Urethral Strictures
Causes
Diagnosis
Assessment
Treatment options
Prognosis
References
Curriculum
•
•
•
•
•
•
•
•
•
•
•
•
Knowledge of the pelvis, male genitalia and urethra including embryology of
urethra including hypospadias and epispadias
Neuroanatomy as it relates to normal and abnormal bladder, urethral and pelvic
floor function
Causes, pathophysiology and complications of urethral strictures
Pathophysiology of traumatic urethral injury
Assessment of patient with urethral stricture
Ability to determine appropriate surgical option for patients with urethral stricture
Be able to advise on the surgical options and the appropriateness of surgery
Knowledge of endourological techniques relevant to urethral stricture
Techniques and complications of urethral reconstruction
Management of postoperative consequences of urethral reconstruction
Arrange appropriate follow up of patients with urethral reconstruction
Liaison with other specialties e.g. radiology, orthopaedics, GI surgeons
Definitions
The term urethral stricture refers:
• to anterior urethral disease
• is a scarring process that involves the epithelium as well as
the spongy erectile tissue of the corpus spongiosum.
• Con- traction of the scar reduces the urethral lumen.
In contrast, posterior urethral strictures are more correctly
referred to as pelvic fracture urethral injuries; strictures of the
prostatic urethra or bladder neck are properly referred to as
contrac- tures or stenoses.
Chapple et al, BJUI 2004
Anatomy
Blood supply
Neuroanatomy
Neuroanatomy
Neuroanatomy of the male urethra and perineum, BJUI 2003
Distribution
• Anterior – 92.2%
• Posterior – 7.8%
Palminteri et al. Contemporary urethral stricture characteristics in
the developed world. Urology 2013
Aetiology
Unknown
41.3
Failed hypospadias repair
17.0
Catheter
9.9
Instrumentation
6.2
Radiotherapy
0.6
TURP
1.3
Trauma
15.8
LS
6.9
Infection
0.8
Congenital
0.2
Stein et al. A geographic analysis of male urethral stricture aetiology and location.
BJUI, 2013
Aetiology
Stein et al. A geographic analysis of male urethral stricture aetiology and location.
BJUI, 2013
Pathology
Noxious stimulus (bacterial, chemical, physical)

