False urethral anastomosis.

We present images of three cases with false urethral anastomosis following urethroplasty. The likely causes are inadequate posterior urethral dissection and blind use of Hey Grove dilator. We recommend use of antegrade flexible cystoscopy to prevent this complication.

INTRODUCTION

False urethral anastomoses are unrecognized cause of failed anastomotic urethroplasty, presenting with recurrent strictures and/or incontinence of urine. We present images of three such cases.

CASE REPORT

A 24-year-old male presented with recurrent poor stream following anastomotic urethroplasty, without relief even after repeated dilatations, urethrotomies, and even a buccal mucosal graft (BMG) urethroplasty. An ascending urethrogram revealed a false anastomosis onto the dorsal aspect of the bulbar urethra. The proximal segment was ending as a blind pouch [Figures 1a and b]. Confirmatory antegrade cystoscopy, excision of the false anastomosis, and corrective augmented roof strip anastomotic urethroplasty solved the problem as shown in Figure 1c.

Figure 1a

Ascending urethrogram shows dorsal false urethral anastomosis with stricture and a ventral blind segment

Figure 1b

Pre-operative voiding cystourethrography (VCUG) shows the bulbar stricture

Figure 1c

Postoperative VCUG shows normal urethral continuity

Following an anastomotic urethroplasty, a 12-year-old boy had persistent poor stream and urinary incontinence. A voiding cystourethrography (VCUG) [Figure 2] revealed the normal urethral passage posterior to the false urethral anastomosis. Confirmatory antegrade cystoscopy, dismantling of the false passage and anatomical anastomotic urethroplasty, resulted in complete relief.

Figure 2

VCUG shows distal urethra anastomosed to the anterior wall of the prostatic urethra and the normal prostatic urethra directed posteriorly

A 7-year-old boy presented with recurrent urinary tract infections and urinary incontinence following two repairs for penoscrotal hypospadias. A false anastomosis had resulted in a long blind-ending tube ventrally [Figure 3], with additional strictures in the distal bulbar and penile urethra. The streak of contrast seen dorsally is possibly the tube constructed during the first urethroplasty. Confirmatory antegrade flexible cystoscopy, correct reanastomosis and a distal buccal mucosa graft resulted in complete relief.

Figure 3

VCUG shows ventral false anastomosis in the bulbar urethra with a dorsal blind segment. Also, note the stricture in distal bulbar urethra and proximal penile urethra with a second streak of contrast parallel to the ventral urethra

DISCUSSION

The above cases illustrate the absence of recognition of a false anastomosis by urologists, despite persisting postoperative problems. A similar experience has been reported by Liu et al.[1] Apart from their recognition, it is also worthwhile dwelling on the likely causes of such inadvertent false anastomosis in the first place. The first is hesitation/inexperience of the surgeon to perform adequate posterior urethral dissection. This can be rather difficult in the event of past pelvic trauma and in children. The second likely cause is the blind use of the Hey Grove dilator, presuming that the tip will come out only at the terminal portion of the proximal urethra. Cutting on the tip of such a dilator, without cystoscopic confirmation can contribute to such a false anastomosis.

Jordan et al.[2] recommended adjuvant use of flexible cystoscopy, or even temporary vesicostomy to avoid misanastomoses, to sites other than the apical portion of the proximal urethra. For some reason, this is not universally followed. Anastomosis to regions other than the normal urethral lumen can definitely lead to strictures. Incontinence is either due to bypassing of the sphinteric mechanism, as was seen in Figure 2 or because of overflow from a proximal ‘sump’ due to a blind ending loop. A similar observation has been made by Al-Rifaei.[3]

CONCLUSIONS

False anastomoses are possible on the ventral as well as the dorsal aspect of the normal urethra as highlighted in these cases. It is important to consider this condition during evaluation of recurrent strictures/post-anastomotic incontinence. The use of antegrade flexible cystoscopy can help prevent the occurrence of such false anastomoses.