Assessment and Management of an Open Bladder Neck at Posterior Urethroplasty

ObjectivesTo determine the factors that may influence the risk of injury to the bladder neck in patients sustaining a pelvic fracture urethral injury and report our experience in the management of an open bladder neck at the time of delayed repair.MethodsWe identified 21 patients with an open bladder neck on cystography before they underwent repair of a pelvic fracture urethral distraction defect. Of these patients, 12 were continent after urethroplasty and 9 received bladder neck reconstruction concomitant with or subsequent to urethroplasty. Bladder neck reconstruction was performed by Young-Dees-Leadbetter (5) or anterior bladder flap-tube (4) procedure.ResultsPatients with an incompetent bladder neck were usually (67%) children ≤15 years old, had been most commonly (75%) managed initially by primary realignment, and all (100%) had fracture of ipsilateral ischiopubic rami. The preoperative cystogram showed a bladder neck opening of a rectangular shape, and suprapubic cystoscopy revealed a fixedly open bladder neck. Of the 9 patients who received a bladder neck reconstruction, 7 (78%) had a successful outcome and 2 (22%) had a treatment failure.ConclusionsIt seems that the risk of injury to the bladder neck increases in children, in ipsilateral ischiopubic rami fracture and in cases managed initially by primary realignment. At posterior urethroplasty, the presence of an incompetent bladder neck is suspected by the finding of an open bladder neck of a rectangular shape on cystography and a fixedly open bladder neck on suprapubic cystoscopy. Reconstruction of the bladder neck by Young-Dees-Leadbetter procedure probably offers the best successful results.