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.