[Personal experience with treatment of posttraumatic urethral distraction defects].

PURPOSE OF THE STUDY: Authors present their experience in the treatment of posttraumatic distraction urethral defect resulting from traumatic rupture of posterior urethra.

MATERIAL: The group comprised 19 patients with posttraumatic urethral distraction defect (average age 41 year, range 27-65 years). In 16 of them (84%) resection urehtroplasty was performed and in three (16%) endoscopic internal urethrotomy was applied. The patients were evaluated of 19 to 48 months after surgery.

METHOD: Urethroplasty was performed at least three months after the trauma, always under general anesthaesia in lithotomic position, using perinal approach. Dissection of bulbar urethra was followed by dissection and resection of fibrous posttraumatic distraction defect (the original membranous urethra). Prostatic apex and proximal end of lumbar urethra were spatulated and bulboprostatic anastomosis was performed restoring urethral continuity. A catheter was left in urethra for three weeks. In 12 patients it was necessary to separe corpora cavernosa addition and 5 patients required a wedge resection of the lower arch of public bones to allow urethral bridge the defect. Endoscopic internal urehtrotomy was also performed minimally three months after trauma, always on position 12 of the clock face opposite to symphysis with a discision of the whole stenotic part. Subsequently, catheter was inserted in urethra and left in place for four days.

RESULTS: Resection urethroplasty as primary surgery was successful in 15 (94%) patients and only 1 patients (6%) required another reconstruction surgery. Endoscopic management was not successful in any patients (100%). Two of them (66%) had to undergo repeatedly a reconstruction surgery, the third one (33%) is regularly dilated. All patients after urethroplasty are under regular circumstances continent, only in two of them (13%) there occurs of urine in case of an extreme increase of abdominal pressure. Erectile function already impaired by the trauma did not worsen by the surgery in 4 patients (25%), in 2 patients (13%) with preoperatively normal erections there developed erectile dysfunction after urethroplasty of which in 1 patient a permanent disorder. The quality of life was in general evaluated by patients as excellent.

DISCUSSION: Epicystotomy is a simple procedure ensuring urinary diversion in patients with posterior urethral rupture. However, such management of urethral rupture almost always results in the development posttraumatic distraction defect. Incontinence occurs in our group only in 2 (12%) patients, mainly in non-standard situations (gym, urgency). Night incontinence does not occur in our patients at all. Continence is in our patients ensured by lissosfincter which is fully sufficient. Erectile dysfunction may result from a trauma or a treatment. In our group all patients have a preserved erection prior to trauma and trauma was evident cause of the loss of erection only in 2 (12%) patients who were primarily treated by epicystotomy. In another 2 patients (12%) who were primarily treated after trauma for coincidental urinary bladder rupture it is impossible to state what caused the erectile dysfunction whether a fracture or surgery. In the acute phase during the revision of the rupture of posterior urethra the peroperative risk of the impairment of neurovascular bundles responsible for erection is much higher than in planned surgery. Satisfaction of patients with the treatment is reflected in the evaluation of the postoperative results and the quality of life in general. None of our patients managed by delayed internal urethrotomy was cured. One is regularly dilated, another two underwent urethroplasty.

CONCLUSION: The technique of resection of urethral distraction defects with bulboprostatic anastomosis is a suitable way of the treatment of the preceding rupture of posterior urethra without impairement of continence or erection. A prerequisite of good results is a simple urine diversion by epicystostomy during the primary management of the posterior urethral rupture. Delayed endoscopic therapy of the distraction defect will not probably cure the patients but will result in regular dilatations. It may be an alternative treatment in polymorbid or biologically older patients.