Predictors of elaborated perineal or a combined abdominoperineal approach during repair for pelvic fracture urethral injury.

PURPOSE: A step-based anastomotic urethroplasty is a standard technique for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). We aim to identify pre-operative factors, including results of conventional radiological imaging, for prediction of elaborated perineal or a combined abdominoperineal procedure. METHODS: Retrospective observational study on 114 consecutive patients undergoing urethroplasty for PFUI between January 2020 and December 2022 was conducted. Surgical procedures were categorized according to the Webster classification into two groups: steps 1-2 (group 1) and steps 3-4 or a combined abdominoperineal repair (group 2). Pre-operative pattern results of RGU/VCUG were categorized regarding the relation between the proximal urethral stump with the pubic symphysis: posterior urethral stump below (pattern 1) or above (pattern 2) the lower margin of the pubic symphysis. Patient demographics were assessed. Univariate and multivariate logistic regression analyses were utilized. RESULTS: Overall, 102 patients were enrolled in the study for data analysis. On the multivariate logistic regression analysis, the presence of erectile dysfunction (OR 4.5; p = 0.014), prior combined treatment (endoscopic and urethroplasty) (OR 6.4; p = 0.018) and RGU/VCUG pattern 2 (OR 66; p < 0.001) significantly increased the likelihood of the need of step 3 or higher. CONCLUSIONS: The need of step 3 or higher during urethroplasty for PFUI can be predicted pre-operatively with conventional imaging (RGU/VCUG). Patients with proximal urethral stump above the lower margin of pubic symphysis were about 66 times more likely to need step 3 or higher during urethroplasty.

Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis.

BACKGROUND: Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis. METHODS: A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment. RESULTS: Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18). CONCLUSION: Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.

Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment.

OBJECTIVE: To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. PATIENTS AND METHODS: This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. RESULTS: All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). CONCLUSION: Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.

[Outcomes of partial pubectomy assisted anastomotic urethroplasty for male patients with pelvic fracture urethral distraction defect].

OBJECTIVE: To summarize the clinical outcomes of partial pubectomy assisted anastomotic urethroplasty for male patients with pelvic fracture urethral distraction defect (PFUDD) and discuss the skills of partial pubectomy. METHODS: The clinical data of 63 male patients with PFUDD were retrospective reviewed. The procedure of the anastomotic urethroplasty was as follows: (1) circumferentially mobilizing the bulbar urethra; (2) separating the corporal bodies; (3) performing the urethral anastomosis after partial pubectomy and exposure of the healthy two ends of the urethra. RESULTS: The mean age of the patients was (39.2±15.6) years (range: 15-72 years). The median time between incidents and operation was 15 months (range: 3-240 months) and the mean length of stricture was (3.85±0.91) cm (range: 1.5-5.5 cm). All the patients had undergone suprapubic cystostomy in acute setting. Thirteen patients (20.6%) were re-do cases and the patients who had undergone dilation, direct vision internal urethrotomy (DVIU), and open primary realignment were 22 (34.9%), 8 (12.7%), and 8 (12.7%), respectively. Assisted with partial pubectomy, the anastomotic urethroplasty had been successfully performed in all the patients. The mean time of operation was (160.2±28.1) min (110-210 min), and the mean evaluated blood loss was (261.1±130.3) mL (100-800 mL). There were 3 cases (4.8%) with perioperative blood transfusions. The postoperative complications were bleeding and urinary tract infection, which were controlled conservatively. The mean maximum urine flow rate was (23.7±7.4) mL/s (15.0-48.2 mL/s) after removing the catheters 4 weeks after urethroplasty. The median follow-up was 23 months (12-37 months). The urethroscopy showed 2 cases of stricture recurrences and 1 case of iatrogenic penile urethral stricture due the symptoms of urinary tract infection and decreased urine flow and all of them were successfully managed with dilation. CONCLUSION: Partial pubectomy can effectively reduce the gap between the ends of the urethra and promote tension-free anastomosis during the anastomotic urethroplsty for patients with PFUDD. The skills of the procedure include good exposure of the anterior surface of pubic symphysis between the separated corporal bodies, carefully mobilizing and securing the deep dorsal vein of the penis, removing the partial pubic bone and the harden scar beneath the pubic bone for good exposure of the proximal urethral end.

Usefulness of a high-speed surgical air drill in pubectomy during delayed anastomotic urethroplasty for pelvic fracture urethral injury.

