Accesso combinato nella chirurgia ricostruttiva delle stenosi post traumatiche dell’uretra posteriore

Urologia 2009; 76: 192-197.

Abcstract: the aim of this study is to show and evaluate the combined procedure, wich uses an endoscopic soprapubic access and a surgical perineal access to repair posterior urethral strictures secondary to traumatic pelvis fracture.

Material and methods: in the period from January 1989 to December 2007 eighty-nine patients underwent urethral surgery for post-traumatic posterior urethral stricture. From January 2003 all patients underwent combined endoscopic and surgery technique. According to this technique, the patient is placed in simple lithotomic position with the calves carefully placed in Allen stirrups. Two surgical teams work simultaneously. A middle-line perineal incision is made and the bulbar urethra is isolated proximally and the membranous urethra is transected at the strictured site. At the same time the second surgical team performs an endoscopic suprapubic access placing the “Amplatz” sheath, previous progressive dilation to 20/22 Ch. By using a rigid or flexible cystoscope the operator follows endoscopically the bladder neck and reaches the stenotic site performing an anterograde urethroscopy. At this point the perineum is transilluminated by the endoscope and the surgeon can easily identify the proximal urethral end. A soft guide wire is inserted at this point into the urethra through the endoscope to facilitate the dilation till a nose speculum can be inserted. At this point an end-to-end anastomosis is performed. A Foley 18 Fr catheter and suprapubic cystostomy are left in place for 1 month; a voiding cystourethrography is then performed.

Results: The bulboprostatic anastomosis shows better results (65% of success) if compared with the other techniques (Badenoch, two-stage urethroplasty, perineal urethrostomy). A definitive increase in the success rate (10%) has been evident in the last five years, simultaneously to the use of combined technique.

Conclusion: The combined perineal and suprapubic access, in post-traumatic posterior urethral strictures repair, allows achieving a better and easy location and a better preparation of the proximal urethra. The final target is to obtain a better bulboprostatic anastomosis, with better results confirmed by long-term follow-up. In particular, the endoscopic management of the suprapubic access is possible anf of minor invasiveness to the patient.