Posterior Urethral Reconstruction

Overview

Posterior urethral reconstruction is a surgical procedure designed for males who have experienced urethral trauma or undergone prostate cancer treatment. The urethra is the tube that carries urine from the bladder, through the penis, and out of the body. The posterior urethra, a one- to two-inch segment, extends from the bladder neck, passes through the prostate gland, and reaches the external urinary sphincter, just before continuing into the anterior urethra. This surgery aims to repair this particular section of the urethra.

Reasons for undergoing the procedure

Posterior urethral reconstruction is commonly performed to treat urethral strictures (narrowing of the urethra) resulting from trauma, such as pelvic (hip) fractures. These fractures can occur due to vehicle accidents, falls, crush injuries, or penetrating wounds like gunshot injuries. Additionally, this procedure is done to address urethral strictures that may develop after prostate cancer treatments, including radiation therapy and radical prostatectomy (complete removal of the prostate gland). The narrowing can cause a reduction in urine flow or, in severe cases, block it entirely.

Risks

Following posterior urethral repair, potential side effects include recurrent stricture, bleeding, and infection. While urinary incontinence due to pelvic damage is rare after the surgery, the risk of incontinence can increase if the surgery follows prostate cancer treatment. Additionally, many men may experience erectile dysfunction (ED) due to pelvic fractures or prostate cancer treatment even before the reconstruction. This ED is unlikely to improve post-surgery, and persistent issues may require further treatment.

Before the procedure

The tests that your doctor will order may include:

• Retrograde urethrogram: This imaging technique uses X-rays and contrast dye to precisely locate and measure the stricture.
• Voiding cystourethrogram: This technique examines the flow of urine out of the bladder using contrast.
• Cystoscopy: This procedure involves looking inside your urethra and bladder with a scope.
• Magnetic Resonance Imaging (MRI): This method is used in certain cases when further details are required.

Your surgeon will need to confirm that your major injuries from the pelvic fracture have stabilized before moving forward with posterior urethral reconstruction, especially if the reconstruction is required due to trauma. Often, a suprapubic catheter will be inserted into your bladder during this period to drain your pee.

Generally, you must:

• If you take any blood thinners, cease taking them temporarily. Your surgical team will talk about the individual medications and when to stop taking them.
• On the day before operation, refrain from eating or drinking anything after midnight.
• The morning of the procedure, you may take your prescribed medications with a tiny sip of water.

It’s possible that your doctor advised starting an antibiotic the day before surgery.

During the procedure

For most men with posterior urethra injuries, anastomotic urethroplasty is an effective surgical option. In this procedure, scar tissue is removed, and the two healthy ends of the urethra are stitched back together. Specifically, the remaining healthy portion of the posterior urethra is stitched back together with the bulbar urethra, which is located between the external sphincter and the base of the penis. The surgery is performed under general anesthesia, so you will be asleep during the procedure, with an incision made through the perineum, the area between the anus and scrotum.

In some cases, the healthy ends of the urethra cannot be directly joined after removing the scar tissue. When this occurs, additional tissue may be needed to bridge the gap. The most commonly used tissue for this reconstruction is buccal mucosa, which is taken from the inside of the cheek. After the tissue is removed, you may experience mild discomfort in your mouth, similar to accidentally biting your cheek. Fortunately, the inner cheek tissue usually heals quickly, typically within a week.

After the procedure

The surgery generally requires a brief observational stay of up to 23 hours. To allow the stitches connecting the two ends of the urethra to heal, a small, soft catheter will be inserted into the penis and left in place for three to four weeks. An X-ray will be performed to verify that the repair is healing correctly. Additionally, several months after the surgery, further tests such as a urethroscopy or flow rate measurement will be conducted to ensure the repair has fully healed.

Outcome

Anastomotic urethroplasty has been shown to yield excellent long-term outcomes. However, the success of the surgery can depend on the extent of pelvic trauma and the skill of the surgeon. Research indicates success rates ranging from 70% to 85% following prostate cancer treatment and from 92% to 97% after reconstruction for pelvic fractures.

Once the penile catheter is removed and you are no longer taking prescription painkillers, you are cleared to drive. Most patients can return to work after the catheter is removed, though it is recommended to stick to light duties for six to eight weeks post-surgery. You may resume walking after surgery, but should avoid vigorous activities or heavy lifting for six to eight weeks. Sexual activity can be resumed eight weeks following the surgery.