Urethral Stricture - Dr.Enzo Palminteri Urethral Center

5. Which kind ofoperationis suitable for urethral stricture ?

The features of the urethral stricture: the cause, the location, the length
The patient’s history: the age, clinical history, general conditions, presence of other diseases

Urethral stricture operation are endoscopic urethrotomy and urethroplasty.

1)Endoscopic urethrotomy for uretrhal stricture
The endoscopic instrument is introduced from the urethral meatus. At the tip of the tool there is a penknife to cut the scar which causes the urethral stricture and to 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 is for 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 of 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.
Disvantages: high surgical success rate ( >80% ).
Complications: < 10 % : bleeding, fistulas, infections, etc…

The urethral fistula is the communication between the reconstructed neo-urethra and 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 the 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.

Fig. X 6 - x 7 - x 8

Buccal Mucosa Urethroplasty[ Fig X 9-10 ]ventral bulbar incision and widening with a buccal mucosa graft.

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 for 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.
Fig. X11 - x12 - x13
Fig. X14 - x15 - x16
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.


Fig. MB 1	Fig. MB 2	Fig. MB 3

Fig. MB 4	Fig. MB 5	Fig. MB 6

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.

Introduction