Surgical outcomes of post traumatic posterior urethral strictures in children - journal club

1. SURGICAL OUTCOMES OF POST-
TRAUMATIC POSTERIOR
URETHRAL STRICTURES IN
CHILDREN
DR ARKA BANERJEE
PAEDIATRIC SURGERY, MAMC
MODERATOR: DR S. S. PANDA

2. INTRODUCTION
• Pediatric pelvic # after blunt trauma – 2.4-4.6%
• Of these, posterior urethral inuries are seen in 0.47-4.2%
• Historically, transpubic approach preferred due to technical difficulty with
transperineal route
• Recent reports suggest a similar clinical outcome

3. DEFICIENCIES IN KNOWLEDGE
• Management algorithms are extrapolations from adult literature
• Difficult challenge for pediatric urologists
• Small pelvis
• Small urethral calibre
• Tissue fragility
• Poor spongiosal support
• Unstable posterior urethra
• Small prostate
• Lax pubourethral ligaments
• Small perineal space
• Small pelvis
• No data
• age-related feasibility of end-to-end urethroplasty
• Functional urinary and sexual outcomes

5. OBJECTIVE
• Validate a simple preoperative radiographic score to predict the type of surgical
repair for traumatic posterior urethral strictures in children
• No previous study has been done in children to correlate gapometry with
posterior urethral defects

6. MATERIALS AND METHODS
• Retrospective study
• 15 yrs (2000-2015)
• Inclusion criteria
• <15yr old pts with bulboprostatic stricture
• Exclusion criteria
• Complex stricture disease
• Bladder neck injury
• Urethrocutaneous/rectourethral fistulae
• H/O multiple prior anatomic repairs

7. MATERIALS AND METHODS
• Calculation of gapometry index [G/U ratio – ]
• VCUG
• RGU
lt of urethral
gapbulbar urethral
length

8. MATERIALS AND METHODS
• Location of PS soft tissue junction noted on xray (corresponds to bulbopendulous
junction of urethra) – transition point between curved bulbar urethra and straight
penile urethra
• Bulbar urethral length – measured from its blind proximal end to the
bulbopendulous junction using a semi-rigid, malleable strip
• Length of the urethral gap – measured as a fraction of bulbar urethral length and
called the index of elastic lengthening or gap/urethral (G/U) index or gapometry index

9. MATERIALS AND METHODS
• End-to-end urethral anastomosis done by single experienced surgeon
• After excision of the intervening scarred segment and circumferential mobilization of the
bulbar urethra down to the penoscrotal junction.
• Gapometry index was analysed for 2 patient groups
• Group 1 – simple perineal approach
• Group 2 – pts requiring a more elaborate procedure (eg. Inferior pubectomy/perineo-
abdominal transpubic approach)
• Subdivisions
• <5 yrs
• 5-15 yrs

10. MATERIALS AND METHODS
• Feasibility of anastomosis analysed from the G/U index
• Follow-up : 22 ± 0.42 months
• Symptomatic worsening of flow
• Success of procedure
• Peak urinary flow > 15 ml/s
• No radiographic evidence of urethral stricture
• No need of urethral instrumentation on follow-up

11. RESULTS
• 38 patients
• 3 excluded due to complex strictures
• 8.86 ± 0.9 yrs

12. RESULTS
• Approach
• Simple perineal – 21
• Elaborate perineal – 14
• Inferior pubectomy – 8
• perineo-abdominal transpubic – 6

13. RESULTS
• Success rate
• Perineal – 94.6%
• Transpubic – 92.3%
• G/U index: gradually increased as the complexity of the surgical approach increased
• Reflected by an increasing urethral gap in pts requiring simple perineal repair than those
needing inferior pubectomy
• Abdominoperineal repair: Urethral gap did not significantly correlate with G/U index
• The urethral gap was significantly less in <5 yrs age in both groups
• did not correlate with increasing G/U index with age

14. DISCUSSION
• Current belief
• Posterior urethral gaps <2 cm can be repaired by simple perineal approach
• Elaborate perineal/transpubic approach needed for longer gaps
• Singular variables reported for predicting the feasibility of a tension-free urethroplasty
• Morey and McAninch [1997] – stretched penile length >15 cm is a good indicator of anastomotic repair
• Da Silva and Sampaio [2002] – to bridge each 1cm gap of excised urethra, the remaining normal urethra
would have to be mobilized by 3.2 cm in a 1 yr old to 6.6 cm in a 70 yr old
• Koraitim [2008] – length of anterior urethra is crucial for bridging the urethral gap [variable in different
patients and elongation on stretch is directly proportional to its original length]

