V1-06: The Urethral Pull-Through: Reconstructing the Devastated Posterior Urethra and Bladder Neck After Radiation
Recurrent posterior urethral stenosis secondary to radiation-induced damage poses a significant challenge to the reconstructive surgeon. Reconstructive options are limited. Using an IRB-approved database, we present our contemporary experience of 20 patients with radiation-induced proximal urethra/bladder beck stenosis who underwent urethral pull-through urethroplasty and staged artificial urinary sphincter (AUS) placement from 2007-2016.
With the patient in lithotomy position, a midline incision is made from the penoscrotal junction to the posterior perineum. The bulbospongiosus muscle is identified and reflected off of the urethra. The urethra is mobilized posteriorly until the point of obstruction where it is then transected. With the proximal urethra and bladder neck visible, the stenosis is incised and the lumen dilated to size 14 Hegar. The urethra is trimmed and spatulated until healthy tissue is encountered. A Lowsley retractor is used to place a 22-Fr Foley as a suprapubic tube (SP) and a 22-Fr Red Robinson as the pull-through catheter. The pull-through catheter is then advanced into the urethra a length that is dependent on the length needed to span the area of stenosis into the bladder neck. The pull-through catheter is secured to the urethra with chromic suture and is then used to bring the urethra up through the proximal urethra which is allowed to heal by secondary intention. The bulb muscle is then split and placed around the urethra to serve as a vascularized layer around the repair. A large AUS cuff is placed to facilitate subsequent AUS placement. After 4 weeks the SP and pull-through catheters are removed. 12 weeks after urethroplasty, an AUS is placed. We initially use a low pressure 51-60 reservoir and the system is activated 12 weeks after placement.
No high-grade intraoperative complications were observed. 16 patients maintained urethral patency with no further dilation and 17 patients were socially continent at a median follow-up of 22 months (6.6-105 months). A median of 1 sphincter revision surgery was required to establish social continence. 4 patients had recurrent stenosis. There were 4 AUS complications (2 infections and 2 erosions). Two of these patients subsequently had new devices placed and are continent at last follow-up. Two are pending AUS reimplantation.
The urethral pull-through combined with placement of an AUS offers patients urinary continence and durable urethral patency. Our technique can be highly beneficial in the patient that traditionally would have limited desirable options.