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Urethral stricture – management

May need acute management of retention or impending retention:

  • Urethral dilation and urethral catheterisation (over wire, with initial cystoscopy preferable)
  • SPC

 

Management options:

  • Endoscopic
    • Dilation
    • Incision/urethrotomy
  • Urethroplasty
  • Long term self-dilation
  • Diversion
    • IDC
    • SPC
    • Perineal urethrostomy
    • Catheterisable channel
  • Novel
    • Optilume
    • Stents

 

Treatment depends on shared decision making between patient and surgeon with defined goals and outcomes.

Advanced reconstructive urethral surgery should be done by high volume urethral surgeons.

 

Patient factors Urethra factors
Age

Motivation

Urinary symptoms and continence

Sexual function

Previous interventions

Co-morbidities and fitness for GA

Medications and immunosuppression

Dexterity and cognition

Preference

 Length of stricture

Location of stricture

Calibre of stricture

Degree of spongiofibrosis

Previous interventions

Cause of stricture

Associated BXO

Hypospadias

Availability of tissue for transfer

 

Observation

  • Stricture will usually only result in diminution of flow if ≤ 10 Fr (EAU guidelines).
  • Often patients if happy with symptoms and no objective concerns, can be observed (especially in recurrent strictures after treatment).
  • EAU “do not intervene in patients with asymptomatic incidental > 16 Fr strictures”

 

Urethral dilation

The goal is to stretch the scar without tearing and causing more scarring.

  • If bleeding occurs, the stricture has probably been torn.

Techniques include:

  • S-shaped co-axial disposable dilators over guidewire
  • Urethral sounds
  • Balloon dilators

Best served for short strictures < 1.5 cm, in the bulbar urethra, without spongiofibrosis – may cure these strictures.

May be done under local anaesthetic.

Complications are rare – infection and bleeding, but urethral injury and rectal perforation via false passage can occur (and recurrence of stricture).

Catheter after for a few days to prevent urinary extravasation and allow healing.

 

Internal urethrotomy (DVIU, optical urethrotomy)

Transurethral incision through the scar to healthy tissue, allowing the scar to expand and releasing the contracture, aiming to heal with an enlarged lumen.

Techniques include:

  • Cold knife incision (classically at 12 o’clock)
  • Laser incision (? more adverse effects cf. cold knife)

Complications:

  • Recurrence of stricture
  • Urethral bleeding, particularly with post operative erections.
  • Extravasation of irrigation fluid and haematoma
  • 5 % erectile dysfunction with fistula between cavernosa and spongiosum and venous leak
  • UTI

 

Dilation vs urethrotomy

  • Similar success and complication rates – no difference found in either technique in meta-analyses.

 

Success rates and predictors:

  • Vary widely depending on definition of success and stricture factors
  • ~ 50 % will not need further intervention after one endoscopic procedure.
    • 35 – 70 % success rates for primary bulbar stricture.
  • 70 – 80 % will need further intervention after a second procedure.
  • All will need ongoing intervention after a third procedure.
  • Highest success rates for endoscopic procedure:
    • Primary bulbar stricture
    • < 15 mm
    • No spongiofibrosis
  • Poor success rates for endoscopic procedure:
    • Previous dilation of urethrotomy
    • Penile urethral stricture (also higher rates of complications and ED)
    • > 2 cm
    • Membranous urethral stricture
    • Multiple strictures
    • Extensive spongiofibrosis

 

Adjuvant injections

  • Injection of triamcinolone or mitomycin C after dilation proposed to reduced fibroblast proliferation and excess scarring.
  • Reasonable results in trials for reduction in recurrence rates – off label use and mitomycin especially may have safety concerns.

 

Catheters after dilation/DVIU

Catheter usually placed after to both act as a stent for healing and divert urine away from any open mucosa.

Duration of catheterisation varies – no proven benefit for anything over 72 hours, and can probably be removed after 24 hours.

 

Self-dilation/catheterisation after urethrotomy with tapering schedule is often employed to stabilise the stricture and it does reduce recurrence rates but:

  • Increased complications (UTIs, epididymitis, pain, poorer quality of life scores) and high drop out rates
  • Stricture often recurs after cessation of self-dilating
  • Generally thought to increase stricture complexity and delays time to urethroplasty.
  • Optimal schedule and duration are unknown.

