Failed posterior urethroplasty: lessons learned

To determine the factors contributing to unsuccessful results after posterior urethroplasty and to establish some guidelines for its prevention. From 1977 through 2000, 130 patients (3 to 58 years old) underwent 145 anastomotic urethroplasty procedures for post-traumatic posterior urethral distraction defects. Bulbo-prostatic anastomosis was performed through the perineum in 105 cases and by a perineo-abdominal transpubic procedure in 40. Factors that might have an impact on the surgical result, such as the size and type of sutures, urethral stents, and use of antibiotics were standardized. The records of all patients with unsuccessful results during a follow-up of 2 to 20 years were analyzed. Overall, the results were unsuccessful in 12 cases (8%). A negative result was related to incomplete excision of the scar tissue in 3 cases, inadequate fixation of the prostatic mucosa in 6 cases, and anastomotic tension in 2 cases; 1 patient was lost to follow-up. Previous repair, length of distraction defect, and urinary infection had no statistically significant influence on the result. The essential operative details of posterior urethroplasty include complete excision of scar tissue involving the membrano-prostatic region, lateral fixation of pliable prostatic mucosa, and creation of a tension-free anastomosis. If a tension-free anastomosis cannot be achieved through the perineum, the perineo-abdominal progressive approach or the elaborated perineal technique should be used at the same setting. Previous repair, a long distraction defect, and urinary infection do not preclude successful posterior urethroplasty.