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.

Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis.

OBJECTIVES: To assess outcomes of transecting vs non-transecting urethroplasty for bulbar urethral stricture in terms of stricture recurrence rate, sexual dysfunction, and patient-reported outcome measures (PROMs) related to lower urinary tract (LUT) function. METHODS: Electronic literature searches were conducted using PubMed, Cochrane Library, Web of Science and Embase databases. The studied population was limited to men with bulbar urethral stricture included in studies that compared outcomes after transecting and non-transecting urethroplasty. The main outcome appraised was the stricture recurrence rate. Additionally, the incidence of sexual dysfunction appraised in three domains (erectile function, penile complications, and ejaculatory function) and PROMs related to LUT function after transecting vs non-transecting urethroplasty were assessed. The pooled risk ratio (RR) respectively for stricture recurrence, erectile dysfunction and penile complications was calculated using a fixed-effect model with inverse variance method. RESULTS: In all, 694 studies were screened with 72 identified as relevant. Finally, 19 studies were suitable for analysis. The pooled difference between the transecting and non-transecting groups relating to stricture recurrence was not significant. Overall, the RR was 1.06 (95% confidence interval [CI] 0.82-1.36) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for erectile dysfunction was 0.73 (95% CI 0.49-1.08) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for penile complications was 0.47 (95% CI 0.28-0.76) and the 95% CI did not cross the line of no effect (line RR = 1). Hence, the risk of penile complications was significantly lower in the non-transecting group. CONCLUSIONS: Our analysis of available evidence indicates that both transecting and non-transecting urethroplasties, are equal in terms of the recurrence rate. On the other hand, non-transecting techniques are better in terms of sexual function, causing less penile complications.

Management of Pelvic Fracture Urethral Injury: Is Supracrural Urethral Rerouting (Step 4) Becoming Anecdotical or Does It Remain in Force?

Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. We evaluated the outcomes of anastomotic urethroplasty (especially Step 4 or higher) or substitution urethroplasty in patients with PFUI at our center. Between 2013 to 2021, we retrospectively collected data on patients with PFUI. Surgical procedures were categorized according to the Webster classification and rates of each step were reported. The success rate was defined as Qmax above 10 mL/s and no need for further treatment. In this period, 737 male patients with PFUI were surgically treated. Notably, 18.8%, 17.6%, 46%, 1.8%, and 5.6% of included patients received steps 1, 2, 3, and 4 and the abdominoperineal approach, respectively. In 68 (9.2%) patients, the substitution of urethroplasty with a pedicled preputial tube (PPT) was needed. The success rate was 69.2% in Step 4, 74.4% in the abdominoperineal approach, and 86.4% in PPT; however, recurrence-free survival was not significantly different between groups (p = 0.22). Step 4 perineal anastomotic urethroplasty represents a surgical option in the armamentarium of PFUI treatment. Indications should be carefully reviewed to improve patient selection and avoid surgical failure, stopping at the step which first gives a tension-free anastomosis.

Which Are the Commonest Sites and Characteristics of Post-Transurethral Prostate Surgery Strictures in a High-Volume Reconstructive Center?

Background: Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center. Methods: We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017 to 2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture. Results: Median stricture length was 5 cm (4-7). One hundred forty-one (70.1%) patients received previous no-invasive treatments (dilatation and/or direct visual internal urethrotomy). Proximal bulbar urethra was the commonest site for stricture, whereas panurethral stricture (≥10 cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared with patients with other involved segments (26% vs 19%, p = 0.03), and it was the only predictor of penile and midbulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naive, p = 0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), whereas ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approaches in membranous strictures. Conclusions: Most patients who were referred for TPS-induced stricture attempted previous noninvasive managements. Referred TPS-induced urethral strictures were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach because of the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in a specific segment of urethra, namely the penile and midbulbar urethra.

Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures.

BACKGROUND: Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. OBJECTIVE: To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. DESIGN SETTING AND PARTICIPANTS: Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. SURGICAL PROCEDURE: The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. MEASUREMENTS: Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. RESULTS AND LIMITATIONS: We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5-8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5-26 ml/min). The median follow-up was 25 mo (IQR 10-30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. CONCLUSIONS: In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. PATIENT SUMMARY: Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.