EAU also notes intra-urethral corticosteroids (triamcinolone ointment) combined with self-dilation delays time to recurrence.

EAU: “perform intermittent self-dilation to stabilise the stricture after dilation/DVIU if urethroplasty is not a viable option”

AUA: “in patients who are not candidates for urethroplasty, clinicians may recommend self-catheterisation after DVIU to maintain temporary urethral patency”

 

Urethroplasty

Gold standard treatment for urethral strictures with highest success rate and cure – excision of the stricture with reconstruction of the urethra

Should be offered for all strictures as either a primary treatment or after failed endoscopic treatment.

Consider urethral rest for 6 weeks prior to urethroplasty (SPC diversion).

 

 

Urethroplasty for bulbar strictures

“Short” bulbar strictures of 1 – 2 cm may be treated with either excision and primary anastomosis (EPA) or substitution/graft urethroplasty.

 

General technique common to all bulbar urethroplasty:

  • Adequate planning pre-operatively – RUG, can do cystoscopy prior to starting.
  • GA, peri-operative antibiotics, ability to harvest buccal mucosa (nasal tube considered but not mandatory)
  • Lithotomy – risk of pressure injuries/compartment syndrome
  • Stool, peri-table, lone star retractor, headlight.
  • Flexible cystoscopy – define location of stricture. If scopes passes easily, can probably abandon.
  • Midline perineal incision – perineoscrotal junction to above the anal verge
  • Open Colles fascia and expose bulbospongiosus muscle – divide in midline.
  • Exposure of corpus spongiosum and urethra
  • Spongiosum dissected away from and off cavernosa

 

Excision & primary anastomosis

  • High success > 90 % for short bulbar strictures
  • Non transecting EPA may have less erectile dysfunction cf. transecting – might be best for short < 1 cm strictures

 

Transecting EPA technique:

  • Expose and mobilise urethra and spongiosum
  • Define distal extent of stricture with (20 Fr) catheter or sound (do not dilate stricture)
  • Vascular clamps above and below stricture on spongiosum and full thickness transection with blade
  • Distal urethra mobilised further with clamp on and any stricture excised
  • Spatulation dorsally of distal urethra and further mobilisation
  • Excision of remaining proximal stricture and ventral spatulation – pass scope or sounds to ensure proximally not obstructed
  • Remember bulbar urethra is more dorsal within sponge – full thickness sutures dorsally, urethra only ventrally
  • Interrupted anastomosis with 4-0 PDS ensuring knots kept on outside, over 16 or 18 Fr IDC
  • Continuous spongioplasty / closure of spongiosum
  • Apposition of bulbospongiosus and closure of Colles’

If transected, and not enough length for tension free (risking chordee) – can place buccal graft dorsally still, tack urethra to dorsal graft and close ventral side

 

Non-transecting EPA:

  • After mobilising urethra, perform dorsal stricturotomy longitudinally, and close transversely a la Heineke Mikulicz
  • Ideal for very short strictures and requires less mobilisation
  • Probably not ideal for traumatic strictures with significant spongiofibrosis

 

Risk factors for failure:

  • Incomplete excision of all scar
  • Anastomotic tension
  • Lichen sclerosis / BXO
  • ?Prior urethral surgery/endoscopic treatment and radiation may not affect success rates
  • Patient factors affecting wound healing (smoking, diabetes, obesity, immunosuppression).

 

Substitution urethroplasty with graft – e.g., buccal mucosal graft urethroplasty

Technique of choice for longer strictures > 2 cm and those not amenable to excision and primary anastomosis.

No proven benefits for dorsal vs ventral onlay – dorsal theoretically has better graft support and vascularity (graft bed on corpora cavernosa). Also significant bleeding with ventral incision through sponge.

