Posterior Urethroplasty After Pelvic Fracture
Urethral injury (pelvic fracture urethral distraction defect)
When a pelvic fracture tears the urethra and a large gap is left between the prostate and the urethra patients need a reconstructive surgery called a posterior urethroplasty, which is usually performed 3 months after their pelvic fracture. During this time most patients rely on a catheter that goes through the abdominal wall into the bladder called a suprapubic tube.
A pelvic fracture urethral injury and the scar that has developed after the injury has healed. The patient underwent a successful posterior urethroplasty.
What is involved in surgery?
In posterior urethroplasty the scarred tissue that has filled in the gap between the urethra and the prostate is removed and the urethra is reconnected to the bottom of the prostate, which reconstructs the channel and the flow of urine. Patients typically have an incision in the perineum measuring about 4-5 inches. The perineum is the area between the bottom of the scrotum and the anus. In some rare cases where there is more extensive damage an incision needs to be made in the abdomen to make the connection.
Sometimes in order to bridge the gap between the urethra and the prostate patients need to have a groove of pubic bone removed from the underside of the pubic arch. Fortunately this does not destabilize the pelvis and does produce any long-term problems. The surgery takes between 3-5 hours and usually patients need to have both a suprapubic tube as well as a catheter in the urethra for about 3-4 weeks after surgery. X-rays are done in our clinic to make sure the connection has healed well between the urethra and the prostate. Then the catheter is removed and the suprapubic tube is plugged and left in for safety for 1-2 additional weeks. As long as patients are urinating well then the suprapubic tubes is removed when they return. This follow up can also be done closer to home by patients referring urologist.
One problem that can arise in men that have had a urethral injury after a pelvic fracture is damage to the urinary sphincter muscle. One of the two sphincters in men is right in the area of the injury at the base of the prostate. Either the injury or surgery to fix the injury can destroy the function of this sphincter in many cases. Fortunately, there is another sphincter muscle at the top of the prostate where it meets the bladder and because of this most men do not leak urine after this injury. If there has been damage to the other sphincter from the original trauma or nerves going to the bladder than occasional men may need additional procedures to regain their sphincter function and treat incontinence (involuntary leakage of urine)
The success of this type of surgery is excellent and in our experience is > 90% at restoring the ability to urinate. This surgery is highly specialized and should be done only by surgeons with experience in treating urethral injuries after pelvic fracture. We do not recommend internal cutting procedures or daily catheterization to treat these injuries as this type of management will often make the area of stricture longer and worsen the ultimate success of surgery. These maneuvers almost never work in the long-term.
The fine connection is made between the urethra and the bottom of the prostate (apex) in posterior urethroplasty.