V1-05: Redo bulbo-prostatic anastomotic (BPA) urethroplasty for recurrent pelvic fracture-related urethral strictures
Surgical reconstruction of bulbomembranous urethral strictures following traumatic disruption of the pelvic ring requires careful assessment of both urethral edges, incision/excision of scar tissue and a tension-free anastomosis. Revision surgery is complicated by further loss of urethral length and often requires certain maneuvers to straighten the course of the proximal urethra and bridge longer defects. These techniques, achieved via a transperineal approach, are demonstrated in this video. The outcomes of redo-BPA are presented.
A 35 year old man developed stenosis of the bulbomembranous urethra associated with a pelvic fracture sustained during a fall from height. This recurred after anastomotic urethroplasty. During revision surgery the midline perineal incision was re-opened.The bulbar urethra was mobilised proximally off the central tendon up the point of obliteration and transected at this level. The proximal end was identified by means of a sound introduced suprapubically and spatulated. The scar tissue was excised until healthy mucosa was exposed. The distal end was mobilised and spatulated. The intercrural plane was developed, inferior wedge pubectomy performed and the urethra rerouted around the left crus of the penis to facilitate fashioning a tension-free anastomosis. _x000D_ _x000D_ Between January 2006 and December 2014, 117 patients with pelvic fracture-related urethral injuries were treated in our unit. 29 patients (24.8%) had previous attempts at repair (one attempt n=24; two attempts n=1; more than two previous repairs n=4)._x000D_
The procedures performed (in a stepwise fashion) were: anastomotic urethroplasty n=10; corporal separation n=4; wedge pubectomy n=3; rerouting of the urethra n=6. Abdomino-perineal exposure was necessary in 6 patients in order to carry out entero-urethroplasty or repair associated bladder neck injuries or fistulae. _x000D_ A successful outcome (unobstructed voiding with no evidence of radiological recurrence and no need for further surgery or instrumentation) was achieved in 22 patients (75.9%) compared to 85% in those having a primary procedure. _x000D_
The best outcome after BPA is seen in previously un-operated patients and recurrences are more difficult to salvage. Revision surgery is technically challenging but is nonetheless feasible and associated with favourable outcomes in a specialised high-volume centre.