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MANAGEMENT OF URETHRAL STENOSIS

The subject of urethral stenosis disease has undergone considerable change in regard to etiology and therapy durir last 50 years. This page has some approaches to the problem of stenotic posterior urethra. These urethral stenosis almost totally result from trauma, either secondary to an external force with shearing of the urethra.Those involving the membranous urethra only can be secondary to transurethral resection.

Urethral stenosis: The etiology

It is important to understand the etiology of urethral stenosis, since post-infectious stenosis generally is far more extensive than appears to be urethrographically or cystoscopically. Trauma results in a more limited set of circumstances and, there the outcome of repair of post-traumatic strictures is (or should be) better than the therapy of post-infectious stenosis.Both factors may have a role in the causation of anterior urethral stenosis secondary to transurethral resection and/or indvwelling urethral catheters. Fortunately, the use of silicone catheters and antibiotics has kept strictures at a minimum following, much of the major cardiac, oncological and reconstructive surgical procedures with necessary urinary output monitoring. It goes without saying that the analogue of the male posterior urethra in the female subject is rarely the site of urethral stenosis.

Another factor is selecting treatment for urethral stenosis is whether the stenosis can be traversed by a filiform or a sound. If passable, one should elect visual internal urethrotomy as initial treatrnent. The procedure should be terminated if one is unable to follow a catheter as a guide through the urethral stenosis . Thus, tortuous stenosis or those with false passages may not meet the criteria for visual incision, although they may be of a reasonably large caliber. A possible exception is the short prostatomembranous stenosis.
Once inside the urethra, a deep incision can be made at tl 12 o'clock position into a normal urethral wall or periurethral tissue. Excessive depth or length of cut into corporeal tissu usually with a high head of irrigant pressure, can result i priapisrn, The erection generally is brief, perhaps 2 hours in duration, but it rnay persist for several hours. Rarely, priaprism has been reported as a cause of impotence following visua urethrotomy. Cessation of the procedure generally is the bes policy if priapism develops early in the dissection of a Ioni stricture.

Urethral stenosis: Mantainance of an open urethra postoperatively


Equally important to adequate incision (28F in adults) is the maintenance of an open urethra postoperatively. We have found that self-catheterization daily with a 24F rubber catheter is the best way to ensure that the urethral stenosis will not recur. Compliance has been good and 4 to 6 weeks of catheterization postoperatively generally is long enough. Panurethral stenosis, well suited to visual urethrotomy, require more diligent and longer followup. A second internal urethrotomy for mild recurrent strictures is better than an open procedure that requires several days of hospitalization and regional or general anesthesia. Visual urethrotomy can be done with the patient under local anesthesia on an outpatient basis unless disease is extensive.

Urethral stenosis: Selection of the proper open procedure

Selection of the proper open procedure for impassable stenosis repair is equally important. In general, a single stage repair is adequate and preferable. Direct anastornosis is the procedure of choice for post-traumatic urethral stenosis less than 2.5 cm. Transpubic and perineal approaches have their advocates. The results should be equally good either way.
The major point of contention seems to be which open procedure yields the best results in longer or post-infectious urethral stenosis.
Although 2-stage repairs occasionally may be necessary (severe infection, fistulas, multiple failures) a single stage repair should yield quite satisfactory results in the surgery for urethral stenosis. Either a free or pedicìe full thickness skin graft will resolve most remaining problems. Care should be taken to avoid hair-bearing skin. The best results are obtained if preputial or penile shaft skin is used. At all costs, avoid infection, get a snug fit of well vascularized periurethral structures to oppose the free graft and leave a stent for 12 to 14 days.
Lastly, a pretty appearance postoperatively rnay be more difficult to achieve than a satisfactory functional result. Persistence of sterile urine and a good stream postoperatively are the goals of treatment. Urinary flow rates may be used for documentation if desired. Calibration at annual intervals in asymptomatic patients should be urged. The presence of residual urine postoperatively usually indicates bladder outlet obstruction rather than recurrent or persistent urethral stenosis disease.

 

 
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