neck repair. Late cases present by a weak urinary stream, are due to narrowing of the anastomosis, and are usually corrected by direct visual internal urethrotomy.

Transpubic urethroplasty revisited: total, superior, or inferior pubectomy?

OBJECTIVES: To describe research base pertaining to transpubic urethral surgery and present our experience with this approach to repair pelvic fracture urethral defects. METHODS: A total of 64 patients, 5-40 years old, underwent repair of a pelvic fracture urethral defect via the partial transpubic approach between 1979 and 2008. The length of urethral gap varied from 2.5 to 8 cm (mean, 4.2 cm). A wedge-shaped piece of bone was subperiosteally resected from the medial portions of the pubic bones by an osteotome. The mobilized bulbar urethra was passed up through the subpubic tunnel or rerouted around the left penile crus to be anastomosed to the prostatic apex inside the pelvis. The site of anastomosis was wrapped by an omental pedicle. Follow-up ranged from 1 to 24 years. RESULTS: The results were successful in 63 (98.4%) patients. None of the patients experienced abnormal gait or pelvic girdle pain. Apart from 2 patients who developed stone bladder 6 and 14 years after surgery, no postoperative complications were encountered. Impotence as a direct result of transpubic surgery occurred in 2 patients. CONCLUSIONS: Partial transpubic approach provides an excellent exposure that greatly facilitates the creation of an undervision tension-free and scar-free bulboprostatic urethral anastomosis. It is the only way to go for complex cases associated with intra-abdominal pathologic conditions. For a long-gap posterior urethral distraction defect the excellent results of both the partial transpubic and elaborated perineal procedures compete rather than contradict each other for the best welfare of the patient.

Assessment and management of an open bladder neck at posterior urethroplasty.

OBJECTIVES: To determine the factors that may influence the risk of injury to the bladder neck in patients sustaining a pelvic fracture urethral injury and report our experience in the management of an open bladder neck at the time of delayed repair. METHODS: We identified 21 patients with an open bladder neck on cystography before they underwent repair of a pelvic fracture urethral distraction defect. Of these patients, 12 were continent after urethroplasty and 9 received bladder neck reconstruction concomitant with or subsequent to urethroplasty. Bladder neck reconstruction was performed by Young-Dees-Leadbetter (5) or anterior bladder flap-tube (4) procedure. RESULTS: Patients with an incompetent bladder neck were usually (67%) children

Role of magnetic resonance imaging in assessment of posterior urethral distraction defects.

OBJECTIVES: To determine the clinical usefulness of magnetic resonance imaging (MRI) in the assessment of posterior urethral distraction defects. METHODS: A total of 21 male patients, 6 to 35 years old, with posterior urethral distraction defects underwent MRI of the pelvis and combined antegrade retrograde urethrography before surgical repair. Repair was performed with a bulboprostatic urethral anastomosis through the perineum in 13 patients and transpubically in 8. The MRI and urethrographic findings were compared and correlated with the operative findings. The MRI findings were also correlated with the incidence of posttraumatic impotence. RESULTS: On MRI, the length of urethral defect and type of prostatic displacement could be correctly determined in 86% and 89% of the patients, respectively. Also, MRI precisely delineated the extent of scar tissue, which varied according to the type and magnitude of the original trauma. Furthermore, MRI revealed the presence of paraurethral false tracks in 3 patients. In addition, MRI demonstrated avulsion of the corpus cavernosum, as well as lateral prostatic displacement in all 6 patients with posttraumatic impotence. CONCLUSIONS: Preoperative MRI can provide useful information that might help determine the appropriate surgical repair. It correctly estimates the length of the urethral defect, clearly demonstrates the type and degree of prostatic displacement, precisely delineates the site and density of scar tissue, and reveals the presence of paraurethral false tracks. Also, MRI can identify the cause of posttraumatic impotence such as avulsion of the corpus cavernosum and thus might predict the potency outcome in these cases.

On the art of anastomotic posterior urethroplasty: a 27-year experience.

PURPOSE: We determined the various operative details of anastomotic posterior urethroplasty that are essential for a successful result. MATERIALS AND METHODS: We reviewed the medical records of 155 patients who had undergone anastomotic repair of posterior urethral strictures or distraction defects between 1977 and 2003. Patient age ranged from 3 to 58 years (mean 21) and all except 1 had sustained a pelvic fracture urethral injury as the initial causative trauma. Repair was performed with a perineal procedure in 113 patients, elaborated perineal in 2 and perineo-abdominal in 40. Followup ranged from 1 to 22 years. RESULTS: The results were successful in 104 (90%) cases after perineal (including 2 elaborated perineal) and in 39 (98%) after perineo-abdominal repair. Successful results were sustained for up to 22 years after surgery. Urinary incontinence did not develop in any patients while 2 lost potency as a direct result of anastomotic surgery. CONCLUSIONS: Of the operative details 3 constitute the gold triad that assures a successful outcome, namely complete excision of scarred tissues, fixation of healthy mucosa of the 2 urethral ends and creation of a tension-free anastomosis. When the bulboprostatic urethral gap is 2.5 cm or less, restoration of urethral continuity may be accomplished with a perineal procedure after liberal mobilization of the bulbar urethra. For defects of 2.5 cm or greater the elaborated perineal or perineo-abdominal transpubic procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely (2%) to urethroplasty itself.