V1-10: Is continence possible in patients with double block at bladder neck -prostate and membrano -bulbar urethra after pelvic fracture urethral injury?
Rarely, pelvic fracture urethral injury can cause simultaneous transection of bladder neck and membrano-bulbar junction. Mundy reported sequestration of prostate. In another report, they found 85% of patients of PFUI have functioning external urethral sphincter mechanism after successful anastomotic repair. This information helped in our development of a new technique for repair in such cases to preserve continence.
We present a retrospective review of 8 patients .Preoperative evaluation requires MCU and RGU. Urethroscopy evaluates the membrano-bulbar obliteration. Antegrade cystoscopy confirms the bladder neck obliteration. Pelvic MRI is also obtained to check for the prostate. Perineal incision- bulbar urethra is mobilized and transected proximally. Suprapubic incision- posterior pubectomy is performed. An endoscope passed through SPC tract and blocked bladder neck area is opened from outside. Semen collected in the sequestrated prostatic urethra is aspirated with needle over which prostatic urethra is opened .A 6Fr endoscope is passed through the prostatic urethra distally to visualize the membranous urethra. The membranous urethra is opened perfectly under vision as distally as possible. Excision of the scar at the apex of membranous urethra is kept to minimum to preserve continence. Bulbo-Membranous Anastomosis (BMA) and bladder neck–prostatic anastomosis is performed .
Mean age 14 (5 to 36) yrs ,mean follow up 26 (14 to 72) months .Initial 2 adults are 100% incontinent . We then modified our technique of identifying membranous urethra through intraprostatic scopy and bulbo membranous anastomosis. The video is of an adult who underwent transpubic urethroplasty at age 7 for double block. As prostatic urethra was rudimentary bulbo vesical anastomosis was performed. He presented at age 18 years with pain after ejaculation. He was reoperated using our modified technique.1 adult and all 5 children were approached through the above improved technique. 2 (40%) children required redo surgery with for revision of the bladder neck anastomosis. as we had tried narrow anastomosis to help continence. All children are continent and have good flow, 2 have occasional nocturnal dribbling.
Double transection with injury at membrano-bulbar and prostate bladder neck junction requires two separate anastomoses to be performed. Postoperative continence is possible .Our step wise technique improved continence rates to ensure proper preservation of the external sphincter.