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PFUDD
• Following a pelvic bone fracture with the
destruction of posterior urethral continuity, a
surrounding hematoma-fibrosis complex will
be formed between the two urethral ends.
• Therefore, instead of “stricture,” the term of
“defect” is usually used for the posterior
urethra
• 3% and 25%

Multimodality Management
• Last of the multimodality management by
– Orthopedic
– Vascular
– General surgeon
– Thoracic

MCU + RGU
•
•

•

Characteristic S-bend deformity at the
site of injury.
an apparently long gap between the
distal limit of a complete obliteration on
ascending (retrograde) urethrogram
and the bladder neck on a cystogram
(through a suprapubic catheter).
only that the detrusor is unable to
contract and open the bladder neck and
so allow contrast down to the upper

end of the obliteration

Beaked BN
• It is also quite common to see an apparently
incompetent bladder neck in association with a
complete obstruction but this is usually misleading.
• The reason for this appearance (of a so-called “beaked”
bladder neck) is not clear, but the vast majority of such
patients have a perfectly competent bladder neck
postoperatively.
• When the bladder neck has been damaged, it produces
an altogether different appearance; indeed, it looks as
thought it has been damaged rather than simply being
beaked open.

Bladder neck – filling phase
• Incompetent
• Fixed neck
• Not seen in voiding phase
– ? Obliteration due to fibrosis or callus
– Inability of detrusor to open the neck

BUT
• “The appearance of the bladder neck on
contrast studies or on antegrade endoscopy
does not accurately predict the ultimate
function of the bladder neck after urethral
reconstruction”

Imaging Modalities
• MRI can provide additional information on the
lateral displacement of the prostate and the
severity of the posterior urethral defect.
• Can detect bone fragments between the 2 ends
of the urethra after pelvic fracture.
• MRI should be used in conjunction with RGU and
VCUG and not as a sole method of evaluation.
• ? not of much utility

Role of Flexible Cystoscopy

• Can Lithotomy be Put? (Xrays / ortho)
• ? VASCULARITY
– ED / IIEF
– COLD CLAMMY PENIS
– Need for angiography and prior revascularisation

Rostral / ? lateral displacement

History
• 1962 – Pierce - the ‘‘splendid’’ exposure of the posterior urethra by total
abdominal pubectomy, but he later abandoned this approach because of
postoperative problems and several failures.
• 1968 - Paine and Coombes - direct transpubic excision of the stricture
associated with primary end-to-end anastomosis of the urethral ends,
using a single abdominal incision.
• 1973 – Waterhouse - perineal incision for mobilization of the anterior
urethra and an abdominal incision for transpubic anastomosis between
the bulbar urethra and the prostatic apex.

• 1976 - Turner-Warwick omental wrap to provide vascular and trophic
support to the transpubic bulboprostatic anastomosis.
• In the 1970s and into the 1980s, the perineal-abdominal transpubic
urethroplasty was considered the gold standard in the majority of adults
and children suffering from PFUDDs showing traumatic strictures that
Turner-Warwick described as complex.

Membranous vs Bulbar
• Mundy showed that the disorder is
accompanied by
– avulsion of the bulbomembranous junction in
two-thirds of the cases
– avulsion of the proximal bulbar urethra in onethird.

Timing
• best left ≥3 months from the time of injury.
• If performed earlier the tissues are often still
insufficiently recovered to be able to hold
sutures.
• severe stenoses or obliterations- an augmented
anastomotic repair is necessary.
• two ends are spatulated dorsally, sutured to each
other over their ventral hemi- circumference and
then the dorsal hemi- circumference is
reconstituted with a graft, generally of buccal
mucosa

Railroading
• Most of these alternatives are a variation on the
theme of ‘retrograde catheterisation’ devised by
Verguin.
• This was ‘rediscovered’ and popularised in the
1890s and became standard treatment during the
1920s and 1930s, particularly after Banks and
subsequently Davis described the technique of
combined antegrade/ retrograde passage of
specially modified urethral sounds and thus of a
urethral catheter, without the need for perineal
exploration

Primary repair
• Main indications for primary repair are
penetrating injuries, injuries of the bladder
neck and prostate, injuries associated with
perineal degloving and injuries associated
with a rectal tear’
• Early intervention for severe dislocation of the
bladder and prostate, the so-called ‘pie-in-thesky’ bladder, and in female patients may be
helpful but less urgent

• the first problem being that it does not
actually realign the urethra, it simply retains
luminal continuity.
• This other premise is that ePR reduces the
length of the fibrotic segment and thereby
facilitates DU.

