الفهرس 
Pelvic anatomyOnly 14 pages are availabe for public view
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Abstract
Repeated internal urethrotomy is best avoided because they produce scarring and loss of elasticity of the anterior urethra, which compromises the chance of subsequent anastomotic urethroplasty. (6)
Corporal splitting, inferior pubectomy, and urethral rerouting are beneficial and useful ancillary procedures in transperineal posterior urethroplasty to achieve tension-free anastomosis (39)
The overall success of a one-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is excellent, with minimal morbidity for intermediate and longer strictures with associated complicating factors. Substitution urethroplasty or abdominoperineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively. (100, 112)
Partial transpubic approach provides an excellent exposure that greatly facilitates the creation of an under vision tension-free and scar-free bulboprostatic urethral anastomosis. It is the only way to go for complex cases associated with intra-abdominal complicated conditions. For a long-gap posterior urethral distraction defect the excellent results of both the partial transpubic and elaborated perineal procedures compete rather than contradict each other for the best welfare of the patient. (116)
Symphysiotomy is hereby revisited as a simple and effective approach for repairing traumatic posterior urethral injuries in the pediatric population. It can be performed instead of transpubic urethroplasty to manage long or otherwise complicated strictures (108). This is attributed to spreading up the pubic rami with a special retractor placed in the symphysiotomy incision that resulted in dislocation of the sacroiliac joints. Changing the transpubic approach by resecting rather than splitting the symphysis pubis do not result in back pain or disability. However, total pubectomy results in its own complications including the problem of a fairly large dead space and bleeding. Copious discharge might persist for a long time and the length of hospitalization has been reported to reach 14-50 days (average 28.2 days). Also, bleeding may be so profuse that at one time the site of bone resection is regularly packed firmly before undertaking the perineal part of the operation so as to allow time for the bleeding to be controlled. (116)
Posterior Sagittal Pararectal Approach; this technique is a good alternative approach for repair of complicated PFUDDs. It is safe and has the advantage of better visualisation of the apex of the prostate and surgical field, with subsequent good outcomes without immediate or remote effects on the sphincteric function of the rectum or bladder. The posterior sagittal pararectal incision is a safe approach that does not violate the principle of staying in the midline. It avoids neurological damage with maximal preservation of important structures in the perirectal area such as the autonomous nerves and ganglia, which are essential for normal erectile and vesical function. It provides excellent exposure of the posterior urethra and retrovesical region, and allows the surgeon to always perform dissection under direct vision. It does not impair anorectal sphincter function or compromise faecal continence . So it is a safe and effective approach for repair of complicated posterior urethral distraction defect (126)
Anterior sagittal transanorectal approach (ASTRA), used in the management of pelvic fracture urethral distraction defects in the cases in which there is a treatment failure through the conventional perineal route associated or not with the transpubic one, and it is currently the approach used in the management of such injuries This approach offers an excellent exposure of the posterior urethra. In the cases in which the prostate has an upper dislocation due to trauma, the opening of the anterior rectal wall can be widened as necessary to identify the prostatic urethra. It also enables an ample mobilization of the bulbar urethra for tension free anastomosis and, in the cases in which this maneuver alone will not suffice the separation of the corpora cavernosa and inferior pubectomy can be easily performed. It can be safely performed simply through proper bowel preparation, with no need for a protective colostomy, imposing no great risk to the continence provided the midline is respected. This approach is also limited to the inferior portion of the prostate, avoiding the plexus that, if injured, could lead to erectile dysfunction. (127)
The sagittal transanorectal approach, that is increasingly being used to approach posterior urethral diseases, has shown to be safe and effective in the treatment of pelvic fracture posterior urethral distraction defects, since it allows severe lesions to be treated with ample exposure of the surgical area, without incurring into complications such as fecal incontinence or rectourethral fistulae. (128)
All types of surgical treatment are equally problematic, with similar complication rates and long-term morbidity. The procedure of choice should be individualized, depending on the anatomy and the extent of the urethral injury, stability of the patient, and presence of additional injuries. (8)
Hyperbaric oxygen therapy (HBOT) may be effective for improving EF recovery after posterior urethral reconstruction. (151), and the acute management of urethral tears may have a profound effect on future sexual function and continence (19)
It 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. (74)
Recto-urethral fistula in children is an uncommon entity that represents a complex management problem. Obviously, appropriate timing of operation and using an appropriate procedure are very important. The fistula can be repaired satisfactorily after the scars around it become soft, and general and local infections are controlled. It is feasible to repair the recto-urethral fistula by one-stage procedure. The York-Mason approach as well as the transperineal approach with interposition of vascularised tunica vaginalis flap has an excellent access and been effective in the repair of recto-urethral fistula. (143)