Urethral Stricture

INTRODUCTION

1.What is urethral stricture?
2.Which are the causes of urethral stricture?
3.Which are the symptoms of urethral stricture?
4.How can we diagnose urethral strictures?
5.Which kind of operation is suitable for urethral stricture?
6.Which postoperative care is used after urethroplasty?
7.Other tissues for urethral reconstruction?


1.WHAT IS URETHRAL STRICTURE?

Urethral stricture or urethral stenosis the urethral lumen obstruction [Fig X 1-2].
 
Urethral stricture is caused by the growth of the scar in the urethral wall.
urethral stricture foto 1 urethral stricture foto 2    
Fig. X 1 Fig. X 2    

2. WHICH ARE THE CAUSES OF URETHRAL STRICTURE ?

  • Urinary tract infections
  • Urethral traumatic injuries
  • Urethral iatrogenic injuries ( catheterism, urethroscopy, cystoscopy, urological surgery)
  • Dermatological diseases : Lichen Sclerosus also known as Balanite Xerotica Obliterans
  • Previous surgery for failed hypospadia
  • Urethral cancer

3. WHICH ARE THE SYMPTOMS OF URETHRAL STRICTURE?

  • A sense of obstruction during urination: thin trickle with decreased strength of the discharge
  • A sense of incomplete emptying of bladder with the need to urinate repeatedly and pain above the pubis area
  • A sense of burning while urinating
  • Blood traces in the urine
  • Blood discharge from the urethral meatus
  • Urinary tract infection, sometimes with shaking fever
  • Epididymitis and orchitis

In the more serious cases, urethral stricture causes:

  • Acute urinary retention with the impossibility to urinate.
  • Bladder stones or urethral stones.
  • Vescicoureteric - Kidney reflux.
  • Kidney failure.

4. HOW CAN WE DIAGNOS URETHRAL STRICTURES ?

The fundamental urethral investigations used to ascertain an urethral stricture are:
  • Uroflowmetry: the patient urinates into a container that is connected to a computer. Urinary flux values are registered: Flow power reduction (flux max <14 ml/sec) can reveal an obstruction to urination.
     
  • Urethrography: radiological examination with contrast medium to make the urethra and bladder visible. If the patient is allergic to the contrast medium, he must inform the doctor. The examination is unpleasant and it must be performed by expert staff who works daily in this field. This is the most important examination for urethral stricture diagnosis and it is fundamental when choosing the right urethroplasty.

    The examination is split into two moments:
    1. Retrograde urethrography[Fig X 3] : The contrast medium is injected into the urethra through a little catheter which is introduced into the urethra lumen only for a few centimetres.This examination allows a full visualization of the anterior urethra (penile urethra and bulbar urethra).
    2. Voiding cistourethrography[Fig X 4]: The bladder is filled with the contrast medium which is introduced into the urethra through the retrograde channel. As soon as the patient feels a full bladder, the catheter, which is introduced into the urethra only for few centimetres, is removed and some urethrographies are made while the patient urinates. The examination looks into all the urethra, including the posterior tract (prostatic urethra) and visualizes the stricture and its degree of importance during the voiding phase.

 

 

urethral stricture foto 3

urethral stricture foto 4    
Fig. X 3 Fig. X 4    

 

  • Urethroscopy: cystoscope introduction through the urethral meatus to study the internal conditions of the urethra and to have all useful information to choose the surgical solution. The examination is performed with extreme delicacy and using a very thin instrument so as not to damage the urethra. In order to have an evaluation which is useful for the doctor and painless for the patient., the examination is done under anesthesia.
     
  • Other additional examinations are:

Ultrasonography: it is done simultaneously with the retrograde urethrography in order to reduce discomfort. This examination supplies additional information: The exact length of the ill urethral tissues involved in the urethral stricture [ Fig X 5].

Urinoculture: Urethral stricture can cause incomplete bladder emptying during voiding with consequent urine staunching, infection and positive urinoculture (germ presence in the urine).

 

 

urethral stricture foto 5

     
Fig. X 5      

 

  • Urinoculture: Urethral stricture can cause incomplete bladder emptying during voiding with consequent urine staunching, infection and positive urinoculture (germ presence in the urine).

The endoscopic instrument is introduced through the urethral meatus. At the tip of the tool there is a penknife which will cut the scar that causes the urethral stricture and will allow the widening of the urethra.

  • Advantages: it avoids open surgery; short surgical time.
    Disadvantages:low surgical successrates < 20%; in most cases after urethrotomy a scar appears and this causes a new stricture.
    Complications: (bleeding, damage to the urethra) < 5 %.

    Hospitalization lasts 2 days and the patient keeps the catheter a few days.
    In the last years, technological innovations have lead to believe that cutting the scar of the urethral stricture by means of laser could guarantee better results. In reality, there is no scientific evidence to prove this and the use of laser could cause considerable damages to urethral tissues.
     

    2) Urethroplasty for urethral stricture

    Open surgery: it’s a delicate operation of microsurgery (employment of magnifying glass) and plastic surgery (aesthetic reconstruction of genitals). Due to the importance of the organs concerned the operation must be performed by extremely competent staff in this field.

