Editorial: Specialty within a specialty – posterior urethroplasty
Posterior urethral distractions occur in up to 25% of cases of blunt force pelvic fractures. Proper repair of these pelvic fracture urethral injuries (PFUI) is an art that requires exquisite attention to technique and tissue handling. Koraitim and Kamel [1] recently reported their single-surgeon series of PFUI repairs on 86 patients, with the specific aim of characterizing risk factors for treatment failure. Success was defined subjectively as absence of urinary symptoms and normal postoperative urethrography. Requirement for repeat procedures constituted failure. At a mean 5.5 years of direct follow-up, 88% of patients were considered to have had successful treatment. Multivariate logistic regression showed that incomplete scar excision and lateral prostatic displacement (as opposed to superior or no displacement) were predictive of treatment failure (odds ratios 122 and 34, respectively). All other factors analysed, including previous treatment, relative bulbar urethral scarring, mucosal fixation, suture size and number of sutures, were not significant predictors of urethral outcomes.
Large patient series of posterior urethroplasty report treatment success rates of 86–97%, although follow-up has been short in general [2-4]. The present report by Koraitim and Kamel compares favourably with these series, despite longer patient follow-up. This suggests that late failures after posterior urethral repair are rare. The authors should be commended for their desire to ascertain risk factors for failure after repair of these urethral injuries; however, several factors that probably affect outcomes were not evaluated and may at least partially explain some of their treatment failures.
Erectile dysfunction (ED) is known to occur in ~5% of men after pelvic fracture, and to increase to a mean of 42% in those with a concomitant urethral injury [5]. A portion of these men with ED will have arterial insufficiency and will be at increased risk of bulbar necrosis and ischaemic stenosis. Before urethral reconstruction, men with ED should be evaluated with penile duplex ultrasonography and, if arteriogenic ED is suggested, pelvic angiogram. In those with bilateral complete obstruction of the deep internal pudendal or common penile arteries, revascularization should be offered before urethral reconstruction. In this patient population, penile revascularization has been shown to reverse arterial insufficiency, leading to both improved erections and enhanced tissue perfusion for optimum outcomes after posterior urethral reconstruction [6].
A progressive perineal approach has been popularized by Webster and Ramon [4] and generally accepted by those regularly performing posterior urethral reconstruction. While the present authors report extensively on relative excision of fibrosis and number, type and location of suture utilization, they do not provide insight into the number of ancillary measures necessary for a tension-free repair. While some argue that the importance of crural separation and infrapubectomy are overstated [3], these techniques are essential in some patients in order to achieve a tension-free anastomosis. Given that fibrosis was incompletely excised in 15% of patients in this cohort, some of these same patients may also have had some degree of tension of the urethral anastomosis. Alternatively, these adjunctive procedures may be independent predictors of treatment success or failure and their role in this series would be interesting to note.
It is our experience, and surely that of others, that direct long-term follow-up after urethroplasty at a tertiary referral centre is often difficult or non-existent. These authors should be applauded for their ability to follow their patients for a mean 5.5 years in this series. They have provided much needed extended outcome data after posterior urethral reconstruction. The challenge going forward will be for high-volume centres of reconstruction to design studies prospectively that answer specific questions using standardized instruments and objective results.
