Perineal Permanent Urethral Ligation (PUL)
Perineal permanent urethral ligation (PUL) is an irreversible perineal salvage procedure that transects and closes the bulbar urethra. It can control leakage through an end-stage urethra and requires an alternative permanent drainage route, usually chronic suprapubic tube (SPT) drainage.[2] It was developed for men with severe refractory stress urinary incontinence (SUI), often after artificial urinary sphincter cuff erosion, when urethral tissue cannot support another AUS and the patient wishes to avoid major abdominal diversion.[1][2][3]
PUL is the perineal, SPT-based alternative to formal bladder-neck closure or cystectomy or diversion. It closes the urethral outlet below the sphincter rather than creating a bladder-neck closure, and it avoids bowel or abdominal stoma construction, with ongoing suprapubic drainage in the adult AUS-erosion series; the neurogenic series used existing catheterizable channels.[2][3][5]
For the adjacent escalation pathways, see Artificial Urinary Sphincter, Male Stress Urinary Incontinence, Bladder Neck Closure, and Urinary Diversion.
Indications
PUL is a niche salvage option for patients who have both refractory incontinence and an end-stage urethra:
- End-stage urethra too scarred or fragile for another AUS cuff after cuff erosion (single or recurrent), multiple failed AUS revisions, or other failed urethral interventions.[1][2][3]
- Severe SUI in a frail or elderly patient who accepts a permanent SPT but wishes to avoid cystectomy, ileal conduit, continent catheterizable channel, or formal bladder-neck closure.[2][3][5]
- Selected neurogenic young men with myelomeningocele, augmentation cystoplasty, and a functioning continent catheterizable channel who continue to leak per urethra despite prior outlet procedures.[4]
Poor Fit
Before outlet closure, assess bladder capacity, compliance, function, distal-ureter health, and pain during SPT capping; use cystoscopy to evaluate stones, tumor, or necrosis. The EAU identifies bladder function and healthy distal ureters as considerations for bladder preservation in devastated posterior outlet disease.[7][9] Avoid PUL when the patient cannot tolerate or manage a chronic suprapubic tube, has a hostile high-pressure bladder that will threaten the closure, has uncontrolled bladder spasms or refractory urgency, or would be better served by bladder-neck closure with a catheterizable channel or by diversion; a painful, contracted or necrotic bladder may favor cystectomy and diversion.[7]
Decision Point
Consider PUL after assessing whether cuff erosion can be managed and whether the urethra can support further outlet reconstruction or repeat AUS.[2] At eroded-AUS explantation, the 2024 AUA/GURS/SUFU guideline lists urethral catheter drainage alone, in situ urethroplasty, or anastomotic urethroplasty .[10] The later salvage options differ as follows:
| Option | Best Fit | Tradeoff |
|---|---|---|
| Repeat AUS salvage | Urethra still healthy enough for cuff placement after erosion treatment and healing | In a broader post-erosion cohort (median follow-up 7.5 years from initial AUS implantation), 96/194 received salvage AUS and 38/96 (40%) were explanted after subsequent erosion. Repeat cuff placement may be impossible in an end-stage urethra.[11][2] |
| PUL + chronic SPT | Frail / elderly end-stage urethra after AUS erosion; wants to avoid abdominal diversion | Lifelong suprapubic tube; bladder spasm and recanalization risk |
| Bladder-neck closure + catheterizable channel | Patient can perform CIC and wants catheterizable continence rather than SPT | Larger abdominal reconstruction; fistula / stomal risks |
| Cystectomy / urinary diversion | Bladder pain, refractory urgency, hostile bladder, or failed PUL | Higher morbidity; bowel diversion burden |
Technique
The contemporary perineal technique emphasizes complete urethral transection, watertight proximal closure, tissue interposition, and maximal bladder quiescence during healing.[2] The earlier Cleveland Clinic AUA abstract describes the same concept as transperineal urethral closure after suprapubic diversion, using distal corpus spongiosum and bulbospongiosus muscle as local coverage over the ligated stump.[6][7]
- Position and expose. Position in lithotomy and administer an intraoperative prophylactic antibiotic regimen according to local resistance patterns ; then make a midline perineal incision and dissect circumferentially around the bulbar urethra.[8]
- Transect the urethra. Transect at the AUS erosion defect if done during explant, or proximal to the abnormal urethra in non-erosion cases.
