Introduction: Posterior urethral stenosis is a complication occurring secondary to transurethral prostate surgery and prostate cancer treatment, and its management remains a significant reconstructive challenge. We herein report our surgical technique of transperineal bulbovesical anastomosis and staged artificial urinary sphincter implantation for extensive posterior urethral stenoses.
Methods: Two male patients aged 77 and 76 years were referred to us for definitive management for posterior urethral stenosis (brachytherapy for prostate cancer, and repeat transurethral surgery for benign prostatic hyperplasia, respectively). A suprapubic tube was placed in both patients due to urinary retention after exhaustive urethrotomies and dilatations. Both patients had normal bladder capacity and extensive posterior urethral stenoses extending from the bulbomembranous junction to the entire prostatic urethra. After making a midline perineal incision, the bulbar urethra was fully mobilized up to the penoscrotal junction distally and transected at the obstruction site. The corpora cavernosa was separated, and a wedge of the inferior pubic bone was excised to expose the ventral side of the bladder neck in the same manner as the repair of pelvic fracture urethral injury. The scarred prostatic tissue was meticulously excised, and the bladder neck was opened. The bladder mucosa was everted and fixed to the surrounding tissue to create an anastomosis site. Eight interrupted 4-0 PDS sutures were placed to reapproximate the bulbar urethra and bladder neck. After confirming the absence of recurrent stenosis at the anastomosis site at 6 months postoperatively, an artificial urethral sphincter was implanted using a transcorporeal approach. We followed up the patients every 6 months, performed uroflowmetry, flexible cystoscopy, and examined the amount of daily pad use.
Results: The operative time and blood loss during bulbovesical anastomosis was 163 minutes and 201 ml in case 1 and 193 minutes and 66 ml in case 2, respectively. No Clavien grade 2 or greater perioperative complications were observed. No recurrent stenosis on cystoscopy was found after 20 and 26 months in cases 1 and 2, respectively. The maximum flow rate and the amount of daily pad use at the last recorded follow up was 32 ml/s and no pad in case 1 and 44 ml/s and one pad in case 2.
Conclusions: A bulbovesical anastomosis combined with staged artificial urethral sphincter placement could effectively manage extensive posterior urethral stenoses.
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