Denuded epithelium

Squamous metaplasia

Fissures develop in epithelium

Urine extravasation

Fibrosis develops in the corpus spongiosum

Fibrotic plaques coalesce

Stricture
Mundy et al. Urethral strictures, BJUI 2010
Pathology of anterior stricture
Campbell’s Urology, 2011
Pathology of contractures/stenoses
• Shearing forces transmitted through the
perineal membrane and pubo-prostatic
ligament
• Distraction-avulsion most commonly at bulbomembranous junction
• Transection by the bony fragments – rare
• Partial or complete ruptures
• Fibrosis interposed between the distracted
ends
Case 1
• 40 Male
• 6/12 h/o flow problem presenting at your
clinic....
Presentation
• Obstructive LUTS: poor stream, incomplete
bladder emptying, hesitancy, dribbling
• Urinary tract infections
• Acute urinary retention
• Haematuria
• Asymptomatic
Investigations
• The aim is to determine:
location,
length,
depth and density of the
stricture/spongiofibrosis.
Campbell’s Urology. 2011
Investigations
• Flow studies
• Flexible endoscopy
– urethral
– suprapubic
– Does not show length, proximal urethra
• Radiology
– Contrast studies- retrograde urethrogram, voiding
cystogram.
– USS useful for bulbar strictures? limited
Case 1
• Flow studies:
• Flexible cystoscopy:
At 12 cm
Urethrogram?
‘there are many urologists who think that a
urethrogram is not necessary before deciding
upon treatment, mainly because they are
going to do a urethrotomy anyway. This is not
the authors’ view. Urethrography gives a more
complete assessment.’
Mundy et al. Urethral strictures. BJUI 2010
Treatment
• Management
•Cure
Both the patient and the physician must have a good understanding of the
goal of treatment before the treatment choice is made. To this end,
treatment options should be discussed with the patient, with care taken to
emphasize the anticipated outcome with regard to potential cure.
Campbell’s Urology, 2011
Treatment
‘In the absence of complications, treatment is
for symptoms and if the symptoms are not
particularly troublesome, treatment is
symptoms are not troublesome, treatment is
unnecessary’
Mundy et al. Urethral strictures. BJUI 2010
Treatment
• Reconstructive ladder – archaic
• Dilatation:
– oldest/simplest
– epithelial stricture without spongiofibrosis
– stretch the scar, avoid bleeding
– Results equal to optical urethrotomy
Treatment
Mundy et al. Urethral strictures. BJUI 2010
Treatment - Optical urethrotomy
- Where to cut? Thinnest portion of corpus spongiosum at 12
o’clock at bulb. Easy to penetrate the corpus cavernosum
- Radial cuts better?
- If wound contraction occurs before re-epithelisation then the
stricture recurs.
- Post-op catheter 3 days
TONKIN et al. Management of distal anterior urethral
strictures. Nat Rev Urol. 2009
Desmond et al. Critical evaluation of direct vision urethrotomy by urine flow
measurement. Br J Urol 1981
Treatment - Optical urethrotomy
Adjuvant modalities to reduce the rate of stricture recurrence include the
following:
• Intermittent self-catheterisation
• Steroids injected at the site of IU
• Anti-inflammatory medication by mouth
• Mitomycin-C injected transurethrally
• Brachytherapy using an intraurethral balloon filled with radio-active isotope
• Captopril gel intra-urethrally
Heyns. Urethral stricture: should we stop urethrotomies? EAU 2011
Treatment - Optical urethrotomy
-Complications:
1. urine extravasation
2. pain
3. UTI
4. ED1
1. McDermott et al. Erectile impotence as complication of direct
vision cold knife urethrotomy. Urology 1981
Recurrence post optical
urethrotomy
? always?
49
50
Albers. J Urol 1996
40
30
25
26
Heyns. J Urol 1997
27
19
20
Pansadoro. J Urol 1996
Charbit. Ann Urol 1990
10
0
McAninch. AUA 2001
Long term success (> 4years)
Recurrence post optical urethrotomy –
factors
• Length of the stricture (longer than 2 cm)
• Extent of spongiofibrosis on ultrasound (or stricture
diameter on retrograde urethrography)
• Previous procedures (UD, IU, UP)
• Shorter time to stricture recurrence after IU or UD
• Longer duration of follow-up (although most
strictures that recur, do so within 12 months)
Heyns. Urethral stricture: should we stop urethrotomies? EAU 2011
Case 1 continued
• 4/12 post urethrotomy pt is back in the clinic
saying symptoms re-occurred...
Treatment
• Management
•Cure
Both the patient and the physician must have a good understanding of the goal of
treatment before the treatment choice is made. To this end, treatment options
should be discussed with the patient, with care taken to emphasize the anticipated
outcome with regard to potential cure.
Campbell’s Urology, 2011
Case 1 continued
• Options:
– 1. Repeat urethrotomy, UD, Laser, Stent
• Rate of success v. low (6%)1
– 2. Open surgery (urethroplasty)
• Rate of success depending on the pathological features
of the stricture.
1. Santucci et al. Urethrotomy has a much lower success rate than
previously reported. J Urol 2010
Treatment
Laser – no evidence
– Ideal laser should
• totally vaporise tissue
• cause negligible peripheral tissue destruction
• not absorbed by water