- Inspect the bladder. Cystoscopy through the proximal urethral stump is retrograde access to the bladder; it permits intravesical assessment and SPT placement under vision.
- Plan detrusor management. Van Dyke’s center used 200 U onabotulinumtoxinA diluted in 20 mL saline and injected at 20 intravesical sites during PUL.[2] Selection and dose depend on the bladder disorder and patient. See Intradetrusor Botulinum Toxin.
- Establish reliable SPT drainage. The published operation placed a 16 Fr SPT under direct vision if one was not already present. The same center later favored 22 Fr to facilitate drainage and irrigation; its effect on ligation failure has not been tested.[2]
- Close the proximal stump. Close urethral mucosa with running absorbable suture, then imbricate the proximal stump with multiple figure-of-eight absorbable sutures.
- Interpose local tissue. Bring bulbospongiosus and surrounding perineal soft tissue over the stump in layers to separate and reinforce the closure. In the Cleveland Clinic description, the spongiosum distal to the transection is preserved and rotated over the ligated stump, with bulbospongiosus as additional cover.[7]
- Leave the distal stump open. This permits dependent drainage if the closure leaks or a distal abscess forms.
- Close the wound. Achieve meticulous hemostasis and close the superficial layers.
When infection is suspected at AUS explantation, Van Dyke’s center favors staged PUL closure to reduce postoperative infection risk.[2]
Postoperative Management
The following drainage and medication schedule reflects the Van Dyke center’s protocol. Duration and drug choice depend on bladder function, wound healing, drug tolerability and catheter complications.[2]
- Keep the SPT on continuous gravity drainage for at least 3 months.
- Prescribe scheduled anticholinergic or beta-3 therapy to reduce bladder spasms; refractory spasms may require repeat botulinum toxin.
- After a dry wound at 3 months, selected patients may trial daytime SPT capping with intermittent drainage and continuous overnight drainage. In the 2021 series, six of nine tolerated capping; one had worse spasms, one developed a fistula and one had recanalization. These events were observed after capping, without a comparison group.[2]
- Teach gentle SPT irrigation when mucus, debris, or intermittent obstruction is a concern.
- Persistent leakage warrants evaluation for recanalization. For repeat PUL, Van Dyke et al. describe antegrade cystoscopy via the SPT, a guidewire through the fistulous site, and scope light to identify the proximal stump in scarred tissue.[2]
Outcomes
| Series | n | Cohort | Continence | Key Tradeoff |
|---|---|---|---|---|
| Higuchi 2012 AUA abstract[6][7] | 6 | Refractory incontinence after SPT placement or urinary diversion | 5/6 had successful urethral closure after one operation (median follow-up 1.45 months) | Earliest adult transperineal-closure signal; the failure occurred in a patient with prior prostate radiation |
| VanDyke 2017[1] | 10 | End-stage urethra, severe incontinence | 80% overall; 70% after initial PUL | Complications in 7/10 patients; initial single-center feasibility report |
| Van Dyke 2021[2] | 20 | 18/20 had prior AUS cuff erosion; 10/18 of these had multiple erosions | 15/20 dry after initial PUL; 18/20 after initial or repeat PUL | At median 27.5 months, 14/19 survivors remained managed by PUL/SPT; 11/20 had 90-day complications, four underwent cystectomy and one perineal urethrostomy |
| Arnold 2022[3] | 7 | AUS failure / end-stage urethra | 6/7 continent at last follow-up | Bladder spasms 43%; persistent urethral leakage 14% |
| Meeks 2009[4] | 4 | Myelomeningocele + CCC / augmentation | 4/4 dry | Different population; small series |
The 2021 report expanded the original 2017 cohort. It reported continence in 18/20 after initial or repeat ligation, but four later underwent cystectomy and one PU.[2] Thirteen remaining PUL patients completed questionnaires and reported improvement. All 10/10 men in the original 2017 series said they would recommend PUL; in the expanded 2021 cohort, all 13 survey respondents among the 14 surviving men still managed by PUL said the same.[1][2]
Complications
| Complication | Pattern |
|---|---|
| Bladder spasms / urgency | VanDyke 2017 reported refractory spasms in 3/10; the expanded 2021 cohort reported 8/20 (40%) within 90 days and 13/20 (65%) during median 27.5-month follow-up, with four later receiving bladder botulinum toxin. Arnold reported 3/7 (43%). Spasms may jeopardize stump healing.[1][2][3] |
| Urethral recanalization | 4/20 (20%) within 90 days in Van Dyke 2021; separately, three of five men with persistent or recurrent leakage became dry after repeat PUL.[2] |
| UTI / catheter problems | Expected chronic-SPT burden |
| Wound infection, cellulitis, abscess | Four of 20 (20%) developed wound infection within 90 days in Van Dyke 2021, reported as cellulitis or abscess.[2] |
| Urethrocutaneous fistula | Particularly concerning in radiated patients with bladder spasms |
| Bladder stones | Chronic catheter / infection / debris risk |
| Progression to cystectomy | Four of 20 (20%) in Van Dyke 2021 elected cystectomy at an average 26 months because of severe pain and refractory urgency related to chronic SPT.[2] |
PUL can restore continence without abdominal diversion, but it exchanges urethral leakage for permanent SPT management. Seven of 10 men in the first series had postoperative complications.[1]
Operative Pearls
- Selection. It is for the end-stage urethra after reasonable reconstructive / device options have failed.