Technique for dorsal onlay graft:

  • Exposure as usual (preference for nasal intubation at start)
  • Urethra and sponge do not need to be circumferentially mobilised like EPA – can keep right side attached to cavernosa, and mobilise left side to ‘roll’ urethra
  • Identify distal extent of stricture with sounds/scope
  • Incise stricture dorsally longitudinally along entire length of stricture (twist urethra/catheter) – scope or sounds to ensure no proximal obstruction
  • Stay sutures for right side to keep urethra rolled
  • Fibrin glue to left corpora cavernosa as bed for graft (?)
  • Graft is sutured in place on fibrin bed on cavernosa
  • Medial edge of urethrotomy sutured to graft – interrupted PDS or monocryl
  • 16 fr IDC
  • Other edge of urethrotomy and graft tied down

 

Technique for harvest of buccal graft:

  • Preparation – nasal intubation or endotracheal to one side
  • Mouth prepared with specific prep and specific retractor
  • Local anaesthetic infiltration – lignocaine with adrenaline – may act as hydrodissection
  • Identify the parotid duct (Stensen duct) opposite the second molar
  • Mark area – elliptical excision – at least 4 x 1 cm
  • Sharp excision and haemostasis
  • I prefer closure with running vicryl rapide – no proven benefit
  • Graft prepared and de-fatted and kept in saline

 

Alternative graft options:

Other oral mucosa (lingual or lip), rectal mucosa, skin grafts

No role for allografts (other humans), xenografts (other species) or synthetic grafts.

 

Tubularised oral mucosal grafts should not be used to due to poor take and high recurrence.

 

Post-operative urethroplasty:

  • IDC for 2 – 3 weeks, peri-catheter urethrogram prior to removal
  • Ice packs to cheek and saline mouthwashes
  • Drain usually not necessary
  • Should be followed long term – flow rates, post void residuals, symptoms.

 

 

Complications of urethroplasty

  • General anaesthetic risks + positioning risks
    • Risks of graft harvest – pain, bleeding, difficult mouth opening. Chronic mouth pain 1 %.
  • Early
    • Infection/abscess, bleeding/haematoma, pain, leak
  • Late
    • Erectile dysfunction in first 6 months (highest with transecting EPA), cold sensation to glans
    • Post micturition dribble
    • Chordee or penile shortening
    • Ejaculatory dysfunction or pain
    • Diverticulum at or adjacent to graft
    • Recurrence of stricture
    • Urethrocutaneous fistula

 

Recurrent stricture post urethroplasty

  • May be managed with urethrotomy/dilation with good success rates.

 

Pan urethral strictures

  • Endoscopic management is essentially palliative and stricture will recur, self-catheterisation will stabilise only.
  • Refer to specialist centres and may require complex reconstruction (or perineal urethrostomy/diversion).

 

Staged urethroplasty

  • An option for complex or re-do urethroplasties – e.g., fistula, false passage, previous abscesses
  • Consider if radiation therapy, severe intra-operative spongiofibrosis, or extensive lichen sclerosis pan urethral stricture

 

 

 

Penile urethral strictures

Avoid dilation or urethrotomy in penile urethral strictures – very low cure rates and higher rates of erectile dysfunction.

Think of and consider complicating factors – lichen sclerosis and previous hypospadias surgery.

Avoid primary anastomotic urethroplasty in penile urethra – high rates of chordee and shortening.

Urethroplasty may employ:

  • Single stage vs staged
    • Staged for more complex strictures with significant spongiofibrosis
  • Oral mucosal graft vs penile skin flap
    • No convincing evidence for efficacy one over the other

Overall patency and success rates 70 – 80 % (i.e. not as high as bulbar urethroplasty).

Orandi flap (ventral dartos fasciocutaneous flap):

  • Supine with penis on stretch, lone star retractor
  • Midline ventral penile urethral incision with semi-circular flap marked
  • Exposure of urethra and urethrotomy over length of stricture laterally on side of flap
  • Flap incised and supported on dartos fascia
  • One side of urethra sutured to one side of skin island, and skin island then rotated over into opened urethra and second side closed over catheter
  • Penile skin closed

Higher risk of urethral diverticulum due to lack of ventral support. Risk of including hair bearing skin more proximally.

 

 

Failed hypospadias repair

Challenging for many reasons:

  • Deficiencies in urethral plate, penile skin and dartos fascia
  • Poor blood supply due to previous surgeries
  • Incomplete records from previous surgeries
  • Often need multiple or staged procedures
  • Often have or have history of complications – fistulae, stones, hair, infections
  • Significant psychological distress accompanying the above

Should be managed in high volume centre.

