Stricture Urethra

  • Introduction: The 18 to 20 cm male urethra is a common passage for urine and semen in a man and has a rich vascular neighborhood. It is the urologists’ window to the urinary system and obstruction to the urethra (Stricture) can sometimes cost ones kidneys.
    Mechanical obstruction the urethra of any kind is called as “urethral stricture disease” and it is the most common cause of difficult Foley catheterization in the world.
    Classification of Stricture Urethra:
    1. As per etiology Traumatic Inflammatory Infective Malignant
    2. As per anatomical location Meatal/ navicular fossa Penile Bulbar Membranous Pan-Urethral (Involving complete urethra)

    When to Suspect Stricture urethra?
    • Every male who complains of poor urinary flow.
    • Recurrent UTI in a young male.
    • Recurrent epididymo-orchitis.
    • Recurrent abdominal wall hernia.
    • Past urethral instrumentation or catheterization.
    • Patients with Lichen sclerosis (Balanitis Xerotica Obliterans )
    • History: Regarding previous catheterization or any urological surgery.
    • USG- KUB Upper tract changes, Post void residue, calculi.
    • Uroflowmetry Baseline and follow-up
    • Retrograde Urethrography For detailed anatomy of the stricture.
    • MRI pelvis Pelvic fracture and other complex cases
    • Sono-urethrogram To know the extent and severity of Spongiiofibrosis
    • Cysto-urethroscopy: In certain indications only.

    It is the best screening, diagnostic and follow-up tool for all cases of bladder outlet obstruction. It is a simple, cheap, non-invasive and reproducible test for acquiring detailed urinary flow parameters. In patients of stricture urethra the uroflowmetry shows a flat graph.

    Retrograde Urethrography:
    It is an imaging study to understand the exact length, extent and severity of the stricture. In cases of traumatic urethral disruption a combined Retrograde Urethrogram and a Micturating Cysto-urethrogram (Up & Down “O” gram) is done to find out the exact length of the stricture.

    Treatment of Stricture Urethra:
    Visual Internal Urethrotomy (VIU): It involves cutting of the stricture with an endoscopic knife. It is usually curative in only 25-30% cases and this becomes a temporary treatment in majority of patients. Multiple attempts at VIU usually lead to worsening of the stricture and hence it is indicated for a maximum of two attempts. VIU can seldom cause profuse urethral bleeding.

    Poor results in
    • Previous VIU,
    • Penile and membranous strictures,
    • Long (>2 cm) and multiple strictures,
    • Untreated perioperative urinary infection and
    • Extensive periurethral Spongiiofibrosis.
    Indicated in
    • Short bulbar strictures
    • Stricture recurrence > 6 months after the initial procedure
    • Severe co morbidity and limited life expectancy
    • Failed previous urethroplasty

    Urethral Reconstruction (Urethroplasty)

    Urethroplasty offers the only chance of permanent cure in stricture urethra. It involves surgical repair and /or reconstruction of the urethra. The basic principle of urethroplasty relies on the etiology of stricture. Non-traumatic strictures are never subjected to urethral division but are treated by augmentation.
    Types of Urethroplasty:
    1) Anastomotic (End-to-End) Urethroplasty: Usually done in traumatic strictures.
    2) Augmentation Urethroplasty: The urethra is patched with free skin or mucosal grafts
    3) Supplementation Urethroplasty: Posterior alternative tissues create completely new urethra.
    4) Posterior Anastomotic urethroplasty: For repair of urethral disruption after pelvic fracture and urethral distraction defect.
    5) Staged Urethroplasty: In cases of multiple failed urethroplasty and complex trauma.

    Anastomotic Urethroplasty:

    Strictures caused due to trauma cause complete loss of vascular connectivity across the stricture. In these cases the stricture is excised and the healthy ends of the urethra are joined over a Foley catheter. Anterior Anastomotic Urethroplasty: Done for traumatic strictures involving the penile or bulbar urethra. Strictures up to a maximum of 3 cm can be treated by this technique. Longer strictures cannot be approximated without tension and hence they need a staged procedure.

    Anterior Anastomotic Urethroplasty:

    Done for traumatic strictures involving the penile or bulbar urethra.
    Strictures up to a maximum of 3 cm can be treated by this technique. Longer strictures cannot be approximated without tension and hence they need a staged procedure.

    Augmentation Urethroplasty:

    Buccal mucosa graft (BMG) urethroplasty is considered as a standard of care for augmentation urethroplasty for non-traumatic urethral strictures and can be used to treat any part of the urethra. In patients where buccal mucosa is unhealthy due to chronic tobacco chewing, either lingual mucosa or penile preputial skin graft is considered.
    Types of Augmentation Urethroplasty:
    It depends on the anatomic orientation of the graft tissue for augmentation.

    • Dorsal Onlay: Preferred for Penile and bulbar urethra and for pan-urethral repairs.
    • Ventral Onlay: Preferred for bulbar urethra
    • Double faced (Dorsal & Ventral): For very long and very narrow strictures.
    • Staged Augmentation: For very complex and failed cases.
    • Augmented Anastomotic Urethroplasty: For long obliterated strictures

    Posterior Anastomotic Urethroplasty:

    In cases of Pelvic Fracture & Urethral Distraction Defect (PFUDD) there is partial or complete posterior urethral disruption following a traumatic pelvic fracture. Immediate management involves insertion of a supra-pubic catheter and posterior anastomotic urethroplasty after a minimum of 3 months. The urethroplasty achieves tension free urethral anastomosis by utilizing 6 steps
    1) Bulbar urethral mobilization
    2) Crural separation
    3) Inferior Pubectomy
    4) Supra-Crural re-routing
    5) Total Pubectomy
    6) Omental wrap

    Ventral Onlay BMG Dorsal Onlay BMG Staged BMG urethroplasty