Urethroplasty - Anastomotic Urethroplasty - Membranous urethra

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Pelvic Fracture Urethral Distraction Defect (PFUDD).


Most patients with pelvic fracture urethral injury are involved in horrific accidents. Urethral distraction injuries occur in about 10% of pelvic fracture patients. India with a population of 1 Billion has 1% vehicle population of the world but the road traffic accident rate is 6%. Around 100,000 people died in road traffic accidents in 2005, and around 1.5 million were injured. The immediate management of PFUDD is resuscitation of the patient from life threatening injuries. The next step is to divert urine from the injury site by suprapubic cystotomy. However the morbidity of  urethral injury often associated with stricture, incontinence and impotence, tends to take a higher profile later on. We reviewed and compared the operative surgical steps to achieve tension free anastomosis and outcomes in a large series of children and adults suffering from PFUDD.


  1. All routine
  2. Ascending and descending urethrogram
  3. Duplex color Doppler for impotence
  4. CT / MRI for large PFUDD’s and complex cases

Pre-operative Preparation

  1. Antibiotics – according to urine culture - Ceftriaxone and Amikacin
  2. Betadine scrub to the abdomen and perineum 
  3. Shaving on the operation table
  4. Check the movement of hip joints to see if proper lithotomy position can be given under anesthesia


  1. Spinal my choice
  2. Epidural for complex cases
  3. General anesthesia supplemented if necessary
  4. Atenelol (Beta Blocker) to maintain heart rate around 60 / minute and systolic BP around 90-100 mm of Mercury


We prefer Lloyd Davis lithotomy position as a routine. Some authors prefer exaggerated lithotomy position. At times, due to the fixed hip joints the Surgeon has to perform surgery through narrow angle between the abducted legs.

Perineo-Abdominal Progression-Approach (PAPA)

The surgery is performed following six steps.