    Disvantages: surgical time from 1 to 4 hours.
    Advantages: high surgical success rate ( >80% ).
    Complications: < 10 % : bleeding, fistulas, infections, etc…

    The urethral fistula is the communication between the reconstructed neo-urethra and the outside: the urine flows from the meatus and also from the opening along the urethral surface of the penis either in the scrotum or in the perineum. For cases in which the fistula doesn’t close up spontaneously, a redo- urethroplasty could be necessary in order to repair it 6 months after the first operation.

    The possibility that complications occur is reduced by:
    • Meticulous surgery care
    • Adequate surgery instrumentation
    • The experience of a surgeon who perform this type of surgery on a routine basis.

    The types of urethroplasty are

    One-stage Urethroplasty :
    the urethral reconstruction is in one-surgical stage
    • End-to-End Anastomosis[ Fig X 6-7-8 ] complete transverse section of the tight urethra. Removal of the scarred tract. The 2 stumps are anastomised.
    urethral stricture foto 6 - 7 - 8      
    Fig. X 6 - x 7 - x 8    
    • Buccal Mucosa Urethroplasty[ Fig X 9-10 ]ventral bulbar incision and widening with a buccal mucosa graft.
    urethral stricture foto 9 - 10      
    Fig. X 9 - X 10    
     
    Staged Urethroplasty:
    the urethral reconstruction is performed in 2 surgical stages which happen with a 6 month-gap between the first and the second one. Sometimes further surgical operations are necessary between the two stages. This surgical technique is used in complex urethral strictures.
    • Staged Penile Urethroplasty[ Fig X 11-12-13] ventral penis incision. The scarred urethra is removed, and substituted with buccal mucosa graft. For some months the patient urinates through a neo-meatus located along the ventral side of the penis. [ Fig X 14-15-16] After some months the buccal mucosa graft is transformed in neo-tube and the meatus is reconstructed again at the tip of the glans.
      urethral stricture foto 11 - 12 - 13
      urethral stricture foto 14 -15 -16
    • Staged Bulbar Urethroplasty [ Fig X 17-18-19-20 ] The urethral plate is opened below the scrotum. The urethral plate is left opened for some centimetres to allow it to heal spontaneously. Meanwhile the patient urinates in the sitting position from this new urethral opening called perineostomy, and which is located between the anus and the scrotum. After 6 months, when the tissues are healed, the urethral plate will be closed, and the patient will be able to urinate standing again.
    • Fig. X 17 Fig. X 18 Fig. X 19
         
      Fig. X 20    
     

    6. WHICH POSTOPERATIVE CARE IS USED AFTER URETHROPLASTY ?

    The hospitalization  is from 2 to 5 days, and the patient keeps  the catheter for 10-20 days depending on the type of operation.

    The postoperative time  is not particularly painful.
    No particular medications are necessary.
    The signs of infection are a cutaneous reddening, pus and fever: in this case it is advisable to address the doctor

    Catheter

    Nowadays we use  soft catheters (silicon).
    The catheter is connected to a bag which collects the urine is kept in place by means of a balloon which is swollen in the bladder.
    Antibiotics are recommended for all the period in which the catheter is in place.
    It is important to check that the catheter is open to ensure the urination, and if possible its permeability with a wash done with physiological solution in order to remove the clots inside it.
    During the first days after the surgery bleeding, and losses of urine are frequent while straining during evacuation
    After the catheter and medication removal it advisable to have an integral bath.
    The stitches are reabsorbed in 1 month.
    It is advisable to avoid pressure on the perineal and the scrotal area, to avoid cycling, riding, contact sports.

    BUCCAL MUCOSA (BM)

    At the present it is the best tissue for urethral reconstructions.
    Buccal mucosa has revolutionised this surgery since it has proved to be resistant and able to substitute the urethral plate.
    Our center has been one of  the first in Italy and in Europe to use buccal mucosa in urethral reconstructions.
    The employment of the BM has replaced the employment of the penis skin, which is not always well accepted because it requirse the circumcision.
    The harvesting (exagon  1,5 x 5 cm) [Fig. MB 1-2-3-4-5-6]  is made from the inner cheek and the wound is then sutured: the discomfort in the cheek lasts only for a few days, the patient can start eating inthe same evening of the surgery and the stitches are reabsorbed in  1 month.
    Since 1995  we have harvested more than 200  BM : no complications occurred, and the patients stated they would undergo again buccal mucosa harvesting if it became necessary.
    It is not advisable  to harvest from the lip  because it may cause  complications: difficulty to open the mouth, alteration of the facial expression.

     


    7.OTHER TISSUES FOR URETHRAL RECONSTRUCTION ?

    Penis skin
    Until 10 years ago it was the most used tissue for urethral reconstruction. When the employment of buccal mucosa was discovered, the use of penis skin decreased for two reasons: buccal mucosa is more resistant and avoids the necessity of circumcision.

    Skin of other body areas
    In rare cases.

    Eterologus tessues
    They are tissues deriving from animals or created in laboratory. In some cases they have already been used, but the results still need assessing in the long term.