Perineal Permanent Urethral Ligation (PUL)
Perineal permanent urethral ligation (PUL) is an irreversible perineal salvage procedure that transects and closes the bulbar urethra, committing the patient to chronic suprapubic tube (SPT) drainage while eliminating leakage through an end-stage urethra. It was developed for men with severe refractory stress urinary incontinence (SUI), most often after recurrent artificial urinary sphincter cuff erosion, who are not candidates for further AUS reconstruction and wish to avoid major abdominal diversion.[1][2][3]
PUL is best understood as the perineal, SPT-based alternative to formal bladder-neck closure or cystectomy/diversion. It closes the urethral outlet below the sphincter rather than creating a bladder-neck closure, and it avoids bowel or abdominal stoma construction at the price of lifelong suprapubic drainage.[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:
- Recurrent AUS cuff erosion or multiple failed AUS revisions, especially when the bulbar urethra is radiated, scarred, or too fragile for another cuff.[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
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 definitive bladder-neck closure with a catheterizable channel / diversion.
Decision Point
PUL sits between repeated failed outlet reconstruction and abdominal diversion:
| Option | Best Fit | Tradeoff |
|---|---|---|
| Repeat AUS salvage | Urethra still healthy enough for cuff placement | Further erosion risk; may be impossible in end-stage urethra |
| 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 | Highest 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 is helpful because it 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. Lithotomy positioning; midline perineal incision; circumferential dissection around the bulbar urethra.
- 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 antegrade. Cystoscopy through the proximal stump permits intravesical assessment and SPT placement under vision.
- Suppress detrusor activity. Many contemporary protocols inject 200 units of intravesical onabotulinumtoxinA at the same setting to reduce early bladder spasms.
- Place / upsize the SPT. A 16 Fr SPT was used initially; larger catheters such as 22 Fr may improve drainage and irrigation in contemporary practice.
- 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.
- 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.
If infection is present at AUS explantation, stage the ligation rather than closing into an infected field.
Postoperative Management
- 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 healing, selected patients may cap the SPT during the day and drain intermittently, often using continuous drainage overnight.
- Teach gentle SPT irrigation when mucus, debris, or intermittent obstruction is a concern.
- Persistent leakage warrants evaluation for recanalization, usually with antegrade imaging through the SPT.
Outcomes
| Series | n | Cohort | Continence | Key Tradeoff |
|---|---|---|---|---|
| Higuchi 2012 AUA abstract[6][7] | 6 | Refractory incontinence after SPT placement or urinary diversion | 5/6 dry after one operation | 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 | Early proof-of-concept; outpatient / low blood loss |
| Van Dyke 2021[2] | 20 | Mostly recurrent AUS erosion | 90% overall; 75% after initial PUL and 15% after repeat PUL | 55% 90-day complication rate; 20% later cystectomy |
| 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 largest adult series reported very low residual M-ISI severity and bother scores, with most patients rating global improvement as "very much better" and all surveyed patients stating they would recommend the operation to others.[2]
Complications
| Complication | Pattern |
|---|---|
| Bladder spasms / urgency | Most common early threat to closure integrity; treat aggressively |
| Urethral recanalization | Often managed with repeat PUL |
| UTI / catheter problems | Expected chronic-SPT burden |
| Wound infection, cellulitis, abscess | More likely in infected or radiated fields |
| Urethrocutaneous fistula | Particularly concerning in radiated patients with bladder spasms |
| Bladder stones | Chronic catheter / infection / debris risk |
| Progression to cystectomy | Usually for intolerable chronic SPT symptoms, pain, or refractory urgency |
The major counseling point is that PUL can restore continence without abdominal diversion, but it is not a "small" operation in lived experience: it trades urethral leakage for permanent SPT management.
Operative Pearls
- Do not offer PUL as a convenience procedure. It is for the end-stage urethra after reasonable reconstructive / device options have failed.
- Make the bladder quiet. Spasm is the enemy of proximal-stump healing.
- Drain continuously and patiently. The first 3 months are about keeping pressure off the closure.
- Interpose tissue generously. The operation succeeds by separating the closed stump from the distal urethra and perineal wound.
- Leave the distal stump open. A drainage path is safer than a sealed infected dead end.
- Counsel about the SPT honestly. 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