Flaps for bulbar urethral ischemic necrosis in pelvic fracture urethral injury

Abstract

Bulbar urethral ischemic necrosis (BUIN) is an iatrogenic entity resulting from repeated attempts at performing anastomotic urethroplasty for pelvic fracture urethral injuries. Etiologically speaking, BUIN is related to a compromised blood supply of the bulbar urethra, which normally relies on anterograde supply from bulbar arteries and retrograde supply from recurrent branches of dorsal penile arteries, through the glans. At each transection of the bulbar urethra, both the anterograde and retrograde supplies are compromised, increasing the risk of BUIN. Even though this term is widely used among reconstructive urologists, BUIN is orphan of an accepted scientific definition. We aim to report our personal perspective on BUIN, to identify factors associated with its occurrence, and to describe the management options in these patients.

Keywords

Bulbar urethral ischemic necrosis / inferior pubectomy / pedicled preputial tube / Q-flap

References

[1] Demetriades D,Toutouzas K,Velmahos G.Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes.J Am Coll Surg2002;195:1-10

[2] Joshi PM.Management of pelvic fracture urethral injuries in the developing world.World J Urol2020;38:3027-34

[3] Webster GD.Perineal transpubic repair: a technique for treating post-traumatic prostatomembranous urethral strictures.J Urol1986;135:278-9

[4] Turner-warwick R.Complex traumatic posterior urethral strictures.J Urol1977;118:564-74

[5] Mundy AR.Entero-urethroplasty for the salvage of bulbo-membranous stricture disease or trauma.BJU Int2010;105:1716-20

[6] Barbagli G.History and evolution of transpubic urethroplasty: a lesson for young urologists in training.Eur Urol2007;52:1290-2

[7] Joshi P,Kulkarni S.Approach to bulbar urethral strictures: which technique and when?.Turk J Urol2016;42:53-9 PMCID:PMC4857917

[8] Kulkarni SB,Desai DJ.Management of complex and redo cases of pelvic fracture urethral injuries.Asian J Urol2018;5:107-17 PMCID:PMC5934510

[9] Kulkarni SB,Hunter C,Shahrour W.Complex posterior urethral injury.Arab J Urol2015;13:43-52 PMCID:PMC4435922

[10] Guan Y,Zhao S.The vascular and neurogenic factors associated with erectile dysfunction in patients after pelvic fractures.Int Braz J Urol2015;41:959-66 PMCID:PMC4756973

[11] Rosen RC,Wagner G,Kirkpatrick J.The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction.Urology1997;49:822-30

[12] Zuckerman JM,Tisdale BE.Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries.Urology2012;80:1369-73

[13] Joshi PM,Shah D,Kulkarni SB.Magnetic resonance imaging procedure for pelvic fracture urethral injuries and recto urethral fistulas: a simplified protocol.Turk J Urol2021;47:35-42 PMCID:PMC7815245

[14] Joshi PM.3D printing of pelvic fracture urethral injuries-fusion of technology and urethroplasty.Turk J Urol2020;46:76-9 PMCID:PMC6944423

[15] Bandini M,Leni R.Assessing in-hospital morbidity after urethroplasty using the European Association of Urology Quality Criteria for standardized reporting.World J Urol2021;39:3921-30

[16] Kulkarni S,Surana S,Joglekar O.Pedicled preputial tube urethroplasty for bulbar urethral necrosis after failed anastomotic urethroplasty for pelvic fracture urethral distraction defects.Eur Urol Suppl2018;17:e1937

[17] Morey AF,Zinman LM.Q-flap reconstruction of panurethral strictures.BJU Int2000;86:1039-42

[18] Barbagli G,Balò S.Patient-reported outcomes for typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting: a single-center analysis of more than 800 patients.World J Urol2021;39:2089-97

[19] Ozkan O.The prefabricated pedicled anterolateral thigh flap for reconstruction of a full-thickness defect of the urethra.J Plast Reconstr Aesthet Surg2009;62:380-4

[20] Harris TGW,Wu WJ.Pedicled anterolateral thigh and radial forearm free flap phalloplasty for penile reconstruction in patients with bladder exstrophy.J Urol2021;205:880-7

[21] Chauhan A,Chee J.Microsurgical urethroplasty for complex bulbar urethral strictures using the radial forearm free flap prelaminated with buccal mucosa.J Reconstr Microsurg2016;32:378-85

[22] Nikolavsky D.Prelaminated gracilis flap with buccal mucosal graft for salvage of devastated urethra.Case Rep Urol2015;2015:490518 PMCID:PMC4519531

[23] Barbagli G,Balò S,Butnaru D.Surgical treatment of bulbar urethral strictures: tips and tricks.Int Braz J Urol2020;46:511-8 PMCID:PMC7239284

[24] Joshi P,Montorsi F.Challenging the dogma of 6 steps for anastomotic urethroplasty in posterior urethral stricture: introducing step 3a.World J Urol2021;