15. DISCUSSION
• This study
• urethral gap (mean length 2.1 cm, range 1.4–2.6 cm) could be bridged by a bulbar urethra
with a mean length of 4.8 cm (range 4.5–5.2 cm) – achieved by elastic lengthening of 44%
(36–52%) of the original length of the bulbar urethra
• Transpubic approach bridged a urethral gap of 3.6 cm (range 3.2–4 cm) for a bulbar
urethral length of 4.6 cm (range 4.4–4.8 cm), translating into a urethral lengthening of 0.78
cm (range 0.72–0.82 cm) using the gapometry score
• Koraitim [2009] in the adult population reported a G/U index of 0.33 for a simple
perineal repair, above which an elaborate perineal or transpubic approach is
recommended

16. CONCLUSION
• Surgical approach to posterior urethroplasty is dependent not only on the length
of the bulboprostatic urethral gap, but also on that of the bulbar urethra
• G/U index is a composite reflection of both these parameters and hence it is the
best representation of urethral elastic lengthening
• Urethral gaps shorter than 44% of the bulbar urethral length can be mostly
corrected by a simple perineal approach
• Urethral gaps more than 40% of the length of the bulbar urethra require an
elaborate perineo-abdominal transpubic procedure

17. CONCLUSION
• G/U index showed a steady increase from 0.44 for simple perineal repair to 0.71 for
inferior pubectomy and 0.87 for perineo-abdominal transpubic repair
• Simple perineal repair and inferior pubectomy showed a significant correlation with
the urethral gaps (2.8 and 3.6 cm respectively)
• Significant difference in the stricture length between age groups of <5 yrs and 5–15
yrs for the same surgical approach
• G/U index however remained unaffected by age
• Age-related increase in bulbar length, which attains maximum dimensions by 5 yrs would
theoretically counter the variations in stricture length. This may account for the relatively
standard G/U index values across all ages

18. LIMITATIONS
• Small sample size (owing to the low incidence of pediatric urethral stricture
disease)
• Impact of other factors that can influence the surgical approach for urethroplasty
• pubic arch width
• initial management (suprapubic cystostomy vs. primary repair)
• previous failed urethroplasties
• bladder base fistulae
• degree of scarred tissue (moderate vs. severe)

20. OBJECTIVE
• Investigate long-term functional outcomes and quality of life (QOL) of adults who
previously underwent urethroplasty for blunt urethral injury at a young age

21. MATERIALS AND METHODS
• Retrospective study
• 35 yrs (1978-2013)
• Inclusion criteria
• Pts who sustained blunt urethral injury at ≤18 yrs age and subsequently underwent urethral reconstruction by a single surgeon
• Exclusion criteria
• <18 yrs at the time of survey collection
• Lack of capacity to participate
• Confirmed incarceration
• Non-English speaking
• Lack of contact information
• Deceased

22. MATERIALS AND METHODS
• Pts contacted, informed consent obtained
• Web-based validated questionnaire via RedCap®
• to assess their current urinary, sexual, and quality of life status
• to obtain current demographic information
• Records reviewed
• Demographic data
• Clinical characteristics
• Age
• Trauma
• Mechanism
• Type of urethroplasty
• Any additional interventions before or after definitive repair

23. MATERIALS AND METHODS
• Urinary function outcome: Urethral Stricture Surgery Patient-Reported Outcome
Measurement (USS-PROM) [2011]
• first questionnaire specifically designed for patients with urethral stricture disease
• LUTS domain
• six-item bother questions that generates a total score that varies from 0 (asymptomatic) to
24 (most symptomatic)
• Urinary symptom-specific QOL question (score of 0 – 10)
• Peeling’s voiding picture, an illustration of a man voiding scored between 1 (best) and
4 (worst)

24. MATERIALS AND METHODS
• Sexual health
• Sexual Health Inventory for Men (SHIM) for erectile function
• 5-item questionnaire
• Rate different aspects of their erections from 1 – 5
• Score varies between 5 (worst function) to 25 (perfect erections)
• A score of 21 or lower is considered erectile dysfunction
• Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) Short Form to specifically assess ejaculatory
function
• 4 questions
• Scores from 0-5
• Three questions relate to the properties of ejaculation
• Frequency (from total absence to always present)
• Strength of ejaculation (from total absence to normal strength)
• Volume of ejaculation (from total absence to normal amount)
• Fourth question regards the patients’ concern about their ejaculatory condition (ranging from the condition without any problems
to deep concerns).

25. MATERIALS AND METHODS
• Quality of Life
• EQ-5D-3L
• 5-item validated questionnaire that assesses individual’s global health on 5 different domains
• Mobility
• Self-care
• Usual activities
• Pain/discomfort
• Anxiety/depression
• Respondents select the level of bother from most bothersome to the least on a 3-level scale: no
problems, some problems, extreme problems
• Dichotomized the responses to “no problem” and “any problem” for final analysis
• Visual analog scale for the respondents to rate their self-rated health on a 0 – 10 scale labeled as
‘Best imaginable health state’ (10) and ‘Worst imaginable health state’ (0).

