Effect of the improved proximal urethral transection in the treatement of posterior urethral stricture
10.3760/cma.j.cn112330-20240402-00164
- VernacularTitle:改良近端尿道断离法治疗后尿道狭窄的效果
- Author:
Xuxiao YE
1
;
Chongrui JIN
1
;
Jiemin SI
1
;
Zuowei LI
1
;
Wenxiong SONG
1
;
Yinglong SA
1
Author Information
1. 上海交通大学医学院附属第六人民医院泌尿外科 上海东方泌尿修复重建研究所，上海 200233
- Publication Type:Journal Article
- Keywords:
Urethral obliteration;
Urological surgery;
Perineal approach;
Repair and reconstruction
- From:
Chinese Journal of Urology
2024;45(12):912-917
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To investigate the therapeutic efficacy of the improved proximal urethral transection method in treating posterior urethral stricture.Methods:A retrospective analysis was conducted on clinical data from 1 787 male patients treated from January 2013 to May 2023 for pelvic fractures associated with posterior urethral disruption or obliteration. The ages of the patients ranged from 18 months to 76 years, with an average age of (34.3±4.1) years. Etiologies included pelvic compression injuries due to traffic accidents (867 cases), falls from height (464 cases), and machine-related pelvic compression injuries (456 cases). Preoperative suprapubic cystostomy was performed in 1 536 cases. All patients underwent preoperative excretory and retrograde urethrography, urethral ultrasonography in 187 cases, urethroscopy in 1 440 cases, and urethral MRI in 38 cases. The average length of the stricture or obliterated segment was (3.1±0.5) cm. Posterior urethral stricture was present in 281 cases (15.7%) with maintained urethral continuity, while complete posterior urethral obliteration occurred in 1 506 cases (84.3%). Preoperative urethrocystoscopy and urethral MRI were used to determine the distance from the verumontanum to the stricture or obliterated segment, >2 cm identified in 1 434 cases (80.2%) and ≤2 cm in 353 cases (19.8%). Before surgery, 1 073 cases had IIEF-5 scores≤21 points, 672 cases had IIEF-5 scores≥22 points, and 42 cases without sexual activity refused the questionnaire survey. Surgical method: The perineal region was disinfected, and a urethral probe was introduced through the suprapubic cystostomy site into the bladder neck, directly reaching the proximal end of the obliterated urethra. The tip of the probe was palpated with the left index finger on the body surface and marked. An inverted " Y" -shaped incision was made centered around this point, followed by dissection of the skin, subcutaneous tissue, and bulbospongiosus muscle to expose the bulbous urethra. The bulbous urethra was isolated and retracted. Scar tissue above the bulbous urethra was incised to expose the perineal transverse ligament. Guided by the probe, the perineal transverse ligament was transected using an electrosurgical knife above the urethra, while horizontal dissection was performed along the perineal central tendon to separate the urethra from the anterior rectal wall. Bilateral dissection of the surrounding scar tissues extended up to the tip of the probe at the posterior urethra. Scar tissue at the probe tip was incised, revealing the probe. Then, proximal urethra was prepared and set aside after its around scar tissue was trimmed. The distal urethra was mobilized to an adequate length upwards, with scar tissue trimmed and prepared as well. Using 4-0 absorbable sutures, eight sutures were placed at positions 1, 2, 4, 5, 7, 8, 10, and 11 on the urethra. An F16 urethral catheter was left in place, and the incision was closed. Record the duration of surgery, amount of bleeding, number of blood transfusions, and transfusion volume. Four weeks postoperatively, the catheter was removed, and patients were instructed to urinate spontaneously. Six months later, assessments included uroflowmetry and the international index of erectile function (IIEF-5) questionnaire, with a Q max>15 ml/s indicating successful surgery and an IIEF-5 score ≥ 22 indicating normal erectile function. Results:All patients successfully completed the surgery, the average operation time was (75.5±8.5) minutes, and the average intraoperative blood loss was (110.4±13.2) ml. 62 patients received intraoperative blood transfusion, with an average volume of (285.5±15.5)ml. The follow-up period was (26.1±4.5) months. A total of 1 729 patients (96.7%) achieved a Q max>15 ml/s. Among the 38 patients with postoperative voiding difficulties, 26 patients improved after internal urethrotomy, and 12 patients underwent a subpubic anastomosis three months later. Postoperative urinary incontinence occurred in 20 patients: 11 patients improved after urethral suspension surgery, and 5 patients achieved urinary control with an artificial urinary sphincter. The remaining patients were under follow-up (unwilling to undergo surgery). Erectile dysfunction (IIEF-5 score≤21) was observed in 1 202 cases (67.2%), with 528 treated with sildenafil, resulting in varying degrees of improvement in 120 cases. Fifteen patients restored erectile function with expandable penile prostheses. Conclusions:The perineal approach for the improved proximal urethral transection is suitable for most posterior urethral stricture surgeries. It enables rapid and accurate identification of the proximal urethra, simplifies the steps of urethral anastomosis, and demonstrates clinical efficacy.
