Posterior urethral reconstruction: perineal anastomotic repair after pelvic fracture

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the nine steps, or use Back and Next. Watch the scar excised onto the sound, the crura parted so the urethra takes a shorter course, and the sutures placed clockwise from twelve. The triggers show the rectum, a narrowed repair, the cavernous nerves and the bladder neck.

Operative steps

1. The defect The repair is delayed until the haematoma has resolved, with the bladder drained by a suprapubic catheter in the meantime. Contrast is run up the urethra from the meatus and down from the bladder through the suprapubic tract. The two columns show the distal and proximal ends; the gap between them is the length of the defect, and its relation to the pubis predicts how much exposure will be needed.
   where it bites: a bladder neck that is open on the cystogram, or injured, is noted before surgery: after the repair continence depends on it.
2. Lithotomy and exposure Intravenous antibiotics and general or regional anaesthesia, then high dorsal lithotomy in well-padded stirrups, a bolster under the buttocks, the images in the room. Under loupe magnification a vertical midline perineal incision runs from the base of the scrotum to just above the anus. Colles fascia is opened, bulbospongiosus is divided in the midline and dissected off the corpus spongiosum, and a self-retaining retractor is set.
   where it bites: the tunica of the corpus spongiosum is thin over the bulb and is perforated by careless dissection of the muscle.
3. Free and transect A catheter passed from the meatus stops at the distal end of the scar. The mid-bulbar urethra is dissected all the way round and freed dorsally from the corporal bodies. It is cut across at the level of the scar and mobilised distally to the penoscrotal junction, off the tunica of the corpora. Proximally it is freed from its posterior midline attachments, the bulbar arteries are preserved and haemostasis is secured.
   where it bites: the bulbar arteries enter the bulb from behind; they are kept, because the mobilised urethra depends on its blood supply.
4. Find the proximal urethra A curved metal sound is passed through the cystostomy tract, gently into the bladder neck and down to the proximal end of the obstruction. The scar between the bulb and the prostatic apex is excised from below until the sound can be felt through it. The obliterated proximal urethra is then incised directly onto the sound.
   where it bites: the excision follows the sound; without it the dissection can wander behind the prostate toward the rectum.
5. Excise to healthy urethra The remaining fibrosis is excised entirely, down to healthy tissue all the way round the proximal end. The sound is withdrawn and cystourethroscopy confirms that there is no false passage and no bladder pathology. Both healthy urethral ends are tagged with stay sutures and calibrated progressively with bougies à boule.
   where it bites: the anterior rectal wall lies immediately behind the deepest part of the scar.
6. Bridge the gap The ends are brought together. For a longer defect the space between the crura is developed sharply in the midline down to the inferior surface of the pubis, without entering the tunica of the corpora, and the dorsal vein met there is ligated and divided. The anterior urethra then takes a shorter course to the proximal stump. If more length is needed, an inferior pubectomy follows; rerouting round the left corporal body is the further option.
   where it bites: the corporal tunica during the crural separation, and the cavernous nerves beside the apex: only the manoeuvres the gap needs are used.
7. Spatulate With a tension-free approximation confirmed, the distal end is spatulated along its dorsal wall and the proximal end along its ventral wall, so that the two openings overlap and the join is wider than either lumen.
   where it bites: any tension left at this point is carried into the anastomosis; the gap is bridged first.
8. The anastomosis Full-thickness interrupted sutures are placed outside-in through the proximal end, clockwise from twelve o'clock, then inside-out through the distal end, taking spongiosum and mucosa. Each is held on a numbered clamp to keep its order. After half the distal sutures are placed, a urethral catheter is passed easily into the bladder. When all are in, they are tied one by one, clockwise from twelve.
   where it bites: the deep anterior sutures lie against the back of the pubis and the posterior sutures toward the rectum; each bite is placed under vision.
9. Layered closure With a tension-free anastomosis and a dry field, the retractor is removed and the wound irrigated. Bulbospongiosus is closed with a running suture, then Colles fascia and the subcutaneous tissue separately to obliterate dead space, then the skin with interrupted sutures. The cystostomy is left to close by secondary intention; the urethral catheter goes to a drainage bag, taped to the abdominal wall.
   where it bites: dead space in the perineal wound collects blood and urine; the deep layers are closed separately to obliterate it.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topics Genitourinary trauma and Urethral stricture disease. Not a workplace-based assessment and not evidence of competence.