26. RESULTS
• 15 patients

27. RESULTS
• Median age: 17 yrs (Range 4-18 yrs)
• Median follow-up: 19 yrs (Range 8-28 yrs)
• Median interval between injury and repair
• Posterior strictures: 4 (3-14) months
• Anterior strictures: 6 (4-108) months
• Satisfaction
• Very satisfied (80%)
• Satisfied (20%)
• Intervention-free survival – 93%
• 3 patients had seen a urologist in past 1 yr
• 2 for unrelated complaints
• 1 for urinary frequency

28. RESULTS: USS-PROM
• Median LUTS bother domain (0 least, 24 worst) was 10 (range 7 – 16)
• 12/15 (80%) reported that urinary symptoms do not interfere with daily life
• 2/15 reported symptoms interfering “a little”
• 1 reported symptoms interfering “a lot”
• urinary frequency despite strong urine stream and lack of incontinence on other domains
• Median force of stream assessed by Peeling’s voiding strength picture (1 strongest stream, 4 weakest stream) was
reported as 2 (IQR: 1.5-2)
• 4 patients reported stream strength of 1
• 8 reported 2
• 3 reported 3
• No patients reported strength of 4
• None reported urinary incontinence or any history of any anti-incontinence procedures

29. RESULTS: SHIM
• Median SHIM score was 24 (IQR: 22.5-24)
• 1 patient with a SHIM score of <20, who reported not being sexually active despite
perfect erectile function (SHIM score was 10 in this patient)
• 1 patient reported a score of 20
• Remainder scored 21 or more
• No one reported medical or surgical intervention for erectile dysfunction (ED)

30. RESULTS: MSHQ-EJD
• 3 questions for orgasmic function (0 worst function, 15 normal function) and one question assessing bother
• Median ejaculatory function score was 14 (IQR: 13-14.75)
• 12/15 patients (80%) reported “no problem at all” or “not at all bothered” by their ejaculatory function
• Six patients reported having fathered a child and none reported infertility
• Two patients reported history of pain that they attributed to their urethroplasty
• 1 patient with moderate pain in the scrotum and perineum
• 1 with mild pain in perineum
• None reported pain interfering with daily activity or compromising function
• Three patients reported penile curvature after urethroplasty which has persisted to date
• All 3 reported a severity of <30 degrees curvature
• None have required treatments
• Results of the self-assessed QOL in 5 different domains of EQ-5D-3L health questionnaire demonstrated
• overall median quality of life was 8 (IQR:7.5-8)

31. RESULTS: EQ-5D-3L
• Overall median quality of life was 8 (IQR:7.5-8)

32. DISCUSSION: OVERALL SUCCESS
• A relatively normal and functional life regarding sexual and voiding function can be expected,
and patients are overall satisfied with their operation with no major residual morbidity
• Similar quality of life score on EQ-5D-3L compared to healthy adults (8 IQR: 7.5 – 8 vs 9 IQR: 7.5
– 9.5 respectively)
• No patients reported erectile dysfunction (SHIM score >21)
• Lack of the need for repeated intervention is a commonly considered successful outcome after
urethroplasty and only 1 patient (6%) in this cohort reported a secondary endoscopic
intervention
• Short-term urethroplasty success rate after anterior and posterior urethroplasty is about 90%
• Urethroplasty outcomes are durable and if the patients have not required an intervention in the
first few years of follow-up, the chance of them needing an additional intervention is low

33. DISCUSSION: ED
• Erectile dysfunction is a dreaded long-term complication after pelvic fracture given severe soft tissue
and vascular injury that can ensue
• The reported rate of de novo ED after pelvic fracture is 34% (25%–45%) in the literature, and
urethroplasty has been reported to harbor an additional 3% risk in the adult population
• In long-term follow-up, patients did not report erectile dysfunction
• This survey did not include a specific question about penile length
• In anterior urethroplasty literature in the adult population, ED has been a matter of debate since
Mundy [1993] reported de novo permanent ED in 5% of patients after anterior anastomotic
urethroplasty and 0.9% after augmented urethroplasty with a graft
• Anterior urethroplasty does not have a deleterious effect on erectile function in pediatric population as
well

34. CONCLUSION
• Urethroplasty after blunt anterior and posterior urethral injury in children is
associated with high surgical success rates, similar to adult population.
• Despite possible transient voiding dysfunction at early postoperative years, these
children seem to be left with minimal voiding and sexual function morbidity in
adulthood

35. LIMITATIONS
• Small sample size
• Urethral reconstruction has undergone significant changes over 35 years
• Although the basic surgical principals have remained constant, follow up protocols and methods
of assessing symptoms have changed
• They did not perform surveillance cystoscopy on any of these patients, which is the routine
current practice in adults within the first year after repair, and therefore these patients might
have anatomic recurrence of stricture
• No preoperative PROM data for comparison and the long interval between survey response and
the injury might affect the participants’ scores
• The data is not equipped to conclusively report the success rate of urethroplasty in children