title: Delayed surgical repair of posttraumatic posterior urethral distraction defects in children and adolescents: long-term results.
abstract: BACKGROUND
  Various surgical techniques have been proposed to treat pelvic fracture urethral distraction defects (PFUDDs) in children (Figure): primary alignment of the acute transected urethra, substitution procedures and delayed anastomosis urethroplasties (DAU) by perineal, elaborated perineal, transpubic or perineo-abdominal/partial transpubic access. However, long-term follow-up of surgical correction for PFUDDS with DAU is infrequently reported in the literature.
  
  
  OBJECTIVE
  Long-term efficacy of DAU in children and adolescents with PFUDDs was evaluated. Other surgical methods used to accomplish tension-free DAU were also described.
  
  
  METHODS
  We reviewed records of 49 male children aged 3.5-17.5 years (median 9.6) with PFUDDS who underwent DAU from 1980 to 2006. Median PFUDDs length was 3 cm (range 2-6). Six patients had prior failed treatments: anastomotic urethroplasties (5) and internal urethrotomy (1). Surgical access was transperineal in 28 cases and perineal/partial pubectomy in 21. Urethral rerouting was performed in 8 cases. Median follow-up was 6.5 years (range 5-22).
  
  
  RESULTS
  On review median PFUDDS length in patients treated with primary cystostomy was 3 cm compared to those initially managed with urethral alignment (4 cm). Five patients treated with perineal DAU developed recurrent strictures at the anastomosis site, successfully managed with additional perineal/partial pubectomy anastomosis (4 cases) and internal urethrotomy (1). Primary and overall success rate was 89, 7% and 100%, respectively. Urinary incontinence occurred in 9 cases. Two had overflow incontinence and performed self-catheterization; 1 developed sphincter incontinence and required AUS placement, while 4 of 6 cases with mild stress incontinence achieved dryness at pubertal age. Retrospectively, associated bladder neck lesions at trauma time were noted in 5 patients. Three patients with erectile dysfunction before DAU remained impotent.
  
  
  CONCLUSIONS
  In children, several factors make management of PFUDDs more difficult than in adults: 1) restricted surgical access to reach a high lying proximal urethral end, 2) long distraction defects, 3) simultaneous bladder neck and membranous urethral lesions and 4) small urethral caliber. In our experience and that of others (Turner Warwick, 1989 and Ranjan, 2012), radiographic and endoscopic findings provide information on stricture features; however, the final choice of surgical exposure to restore urethral continuity is made at operative time based on PFUDD complexity. Perineal exposure usually allows performing DAU in 2 cm long PFUDDs. Ten percent of our patients treated with perineal DAU developed recurrent strictures attributed to inappropriate access selection or unrecognized PFUDD complexity. Failures were treated endoscopically (1) and by perineal/partial pubectomy anastomotic urethroplasty (4) with 100% final success. We used perineal/partial pubectomy DAU in 43% of the cases to excise pelvic scarring and bridge long urethral gaps, with urethral rerouting in 8 cases. Success rate of initial perineal and perineal/partial pubectomy anastomotic procedures was 82% and 100%, respectively. Koraitim (1997), Orabi (2008) and Ranjan (2012) reported excellent outcomes in children with either transperineal or transpubic anastomotic repair, as opposed to poor results in those undergoing substitution urethroplaties. Most reports rarely evaluate urinary incontinence after successful DAU. At the end of follow-up only 2 of our 9 initial incontinent cases remain with acceptable stress incontinence. Retrospectively, in 5 cases the original trauma comprised the bladder neck and the membranous sphincter mechanism. In our series erectile dysfunction after trauma did not change after DAU except in 1 patient who regained potency 1 year after repair.
  
  
  CONCLUSIONS
  All patients were referred after initial treatment was done elsewhere, thus they may represent the most severe PFUDDs cases. Additionally, erection dysfunction was not investigated in the kind of detail required due to patients' age.
  
  
  CONCLUSIONS
  DAU has durable success rate for PFUDDs treatment in children with a healthy bulbar urethra. In childhood, additional surgical steps are frequently needed to achieve direct anastomotic repair.
authors: Urology Unit, Department of Surgery, Hospital de Niños "Ricardo Gutierrez" and Associated Hospital to The University of Buenos Aires, Buenos Aires, Argentina. Electronic address: podesta@arnet.com.ar.
authors: Miguel
authors: M
authors: Podesta
authors: Urology Unit, Department of Surgery, Hospital de Niños "Ricardo Gutierrez" and Associated Hospital to The University of Buenos Aires, Buenos Aires, Argentina.
authors: Miguel
authors: M
authors: Podesta
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D010384:Pelvic Bones / Q000293:injuries*; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014521:Urethra / Q000293:injuries* / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods
keywords: Children; Pelvic fracture; Post-traumatic; Urethra; Urethral stricture