Urethral Stricture Surgery
The aim of the leaflet is to provide you with detailed information about what causes urethral stricture disease and how it is treated.
Where is the urethra and what does it do?
In men, the urethra is a tube that carries urine from the bladder, and semen from the ejaculatory ducts, out of the body. From the bladder, it goes through your prostate, your external sphincter (muscle that helps you remain continent), your perineum (the area between scrotum and anus) and your penis.
What is a Urethral Stricture?
A urethral stricture is a narrowing caused by scarring of the lining of the urethra and the surrounding corpus spongiosum.
Strictures can range from less than 1cm long to those that extend the entire length of the urethra.
They can occur at any point along the urethra, but are most often seen in the bulbar region.
What are the causes of Urethral Strictures?
The most likely cause depends on the site of the stricture. Broadly, the commonest reasons are:
- Idiopathic- Cause unknown
- Inflammatory- Caused by infection or inflammation in the urethra, e.g. sexually-transmitted infections (STIs) e.g. gonorrhoea, chronic inflammation e.g. lichen sclerosus (LS) also known as balanitis xerotica obliterans (BXO)
- Traumatic- Caused by injury to the urethra, e.g. a fall astride the cross-bar of a bicycle other crushing pelvic trauma
- Iatrogenic- Caused by medical intervention, e.g. repeated urological procedures that involve passage of instruments along the urethra, urethral catheterisation, radiotherapy or surgery to adjacent organs
- Congenital- Inherited conditions e.g. hypospadias (or as a result of previous surgery to correct hypospadias)
What symptoms might I have with a urethral stricture?
With minor strictures, you may not have any symptoms. With tighter strictures, you may experience one or more of the following:
- Poor urinary flow and needing to strain to pass urine;
- Spraying or splitting of the urinary stream;
- Dribbling of urine after urination;
- Needing to pass urine often (urinary frequency);
- Urinary tract infections;
- Reduced force of ejaculation and low ejaculate volume; and
- Pain on passing urine.
What are the risks if I leave stricture untreated?
A stricture can act as a “bottleneck” which prevents complete bladder emptying. This can cause you to retain urine in your bladder after you pass urine, which can result in bladder, prostate or kidney infections, and lead to the formation of stones. All these conditions can cause long-term bladder damage and kidney failure.
How is a stricture diagnosed?
A stricture may be suspected if you have a reduced urinary flow rate or your bladder does not empty completely on an ultrasound scan after you have passed urine.
A stricture may be diagnosed by:
- Examination – especially if the narrowing is visible at the tip of the penis;
- Uroflowmetry test showing box pattern graph;
- RGU-MCU (urethrogram) – an X-ray performed using contrast medium (dye) put into your urethra to show the anatomy;
- Failure to pass catheter or telescope – during investigation of your urinary symptoms, especially when the stricture is close to the bladder;
- Ultrasound scan; and an MRI scan.
A urethrogram (pictured above) is an X-ray that shows the anatomy of urethra (done after the urine culture report has been obtained as sterile). We place a very fine catheter inside the tip of the penis and use it to inject a dye which shows up on X-ray. This procedure is done under intravenous antibiotic coverage.
What treatments are available for my stricture?
Many types of treatment are available, ranging from conservative or minimally invasive procedures, right through to complex reconstructive operations.
The type of treatment we recommend depends on several factors:
- Your preference as the patient;
- The site and length of your stricture;
- The cause of your stricture;
- Any previous treatments you have received for your stricture; and
- Your general health.
What is Urethral dilatation procedure?
Under local anaesthetic, we pass a plastic or metal dilator (pictured) into your urethra to stretch the narrow area. Afterwards, we may teach you to pass a similar dilator or “slippery” catheter into your urethra (intermittent self-dilatation, ISD). There is a relatively high risk that the stricture will return using this method, so your urologist may need to repeat the dilatation from time to time.
What is Optical Internal Urethrotomy (OIU) procedure?
Under an anaesthetic, we pass a telescope through urethra to cut the stricture. This opens, but does not remove, the scar tissue causing the narrowing. You will usually need a catheter for at least 3 days after the procedure. You will be asked to return later, as an outpatient, to have the catheter removed.
