|Year : 2017 | Volume
| Issue : 1 | Page : 23-28
Progressive perineal urethroplasty for pelvic fracture urethral distraction defect in prepubertal children: The outcome
Bipin Chandra Pal, Pranjal R Modi, Syed Javid Farooq Qadri, Jayesh Modi, Suresh Kumar, Ramya Nagarajan, Yusuf Safee
Department of Urology and Transplantation Surgery, Institute of Kidney Diseases and Research Center and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India
|Date of Web Publication||23-Nov-2016|
Bipin Chandra Pal
Department of Urology and Transplantation Surgery, Institute of Kidney Diseases and Research Center and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children.
Materials and Methods: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1 st year and for every 6 months in the subsequent years.
Results: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients.
Conclusion: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.
Keywords: Pelvic fracture urethral distraction defect, prepubertal, urethra, urethroplasty, urethrotomy
|How to cite this article:|
Pal BC, Modi PR, Qadri SJ, Modi J, Kumar S, Nagarajan R, Safee Y. Progressive perineal urethroplasty for pelvic fracture urethral distraction defect in prepubertal children: The outcome. J Indian Assoc Pediatr Surg 2017;22:23-8
|How to cite this URL:|
Pal BC, Modi PR, Qadri SJ, Modi J, Kumar S, Nagarajan R, Safee Y. Progressive perineal urethroplasty for pelvic fracture urethral distraction defect in prepubertal children: The outcome. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2017 Jul 22];22:23-8. Available from: http://www.jiaps.com/text.asp?2017/22/1/23/194616
| Introduction|| |
Management of obliterative strictures after pelvic fracture and urethral injury in children is a challenging task for the reconstructive urologists. The urethra is small, the pelvis is narrow, and the tissues are fragile. Most of the studies of pelvic fracture urethral distraction defect (PFUDD) in children have varying age range from 3 to 18 years. ,,, The pelvic anatomy after adolescence almost represents the adult pelvis. We believe that the complexity and outcome of this surgery in prepubertal children truly demand a separate analysis.
Here, we present our series of PFUDD in prepubertal children and discuss the challenges encountered, the lessons learnt, and the outcome of urethroplasty in these subgroup of patients.
| Materials and Methods|| |
Retrospective data of nine prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. The etiology of PFUDD was road traffic accident in seven patients and fall from height in two patients.
All these patients were initially managed for their injury at other centers. Five of these patients were referred primarily to our center for urethroplasty while four were referred after a failed urethroplasty. Eleven urethroplasties were performed in these nine patients.
All the patients had a suprapubic catheter at the time of referral which was changed at the time of admission. Basic investigations in the form of complete hemogram, serum creatinine, urine culture sensitivity, and ultrasonography of the abdomen were done. Micturating cystourethrogram (MCUG) and retrograde urethrogram (RGU) were performed subsequently [Figure 1]. Two patients were very apprehensive and required sedation before the procedure. Patients were subjected to antegrade and retrograde endoscopic assessment of the urethra before the definitive surgery.
|Figure 1: Micturating cystourethrogram showing complete block below verumontanum (left side) and retrograde urethrogram showing complete block at proximal bulbar urethra (right side)|
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Under general anesthesia, the patients were placed in a lithotomy position with precautions to prevent position-related injury. The infraumbilical abdominal and perineal area was painted and draped in one field. An inverted Y-shaped incision was given in the midline of the perineum. Colles' fascia was cut with the electrocautery. Bulbospongiosus muscle was identified and gently dissected off the corpus spongiosum and opened in the midline. The urethra was circumferentially dissected distally up to the penoscrotal junction and proximally up to the scarred fibrotic tissue and transected at this level.
The dense sclerosed fibrotic tissue was carefully excised completely till the supple tissue was reached. If needed, crural separation and inferior pubectomy were performed.
The proximal urethra was opened over a Haygrove staff. This urethra was spatulated at 12 o'clock position. Mucosal everting fixation sutures were taken with 4-0 vicryl (polyglactin 910) interrupted sutures. Hemostasis was achieved meticulously.
The bulbar urethra was mobilized up to the penoscrotal junction. It was trimmed back to a visibly normal area and spatulated at 12 o'clock position. The mucosa was fixed with 4-6 interrupted 4-0 vicryl suture. A tension-free bulboprostatic anastomosis was done by 8-10 interrupted 4-0 vicryl sutures over an 8 or 10 Fr Foley catheter according to the age of the children.
The bulbar urethra is fixed on each side near the anastomotic site with two 2-0 vicryl interrupted sutures to further reduce any tension.
The wound was closed in layers after obtaining hemostasis and putting a drain. The operating surgeon routinely used a ×2.5 magnification throughout the procedure. A light compression dressing was applied.
Postoperatively, the patients were given intravenous antibiotics for 5 days followed by oral antibiotics till the removal of catheter. The drain was removed on the 2 nd postoperative day. The patients were discharged on the 7 th postoperative day.
