Urethral Stricture

WHAT IS URETHRAL STRICTURE?

Urethral stricture means the reduction or even complete blockage of the urethral lumen, which is the canal through which urine flows. This is due to the growth of scar tissue along the walls of the urethra.

 

What are the main CAUSES OF URETHRAL STRICTURE?

  • Urinary infections
  • Urethral trauma
  • The maneuver of instruments in the urethra (catheterisation, urethroscopy, cystoscopy, urological surgeries)
  • Skin diseases: Lichen Sclerosus
  • Failed hypospadias
  • Urethral tumors

 

What are the possible symptoms?

  • Sensation of blockage while urinating
  • Sensation of incomplete emptying of the bladder, making it necessary to urinate repeatedly. Pain in the suprapubic region.
  • Stinging sensation while urinating
  • Presence of blood in the urine
  • Blood leakage from the urinary meatus
  • Urinary infections, sometimes with shaking and fevers
  • Epididymis and orchitis

 

In more serious cases, urethral stricture can cause:

  • Sudden retention of urine, making it impossible to empty the bladder
  • Calculi in the bladder or in the urethra
  • Vesicoureteral reflux
  • Kidney failure

HOW IS URETHRAL STRICTURE DIAGNOSED?

Diagnoses happens through a series of tests.

 

a. Uroflowmetry

Urine pressure will be measured during the urination period with the use of a container that you will take to the bathroom. If there is a reduction in the force of urine flow (maximum flow < 12 ml/sec.), this could indicate a urinary blockage and the presence of a stricture.
uroflowmetry

b. Urethrogram

This involves an X-ray examination using a contrast medium that shows a visual of the urethra and bladder.

 

This test is divided into two parts:

urethrography

1. Retrograde urethrogram

A small catheter is placed in the external urinary meatus (only a few centimetres) and the contrast medium is injected through the catheter into the urethra, in order to see the urethral canal. The test does not require any preparation, but it should be carried out while working closely with the patient, who will need to endure the annoyance of the catheter in the penis and the contrast medium flowing through the urethra.

cystourethrogram

2. Cystourethrogram

Once the bladder is filled by the contrast medium, which is introduced into the urethra in a retrograde manner, the patient will have the sensation of a full bladder. The catheter will be removed and the patient is invited to urinate. During the urination period, X-rays are taken.

c. Ureteroscopy

A ureteroscopy is an endourological procedure allowing specialised, semi-rigid and flexible instruments to explore the urethra internally. A ureteroscopy is connected to a video camera which allows the urologist to see the inside of the urethra on the monitor (the appearance of the mucous membrane, the presence of new formations and the presence of calculi).

 

Other additional tests include:

urethral ultrasound

Urethral ultrasound

this is an exam that provides additional information: the exact length of diseased urethral tissues involved in the urethral stricture.

Urine culture

The presence of cultures often tests positive during urethral stricture due to the unsuccessful complete emptying of the bladder.

How is URETHRAL STRICTURE treated?

To treat urethral stricture, surgical intervention is required. The choice of surgical procedure depends on the characteristics of the urethral stricture (cause, length and site) and on the patient's history (age, related illnesses, general conditions, etc.).

 

There are two types of urethral surgery:

  • Endoscopic urethrotomy
  • Urethroplasty

Endoscopic urethrotomy

Urethrotomy is the treatment of the narrow areas of the urethral canal by endoscopy.


Its purpose is the incision and opening of the narrowed urethral canal, thereby allowing healthy urination.

 

The technique consists of an endoscopic incision in the urethral canal using a cooled blade. The procedure can be carried out blindly (an Otis urethrotomy) or while seeing (a Sachse urethrotomy). For a few years, internal urethrotomy has also been successfully carried out using a laser.

 

Duration of procedure: the procedure usually lasts a few minutes and can be done both under general anaesthesia or under simple sedation of the patient.

 

Duration of recovery: after the procedure, the bladder catheter is left in place. If there are no complications, the hospital stay is just one night.

Urethrotomy Procedure

Urethroplasty

A urethroplasty is the surgical reparation of the urethral canal. Depending on the characteristics of the lesions, (length, cause of stricture, fistula or presence of urethral calculi) and the conditions of the local tissue, the surgeon is able to choose the most suitable surgical solution from a wide variety of different techniques.

