Introduction: In 1986, George Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The progression between one to the next consecutive step was based on the complexity of the urethral stenosis and the distance between the proximal and distal urethral stumps. At the same time, the higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. Thus, step 4 (supracrural rerouting) or transpubic urethroplasty (step 5 and 6) are performed only in selected patients where no other option is possible. We explored the number of patients with PFUI that received step 4 or higher in the last 9 years of practice at our center.
Methods: Between 2013 to 2021, we prospectively collect data on patients with PFUI treated at our tertiary center. Surgical procedures were categorized according to the Webster classification and rates of each step were compared. Characteristics of patients with step 4 or higher are presented. Success rate was defined as Qmax above 10ml/sec and no need for further treatment.
Results: In over 9 years, we have surgically treated 737 male patients with PFUI. Among those, 140 received step 1, 130 received step 2, 345 received step 3, 13 received step 4, and 41 received step 5/6. Among patients who received step 4, median age was 23 yearrs (range 11-40). 11 patients with step 4 underwent to one or multiple attempts of PFUI repair before definitive surgery. Only two patients were primary cases. 6 of them had also preoperative erectile disfunction and one subsequently placed a penile prosthesis. All patients who received step 5/6 presented complex pelvic fracture urethral injuries such as: multiple failed prior urethroplasty (re-redo), ischemic narrowing or necrosis of the bulbar urethra, boys aged =12 years, girls aged =12years with associated urethrovaginal fistula, double block at bulbomembranous junction and bladder neck – prostate, recto urethral fistula, incontinence due to bladder neck injury and patients who have concomitant posterior urethral injury with anterior urethral strictures. Success rate was 69.2% in step 4 and 74.4% in step 5/6. In this time span, the number patients receiving pedicle preputial tube was 68.
Conclusions: Step 4 perineal urethroplasty was rarely performed, while the majority of our cases were successfully managed with step 3 or inferior. The reason behind this decline are several including improved technique of inferior pubectomy, and attempt to avoid supracrural rerouting in PFUI patients. Indeed, the urethral anatomy after step 4 is significantly altered making extremely challenging any surgical revision and possibly any attempt to perform lower urinary tract instrumentation. Thus, longer urethral defects were preferably managed with pedicle preputial tube. Step 5/6 was only performed in extremely complex pelvic fracture urethral injuries due to do the surgical challenge they represent.