Posterior Urethral Reconstruction

What is posterior urethral reconstruction?

Posterior urethral reconstruction is a surgical procedure for males that is sometimes needed after trauma to the urethra or after treatment for prostate cancer. Your urethra is the tube that carries urine from the bladder through the penis and out of your body. The posterior urethra is the one- to two-inch section of your urethra that extends from the neck of the bladder, through the prostate gland and the external urinary sphincter, which is the area immediately before the urethra enters the anterior urethra. Posterior urethral reconstruction is surgery to fix this section of your urethra.

Why is posterior urethral reconstruction performed?

Posterior urethral reconstruction is most often performed for urethral stricture (narrowing of the urethra) after trauma, such as a pelvic (hip) fracture. Pelvic fractures can be caused by vehicle crashes, falls, crush injuries or penetrating injuries such as from bullets. It’s also done for urethral strictures that occur after prostate cancer treatment, including both radiation therapy and radical prostatectomy (removal of the entire prostate gland). Urine flow can be slowed or completely stopped depending on the severity of the narrowing.

How are posterior urethral strictures evaluated?

Your healthcare provider will order tests, which could include:

• Retrograde urethrogram (uses contrast dye and X-rays to see exact location and length of the stricture).
• Voiding cystourethrogram (uses contrast to look at urine flow out of bladder).
• Cystoscopy (uses a scope to look inside your bladder and urethra).
• Magnetic resonance imaging (MRI) (used in select people if more information is needed).

Before being considered for posterior urethral reconstruction, your surgeon will want to make sure your major injuries from the pelvic fracture have stabilized (if trauma is the cause for the needed urethral reconstruction). During this time your urine will often be drained with a suprapubic catheter placed into your bladder.

How do I prepare for posterior urethral reconstruction?

In general, you’ll need to:

• Temporarily stop all blood-thinning medications (if you take them). Your surgical team will discuss the specific drugs and when to stop them.
• Not eat or drink anything after midnight on the day of surgery.

You’ll be allowed to take approved medications the morning before surgery with a small sip of water.

Your doctor may have prescribed an antibiotic to be started the day before surgery.

How is it decided which approach to use in posterior urethral reconstruction?

Most men with an injury to the posterior urethra can be managed with a surgical technique called anastomotic urethroplasty. In this procedure, scar tissue is removed and then the two healthy ends of the urethra are stitched back together. More specifically, the healthy remaining part of the posterior urethra and the bulbar urethra, which is the section between the external sphincter area and base of the penis, are stitched back together. You are asleep during this procedure (under general anesthesia). The surgery is performed through the perineum (area between your anus and scrotum).

Sometimes the two healthy ends of the remaining urethra can’t be stitched together after removal of the scar tissue. In this case, the gap between the two urethral ends may need to be repaired with tissue. The most commonly used tissue used to reconstruct a portion of the urethra is taken from the inside of the cheek of your mouth (called buccal mucosa). After removing the tissue, you’ll feel a little bit of discomfort in your mouth, similar to the pain you feel with you bite your inner cheek. Tissue inside your mouth heals quickly – usually in less than one week.

What happens after surgery?

Surgery is usually performed with a short observational stay of up to 23 hours. While the stitches connecting the two ends of the urethral are healing, a small, soft catheter will be placed in your penis and left in for three to four weeks. An X-ray will be taken to determine if the repair has healed. You will have other tests, such as a urethroscopy or flow rate, several months after your surgery to make sure the repair has properly healed.

What complications could happen?

Side effects of posterior urethral reconstruction include bleeding, infection and recurrent stricture. Urinary incontinence after the procedure is rare when done after pelvic trauma. The chance of incontinence is higher when the surgery is done after treatment for prostate cancer. A significant number of men will have erectile dysfunction (ED) following pelvic fracture or treatment for prostate cancer, even before posterior urethral reconstruction. The surgery will not help the ED, and it may require additional treatment in the future if the problem persists.

What is the prognosis after posterior urethral reconstruction?

Anastomotic urethroplasty has been shown to have very good long-term results. However, long-term success will depend on the extent of pelvic trauma and the expertise of your surgeon. Studies have shown success rates in the 92% to 97% range following reconstruction after pelvic fracture, and 70% to 85% after treatment for prostate cancer.

When can I drive?

You can drive if you are not taking a prescription pain medication and the penile catheter has been removed.

When can I go back to work?

Most people go back to work after the penile catheter is removed, but light duty is recommended until six to eight weeks after surgery.

When can I return to exercising?

Walking is fine after surgery, but you should not engage in heavy lifting, golf, or strenuous activity until six to eight weeks after the procedure.

When can I resume sexual activity?

You can resume sexual activity eight weeks after surgery.