? Primary repair
Primary realignment techniques described in the literature include
• simple passage of a catheter across the defect
• catheter realignment using flexible/rigid endoscopes and
biplanar fluoroscopy
• use of interlocking sounds (‘railroading’) or magnetic catheters
to place the catheter
• catheter traction or perineal traction sutures to pull the prostate
back to its normal location
• pelvic haematoma evacuation and dissection of the prostatic
apex (without suture anastomosis) over a catheter.
• Open realignment techniques that include suture anastomosis
between the prostatic apex and the membranous urethra should
be considered a form of immediate open urethroplasty.

Paediatric PFUDD
• Reconstruction of pediatric PFUDD represents
a significant surgical challenge because of the
– smaller pelvic confines,
– smaller caliber of the urethra,
– the less developed and therefore less elastic
nature of the preadolescent corpus spongiosum
– Less developed vascularity
– increased tissue fragility.

Delayed repair
• Webster
• Turner warwick
• Waterhouse

• Perineal approach
• Progressive perineal
• PAPA / Transpubic

? Approach
• Most posterior urethral distraction defects are short
and usually resolved by a perineal approach
anastomotic repair.
• However, a ‘perineal progressive approach’ is required
when the prostatobulbar gap is longer than 2–3 cm
due to a high dislocation of the prostate or when the
mobilized urethra is too short because of damage
during a previous surgical procedure.
• The progressive approach involves a series of
manoeuvres to produce sufficient anterior urethral
mobility to bridge up to 8 cm of separation

Caveat
• While there is no panacea for the management of
posterior urethral strictures, it is generally agreed
that the optimal procedure is a one-stage
anastomotic repair, preferably performed
through the perineum alone
• It is only uncommon, extremely complex
strictures that should require an
abdominoperineal approach or substitution urethroplasty

Procedure
• perineal exposure of the bulbar and posterior
urethra facilitated by a perineal Book-Walter retractor or perineal OmniTrac retractor.
• The first step of the procedure is circumferential
mobilization of the bulbar urethra as far
proximally as the obliterated segment
• The proximal urethra is transected at the point of
obliteration, and the urethra is then mobilized
distally to a few centimeters distal to the crus

• A descending urethral sound is passed
through the suprapubic cystostomy and
negotiated by ‘‘feel’’ through the bladder neck
and into the proximal urethra.
• If the stricture is short and pelvic floor fibrosis
minimal, the tip of the sound can be palpated
easily in the dissection in the perineum.
• In these circumstances a one-stage perineal
anastomosis can usually be assured.

? Haygrove dilator
• Hossieni et al. in their experience have described the
role of flexible cystoscopy in the intraoperative
localization of the proximal healthy urethra.
• In this technique, cystoscope is passed through the
bladder neck from the prostatic urethra and the tip of
the cystoscope is placed on the end of the stricture.
• The scar tissue is resected under the guidance of
cystoscopic light. Then a needle is passed through the
perineum into the proximal urethral end under the
guidance of the flexible cystoscope light.

Use of haygrove dilator?
• This maneuver has eliminated the occurrence
of false passages with use of a sound such as
the Haygrove staff through the suprapubic
site, and also has eliminated the occurrence of
misanastomosis of the anterior urethra to
sites other than the apical proximal urethra.

• The pelvic floor scar is incised perineally until the
tip of the sound is exposed and the
prostatomembranous urethra spatulated
posteriorly.
• The verumontanum should be visible in the floor
of the spatulated opening.
• At this point it will be apparent whether a simple
anastomosis will be possible or if further maneuvers will be necessary to achieve a tension-free
anastomosis

Bulbar dissection
• Further circumferential mobilization of the
distal urethra as far as the suspensory ligament of the penis.
• To prevent chordee, the dissection should not
extend beyond the ligament, which can be
incised to facilitate urethral elongation.
• After this mobilization, the healthy adult
urethra can be stretched as much as 2 to 3 cm,
which proves sufficient for anastomosis

corporal separation
• Separation of the proximal 4 to 5 cm of the
corporal bodies beginning at the level of the
crus distally, dissecting in the relatively bloodless plane between them
• The urethra can be laid between the
separated corporal bodies, which can shorten
the distance for anastomosis by 1 to 2 cm and
is sufficient for anastomosis in 41% of cases

Inferior pubectomy.
• A 1.5 to 2 cm wide wedge of bone can be
excised from the inferior surface of the pubis
exposed by corporal separation
• Routing the mobilized urethra between the
separated corpora and through the bony
defect will further shorten the distance to the
prostatic urethra by 1 to 2 cm and facilitates
anastomosis in 28% of cases.

