Sep 1 2006
A Recent Review from J. Zhang and Colleagues from ShangHai, China Examined the Surgical Approach to the Posterior Urethral Distraction Defect in Boys.
An elaborate 1-stage anastomotic repair via a perineal exposure has been described by Webster which allows a tension-free anastomosis even in long defects if a 4-step sequential approach in followed. This technique which involves, in order, distal urethral mobilization, crural separation, inferior pubectomy, and urethral rerouting has been described specifically in adults but there is no reason to believe that the technique couldn't be transferred to the pediatric population.
The study group was comprised of 24 boys 7 to 14 years old (mean 10) who underwent posterior urethroplasty between 1998 and 2002. All patients had sustained pelvic fractures with urethral disruptions. Initial treatment was primary realignment in 6 patients (25%) and suprapubic cystostomy alone in 18 (75%). The urethral distraction defects, as measured by retrograde urethrography and antegrade cystography, were 1 to 5 cm long (mean 2.9cm). One of three surgical approaches was used. Five patients underwent perineal approaches, 10 patients underwent a transperineal-inferior pubic approach as described by Webster, and 9 patients underwent a combined transperineal and transpubic repair in which a wedge-shaped piece of pubis was resected in order to achieve a tension-free anastomosis.
Patients were followed post-operatively for 12 to 60 months (mean 31.7). Analysis of the results showed that a 1-stage anastomotic repair was successful in 3 of 5 patients (60%) using a perineal approach, in 9 of 10 (90%) using a transperineal-inferior pubic approach, and in 7 of 9 (77%) using a transpubic-perineal approach. All failed treatments were at the anastomosis and occurred within the first year post-operatively.
The authors suggest that posterior distraction defects in boys differ from adult males in a couple of ways. First, because the prostate and puboprostatic ligament are not fully developed in boys, the disruption sometimes occurs across the prostatic urethra or the bladder neck, and the posterior urethral stricture tends to be higher. The authors also believe that the narrowness of the pelvis in young boys limits exposure and the use of normal surgical instruments and a transpubic approach may solve this problem. There is some concern, however, about the stability of the pelvis if total pubectomy is performed. With this in mind, the authors finally conclude that the inferior pubectomy, performed via a perineal approach described by Webster, should be the surgical approach of choice when dealing with posterior distraction defects in boys.
Written by Michael J. Metro, MD - UroToday
J Urol. 2006 July;176 (1):292-95
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