Year : 2012 | Volume
: 28 | Issue : 1 | Page : 113--114
Entero-urethroplasty: A new hope for complicated bulbo-membranous urethral strictures
Dheeraj Kumar Gupta
Dheeraj Kumar Gupta
|How to cite this article:|
Gupta DK. Entero-urethroplasty: A new hope for complicated bulbo-membranous urethral strictures.Indian J Urol 2012;28:113-114
|How to cite this URL:|
Gupta DK. Entero-urethroplasty: A new hope for complicated bulbo-membranous urethral strictures. Indian J Urol [serial online] 2012 [cited 2020 Oct 28 ];28:113-114
Available from: https://www.indianjurol.com/text.asp?2012/28/1/113/94973
In this study, 11 men with complicated strictures of the bulbo-membranous urethra were treated by interposition of a tailored intestinal flap. A segment of intestine, with a mean length of 8 cm (range 5-12), was harvested from the ileum (n=1), the stomach (n=1), the right colon (n=2) and the sigmoid colon (n=7); mobilized on its vascular pedicle and tailored to a caliber of 26-30 Fr. Harvesting a vascular pedicle for the selected intestinal segment was the vital step of the procedure. This was partly achieved by mobilization but mostly by sacrifice of part of the bowel it supplies. Intestinal flap was then sutured between the stump of the prostate and the distal bulbar or proximal penile urethra either through the normal perineal route for the urethra or a more direct route through a gutter cut in the superior pubic ramus.
The sigmoid colon was the preferred segment because it is physiologically more expandable and the origin of its vascular pedicle is closest to the apex of the prostate and the perineum. However, other bowel segments had to be used because of previous surgery or extensive fibrosis in the pelvis.
A catheter was kept for 3 weeks post-operatively and voiding trial was given when a peri-catheter urethrogram showed no evidence of extravasation. Patients were followed up for a mean duration of 7 years (range 2-12). Six patients had an uneventful post-operative course while three developed a proximal anastomotic contracture that was managed initially by interval dilatation. Out of these three, finally one required revision of the proximal anastomosis while another patient was managed by creating an entirely new flap. Two patients developed a stone in the gut segment. The complication rate with technique was less than with a scrotal tunnel or tubularized free-grafts of bladder mucosa.
Posterior urethral distraction injuries are best managed by tension-free end-to-end anastomosis in a delayed one-stage perineal repair. Tension is relieved by full mobilization of bulbar urethra. When mobilization alone is insufficient to reduce tension, same can further be reduced by straightening out the natural course of the bulbar urethra from the peno-scrotal junction to the apex of prostate. This sequence of mobilization from crural separation to inferior wedge pubectomy and, proceeding ultimately to rerouting of the urethra when necessary, is known as the "trans-perineal progression approach." 
Occasionally, an abdomino-perineal trans-pubic approach may be required when the stricture is >3 cm long, is complicated by recto-cutaneous or peri-urethral fistula, chronic peri-urethral cavity, simultaneous bladder neck or rectal injury, and when proximal urinary tract is displaced anteriorly and stuck to the back of pubis. 
Recurrence after primary perineal repair can be treated with an abdomino-perineal approach, although repeat perineal anastomosis can be done with high success rates. When repeated surgery fails, salvage is technically more difficult and challenging. The commonly used salvage procedure is to make a scrotal flap and tunnel it up to the apex of the prostate, provided the bladder neck sphincter is competent. Unfortunately, the perineo-scrotal skin, by this time, is commonly scarred by previous surgery or trauma, increasing the failure rate. Colonic tube grafts have been tried but have failed as grafts require a vascularize bed to survive.  The authors have used an intestinal flap for salvage based on previous two reports of entero-urethroplasty. ,
In conclusion, entero-urethroplasty is suitable for patients with urethral distraction defect due to pelvic fracture with previous failed urethroplasty but competent bladder neck. It is not suitable for those who have incompetent bladder neck or scarred prostatic urethra and bladder neck.
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