MCUG was done at 3 weeks, and if no extravasation was observed, the urethral catheter was removed and voiding trial was given. Suprapubic catheter was removed subsequently after 48 h. These children were followed up 3 monthly in the 1 st year and 6 monthly in subsequent years with uroflowmetry.
| Results|| |
Mean age of the patients was 7.3 (range 5-11) years. Complete loss of urethral continuity was observed in all the cases during the antegrade and RGU. MCUG showed a complete block distal to verumontanum in all the cases. In one case, the bladder neck was open during the cystogram phase. Three cases had associated vesicoureteral reflux (VUR). One had the right Grade II VUR while the other two had bilateral Grade II/III VUR. RGU showed a complete block at the level of the proximal end of bulbar urethra in all the cases. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. Antegrade cystourethroscopy revealed a normal bladder neck with mucosal coaptation in all the cases. Verumontanum was visualized in all the cases. There was no evidence of scarring or false passage at or distal to the level of the bladder neck. Retrograde urethroscopy revealed normal penile and bulbar urethra with complete block at the level of proximal bulbar urethra. All the 11 urethroplasties were successfully performed by the perineal approach. Crural separation was performed in all the cases while inferior pubectomy was additionally required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. Intraoperative blood transfusion was given in three patients. None of the patients had any wound infection. One patient had a left calf hematoma, related to the lithotomy position, which resolved over a period of 2 weeks.
Two patients had minimal extravasation at the anastomotic site after catheter removal which was treated by re-catheterization for further 2 weeks. All the patients were continent after surgery except one. This patient had transient incontinence with the passage of few drops of urine two to three times a day. It resolved over a period of 6 months with conservative management.
Successful urethroplasty was defined as having voiding history as before the surgery with normal patency at the site of anastomosis during postoperative MCUG. Failure was defined as need of any intervention after the urethroplasty. Seven out of nine patients had successful urethroplasty. Two patients had failed urethroplasty and presented within 1 month of the surgery. Redo-urethroplasty was performed successfully after waiting for 3 months in both the cases. Both patients required inferior pubectomy for the tension-free anastomosis. An initial success of 77.7% was achieved whereas an overall success of 100% was achieved. MCUG at the time of catheter removal showed worsening of VUR in two cases, resolution of reflux in one case, and appearance of VUR in one case.
Erectile function could not be assessed in these patients because of their tender age.
The description of all the patients is shown in [Table 1].
|Table 1: Progressive perineal urethroplasty: Description of all the patient|
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| Discussion|| |
Boone et al. have described three different types of urethral injury (supraprostatic, transprostatic, and prostatomembranous) in prepubertal boys.  They speculated that intra-abdominal position of the bladder and ill-developed prostate are responsible for the varying locations of the distraction defect. Glassberg described the extension of the prostatomembranous injury into the bulbar urethra. 
However, we and others Koraitim, Podesta and Kardar ,, believe that the pelvic trauma leads to snapping off of the bulbomembranous junction which is the weakest and unsupported area rather than any other mechanism of injury. ,, In our study, verumontanum was visualized in all the cases during antegrade scopy which further bolsters our belief. The defect is longer because of the proximal migration of prostate due to shearing off of the delicate puboprostatic ligament. The aim of the surgery in such cases is to have a patent, continent, and durable repair of the urethra with least number of urethral instrumentation. 
These children are very apprehensive, and at times, it is difficult to perform the urethrogram and cystogram in them. They should be made comfortable, and if needed, sedation should be judiciously used in them while performing the study. Besides, sometimes, the prostatic urethra may not fill with the contrast during cystography due to various reasons and may depict a bigger defect than usually it is. Therefore, it is mandatory to do an endoscopic assessment before the definitive surgery which gives additional information.
Before the commencement of the surgery, an emphasis should be given on proper positioning of the patients and cushioning of the lower limbs to avoid the hematoma and compartment syndrome formation as observed in one of our case and reported once in literature. 
During surgery, in redo cases, it is prudent to put a catheter in the urethra at the time of initial dissection as proper planes between the tissues are lost; as a result, the delicate urethra can be easily injured.
Once the bulbar urethra is dissected and freed from the scar tissue, it usually retracts significantly. Furthermore, the bulbar urethra is not well developed in these children. Both these factors produce a significant gap between the two urethral segments.
The excision of the scar is of paramount importance as has been described by various studies. ,, Four of our referred cases had failed anastomotic urethroplasty. During the surgery, dense fibrotic tissue was encountered in all these cases. The practice of cutting over a Haygrove staff and performing anastomosis without excising scar should be abandoned. 
