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Urethral Stricture Repair
What is
Urethral Stricture Repair?
A
urethral stricture is a scar in or around the
urethra, which can block the flow of urine, and
is a result of inflammation, injury or
infection.
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Effects
of Urethral Stricture Repair
If no
treatment is taken, the patient would have to
continue to tolerate problems with urination.
Urinary and/or testicular infections and stones
can develop. Also, there is a risk that urinary
retention may occur which can cause the bladder
to enlarge and also lead to kidney problems.
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Candidates for Urethral Stricture Repair
Urethral strictures are more common in men
because their urethras are longer than those in
women. Thus men's urethras are more susceptible
to disease or injury. A person is rarely born
with urethral strictures.
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Your Consultation
Evaluation of patients with urethral stricture
disease includes a physical examination,
urethral imaging (X-rays or ultrasound) and
sometimes urethroscopy. The retrograde
urethrogram is an invaluable test to evaluate
and document the stricture. Combined with
antegrade urethrogram, length of the stricture
can be determined. The retrograde urethrogram is
performed as an outpatient X-ray procedure and
can indicate the number, position, length and
severity of the stricture(s). This study
involves insertion of contrast dye (fluid that
can be seen on an X-ray) into the urethra at the
tip of the penis. No needles or catheters are
used. The retrograde urethrogram study allows
doctors to see the entire urethra and outlines
the area of narrowing at the stricture.
Ultrasound is performed by placing a small,
pencil-like ultrasound wand on the skin over the
stricture to view it and surrounding tissue.
Urethroscopy is a procedure where the doctor
gently places a small, flexible, lubricated
telescope into the urethra and advances it to
the stricture. This study permits the doctor to
see the urethra between the tip of the penis and
the stricture. All of these tests can be
performed in an office setting and will allow
the urologist to provide treatment
recommendations.
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The
Urethral Stricture Repair Procedure
Treatment options for urethral stricture disease
are varied and selection depends upon the
length, location and degree of scar tissue
associated with the stricture. Options include
enlarging the stricture by gradual stretching
(dilation), cutting the stricture with a laser
or knife through a telescope (urethrotomy) and
surgical removal (excision) of the stricture
with reconnection and reconstruction with
grafts.
Dilation
This is usually performed in the urologist's
office under local anesthetic and involves
stretching the stricture using progressively
larger
dilators
called "sounds." Alternatively, the stricture
can be dilated with a special balloon on a
catheter. Dilation is rarely a cure and needs to
be periodically repeated. If the stricture
recurs too rapidly the patient may be taught how
to insert a catheter into the urethra
periodically to prevent early closure.
Pain, bleeding and infection are the main
problems associated with dilation procedures.
Occasionally, a "false passage" or second
urethral channel may be formed from traumatic
passage of the "sound."
Urethrotomy
This procedure involves use of a specially
designed
cystoscope
that is advanced along the urethra until the
stricture is encountered. A knife blade or laser
operating from the end of the cystoscope is then
used to cut the stricture, creating a gap in the
narrowing. A catheter may be placed into the
urethra to hold the cleft open for a period of
time after the procedure to allow healing in the
open position. The suggested length of time for
leaving a catheter tube draining after stricture
treatment can vary.
Urethral Stent
This procedure involves placement of a metallic
stent
that has the appearance of a circular chain link
fence. The stent is placed into the urethra
through the penis using a specially designed
cystoscopic insertion tool after the urethra is
widened. The stent expands within the widened
stricture and prevents the urethra from closing.
The lining of the urethra eventually covers the
stent, which remains in place permanently. This
treatment has the advantage of being "minimally
invasive." However, it is only suited to very
select strictures and frequently causes
significant swelling around the device. Removal
of these devices is very difficult and may
result in a more significant stricture.
Open surgical urethral reconstruction
Many different reconstructive procedures have
been used to treat strictures, some of which
require one or two operations. In all cases, the
choice of repair is influenced by the
characteristics of the stricture, and no single
repair is appropriate for all situations. Open
reconstruction of a short urethral stricture may
involve surgery to remove the stricture and
reconnect the two ends (anastomotic
urethroplasty). When the stricture is too long
and this repair is not possible, tissue can be
transferred to enlarge the segment to normal
(substitution procedures). Substitution repairs
may need to be performed in stages in difficult
circumstances.