- Bladder quiescence. Make the bladder quiet. Spasm threatens healing of the proximal stump.
- Drainage. Drain continuously. The Van Dyke protocol keeps the SPT on continuous drainage for at least 3 months to keep pressure off the closure.[2]
- Interposition. Interpose tissue generously to separate the closed stump from the distal urethra and perineal wound.
- Distal stump. Van Dyke’s center leaves it open to permit drainage from a proximal leak or abscess; the reported safety experience involves only two patients and is not comparative.[2]
- Counseling. Explain the SPT burden. Pain, blockage, bladder spasms, stones, and later cystectomy are the failure modes patients must understand.
References
1. VanDyke ME, Viers BR, Pagliara TJ, et al. Permanent bulbar urethral ligation: emerging treatment option for incontinent men with end-stage urethra. Urology. 2017;105:186-191. doi:10.1016/j.urology.2017.02.042
2. Van Dyke M, Ortiz N, Baumgarten A, et al. Permanent urethral ligation after AUS cuff erosion: is it ready for prime time? Neurourol Urodyn. 2021;40(1):211-218. doi:10.1002/nau.24535
3. Arnold PJ, Soyster ME, Burns RT, Mellon MJ. The role of urethral ligation after AUS failure and end stage urethra. Int Urol Nephrol. 2022;54(11):2827-2831. doi:10.1007/s11255-022-03315-0
4. Meeks JJ, Hagerty JA, Chaviano AH. Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele. BJU Int. 2009;104(2):221-224. doi:10.1111/j.1464-410X.2009.08444.x
5. Volz Y, Eismann L, Pfitzinger PL, et al. Salvage cystectomy and ileal conduit urinary diversion as a last-line option for benign diseases - perioperative safety and postoperative health-related quality of life. Neurourol Urodyn. 2021;40(5):1154-1164. doi:10.1002/nau.24671
6. Higuchi T, Yamaguchi Y, Wood H, Angermeier K. 238 Transperineal closure of the male urethra in the setting of suprapubic diversion - an alternative management for urinary incontinence. J Urol. 2012;187(4S):e98. doi:10.1016/j.juro.2012.02.293
7. Anderson KM, Higuchi TT, Flynn BJ. Management of the devastated posterior urethra and bladder neck: refractory incontinence and stenosis. Transl Androl Urol. 2015;4(1):60-65. doi:10.3978/j.issn.2223-4683.2015.02.02
8. European Association of Urology. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery," §10.2. 2026. Guideline.
9. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males," §6.3.5.a.4. 2026. Guideline.
10. Breyer BN, Kim SK, Kirkby E, Marianes A, Vanni AJ, Westney OL. "Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024)." J Urol. 2024;212(4):531-538. doi:10.1097/JU.0000000000004088
11. Findlay BL, Fadel A, Pence ST, Britton CJ, Linder BJ, Elliott DS. "Natural History of Artificial Urinary Sphincter Erosion: Long-term Lower Urinary Tract Outcomes and Incontinence Management." Urology. 2024;193:204-210. doi:10.1016/j.urology.2024.06.054