Once the supple tissue is reached, the proximal urethra is opened and spatulated at 12 o'clock position. The mucosa of the spatulated urethra has a tendency to retract proximally. The visualization of this retracted mucosa is difficult in the narrow space and the small urethra with the naked eye. We use ×2.5 loupe for the proper and magnified visualization so that the mucosa can be held and fixed laterally with the prostatic tissue as described by Koraitim.  The bulbar urethra is trimmed back to normal area and again spatulated at 12 o'clock position. Mucosa is fixed by interrupted 4-0 vicryl. Fixing the mucosa helps in mucosa-to-mucosa bulboprostatic anastomosis. We spatulate the two ends of urethra on the same side [Figure 2]. This step minimizes tension at the anastomosis when tying sutures, as the distance between the two spatulated edges is less on the same side at 12 o'clock position rather than when the urethra is spatulated on opposite sides.
Two of the cases where the urethroplasty was primarily performed by us failed because of the tension at the anastomotic site. Tension at the anastomosis produces ischemia and can lead to restricture formation. Moreover, in children, the vascularity of the bulbar urethra could be further compromised because of the less developed dorsal artery of the penis. In our series, to lessen the anastomotic site tension, crural separation was required in all the cases while inferior pubectomy was needed additionally in six cases.
Transpubic approach is advocated more often in children. Podestα described the requirement of transpubic approach in defects of more than 3 cm.  In our series, all patients had a defect of <3 cm. However, in cases that had a defect of more than 2 cm, the operative time was consistently more than 300 min. One of the patients in this group had a calf hematoma. More operative time can lead to position-related complications or other complications related to prolonged surgery, and these cases can be labeled as moderate or high risk.
Free hand tying of the preplaced anastomotic suture is difficult in these cases. The tip of the finger may not go deep enough for the proper placement of suture because of the narrow pelvic angle; as a consequence, the knots may remain loose. In such scenario, it is better to use the needle driver and the forceps for the proper placement of sutures. Again, the use of magnifying loupe is advisable at this step.
We observed transient incontinence in one patient after surgery which resolved over a period of 6 months. Incontinence in such cases usually occurs when there is an associated bladder neck injury which is evident during radiological and endoscopic evaluation or because of detrusor overactivity. Senocak observed 30% incidence of incontinence in his series because the patients had a high incidence of primary bladder neck injuries.  Podesta and Podesta had similar observation where five out of nine incontinent patients had bladder neck or sphincteric injury.  In our series, all but one patient had closed bladder neck during MCUG. There was no endoscopic evidence of bladder neck injury in any of our cases, and mucosal coaptation at bladder neck was seen in all the cases including the case where the bladder neck was open during the cystogram. We did not do urodynamic study to document whether the incontinence was due to detrusor overactivity or sphincteric weakness. The incontinence usually settles over a period of time by conservative management.
Few of these patients had worsening of VUR or appearance of VUR during MCUG at the time of catheter removal after urethroplasty. These patients were on suprapubic catheter for a long time after the injury as the definitive surgery has to be delayed for 3-6 months. This can lead to a decrease in the capacity and compliance of the defunctionalized bladder. Furthermore, the catheter makes the bladder irritable. Following catheter removal after urethroplasty, as the bladder regains its function and bladder cycling ensues, the capacity and compliance of the bladder usually improve which leads to the resolution of the VUR in these patients. In the study by Koraitim and Senocak, reflux resolved in 76% and 78% of the cases, respectively, after urethroplasty. ,
Two patients had failed urethroplasty. They presented within 1 month of the surgery. Many authors have concluded that most failures occur within the 1 st postoperative year, after which the results are durable. , Redo-anastomotic urethroplasty was done in both of them. Conflicting views exist regarding the outcome of internal urethrotomy in the failed urethroplasty for children. Helmy and Hafez have described a success of 90% with visual internal urethrotomy in failed urethroplasty with short strictures.  Noe et al. have described an initial success of 87%, but one-third of their patients required another intervention.  We believe that most of the restrictures are because of the residual fibrosis or ischemia, and a redo-urethroplasty is a better and more durable solution than the internal urethrotomy or dilatation in children.
The erectile function of these patients could not be assessed because of their young age. It will be interesting to look into this matter as the age advances and the children grow to adulthood.
There is a lack of guidelines in literature regarding the follow-up tool for these children. We follow-up these patients with uroflowmetry and rely more on the bell-shaped pattern of the flow rather than the Qmax. We achieved an initial success of 77.7% and an overall success of 100% in our study. Similar results were observed in other studies too; however, the age range was variable and included older children also. ,,
| Conclusion|| |
This study shows the feasibility of perineal approach for PFUDD in prepubertal children. Combined antegrade and RGU should be bolstered with preoperative endoscopy before definitive surgery. Incontinence and VUR can develop after urethroplasty, but often resolve with conservative management. Redo-urethroplasty rather than the internal urethrotomy should be done in failed urethroplasty. These surgeries should be performed at a tertiary care center by an experienced reconstructive urologist with the help of proper armamentarium.
We are thankful to our librarian Jyotsana Suthar for literature search and submission.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]