• suitable fibre
– Carbon dioxide ideal, needs gas cystoscope, CO2
embolus
– Argon/Nd:Yag causes thermal necrosis can injure
peripheral tissues
– Holmium YAG
Treatment - Stents
– Wallstent or UroLume® (Pfizer Inc., UK) which is
incorporated into the urethral wall
– Memokath® (Engineers & Doctors A/S Ltd.,
Hornbaek, Denmark) which is not.
Results are v. poor- De Vocht et al BJU 2003.
Makes reconstruction more difficult.
UroLume®
Memokath®
Repeat urethrotomy
• 1. A second DVIU/dilation can be indicated for recurrent urethral strictures
with favourable characteristics (<1-2 cm, single, bulbar stricture) with
recurrence >3 months after previous treatment (B).
• 2. A third DVIU/dilation is not recommended, except if necessitated by
patient comorbidities or economic resources (A).
• 3. Urethral reconstruction over repeat DVIU/dilation should be offered for
urethral strictures that recur within 6 months or are refractory to a second
DVIU/dilation (A).
Heyns et al. SIU/ICUD Consultation on Urethral Strictures: Dilation, Internal
Urethrotomy, and Stenting of Male Anterior Urethral Strictures. Urology 2014
Repeat urethrotomy
• Issue the cost effectiveness of a repeat DVIU
vs urethroplasty
• Greenwell et al. Repeat urethrotomy and dilatation for the
treatment of urethral stricture are neither clinically effective
not cost effective. J Urol 2004
• Rourke et al. Primary urethral reconstruction: the cost
minimised approach to the bulbous urethral stricture. J Urol
2005
Open Trial in UK
• Randomised, multicentre trial of open
urethroplasty versus endoscopic urethrotomy
• For men who have got 1st recurrence of
stricture
Case 1 continued
• Pt opts for open surgery...
Treatment
Bulbar urethroplasty
Penile urethroplasty
Posterior urethral reconstruction
Bulbar urethroplasty
• Anastomotic or substitution?
• Ventral or dorsal graft location?
• One stage or two stage repair?
Barbagli. EAU 2008
Treatment – anastomotic
urethroplasty
• Indications
– < 2cm- historically
– bulbar urethra
– relies on mobilisation of corpus spongiosum
• Best results
– excise stricture
– spatulated anastomosis
– overlaping ends
• Outcomes – long term success over 90 – 95%1-2
1. R.A. Santucci et al. Anastomotic urethroplasty for bulbar urethral stricture: analysis
of 168 patients. J Urol. 2002
2. G. Barbagli et al. One-stage bulbar urethroplasty: retrospective analysis of the
results in 375 patients. Eur Urol. 2008
Treatment – anastomotic
urethroplasty
Complications
•
•
•
•
Ejaculatory dysfunction 20%
Decreasedd glans sensitivity 18%
Poor glans erection 11%
Cold glans 1.6%
Barbagli. EAU 2008
Augmented anastomosis with graft
onlay
Grafts/Flaps
• Graft ‘tissue excised from a donor site which
re-establishes its blood supply by
revascularisation’
• Process by which revascularisation occurs =
‘take’
• Take = 3 to 4 days
• 2 processes – imbibition and inosculation
Imbibition
• 48 hours
• Graft survives by ‘drinking’ nutrients from
host bed
• Graft temperature lower than host
temperature
Inosculation
• 48 hours
• Development of true circulation
• Graft temperature rises to that of host
• Features affecting ‘take’:
-Graft type
-Donor site vascularity (tendon, smoking)
-Infection
-Movement
Grafts examples
• Skin (full thickness, split thickness)
• Buccal mucosa
• Bladder mucosa
• Rectal mucosa
Skin vs Buccal mucosa
Cornified layer
Oral epithelium
Epidermis
Superficial lamina (submucosa)
Papillary dermis
Deep lamina (submucosa)
Reticular dermis
Muscle and minor salivary glands
Buccal Mucosa Graft
•
•
•
•
•
•
•
Easy to harvest
Easy to handle
Thick
Panlaminar vascular plexus – good take
Waterproof
Antibacterial
Resists skin diseases
Harvesting buccal mucosa
•
•
•
•
•
•
•
•
Normal intubation OK vs. nasal intubation
Avoid Stensen’s duct opposite second upper molar
Mark excision site
0.5% lignocaine and adrenaline
Tenotomy scissors (superficial vs. deep)
2cm wide, at least 1cm from vermillion border
Side effects worse for closure vs. secondary intention
Lignocaine lozenges
Flaps
• Penile/preputial
• Based on Dartos
• Useful when infection or extensive fibrosos
present
• Transverse, Longitudinal, Circumferencial
Onlay urethroplasty methods
Augmented urethroplasty
Barbagli dorsal onlay BMG
Bulbar urethroplasty - outcomes
• Ventral OMG – 90%
• Lateral OMG – 83%
• Dorsal OMG - 77
Barbagli. EAU 2008
Penile urethroplasty
• One stage or two stage repair?
• Flap or graft urethroplasty?
Barbagli. EAU 2008
Penile urethroplasty
Special circumstances
• BXO
– avoid skin flaps/grafts as it is a skin condition
– buccal mucosa is better
Special circumstances
• Options
– Dilatation
– Holmium laser stricturotomy
– Urethrotomy (avoid 6 o’clock)
– Urethrotomy + AMS sphincter
– Open reconstruction
– Urinary diversion
Post TURP stricture
• Tend to be at bladder neck (incise)
• More difficult at membranous urethra since
incision here will compromise continence as
bladder neck mechanism lost
• Gentle ISD
• Anastomotic urethroplasty + sphincter
(problems with erosion)
• Multistage scrotal flap technique
Thank you