ASTRA – An alternative approach for the posterior urethra

ABSTRACT

Introduction:

Access represents one of the main challenges in performing posterior urethroplasty (¹, ²). Several approaches and tactics have been previously described (³). This video demonstrates the Anterior Sagittal Transrectal Approach (ASTRA), which allows better visualization of the deep perineum (⁴).

Materials and Methods:

Our patient was a 65-year-old man with post radical prostatectomy vesicourethral anastomotic stenosis. He failed repeated endoscopic interventions, eventually developing urinary retention and requiring a cystostomy. We offered a vesicourethral anastomotic repair through ASTRA. The patient was placed in the jackknife position and methylene blue instilled through the cystostomy. To optimize access to the bladder neck, an incision of the anterior border of the rectum is performed. Anastomosis is carried out with six 4-0 PDS sutures. These are tied using a parachute technique, after insertion of a 16F Foley.

Results:

The patient was discharged after 72 hours, and the Foley catheter was removed after 4 weeks. There were no access-related complications. Retrograde urethrogram 3 months after surgery confirmed patency of the anastomosis. Upon review 5 months after surgery the patient had urinary incontinence requiring 5 pads/day and was considered for an artificial urinary sphincter.

Discussion:

In our series of 92 patients who have undergone reconstructive procedure through ASTRA there have been no cases of fecal incontinence. Two patients with prior history of radiotherapy developed rectourethral fistulas. Urinary incontinence was observed in those patients with stenosis after radical prostatectomy.

Conclusion:

This video presents a step-by-step description of ASTRA, an approach that provides excellent visualization to the posterior urethra, representing an alternative access for repair of complex posterior urethral stenosis.

• Available at: http://www.intbrazjurol.com.br/video-section/20220164_Pinto_et_al

REFERENCES

• ¹
  Gomez RG, Scarberry K. Anatomy and techniques in posterior urethroplasty. Transl Androl Urol. 2018; 7:567-579.
• ²
  Kulkarni SB, Joshi PM, Hunter C, Surana S, Shahrour W, Alhajeri F. Complex posterior urethral injury. Arab J Urol. 2015; 13:43-52.
• ³
  Webster GD, Peterson AC. Simple perineal and elaborated perineal posterior urethroplasty. Arab J Urol. 2015; 13:17-23.
• ⁴
  Macedo A Jr, Silva MIS, Pompermaier JA, Ottoni SL, de Castro R, Leal da Cruz M. The anterior sagittal transrectal approach (ASTRA) for cases associated with rectal implantation of the urethra: A retrospective review of six cases. J Pediatr Urol. 2017; 13:613.e1-613.e4.

Publication Dates

• Publication in this collection
  03 Feb 2023
• Date of issue
  Jan-Feb 2023

History

• Received
  20 Mar 2022
• Accepted
  04 Apr 2022
• Published
  10 May 2022