  1. Bulbar urethral mobilization.
    Incision: Vertical midline incision is preferred.  Inverted Y fork at the bottom of the incision is usually not required.  For complex urethroplasties with skin substitution in mind an inverted U incision may be made.   The skin incision is deep up to the bulbo spongy muscle.  Then lateral dissechon is performed superficial to the muscle.  This helps in maintaining the integrity of the muscle.  A Turner Warwick ring retractor with six blades is applied.  The Bulbo Spongiosus muscle is split in the midline.  The dissection continues lateral to the corpora spongiosa.  The spongiosa is lifted from the cavernosa by sharp dissection and circumflex vessels from cavernosa to spongiosa are coagulated.
    A 6 F feeding tube is passed around the mobilized urethra.  The feeding tube is manipulated to further dissect the urethra from cavernosa.    This minimizes handling of spongiosa.
    The distal mobilization of the bulbar urethra is continued till the penoscrotal junction. Index finger is passed posterior to the mobilized distal urethra between spongiosa and cavernosa.  The penis is pulled up and the finger should reach up to the penile base but should not encroach on the penile urethra.  Mobilization of the penile urethra may lead to chordee formation and is avoided.  Mobilization of the distal end of the bulbar urethra up to the suspensary ligament of the penis as described by some authors is difficult to perform as we do not dissect dorsal to the penis at its base.
    Proximal dissection of the bulbar urethra allows lifting of the bulb from the perineal body.  A mastoid retractor is placed inside the bulbo spongiosus muscle and spread to allow the proximal bulb dissection.  Alternately stay sutures placed at the corners of the bulbo spongiosus muscle and with the use of ring retractors knobs the stay sutures can be anchored safely.  A Babcock forceps applied gently to the ventral spongiosa squeezes it and allows lateral and posterior dissection of the bulb under vision.
    The next step is to pass a urethral bougie ( sound ) through the meatus proximally.  The tip is rotated laterally with the help of the knob of the dilator.  If I can feel the tip with a finger my proximal dissection is sufficient.  If I don’t feel the tip, I need more dissection proximally.
    Proximally the urethra is transected at the site of fibrosis. The bulbar urethra is opened and spatulated for 1.5cm. A rigid 17-Fr cystoscope is passed through the suprapubic cystotomy and passed  into the prostatic urethra. An incision is made in the perineum over the scar and the cutting is performed under the light of the endoscope. This maneuver prevents anastomosis to the false passage. The scar at the apex of the prostatic urethra is completely excised avoiding aggressive dissection on the postero-lateral surface of the prostate near the neuro-vascular bundles.
  2. Crural separation
    An incision is made between the corpora cavernosa at the midline and the avascular plane between the corporal bodies is created using Metzenbaum scissors, at a length of 3-4 cm. In redo cases, the crural separation may be difficult and any inadvertent opening of the corpora cavernosa is immediately repaired.
  3. Inferior pubectomy
    A mastoid retractor is applied to spread the crura apart. Gentle dissection allows visualization of the dorsal penile vein, which is laterally retracted, its collateral tributaries require coagulation with a bipolar current or ligation. An incision is made at the midline on the anterior aspect of the pubic symphysis. Using a diathermy blade bent to 45 degrees at the half-way point, the periostium is elevated from the pubic bone laterally on either side. Inferior pubectomy is performed using a Capener’s gouge and a rongeur. Adequate size of the bone is excised providing space enough to rotate the needle holder.
  4. Supra-crural rerouting (Figure 1)
    The mobilized bulbar urethra is pushed in, up to the prostatic urethra to check the tension at the anastomotic site. If there is any tension at the anastomosis, the next step is followed. At the base of the penis, one side of the corpora cavernosa is dissected. A small pubectomy is necessary to make room for the urethra and its supracrural route. The surgeon’s index finger should be able to go through the space smoothly without bony spicules and fibrous tissue. This maneuver allows the S-shape of the urethral route to be straightened out and gives us a tension-free anastomosis.
  5. Total pubectomy using transpubic approach ( Figure 2)
    If supracrural rerouting of the urethra still does not allow for a tension-free anastomosis, the next step is followed. This step may be necessary for complex, redo and pediatric cases with the classical pie in the sky bladder and extensive hematoma fibrosis. Through a midline infra-umbilical incision, the retropubic space is dissected. The anterior surface of the bladder is gently dissected all around. The periosteum over the anterior surface of the pubic bone is incised, and a total pubectomy is performed with a Capener’s gouge and rongeur or using a Gigli saw. The bladder is inspected and the bladder neck is evaluated. A retrograde bougie is passed through the bladder neck into the prostatic urethra. The firm and white scar at the prostatic apex is excised. We insert non-tooth forceps to open the prostatic urethra, placing six sutures at positions 1,3,5,7,9, and 11 o’clock using 4/0 polyglycolic acid suture on a 16mm 3/8th circle taper cut needle. All the sutures are placed on the mosquito forceps and parked with the ring retractor following a clock format. Care is taken not to tangle the sutures. A 14-Fr Foley silastic catheter is inserted and the knots are tied.
  6. Omental wrap   (Figure 3)
    The peritoneum is incised at the midline towards the umbilicus. The omentum is mobilized. At this point, the patient may notice some discomfort under spinal anesthesia and general anesthesia may have to be supplemented. The omentum is wrapped around the anastomosis and fixed to itself with sutures. The omentum fills the dead space created by the pubectomy and keeps the anastomotic site supple. The peritoneum is closed leaving a small gap for the omentum. A 16-Fr Foley catheter is used as a suprapubic tube. Abdominal or perineal drains are rarely used. The abdominal and perineal incisions are closed and an X-shape compressive dressing is applied to the perineum.

Post-operative Care and Follow up

Once the patient is mobile and well, he is discharged from the hospital usually 4 days later.
A pericatheter urethrogram is obtained 3 weeks post operatively and the urethral catheter is removed in the absence of extravasation. The suprapubic catheter is removed a day later. Uroflowmetry was performed at the end of 3 months and annually thereafter. When symptoms of decreased force of stream were present or uroflowmetry was less than 12 ml per second, retrograde urethrography was repeated. If urethral narrowing was evident urethroscopy was performed. Follow-up ranged from 12 to 120 months.

Criteria of success

Normal voiding with normal flow on uroflowmetry, freedom from instrumentation such as dilation, DVIU and self calibration.