CPT® Code 53515

1. Indications

The procedure of urethrorrhaphy is indicated for the following conditions:

• Urethral Injury: Surgical repair is necessary for injuries specifically affecting the prostatomembranous urethra, which may occur due to trauma or surgical complications.
• Exploratory Surgery: Urethrorrhaphy may be performed immediately if the patient requires exploratory surgery to identify potential rectal or vascular injuries.
• Delayed Repair: In cases where a hematoma is present, a delayed repair may be indicated, allowing for the absorption of the hematoma over a period of 6 to 12 weeks.

2. Procedure

The procedure of urethrorrhaphy involves several critical steps to ensure successful repair of the urethral injury:

• Step 1: A suprapubic catheter is placed to divert urine, which can be done either percutaneously or through an open cystotomy, depending on the clinical scenario.
• Step 2: For delayed repairs, a midline perineal incision is made, and the bulbospongiosus muscle is divided to gain access to the urethra.
• Step 3: The surgeon continues dissection through the corpus spongiosum until the urethra is located, identifying the proximal point of obliteration using a catheter and assessing the distal point as far as the suspensory ligament to the penis.
• Step 4: A sound is passed via the suprapubic cystotomy tract through the bladder neck and into the prostatic urethra to facilitate alignment of the urethral ends.
• Step 5: The right and left corporal bodies are separated in the midline for a distance of 4-5 cm, allowing the urethra to move upwards and shortening the distance between the urethral ends.
• Step 6: If urethral tension remains, dissection continues by displacing or ligating the penile vessels laterally to relieve tension.
• Step 7: A wedge of bone is removed from the pubis at the inferior aspect using bone rongeurs or an osteotome, creating a groove for the urethra and adding 1-2 cm of urethral length.
• Step 8: If anastomosis is still not possible due to tension, the urethra is rerouted around the corporal body through a larger resection of the pubic bone, ensuring careful dissection to avoid injury to neurovascular tissue.
• Step 9: The distal urethral stump is spatulated and brought down from a 12-o'clock position, while the proximal urethral stump is spatulated and lifted from the 6-o'clock position, identifying healthy tissue and seminal ducts in the verumontanum of the prostatic urethra.
• Step 10: Anastomosis of the two ends of the urethra is accomplished by placing sutures through the urethral mucosa and tying them after all sutures have been placed.
• Step 11: A fenestrated catheter is placed transurethrally to maintain patency during healing.
• Step 12: The corpus spongiosum is closed, followed by closure of the bulbospongiosus muscle, and finally, the perineal skin is sutured, with the suprapubic catheter being replaced as necessary.

3. Post-Procedure

Post-procedure care following urethrorrhaphy includes monitoring for complications such as infection, urinary retention, or anastomotic leakage. Patients may require a period of catheterization to ensure proper healing and urinary function. Follow-up appointments are essential to assess the success of the repair and to manage any potential complications. The recovery process may vary based on the extent of the injury and the surgical technique employed, and patients should be advised on activity restrictions during the healing period.