INTRODUCTION
Posterior urethral stricture or pelvic fracture urethral distraction defect (PFUDD) is relatively uncommon in chil-
dren. Trauma and iatrogenic injury are the most common causes of stricture occurrence.(1) Given the specificity
of children’s urethra, treating their posterior urethral stricture is difficult, specifically for the children with long
segment urethral stricture. We report a successful perineal urethroplasty for 6 cm long PFUDD in a 9 year-old boy.

CASE REPORT
A 9 year-old boy with a long PFUDD was admitted to our hospital in April 2013. Five months before the admission,
the boy suffered pelvic fracture and posterior urethral disruption caused by a traffic accident. Given the severity of
the combined injuries, he underwent suprapubic cystostomy for acute phase management. Five months later, we
performed urethrogram and cystoscopy and found that the urethral distraction defect was 6 cm in length (Figure
1). Perineal urethroplasty was thereby performed. In the operation, the boy was placed in the lithotomy position.
The bulbospongiosus muscle was dissected through an inverted Y-shaped incision. Afterwards, the bulbar urethra
was circumferentially dissected down to its proximal end and sharply divided at the strictured segment. To increase
the perineal space, the midline intercrural incision was made and the lower part of pubic symphysis was removed
with a power drill. The scar tissue involving the membranoprostatic region was excised using retrograde piecemeal
method until healthy, soft and pliable mucosa of proximal urethra was identified. This step was assisted by ante-
grade passage of a bougie through the suprapubic tract. In the last procedure, we placed a 10 French Foley cath-
eter through the urethra into the bladder and performed the end-to-end anastomosis. The operation lasted for five

Case Report 2576

CASE REPORT

Successful Perineal Urethroplasty for Long Pelvic Fracture Urethral Dis-
traction Defect (PFUDD) in a 9 Year-Old Boy

Zhai Jianpo,* Wang Jianwei, Li Guizhong, Wang Hai, He Feng, Huang Guanglin, Man Libo

Keywords: fractures; bone; complications; pelvic bones; urethra; injuries; surgery; treatment outcome.

Department of Urology, Beijing Jishuitan Hospital, Beijing 100035, China.
*Correspondence: Department of Urology, Beijing Jishuitan Hospital, Beijing 100035, China.
Tel: +86 010 58398241. E-mail: dczhaijp@126.com.
Received May 2015 & Accepted November 2015

Figure 1. Preoperative combined cystography and retrograde urethrog-
raphy.

Figure 2. Postoperative cystourethrography.

Vol 13 No 01 January-February 2016 2577

hours, and the blood loss was less than 200 mL. One
month after the operation, the Foley catheter was re-
moved, wherein no post-operative complications were
found. The boy recovered well without penile curvature
or penile shortening. Urinary incontinence and urethral
diverticula were not observed. Currently, the boy has
normal urination functions and does not need urethral
dilatation (Figure 2).

DISCUSSION
Posterior urethral stricture in children is common and
the causes include pelvic fracture, straddle injuries, or
crush injuries. Sunay and colleagues(2) reported that the
most frequent cause of urethral stricture is urethral in-
jury (78.6%), which results from pelvic fracture caused
by a traffic accident. In the study by Pfalzgraf and col-
leagues,(3) 47.1% of the children have post-traumatic
strictures. The urethral distraction defect in the present
case report was also caused by pelvic fracture.
Urethral strictures in children, whether caused by trau-
ma or surgery, are difficult to treat due to smaller pelvic
confines, decreased caliber urethra, and increased tissue
fragility. Posterior urethral trauma imposes severe im-
pairment on the quality of life and is considered one of
the most debilitating injuries if not managed properly. It
can cause urinary incontinence and impotence, as well
as urethral stricture which may require repeated inter-
ventions.(4)

Several treatments options, including urethral dilata-
tion, endoscopic visual internal urethrotomy, and open
urethral reconstruction, are available for the manage-
ment of urethral strictures in children. Urethral dilata-
tion is one of the commonly applied procedures in the
initial management of urethral strictures. However, the
long-term outcome of this procedure is unsatisfactory.
Anastomotic urethroplasty is another option for the
treatment of urethral strictures. Podesta and Podesta(5)
reviewed records of 49 male children with PFUDDS
who underwent anastomotic urethroplasties from 1980
to 2006. The median follow-up time was 6.5 years and
they found that the primary success rate was 89.7%.
Similarly, Shenfeld and colleagues(6) evaluated the
safety and efficacy of urethroplasty, which applies the
perineal approach for bulbar and membranous ure-
thral strictures in children and adolescents. The study
showed that the primary success rate of the surgery was
93%. The mean maximal urinary flow rate increased
from 2.65 mL/s preoperatively to 27.65 mL/s postoper-
atively, and no significant complications occurred. The
researchers suggested that in pediatric patients, bulbar
and membranous strictures can be treated successfully

with urethroplasty using the perineal approach. These
patients probably shouldn’t be treated “conservatively”
with urethral dilatation or endoscopic incision. In addi-
tion, the long-term treatment effect of perineal urethro-
plasty was also confirmed by Orabi and colleagues.(7)

Therefore, perineal urethroplasty is a safe and effective
treatment for urethral strictures in children.
The maximum length of stricture that can be treated
by end-to-end anastomosis is inconclusive. Koraitim(8)

found that a satisfactory perineal anastomosis could
be achieved if the stricture segment was up to 3 cm in
length. Moreover, Morey and colleagues demonstrated
that they could successfully bridge a urethral gap of up
to 5 cm in length after fully mobilizing the urethra.(9)

Regardless of the length of stricture segment, the key
to a high success rate in urethral stricture repair is the
excision of all of the fibrous tissues along with the com-
plete mobilization of the proximal and distal urethra so
as to achieve a tension-free anastomosis. Partial sym-
physiectomy is sometimes needed to achieve this goal.
(10) Given that the length of urethral stricture is 6 cm in
this case report, partial symphysiectomy (the lower part
) was performed to insure tension-free anastomosis.

CONCLUSIONS
In conclusion, perineal urethroplasty is an excellent sur-
gical procedure for treating children with long segment
PFUDD. Partial symphysiectomy is sometimes needed
to achieve the tension-free anastomosis.

CONFLICT OF INTEREST
None declared.

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Urethroplasty for PFUDD in Boy-Zhai Jianpo et al.

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