For referring physicians
Posterior urethra: pelvic fracture and radiation, how I choose the operation
The urethra behind the bulb: the distraction defect after a pelvic fracture, in an adult or a child, and the membranous urethra that has scarred after radiation for prostate cancer. The anastomosis after prostatectomy and the bladder neck have their own page. The questions I ask, in order, with a video for each operation.
Where is it relative to the external sphincter?
The external sphincter sits at the membranous urethra, and the approach is chosen by where the disease sits relative to it. Everything else is tooling. Below the sphincter, the operation is perineal. Above it, the corridor is abdominal, and the route inside that corridor turns on the lumen: retropubic excision and anastomosis if the segment is obliterated, a transvesical graft if there is a lumen that is merely too narrow. A stenosis that spans the membranous urethra, above and below, gets a combined abdominoperineal operation. Forty-one of the 105 robotic posterior urethroplasties in our series needed that combined approach.
Pelvic fracture urethral injury
Most distraction defects are repaired through the perineum, and in the TURNS series 91 percent of men needed no further intervention. The defects that fail are the long ones and the ones that were embolized in the acute setting, and those are the cases where the surgeon has to be ready to split the corpora, take part of the pubis, or reroute the urethra to reach a tension-free anastomosis. My own anastomosis is non-transecting where the anatomy allows it, which keeps the blood supply of the bulbar urethra intact for whatever comes later.
When the defect sits above the sphincter or the perineum has already been operated, the robot reaches the prostatic urethra from above while the perineal team works from below. The videos show that abdominoperineal approach in an adult, in an adolescent with the SP robot, and in a child after a failed pediatric repair.
The radiated membranous urethra
Radiation does not remove the endoscopic option. It gets one attempt, the same as everywhere else, and below about 1 cm that attempt can be durable. Above it, the durable operation for a bulbomembranous stenosis after radiation is excision and primary anastomosis: 87 percent of 137 men across ten centers were voiding without instrumentation at a mean of 32 months, and the failures tracked with stenosis length, patient age and combined-modality radiation. One in five later needed a sphincter, most of them with a transcorporal cuff. That is the counseling, and it happens before the repair.
The radiated posterior urethra has a longer menu than the pelvic fracture. Where the prostate itself is the obstruction I do a transvesical or a salvage prostatectomy with the urethral repair in the same sitting. Where the defect reaches the bladder neck, a bladder flap or a downward rotation of the bladder brings healthy tissue to the anastomosis. Where nothing local will heal, NYU plastic surgery and I bring a free ileal flap on the deep inferior epigastric vessels, a 20 cm segment designed as a chimeric construct; in the first six men none lost the flap, and four were voiding at follow-up. It is a long operation with a long stay and it is for the outlet that has no other option.
Continence is the price, and the sphincter waits
Before I operate on a continent man, he understands that he may not stay continent and that incontinence has treatments. That conversation is the operation's price, not a formality. When the bladder is small the honest choice is leaking versus the suprapubic tube, not repair versus the tube; framed the second way it looks like an obvious yes.
I never place a sphincter at the same sitting. The reconstruction has to prove itself on a cystoscopy that shows a patent, stable and healed lumen: three months is the floor, because the wound has to heal and the sutures have to dissolve, and six months is the default in a radiated field. The cysto, not the calendar, decides where between them a patient lands. The sequencing and the sphincter are on the incontinence page.
A good decision that ended badly
A man with a radiated, obliterated posterior urethra, continent on a suprapubic tube he hated, with recurrent infections, refused cystectomy and diversion. I repaired the urethra through a combined abdominoperineal approach and told him what I estimated the risk of ending at a cystectomy to be. He developed osteomyelitis of the pubis and eventually needed the cystectomy. The decision at the time was the right one for the choice he was actually making, which was repair versus a tube he would not accept. What I would change is technical: a non-transecting repair, because it has less chance of everything falling apart. The number was said at consent and it still did not land, which is why I now say the bailouts out loud before the incision.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Pelvic fracture urethral injury
Radiated posterior urethra
- SP inside-outside posterior urethroplasty for a radiation stricture
- Robotic posterior urethral stenosis excision after microwave therapy, full length
- Robotic urethroplasty after prostate cancer complications
- Transvesical simple prostatectomy for radiation prostatic stenosis
- Retzius-sparing SP salvage prostatectomy for prostatic urethral stenosis
- Salvage prostatectomy with abdominoperineal posterior urethroplasty and downward bladder rotation
Abdominoperineal and bladder-based repairs
Free flaps for the devastated outlet
Papers
- Robotic-assisted posterior urethroplasty: outcomes from 105 men in a single-center experience. Urology. 2023. PubMed 37543119
- Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury. World J Urol. 2019. PubMed 31144093
- Nontransecting anastomotic urethroplasty of pelvic fracture urethral injury: a demonstration of technique. Urol Video J. 2020. DOI 10.1016/j.urolvj.2020.100061
- Decision analysis model comparing cost of management strategies for pelvic fracture urethral injuries. Urol Pract. 2016. PubMed 37592686
- Management of pelvic trauma-associated urethral injury in men. Curr Surg Rep. 2023. DOI 10.1007/s40137-023-00365-w
- Multi-institutional outcomes and associations after excision and primary anastomosis for radiotherapy-associated bulbomembranous urethral stenoses following prostate cancer treatment. Urology. 2021. PubMed 33556448
- Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease. J Urol. 2013. PubMed 24333513
- Clinical outcomes of a combined robotic, transabdominal, and open transperineal approach for anastomotic posterior urethroplasty. J Endourol. 2021. PubMed 33820448
- Single-port robotic posterior urethroplasty using buccal mucosa grafts: technique and outcomes. Urology. 2021. PubMed 34624362
- Posterior urethral reconstruction with ileal chimeric free flap: a novel approach for management of radiation-induced devastated bladder outlet. Urology. 2025. PubMed 41106522
- Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from TURNS. World J Urol. 2016. PubMed 27928592
- Management of urethral stenosis after treatment for prostate cancer: NYU case of the month, August 2020. Rev Urol. 2020. PubMed 33239974
- Outcomes and risk factors of revision and replacement artificial urinary sphincter implantation in radiated and nonradiated cases. J Urol. 2020. PubMed 31951498