Anastomotic
Procedures
These are usually reserved for urethral
strictures of two centimeters or less where the
urethra can be reconnected after removing the
stricture. This procedure involves a cut between
the
scrotum
and
rectum.
This is usually performed as an outpatient
procedure or with a brief hospitalization. A
small, soft catheter will be left in the penis
for 10 to 21 days and removed after an X-ray is
performed to ensure healing of the repair.
Substitution Procedures
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Free
Graft Procedures:
Strictures significantly longer than two
centimeters may be repaired with a free graft
procedure to enlarge the urethra. The graft
may be skin (usually removed from the
shaft of the penis) or buccal mucosa
removed from inside the cheek. Brief
hospitalization and catheterization for two or
three weeks are usually required after this
procedure.
-
Skin
Flap Procedures:
When a long stricture is associated with
severe scarring and a free graft would not
survive, flaps of skin can be rotated from the
penis to ensure survival of the newly created
urethra. These procedures are complex and
require a surgeon experienced in plastic
surgery techniques. Brief hospitalization and
catheterization for two or three weeks are
usually required after this procedure.
Staged
Procedure:
When sufficient local tissue is not available
for a skin flap procedure and local tissue
factors are not suitable for a free graft, a
staged procedure may be required. The first
stage in a staged procedure focuses on opening
the underside of the urethra to expose the
complete length of the stricture. A graft is
secured to the edges of the opened urethra and
allowed to heal and mature over a period of
three months to a year. During that time,
patients urinate through a new opening behind
the stricture, which in some cases will require
the patient to sit down to urinate. The second
stage is performed several months after the
graft around the urethra has healed and is soft
and flexible. At this stage the graft is formed
into a tube and the urethra is returned to
normal. A small, soft catheter will be left in
the penis for 10 to 21 days.
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Recovery
Because urethral strictures can recur at any
time after surgery, patients should be monitored
by a urologist. After removal of the catheter,
followup of the repair should be performed
intermittently with physical examination and
X-ray studies being performed as necessary.
Sometimes, the doctor will perform urethroscopy
to evaluate the repaired area. Some patients
will have recurrence of stricture at the site of
the prior repair. These are sometimes mild and
require no intervention, but if they cause
obstruction they can be treated with urethrotomy
or dilation. A repeat open surgical repair may
be needed for significant recurrent strictures.
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Risks
Urinary catheters need to stay in place for a
period of time after many procedures. These can
cause infection, bladder irritation, and
discomfort.
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Frequently Asked Questions
Q: What are some causes of urethral stricture?
A:
Stricture disease may occur anywhere from the
bladder to the tip of the penis. The common
causes of stricture are trauma to the urethra
and gonorrheal infection. However, in many
cases, no cause can be identified. Stricture of
the posterior urethra is often caused by a
urethral injury associated with a pelvic bone
fracture (e.g., motor vehicle or industrial
accident). Patients who sustain posterior
urethral injuries from pelvic fracture generally
suffer a disruption of the urethra, where the
urethra is cut and separated. These patients are
completely unable to urinate and must have a
catheter to realign the urethra. The
catheter is placed through the penis up into the
bladder to allow urine to drain until a repair
can be performed. Trauma such as straddle
injuries, direct trauma to the penis and
catheterization can result in strictures of the
anterior urethra. In adults, urethral strictures
may occur after prostate surgery, removal of
kidney stones, urinary catheterization or
other instrumentation. In children, urethral
strictures most often follow reconstructive
surgery for
congenital abnormalities of the penis and
urethra,
cystoscopy and urethral catheter drainage.
Q: Is there a risk of infecting others with
urethral strictures?
A: Urethral strictures are not contagious
but the underlying cause, like an STD, may be
contagious.
Q: Can urethral strictures be treated with
medicine?
A:
No
Q: What happens after treatment for the
condition?
A:
Strictures are prone to return after dilation
with catheters or endoscopic removal. Open
surgery to repair the stricture carries the
risks of bleeding, infection, and damage to the
penis or other pelvic structures.
Q: How is the condition monitored?
A:
A person treated for urethral strictures should
have follow-ups for at least one year. This is
to watch for reoccurrence of the stricture. The
primary monitoring test used is uroflowmetry, a
test which measures the rate of urine flow
during urination.
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The following list of Urology procedures are
performed at Beverly Hills Medical Group -
please click the links to find out more:
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