 

Lichen sclerosis / BXO strictures

  • Respond poorly to dilation and inevitably occur
  • Use of genital skin in reconstruction is largely contraindicated due to likelihood of recurrence of BXO
  • Consider staged repair with use of oral mucosal grafts

Manage in high volume centre.

Don’t forget this is a pre-malignant condition.

 

Meatal or navicular fossa strictures

Uncomplicated, primary metal or navicular fossa strictures can be treated with dilation or meatotomy.

  • i.e., not associated with BXO, hypospadias repair, previous urethroplasty or previous meatotomy/dilations

Recurrence after that should be considered for urethroplasty, as recurrence with ongoing endoscopic or simple procedures is unlikely to be successful.

Many penile fasciocutaneous flaps are described for meatal reconstruction (in the absence of BXO and previous surgery).

Must exclude more proximal stricture with either RUG/VCUG or cystoscopy.

 

Meatotomy generally done on ventral surface with an 11 blade (or clamp followed by metz) +/- suture meatoplasty to evert mucosa (kind of creating a mild hypospadias).

“Golf tee” dilators often useful if patients unwilling or unfit for complex reconstruction.

 

 

 

Female urethral stricture

Often presents with mixed urinary symptoms with delay to diagnosis.

Can be managed with:

  • Urethral dilation or urethrotomy
  • Usually followed by self-catheterisation (weekly)
  • Urethroplasty in expert centre – can use buccal grafts or local flaps – usually after failure of dilation and self catheterisation

Think about:

  • Urethral cancer
  • Urethral diverticulum
  • Urodynamics to assess bladder compliance and overactivity
  • Flow rates

 

Stents

Permanent stents are no longer available.

  • Complications include encrustation, migration and urethral hyperplasia.
  • Recurrent UTIs, haematuria and chronic perineal pain, ejaculatory pain and discomfort on sitting are also noted.
  • Subsequent urethroplasty is challenging.

Temporary stents – Memokath – thermoexpanding which becomes rigid at body temperature.

 

Transgender male urethral strictures

EAU guidelines:

  • Do not treat strictures with dilation or endoscopic incision within first six months due to ongoing wound healing
  • Insertion of SPC is first line treatment early on
  • After two endoscopic treatments, further endoscopic treatments are palliative in nature

Involve experienced or original surgeon.

 

Optilume

Drug coated balloon used for anterior urethral strictures – combines balloon dilation with anti-proliferative drug (paclitaxel) to reduce stricture recurrence.

May be an option for complex strictures as an intermediate option between self-dilation and urethroplasty.

 

Perineal urethrostomy

Indications:

  • Complex pan-urethral strictures
  • Men who do not desire complex reconstruction, and are OK sitting to void

Contra-indications:

  • Involvement of membranous urethra or posterior urethra
  • Pre-existing stress incontinence or sphincteric weakness

 

Technique (Blandy):

  • High lithotomy position, lone-star retractor
  • Inverted U incision – base of scrotum for apex
  • Mobilisation of inverted U fat pad with skin flap off bulbospongiosus
  • Divide bulbospongiosus in midline and expose bulbar urethra
  • Stabilise urethra proximally and distally with forceps then make longitudinal urethrotomy on ventral surface of urethra
  • Stay sutures on lateral urethra
  • Scope proximally to bladder ensure no obstruction proximally, no bladder stones or tumours, and assess distance to sphincter
  • Apex of the inverted U is sutured first to the proximal aspect of the urethrotomy
  • Interrupted sutures then used to join urethra to skin – 3 layers – mucosa, adventital edge of spongiosum and skin
  • Catheter placed to bladder. Dorsally the urethral plate is intact. Skin closed.
  • Catheter left for a week.

 

Complications:

  • Stenosis – more common with history of radiation

 

If membranous urethra involved with stricture, buccal mucosa graft onlay has been described.

 

NB technique different following radical penectomy – urethra is divided during penectomy with a long stay suture tail left on, then separate perineal incision made and urethra brought through perineum, spatulated and sutured to skin.

 

Other options – “7-flap” for very obese men – amputation and closure of the distal urethra with sacrifice of the dorsal urethral plate, with lateral urethrotomy