Supra-crural re-routing
• If the urethra still appears to be too short after
the three previous maneuvers, the urethra can be
re-routed around the lateral surface of a corporal
body
• It is necessary to create a tunnel in the bone
beneath the corporal body and communicate this
with the tunnel created by inferior pubectomy.
• The urethra is then laid in this pathway, rerouting it around the corporal body, which
shortens the distance to the anastomosis by 1 to
2 cm.
• This is usually sufficient for the final 23% of cases

Pubectomy
• changed from total to partial
• complications, such as
– profuse bleeding and
– problems arising out of the large dead space including the
cosmetic deformity of an externally visible depression in
the prepubic region.

• Partial pubectomy may be in the form of a
superior or inferior pubectomy.

Pubectomy
• pubectomy can be associated with long-term
sequelae that include
– shortening of the penis,
– destabilization of erection, and
– destabilization of the pelvis,
– resulting in a chronic pain syndrome with exercise

Partial sup pubectomy
• Koraitim et al - perineoabdominal partial superior pubectomy
complex posterior urethral distraction defects.
• In superior pubectomy, about 1.5 × 0.5 inch of bone is resected
along with the arcuate ligament.
• superior pubectomy  greatly facilitates exposure of the normal
urethra proximal to the injury site and thereby downward
mobilization of the superiorly displaced prostate.
• fistulous communication to the surrounding organs and bladder
neck incompetence at the same time.
• pedicled omental graft can be brought down to obliterate the
perianastomotic dead space
• This is also helpful in managing the defects in prepubescent boys
who may have a narrow body habitus and in whom the distal
urethral mobilization may be limited by the insufficient blood
supply to the glans

PERINEAL REPAIR
(Webster)

Urethral mobilisation upto the
suspensory ligament

Corporal splitting

PERINEAL REPAIR
(Webster)

Inferior pubectomy

Corporal re-routing

PAPA
• majority of posterior urethroplasties can be performed
through the perineum alone
• The abdominoperineal approach involves both perineal
and retropubic exposure of the urethra and prostate
with removal of a segment of pubic bone to facilitate
exposure.
• The main indication for this approach is to improve
visualization and to facilitate the removal of fistulous
tracts and periurethral epithelialized cavities, the
excision of scar tissue at the prostatic apex, and the
performance of a tension-free anastomosis

• The patient is positioned in the lithotomy position but prepped for
a possible abdominal exploration.
• The initial dissection is perineal and the urethra is transected at the
level of obliteration.
• The first three steps of the progressive perineal approach are
performed, including inferior wedge pubectomy.
• If retropubic exposure is needed, a lower midline abdominal
incision is made down to the base of the penis.
• The prevesical or retropubic space is dissected down to the level of
the prostatic apex, staying close to the periosteum of the
retropubis, until communication is made with the perineal
dissection.
• It is helpful to open the bladder high on the anterior wall so a finger
can be used to help direct the retropubic dissection and avoid the
bladder neck

• Excising an entire anterior wedge of pubis using a Gigli saw
• however, equally good access is achieved by partial removal of the
posterior surface of the pubis using a Capener’s gouge
• Inferior wedge pubectomy will have been completed perineally, and
this—combined with retropubic bone removal—will provide wide
anterior access, which facilitates anastomosis and access to the
pelvic floor to manage the complicating features that were the
indication for this approach.
• At the completion of the procedure the bladder neck and
anastomosis should be wrapped with an omental flap to preserve
functional mobility as well as facilitate future re-exposure if
needed.

• This approach is very successful (greater than
85% success rate) in expert hands with few
complications.
• A re-stricture rate of ~50% has been reported by
some surgeons using a transpubic approach,
which emphasizes the importance of surgeon
experience and proper patient selection.
• The technique has been criticized for causing
excessive blood loss as well although McAninch
did not find this to be the case in 30 patients who
underwent the procedure

Combined Abdominoperineal Transpubic
Approach for More Complex Injuries
• Indications for this approach
Fistulous tracts
Inability to achieve the lithotomy position
Pelvic floor cavities
Long posterior urethral strictures

Waterhouse procedure
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Postoperative Problems
Incontinence
Anastomotic stenosis
Impotence
Nerve injury
Rhabdomyolysis

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