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Paediatric Urology
Table 4: Success After Delayed Anastomotic Urethroplasty of
approach is related to stricture length, with a transpubic approach
the Posterior Urethra
utilised in longer strictures (commonly >3cm). We prefer to begin all
paediatric posterior urethroplasty operations via the perineal
Series Number Success (%)
approach. If circumurethral mobilisation is not able to achieve a
Onen et al.
27
16 12 (75)
tension-free anastomosis or if excessive urethral mobilisation is
Rourke et al.
4
8 7 (87.5)
Das et al.
3
10 8 (80)
thought to potentially result in penile shortening, additional
Podesta
1
30 26 (86.7)
maneouvres such as splitting the corporal bodies, partial pubectomy or
Koraitim
2
65 60 (92.3) re-routing of the urethra around the corporal bodies can be employed.
Converting to a transpubic approach via an infra-umbilical incision will
delayed anastomotic urethroplasty, primary alignment and immediate allow total pubectomy if the above steps are insufficient for successful
anastomotic urethroplasty). We do not advocate immediate repair as outcome. There is added morbidity to the operation, with a second
we feel that proceeding with a prolonged operation in the setting of incision and total pubectomy; however, there has not been a negative
a child with more serious injuries is not appropriate. Impotence and association with eventual bone growth, posture or gait from total
incontinence have been reported to be worse after acute repairs, and pubectomy in the paediatric population.
1,3,6
If total pubectomy has
are likely related to overaggressive dissection of tissue that is inflamed been performed, clinicians should monitor the pubic bone with
from the acute injury.
24
periodic plain radiographs of the pelvis for potential re-growth of the
pubic bones medially (which could impinge on the re-routed urethra).
Direct comparison of primary alignment and suprapubic cystostomy
with delayed repair is difficult due to the absence of studies that rigidly Boys – Outcome
subject each management option to the same definition of success Table 4 details the success rates from the some of the largest modern
(i.e. absence of the eventual need for future intervention, such as series of paediatric pelvic fracture urethral disruption defects after
urethral dilation or internal urethrotomy). One obvious advantage of anastomotic urethroplasty.
1–4,27
With regard to successful resolution of
primary alignment is that if urethral stricture persists after urethral posterior urethral stricture after primary alignment, Podesta and
catheter removal, the stricture length will potentially be shortened and colleagues reported no patients to be successfully managed with
future management might be successfully achieved with a less invasive
procedure (i.e. urethral dilation or internal urethrotomy versus more
invasive anastomotic urethroplasty). The validity of this statement has
Crucial to the success of an
been questioned in a study of paediatric boys with pelvic fracture
posterior urethral disruptions, which found no difference in eventual
anastomotic urethroplasty is total
urethral stricture length between the delayed-repair (n=19) and
excision of the stricture and a
primary alignment (n=10) cohorts.
24
Even so, small numbers in this
study preclude the ability to translate these results into a definitive
tension-free urethral anastomosis.
management strategy. We do not believe that periodic urethral
dilation or internal urethrotomy is appropriate, especially in the
paediatric population. Instead, we favour anastomotic urethroplasty, primary urethral alignment (0/10); however, a different study did
which is a more definitive repair and has the advantage of reducing report urethral patency without need for additional procedures in
the psychological stress associated with multiple procedures, long- 57% (8/14). These results are significantly worse than those achieved
term complications and frequent hospitalisations.
9
with delayed repair. We have not discussed the role of urethral dilation
or endoscopic internal urethrotomy in this article. We do not favour
Impotence and incontinence outcomes in the literature can be difficult urethral dilation for management of paediatric urethral strictures.
to compare, with multiple reports claiming different results after Endoscopic internal urethrotomy is most useful in select situations,
endoscopic alignment and suprapubic tube with delayed such as short bulbar urethral strictures associated with minimal
urethroplasty. In experienced centres, incontinence and impotence spongiofibrosis; however, we do not favour repeated utilisation of this
rates after endoscopic alignment in adult patients are 4 and 36%, procedure for recurrent strictures as it is not associated with cure.
28
respectively.
25
Suprapubic tube with delayed urethroplasty in the same
study found minimal improvement in incontinence (2.7%) but a more Girls – Management and Outcome
significant reduction in impotence among those with erections Management of acute paediatric female urethral disruption is different
pre-injury (18 versus 36% endoscopic alignment). Lastly, it has been from that in boys secondary to the common association of vaginal
shown that impotence can occur after pelvic fracture in the absence of injuries that can make delayed repair more complex. Due to the limited
urethral disruption in the adult male; therefore, eventual urethra number of case series and isolated case reports, it is difficult to make a
management decisions may have less of an impact on eventual definitive statement for the optimal treatment strategy. Despite this,
potency than previously thought.
26
the most important message is to always perform a vaginal
examination and possibly vaginography in the presence of a pelvic
With regard to anastomotic urethroplasty (immediate or delayed), fracture to assess for vaginal/urethral injury. As stated above, the force
perineal and transpubic (abdominal and perineal sugical approach required to create a urethral disruption will almost always be associated
with potential pubectomy) approaches have been reported. Crucial to with major morbidity that will preclude immediate management. As
the success of an anastomotic urethroplasty is total excision of the such, the best initial strategy is to identify the urethral and/or vaginal
stricture and a tension-free urethral anastomosis. The choice of injury and to provide urinary diversion. With regard to staging of
120 EUROPEAN UROLOGICAL REVIEW