Anastomotic urethroplasty as management for iatrogenic posterior urethral injuries in an infant

Introduction: Boys born with high imperforate anus have a rectourethral fistula, which usually occurs at the prostatomembranous junction. A recent trend has been to perform a single-stage posterior sagittal posterior anorectoplasty (PSARP) with pull-through and closure of the rectourethral fistula. Inadvertent posterior urethral injury during repair may result in traumatic obliteration of the posterior urethra. Posterior urethral injury is also possible after other procedures such as ablation of posterior urethral valves (PUVs). We evaluated our outcomes of posterior anastomotic urethroplasty in such infants. Materials and Methods: We managed four infants with posterior urethral injury after PSARP and one after endoscopic ablation of PUVs during 2012–2018 at our institution. Iatrogenic injury was noticed post-PSARP on the removal of the urinary catheter. Suprapubic catheter (SPC) was subsequently inserted. Retrograde urethrogram, voiding cystourethrogram, and endoscopy through the SPC tract and urethra were performed before undertaking an anastomotic urethroplasty. Results: Three infants required crural separation and inferior pubectomy. Four infants had an uneventful recovery. One infant had an annular narrowing at the anastomotic site and required endoscopic urethrotomy twice. We waited till the child was older (age 4) and performed urodynamics. This revealed obstructive uropathy. The patient subsequently underwent redo anastomotic urethroplasty with crural separation and inferior pubectomy. He had an uneventful recovery. Our follow-up ranged from 1 to 7 years. Conclusions: Iatrogenic urethral injuries are rare in infants. Anastomotic urethroplasty achieves physiological voiding and prevents complications of prolonged SPC. Even though surgery is challenging, our series suggests that it is feasible with good outcomes.