[Abstract] OBJECTIVE: To investigate the effect of combined transabdominal perineal approach in the treatment of complex posterior urethral strictures. METHODS: Forty-eight patients with complex posterior urethral strictures were treated by combined transabdominal perineal pathway, and their clinical data were retrospectively analyzed. RESULTS: Forty-two cases were cured in one operation, including 20 cases with straight needle anastomosis and 22 cases with curved needle anastomosis. There were 6 cases of failure, 1 case of postoperative perineal hematoma infection, 1 case of incomplete treatment of perineal fistula and pubitis before surgery, and 4 cases of complicated rectal fistula without prior colostomy. Lin Guotai, Department of Urology, Putian First Hospital Conclusion: For the repair of posterior urethral stricture with long segment, high level, repeated surgical failure or severe pelvic deformity, the direct needle anastomosis by combined abdominal perineal pathway is one of the ideal procedures worth adopting. [Keywords] Posterior urethral stricture, complexity; surgery, surgery Complex posterior urethral stricture is one of the difficult problems in urology. 48 cases were admitted to our hospital from January 1989 to January 2003 and treated by open surgery with satisfactory results, which are reported as follows. 1. Clinical data The 48 cases in this group, aged 6 to 71 years, had a medical history of 3 months to 27 years. There were 38 cases due to traumatic pelvic fracture, 5 cases of ball urethral stricture involving the posterior urethra due to multiple failed surgeries outside the hospital, 1 case of posterior urethral sand gun injury with sand bullet retention, and 4 cases due to congenital anal atresia after anoplasty. The length of the strictures ranged from 1.4 to 5.0 cm, with an average of 3.4 cm, of which 13 cases were complete atresia, 9 cases were prostatic urethral strictures, 21 cases were membranous urethral strictures, and 5 cases were bulbous urethral strictures. There were 6 cases of combined urethrorectal fistula, 7 cases of perineal fistula, 4 cases of false tract, 2 cases of diverticulum, and 19 cases of urethral cystitis. 2. Methods and results All 48 cases were excised by combined abdominal-perineal route for posterior urethral stricture scar, including 22 cases with straight needle method for end-extrusion anastomosis and 26 cases with curved end-extrusion anastomosis, and the urethra was removed 2-4 weeks after surgery. Forty-two cases were cured in one operation, and 39 cases were followed up for 6 months to 2 years, and all of them had urinary passage and thick urinary line without long-term regular urethral dilatation. In 6 cases with urethrorectal fistula, fistulotomy and rectal wall repair were performed at the same time, among which 3 children and 1 adult were caused by post-anal lock, and after strict bowel preparation, curved and straight needle anastomosis, sigmoid colostomy and cystostomy were used respectively. One case with complicated urethral perineal fistula and pubitis was cured by straight-needle anastomosis after strict bowel preparation before surgery. one case with curved-needle anastomosis was cured by straight-needle anastomosis, and the infection failed in two operations in six months, and finally the third operation. one case with curved-needle anastomosis was found to have a large hematoma in the perineum on the third day after surgery, and the perineal incision was opened and drained, but the secondary infection failed, and the patient was lost. 3. Discussion Complex posterior urethral stricture is a difficult problem in urology because of the complexity of its local lesion and the peculiarity of the anatomical site of the posterior urethra, which is clinically difficult to operate and has a high failure rate of infection. We have learned that before surgery, we must first clarify the condition and make a comprehensive and detailed examination according to its diagnostic criteria in order to make adequate preoperative preparations as well as to choose the appropriate surgical route, surgical modality and timing of surgery. At the same time, it is necessary to eliminate potential infection factors and pay attention to the management of serious complications. ① The presence of preoperative infectious factors is an important reason for failure of posterior urethral surgery. In addition to strict bowel preparation before surgery, those with severe perineal fistula, urethral cystitis or upper urinary tract fluid should have a cystostomy for 1 to 2 months in order to give the bladder and urethra adequate rest and effectively control potential infection factors, especially for perineal fistula and sinus tract to be repeatedly scraped and changed for clean drainage, periurethritis or abscess to be promptly incised and drained, and pubitis to be thoroughly treated before surgery. (ii) for complications of urethro-rectal fistula and sinus, repeated scratching and changing of medicine and drainage should be done. For patients with complicated urethrorectal fistula, it is often difficult to accurately determine the size of the fistula and the degree of infection before surgery. We believe that regardless of the size of the fistula and the degree of infection, colostomy and cystostomy should be performed first, and then surgery should be performed after 3 months of strict bowel preparation. In complex posterior urethral strictures, the local pathological changes are complex, and generally posterior urethral stricture surgery should be performed 3-6 months after urethral trauma, but if the local reaction is heavy or the scar growth is hard and extensive, local physiotherapy, hot compresses or corticosteroids should be used first or cystostomy should be performed at the same time for drainage, and surgery should be performed only after the local reaction has subsided or the scar has softened. To improve the success rate of intraoperative anastomosis, the following points should be noted: ① Adequate excision of the scar. The fibrous scar of the posterior urethral stricture or atresia is richer and more difficult to be completely excised. We believe that the tip of the index finger should be able to pass the original urethral bed smoothly, and any part of the finger that feels like a bump or doorway should be excised, and the scar should be excised with a probe in the urethra and bladder neck or an assistant’s finger in the rectum for guidance, and excised in small pieces to prevent damage to the rectum. ② Reliable anastomosis. The two ends of the urethra before anastomosis should be well hemorrhaged, the proximal urethra should be free for more than 0.5 cm, the traumatic edge is neater, the appearance is light red, the finger is softer to touch, the index finger tip can be inserted smoothly into the posterior urethra or bladder neck, the distal urethral spongy body should be properly free so that the two broken ends of the urethra are close together without tension, and a full-layer external suture should be made, the posterior urethra should be anastomosed first, and then several stitches should be made to reduce the tension. (iii) Prevent anastomosis with the pseudotract. Theoretically, the pseudo-tract needs to be resected and closed, but in practice it is difficult to completely resect and close the pseudo-tract, we believe that the pseudo-tract can be scraped and cleaned with iodine, and then left open. ④ Strict repair of rectal fistula. The fistula of the anterior rectal wall should be researched accurately and excised at about 0.3 cm from the edge, and the repair should be made with inward sutures, so that the rectal mucosa cannot be turned out to the operative area, and the anterior rectal wall should be properly freed so that the staggered anastomosis of the repair is located about 1.0 cm below it, and the rectum should be drained by built-in anal canal and iodophor cloth to promote the healing of the fistula. ⑤ Tight hemostasis and unobstructed drainage. For routine cystostomy, the urethral stent tube should not be too thick, 16-18F silicone balloon urethra is preferred for adults, regular flushing and iodine drip washing of the urethral orifice, which facilitates timely drainage and removal of oozing blood and secretions around the anastomosis of the urethral cavity and reduces infection. Complex posterior urethral strictures are often difficult to achieve ideal butt-end anastomosis using traditional surgical trails and sutures. Huang Ankang et al. (1991) used the pubic symphysis pathway to achieve ideal butt-end anastomosis under direct vision of the urethra, but its surgical injury was high and the incidence of postoperative impotence was high. Zhang Jiong et al. used the perineal joint resection infrapubic rim pathway for urethral counter-end anastomosis also received good results without serious complications, but the operative time was longer and the injury was also greater.