OBJECTIVES: Pubectomy is an ancillary technique used to increase exposure of the disrupted urethra and reduce anastomotic tension, which can be difficult for inexperienced surgeons. The objective of the present study was to illustrate the use of an air drill enabling delicate and precise bone resection in pubectomy for delayed anastomotic urethroplasty for pelvic fracture urethral injury. METHODS: Between 2009 and 2019, 88 male patients underwent delayed anastomotic urethroplasty with pubectomy for pelvic fracture urethral injury. A total of 73 procedures used a high-speed surgical air drill (HiLAN HS; Aesculap, Tuttlingen, Germany) equipped with a short-hand piece. Operative time and blood loss in the air drill patient group (group 1) were compared with that of patients who underwent pubectomy using a rongeur and/or gouge (group 2, n = 15). RESULTS: In 65 group 1 patients, urethroplasty was carried out using the perineal approach, with partial inferior pubectomy. Eight group 1 patients, whose proximal urethral end was displaced upward superior to the upper edge of pubis, underwent urethroplasty using the perineal and abdominal approach, with a superior partial pubectomy and supracrural urethral rerouting. No difficulty was encountered using the air drill in any of the cases. There was no significant difference in median operative time between the groups (group 1 256 min vs group 2 228 min; P = 0.31). The median blood loss in group 1 was significantly lower than group 2 (149 mL vs 453 mL; P < 0.0001). CONCLUSIONS: Surgical air drills might facilitate pubectomy in patients undergoing delayed anastomotic urethroplasty for pelvic fracture urethral injury. This tool offers the advantage of a delicate bone resection with reduced blood loss.

[Combined transperineal and transpubic urethroplasty for patients with complex male pelvic fracture urethral distraction defect].

OBJECTIVE: To evaluate the clinical effects and characteristics of combined transperineal and transpubic urethroplasty for patients with complex pelvic fracture urethral distraction defect (PFUDD). METHODS: We retrospectively reviewed the clinical data of 17 male patients with complex posterior PFUDD from January 2010 to December 2019. The complications included urethrorectal fistulas in 2 patients (11.8%), urethroperineal fistula in 1 patient (5.9%). Ten patients had undergone previous treatments: dilatation in 3 patients (17.6%), internal urethrotomy in 1 patient, failed urethroplasty in 6 patients (35.3%), of whom 2 patients had two times of failed urethroplasties. All the patients were performed with urethroplasty by combined transperineal and transpubic approach with removing the entire pubic bone followed by the anastomosis. RESULTS: The mean age of the patients included in this study was 35.5 (range: 21-62) years. The mean length of stricture was 5.5 (range: 4.5-7.0) cm, the mean follow-up was 27 (range: 7-110) months, the mean time of operation was 190 (range: 150-260) min, the mean evaluated blood loss was 460 (range: 200-1 200) mL. There were 5 patients who needed blood transfusion intraoperatively or postoperatively. Wound infection was seen in 4 out of 17 patients and thrombosis of lower extremities in 1 out of 17 patients. The last follow-up showed that the mean postoperative maximum urinary flow rate was 22.7 (range: 15.5-40.7) mL/s. After removing the catheter, one patient presented with decreased urinary flow and symptoms of urinary infection. Cystoscopy showed the recurrent anastomotic stricture, which was cured by internal urethrotomy. In our series, the success rate of the combined transperineal and transpubic urethroplasty was 94.1% (16/17). CONCLUSION: Combined transperineal and transpubic urtheroplasty can achieve a tension free anastomosis after removing the entire wedge of pubis in some patients with complex PFUDD. However, this procedure should be completed in a regional referral hospital due to the complexity of the operation and the high percentage of complications.

Redo inferior pubectomy for failed anastomotic urethroplasty in pelvic fracture urethral injury.

Objectives: To assess the effect of redo inferior pubectomy on the management of complicated pelvic fracture urethral injury (PFUI) in patients with a history of failed anastomotic urethroplasty. Materials and methods: We retrospectively reviewed all patients receiving redo anastomotic urethroplasty with redo inferior pubectomy for failed PFUI between January 2010 and December 2021. Patients with incomplete data and those who were lost to follow-up were excluded. Successful urethroplasty was defined as the restoration of a uniform urethral caliber without stenosis or leakage and further intervention. Functional results, including erectile function and urinary continence, were evaluated. Descriptive statistical analyses were then performed. Results: Thirty-one patients were included in this study. Among them, concomitant urethrorectal fistula occurred in 2 patients, and concomitant enlarged bladder neck occurred in 1. The stenosis site was the bulbomembranous urethra in 2 patients and the prostatomembranous urethra in 29. The mean length of urethral stenosis in all patients was 3.1 cm (range, 2.0-5.0 cm). After a mean follow-up of 34.6 months, the final success rate was 96.8%. The incidence of erectile dysfunction reached 77.4% (24/31). Normal continence was achieved in 27 (87.1%) patients. One patient developed urinary incontinence of grade II requiring urinary pads because of an enlarged bladder neck. According to the Clavien-Dindo classification, postoperative complications of grade I occurred in 7 patients and grade II in 4. Conclusions: Repeat anastomotic urethroplasty with repeat inferior pubectomy provides reliable success rates for failed PFUI. In complicated cases, it should be known and mastered.

Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control.

BACKGROUND: Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE: To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS: We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS: Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS: Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY: We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

Outcome of anastomotic urethroplasty in traumatic stricture (distraction defect) of posterior urethra in boys.

OBJECTIVE: To report the outcomes of operative management of traumatic posterior urethral distraction defect in boys at our Centre, as traumatic posterior urethral stricture in children is a rare condition that presents a major surgical challenge to the paediatric urologist and consensus on the optimal treatment of these strictures in children has not been reached. PATIENTS AND METHODS: We retrospectively analysed our data from July 2013 to June 2018. All boys aged ≤16 years with traumatic posterior bulbo-prostatic obliteration (distraction defect) were included. Initial suprapubic cystostomy and delayed definite anastomotic urethroplasty was done in all the boys. The boys were evaluated preoperatively with a retrograde urethrogram and simultaneous voiding cystourethrogram, as well as cystourethroscopy. RESULTS: A total of 38 boys, with posterior urethral distraction defect, were divided into primary and redo surgery groups. The primary group comprised 34 boys who were operated upon for the first time. A perineal approach with development of an inter-crural space was done in 12 boys and along with an inferior pubectomy in 19 boys. Three boys in the primary group needed a transpubic approach due to a longer defect. In the redo group, there were six boys, of which four were operated initially outside our hospital, while two were our own unsuccessful urethroplasties. In the redo group, a perineal approach with inferior pubectomy was done in two boys and a transpubic urethroplasty in the remaining four boys. The success rate of anastomotic urethroplasty without any ancillary procedures was 81.5% (strict criterion), while the overall success rate was 94.7% (permissible criterion, which included boys who were managed later with direct vision internal urethrotomy and dilatation). CONCLUSION: The ideal treatment of post-traumatic posterior urethral defect/strictures in boys is tension-free bulbo-prostatic anastomosis. This was done using a transperineal approach in most of the boys, but a few required a transpubic approach, with good results. ABBREVIATIONS: DVIU: direct vision internal urethrotomy; SPC: suprapubic cystostomy; SUI: stress urinary incontinence.

Outcome of anastomotic posterior urethroplasty with various ancillary maneuvers for post-traumatic urethral injury. Does prior urethral manipulation affect the outcome of urethroplasty?

PURPOSE: We present our success rate and complications of delayed anastomotic urethroplasty (DAU) in patients with post-traumatic posterior urethral injury. MATERIALS AND METHODS: This was a retrospective study of patients aged ≥17 years that underwent DAU for post-traumatic posterior urethral injury during 2010-2014. Stricture length was measured by ascending and descending urethrogram. Success of procedure was considered when the patient was free of stricture-ralated obstruction and needed no further intervention. Primary group includes patients who underwent first time delayed urethroplasty while secondary group included patients who had some sort of urethral manipulation in local hospital. Results were analyzed using unpaired t-test, Chi-square test, binary logistic regression, Kaplan-Meier curves, and log-rank test. RESULTS: Of the 80 male patients, 73 (91.25%) patients underwent primary DAU while 7 (8.75%) patients had secondary DAU. Median age, stricture length, and follow-up were 27.0 ± 12.7, 1.6 ± 0.9, and 3.2 ± 0.9, respectively. Overall, success rate was 83.75% while success rate in primary group was 89.04% and secondary group was only 28.57% (P = 0.0059). Regarding ancillary maneuvers, urethral mobilization alone was done in 29 (36.25%) patients with success rate (72.41%), corporeal body separation in 36 (45%) patients with success rate (91.66%), inferior wedge pubectomy in 13 (16.25%) with success rate (84.61%), supracrural rerouting in 1 (1.25%) with success rate (100%), and abdominoperineal approach in 1 (1.25%) with success rate of 100% (P = 0.193). Patients who had prior urethral manipulation affect the outcome of definitive anastomotic urethroplasty. CONCLUSION: DAU has durable success rate with less morbidity. Ancillary elaborated maneuvers are frequently needed in patients with complex and elongated post-traumatic posterior urethral defect with successful outcome.