Perineal urethrostomy (PU) is a surgical procedure primarily utilized in the treatment of urethral strictures or other severe urethral pathologies that are refractory to less invasive methods. This procedure creates a permanent opening between the perineum and the urethra, bypassing the scarred or obstructed section. While PU is a procedure often considered as a last resort, it plays a critical role in providing patients with relief from debilitating urinary symptoms, preserving renal function, and improving overall quality of life. This article delves into the indications, preoperative evaluation, contraindications, surgical techniques and steps, postoperative care, possible complications, different approaches, prognosis and outcome, alternative options, average cost, recent advances, and more. Indications for Perineal Urethrostomy Perineal urethrostomy is indicated in the following clinical scenarios: Recurrent Urethral Strictures: PU is often recommended for patients with recurrent strictures, especially those involving the bulbar urethra, where repeated endoscopic interventions have failed. Strictures may arise from trauma, infection, or idiopathic causes. Complex Urethral Trauma: In cases of severe urethral injury, particularly where primary repair is not feasible or has failed, PU provides a solution by diverting the urine flow away from the damaged urethra. Failed Urethral Reconstruction: Patients who have undergone unsuccessful urethroplasty or other urethral reconstruction surgeries may benefit from PU as a salvage procedure. Lichen Sclerosus: This chronic inflammatory condition affecting the skin and mucous membranes, particularly the genitalia, can lead to extensive urethral scarring. PU may be indicated when the disease causes significant urethral involvement. Urethral Carcinoma: In certain cases of urethral cancer where extensive resection is required, PU may be necessary to ensure complete removal of the affected tissue. End-Stage Bladder Disease: Patients with end-stage bladder conditions requiring cystectomy may undergo PU to manage urinary diversion, especially when other forms of urinary diversion are contraindicated. Preoperative Evaluation A thorough preoperative evaluation is critical to the success of a perineal urethrostomy. The following assessments are essential: Patient History and Physical Examination: Detailed documentation of the patient’s medical history, including previous surgeries, comorbidities, and the severity of symptoms, is vital. A focused genitourinary examination should assess the extent of urethral pathology and any associated complications. Imaging Studies: Retrograde urethrography (RUG) and voiding cystourethrography (VCUG) are pivotal in delineating the location, length, and severity of the stricture. Additionally, ultrasound or MRI may be employed to evaluate surrounding structures. Endoscopic Evaluation: Cystourethroscopy allows direct visualization of the urethral lumen, aiding in the assessment of the stricture’s extent and other potential pathologies. Urodynamic Studies: In select cases, urodynamic testing is performed to evaluate bladder function, especially in patients with concurrent bladder dysfunction or suspected neurogenic bladder. Laboratory Tests: Routine blood work, including a complete blood count, renal function tests, and urinalysis, should be conducted. Additionally, cultures may be taken if infection is suspected. Psychological Evaluation: Given the life-altering nature of PU, a psychological assessment may be warranted to ensure the patient is mentally prepared for the outcomes and potential lifestyle changes following surgery. Contraindications Contraindications for perineal urethrostomy include: Active Infection: Active urinary tract infections or perineal sepsis must be resolved before proceeding with PU to reduce the risk of postoperative complications. Inadequate Perineal Tissue: Previous perineal surgery or radiation therapy that has compromised the tissue integrity may preclude successful urethrostomy creation. Significant Comorbidities: Patients with severe cardiovascular, respiratory, or other systemic conditions may not tolerate the surgical procedure or anesthesia. Non-compliance: Patients who are unlikely to adhere to postoperative care and follow-up protocols are not ideal candidates for PU. Surgical Techniques and Steps Perineal urethrostomy is a specialized procedure requiring meticulous surgical technique. The following outlines the general steps involved: Anesthesia and Positioning: The patient is placed in the lithotomy position under general or regional anesthesia. Incision and Exposure: A midline perineal incision is made, and the underlying tissues are carefully dissected to expose the bulbar urethra. Care must be taken to avoid injury to surrounding structures, such as the rectum. Mobilization of the Urethra: The bulbar urethra is dissected free from its surrounding attachments, allowing it to be mobilized adequately for the creation of the stoma. Creation of the Stoma: A longitudinal incision is made in the ventral aspect of the urethra, which is then spatulated to create a wide stoma. This opening is sutured to the skin of the perineum using absorbable sutures, ensuring a tension-free anastomosis. Hemostasis and Wound Closure: Meticulous hemostasis is achieved, and the wound is closed in layers, leaving a small drain if necessary. A Foley catheter is placed through the stoma to ensure urinary drainage during the initial healing period. Postoperative Care: The patient is monitored in the postoperative