 

All urethroplasties, except for termino-terminal anastomosis, provide the possibility of using tissue transplants without vascular support (grafts) or with vascular support (flaps). Grafts are generally from skin taken from the foreskin  or other extragenital skin regions, or from mucous membranes generally taken from the inside of the cheek or lips. Flaps, on the other hand, are skin areas with their own blood supply intact. All the surgical operations on the urethra provide the possibility of carrying out histological tests of a urethral sample with the purpose of highlighting any disorders requiring further treatment or careful monitoring over time.

 

A. ONE-TIME URETHROPLASTY

- Termino-terminal anastomosis: Consists of completely dissecting the affected urethral tract, removing fibrosclerotic tissue and rejoining the two urethral stumps. With this surgery, the urethra will be repaired using this unique technique.

anastomosis

- Urethroplasty to enlargethe urethral lumen with the use of skin or mucous tissue transplants.

The urethra is opened longitudinally at the location of the stenotic tract and the canal is expanded with an oral mucosal strip taken from the inside of the cheek or the tongue. It is a true self-transplantation, as the mucosal strip is completely detached fromthe inside of the mouth or tongue and sutured to the urethra using various techniques (urethroplasty with dorsal, ventral or double graft, etc.).

urethroplasty for enlargement

Oral Mucosa (MB)

Oral mucosa is currently the best choice of tissue for use in urethral surgery. The use of oral tissue replaces the use of penile skin, which is not always easily accessible on the part of the patient because it requires circumcision.

Its retrieval is carried out on the inside of the cheek and the wound will be sutured: irritation in the mouth lasts only a few days, the patient can begin eating again the day after the surgery, and the suture points will spontaneously dissolve after about one month.

It is inadvisable to retrieve mucosa from the lip because there is a risk of complications, including difficulty opening the mouth and alteration of the facial expression.

oral mucosa

B. URETROPLASTY IN TWO STAGES

The urethra will be repaired in two or more stages, carried out with 6 to 12 months of time between them.

In penile urethral stricture, during the first operation, the urethra will be opened or completely removed and replaced with a wide strip of oral mucosa or penile skin, which will be sutured directly on the cavernous bodies and the glans. If the graft is well-vascularised, the strip of mucosa will be transformed into a tube and the urethra will be moved to the center of the glans after about 6-12 months.


1st Stage:

Opening of the urethral canal, formation of a new urinary meatus at the perineum or along the ventral surface of the penis (penile urethrostomy) depending on the length of the stricture.

 

2nd Stage:

Consists in surgically closing the aforementioned urethral deviation (perineal or penile urethrostomy) resulting in reconstruction of the continuous urethral lumen. Finally, the patient is then able to urinate again from the original urinary meatus.

urethroplasty in two stages

In bulbar urethral stricture, during the first operation, the urethra will be opened below the scrotum and the urine will flow from this new stoma, requiring the patient to urinate in a seated position. When possible, this perineal stoma can be resealed, allowing the patient to urinate again through the penis. In other cases, the perineostomy becomes standard, not giving the patient the possibility to reacquire urination through the penis.

bulbar urethral stricture

In the interval between the first and second stages of a urethroplasty, it may be necessary to resort to revisionary surgical interventions due to the progress of the main urethral stricture disease. These revisions can correspond to the surgeon's point of view on a proper urethroplasty.

Postoperative Assistance for Urethral Stricture

The patient stays in the hospital from four to six days and keeps the catheter for 10-21 days depending on the type of surgery they have undergone.

The postoperative period is not particularly painful, and special medications are not needed.

The signs of an infection are redness of the skin around the wound, pus and fever. In this case, it is advisable to return to the doctor to find treatment for these symptoms.

 

Catheter

The catheter is connected to a sack for collecting urine, which is held in place by an inflated balloon in the bladder.

It is important during the postoperative period to make sure that the catheter is continuously draining urine.

In the first days after the operation, small losses of blood are frequent and normal, as are losses of urine accompanying the pushes during defecation.

Before removing the catheter, it is advisable to carry out a urinary urethrocystograph to verify that the urethra is completely unobstructed and whether or not there are complications, such as fistulas.

The sutures are dissolvable and require one month or more to disappear.

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