What is the risk of recurrence after OIU?
If you are having an optical urethrotomy for the first time, there is almost 50% risk of stricture recurrence, so it may need to be repeated. If your stricture has recurred after a previous urethrotomy, the risk of further recurrence is higher.
What is the open urethroplasty procedure?
Urethroplasty has a much higher success rate in curing symptoms and preventing the stricture from returning than most other forms of treatment. It requires a longer anaesthetic time; it is complex open surgery. The type of procedure needed can vary a lot depending on the site, length and tightness of the stricture but, in general terms, the following approaches are most commonly used-
Anastomotic urethroplasty – if your stricture is short, we cut out the narrowed area and join the healthy ends together again.
Augmentation buccal mucosa graft urethroplasty – if your stricture is longer, we cut open the narrowed area and use a piece of your cheek lining (buccal mucosa) as a graft to widen the stricture
Augmented anastomotic buccal mucosa graft urethroplasty – for long, tight strictures, we cut out the diseased area, join the healthy ends together and use a buccal mucosal graft as well to widen the urethra.
When are sutures and catheter removed after urethroplasty?
These procedures all need an incision in your perineum (between your anus & scrotum), 2- 3 day hospital stay, a catheter in your bladder for 2 – 3 weeks and 4 – 6 weeks off work.
What is the Two-stage penile urethroplasty procedure?
This involves two operations several months apart, and is most often used for strictures of the penile urethra. In the first stage, we make a cut on the under-surface of your penis, open the urethra and remove all diseased tissue. We use a piece of buccal mucosa (cheek mucosa) as a graft and fix it in, leaving the graft itself exposed.
After this, your urethral meatus (external opening) will be further back on the underside of your penis than it as before the procedure. We perform the second stage several months later, once the graft has picked up a new blood supply. We roll the graft into a tube to reconstruct the urethra, and put a catheter into bladder for two to three weeks.
Is long-term urethral catheter or suprapubic catheter an option for my urethral stricture?
If you have multiple medical problems or you wish to avoid complex treatment, we may recommend putting in a long-term catheter. This can be put into your bladder through the abdomen wall above the pubic bone (a suprapubic catheter). Catheters can cause irritation of the bladder, urinary infections and bladder stones. Long-term catheters need to be changed every eight to 10 weeks.
What are the daily routine life problems with perineal urethrostomy procedure?
This is a procedure to “short-circuit” the diseased urethra by bringing it out to the skin surface in the perineum (between the back of the scrotum and the anus). It is less complex than urethroplasty, and may be considered if you have extensive stricture disease where reconstructive surgery might not be technically possible, or if you wish to avoid further surgery. After this, you will need to sit down to pass urine. You will also ejaculate through this opening (not through your penis).
What is the long-term outlook of the treatment of urethral stricture?
Most of the patients have a good outcome after treatment for a urethral stricture. You may not need any further treatments in the future.
In some cases, we may need a few sessions of urethral dilatation in the immediate post-operative year.
How can I prevent urethral stricture?
It’s not always possible to prevent urethral stricture. Since STDs are one cause, using protection during sexual contact can prevent some cases. However, injuries and other medical conditions associated with urethral stricture can’t always be avoided.
It’s important to see a doctor right away if you’re experiencing symptoms of urethral stricture. Treating the problem quickly is the best way to avoid serious complications.
Are urologist here doing all the above mentioned procedures?
Yes, all above mentioned procedures are regularly being done here by experienced urologist. We have repaired few of the most complex urethral stricture disease with excellent results.
Dr Anantkumar Urologist
Best Robotic Surgeon In Delhi
Location: Max Supper Speciality Hospital (A Unit of Devi Devki Foundation) 2, Press Enclave Road Saket, New Delhi – 110017.
Dr Anantkumar Urologist
Best Robotic Surgeon In DelhiLocation: Max Supper Speciality Hospital
(A Unit of Devi Devki Foundation) 2, Press Enclave Road Saket, New Delhi – 110017