recovery area, with particular attention to pain management, fluid balance, and catheter care. Postoperative Care Effective postoperative care is essential for the successful outcome of perineal urethrostomy. Key aspects include: Catheter Management: The Foley catheter is typically left in place for 2-3 weeks to allow the stoma to heal. Proper catheter care, including regular cleaning and monitoring for blockages, is critical. Wound Care: The perineal wound should be kept clean and dry, with daily inspection for signs of infection or dehiscence. Any seromas or hematomas should be promptly addressed. Pain Management: Adequate analgesia, including non-opioid and opioid medications, should be provided. Patients may also benefit from sitz baths to reduce discomfort. Follow-up Imaging: A pericatheter urethrogram may be performed before catheter removal to ensure the stoma is patent and there is no evidence of stricture formation. Patient Education: Patients should be educated on signs of complications, such as urinary retention, hematuria, or fever, and advised to seek immediate medical attention if they occur. Possible Complications While perineal urethrostomy is generally a safe procedure, complications can occur. These include: Stenosis of the Stoma: Stenosis or narrowing of the urethrostomy stoma is a common complication that may require dilatation or revision surgery. Infection: Surgical site infections or urinary tract infections can develop postoperatively, necessitating antibiotic therapy. Urinary Incontinence: Although rare, some patients may experience stress urinary incontinence due to damage to the external sphincter mechanism. Bleeding: Significant intraoperative or postoperative bleeding may occur, particularly in patients with coagulopathies or on anticoagulant therapy. Fistula Formation: Urethroperineal or urethrocutaneous fistulas can form, leading to urinary leakage and requiring further surgical correction. Recurrence of Stricture: Despite the creation of a new urinary pathway, stricture recurrence is possible, necessitating close follow-up. Different Techniques and Approaches Several variations of the perineal urethrostomy technique have been described, tailored to the patient’s specific condition: Classic Perineal Urethrostomy: The traditional approach involves spatulating the bulbar urethra and creating a wide stoma in the perineum. This is the most common technique used. Buccal Mucosa Graft Urethrostomy: In cases where the perineal skin is insufficient or scarred, a buccal mucosa graft may be used to create the stoma. This approach can reduce the risk of stenosis. End-to-End Anastomotic Urethrostomy: This technique involves anastomosing the proximal and distal ends of the urethra after resection of the stricture. It is typically reserved for shorter strictures. Two-Stage Urethrostomy: In complex cases, a two-stage approach may be employed. The first stage involves creating a perineal urethrostomy, followed by a second stage where definitive reconstruction is performed. Prognosis and Outcome The prognosis for patients undergoing perineal urethrostomy is generally favorable, particularly in terms of symptom relief and preservation of renal function. Long-term outcomes depend on factors such as the underlying cause of the urethral pathology, the presence of comorbidities, and adherence to postoperative care protocols. Symptom Relief: Most patients experience significant relief from urinary symptoms, including improved urinary flow and reduced post-void residual volumes. Renal Function: By bypassing obstructive urethral segments, PU helps prevent upper urinary tract deterioration, thereby preserving renal function. Quality of Life: Despite the lifestyle changes associated with having a perineal urethrostomy, many patients report an overall improvement in quality of life due to the resolution of bothersome symptoms. Alternative Options Perineal urethrostomy is typically considered when other less invasive interventions have failed. Alternative options may include: Endoscopic Urethrotomy: This procedure involves the incision of the stricture using an endoscope. It is less invasive but associated with higher recurrence rates. Urethral Dilation: Serial dilation of the stricture can be performed, though it often requires repeated procedures and has a high rate of recurrence. Urethroplasty: Urethral reconstruction, either with excision and primary anastomosis or with grafting, is an alternative to PU in selected cases. Urinary Diversion: For patients with extensive urethral pathology or those not suitable for PU, urinary diversion with a suprapubic catheter or ileal conduit may be considered. Average Cost The cost of perineal urethrostomy can vary significantly depending on the region, healthcare facility, and patient-specific factors. Generally, the procedure may range from $10,000 to $30,000, including preoperative evaluations, surgical fees, hospitalization, and postoperative care. Recent Advances Recent advances in perineal urethrostomy include: Tissue Engineering: Research into tissue-engineered grafts for urethral reconstruction is ongoing, with the potential to improve outcomes in patients with complex urethral strictures. Minimally Invasive Techniques: Laparoscopic or robotic-assisted approaches to perineal urethrostomy are being explored, offering the possibility of reduced morbidity and faster recovery. Enhanced Recovery Protocols: Implementation of enhanced recovery after surgery (ERAS) protocols in PU has shown promise in reducing hospital stay and improving patient outcomes.
