STOP DILATING URETHRA! Urethral stricture surgery - Urethroplasty
- Oct 20, 2021
- 11 min read
Urethral stenosis (stricture), or narrowing of the urethra, is a very common disease that dramatically reduces the quality of life
The classic urological approach to the treatment of urethral stenosis is violent dilation of the narrowed part - urethral buccal, and endoscopic resection - internal urethrotomy. These methods never solve the problem in the long run.
Get well informed before giving your trust to one of the urologists
The most common symptoms of urethral stricture coincide with the symptoms of an enlarged prostate:
weak urine stream, straining when urinating, pain when urinating, frequent urination of small amounts of urine, constant urinary tract infections, bloody urine, formation of bladder stones, bladder diverticulum, weakening of renal function associated with dilation of the upper urinary tract, etc.
In the most severe forms of urethral stricture, urine comes out in drops or does not come out at all on the urethra (obliteration, complete cessation of urination) and then it is necessary to place a urinary catheter through the abdomen, the so-called Cystofix. By placing a Cystofix rather than a urethral (Foley) catheter, further damage to the urethral wall and increased stenosis are avoided.
I can't urinate! What should I do?
If the interruption of urination occurred suddenly and if you have pain in the area of the urinary bladder, contact the emergency service immediately to provide you with emergency assistance in the form of placing a urinary catheter. A urethral urinary catheter is a long soft tube that is inserted into the bladder through the urethra so that urine can come out of the bladder unhindered.
Why a catheter through the abdomen? It must be very painful!
Cystofix placement is performed under local anesthesia under ultrasound control. The procedure itself, apart from minor discomfort during the administration of a local anesthetic, is not painful. Cystofix allows unimpeded urination while avoiding further damage to the urethra by possibly placing a Foley catheter. Another advantage of Cystofix is that it avoids the passage through the posterior urethra where the prostate is located, which is very sensitive to the placement of a classic Foley catheter.
After the symptoms subside, it is necessary to examine the cause of the inability to urinate. Urination requires preserved patency of the lower urinary tract, and a specialist in reconstructive urology is the only one who can find out why you are not able to urinate.
In the following text, we will talk about the problems that are mainly related to the narrowing of the urethra in men. Disorder inside the urethra can lead to narrowing of the urethra (stricture), which results in symptoms such as: a thin stream of urine, pain when urinating, a feeling of emptying the bladder, and sometimes the inability to urinate.
What is urethral stenosis?
Urethral stricture, ie urethral stenosis, is a narrowing of the urethra that leads to reduced urine flow or even complete blockage of the inner part of the urethra, or the channel through which urine exits.
Usually the first symptom is decreased urine flow and strain due to the passage of urine. Uncontrolled urination of urine may occur during urination or the formation of a "double jet". Sometimes there is a frequency (need to urinate more often than usual), urinary tract infection, reduced power of ejaculation or the appearance of blood on the tip of the penis shortly after the end of urination. The severity of the discomfort varies from one individual to another, but what they all have in common is that the problems get worse over time.
In the most severe forms of urethral stricture, urine comes out in drops or does not come out at all on the urethra (obliteration, complete rupture of the urethra) and then it is necessary to place a urinary catheter through the abdomen, the so-called Cystofix. By placing a Cystofix rather than a urethral (Foley) catheter, further damage to the urethral wall and increased stenosis are avoided.
What causes a narrowing of the urethra?
Trauma, injury and damage to the urethra are the most common causes of permanent urination problems. Any damage to the sensitive inner wall of the urethra results in the formation of a scar that further narrows the canal and creates difficulties with the passage of urine.
Unfortunately, the most common cause of urethral injury is by medical staff: the consequence of a traumatic urinary catheter placement, injuries during endoscopic procedures - examination of the bladder through the urethra, transurethral endoscopic resection of prostate tissue (TURP) or endoscopic resection of bladder tissue (TURB).
Other causes of urethral canal narrowing:
Lichen sclerosis
Injuries when falling or hitting the urethra
Injuries during pelvic fractures with separation of the urethra from the prostate and bladder
Injuries to the urethra associated with a fracture of the penis
Previously unsuccessfully operated hypospadias
Urethral stenosis after surgery for benign prostatic hyperplasia
Urethral stenosis after prostate cancer surgery
Urethral infections with gonorrhea or chlamydia
Urethral tumor as the rarest cause of urethral narrowing
Sometimes strictures will develop without a known cause when we call them idiopathic
In this text, we will not deal with problems related to the inability to urinate due to posterior urethral valves, neurogenic bladder dysfunction, urinary stones, bladder tumors, benign prostatic hyperplasia, prostate cancer and urethral cancer.
A urethral catheter is a very common cause of urethral damage. Catheters are a necessary evil of modern medicine. They are used to carry urine from the bladder when the patient cannot urinate for any reason (this often happens in men with severely enlarged prostate), or they are used during longer operations under general or spinal anesthesia as well as during longer hospital recovery when monitoring is needed. and urination control. Almost as a rule, any catheterization of the urethra leaves consequences. If it does not lead to narrowing of the urethra immediately, the scar can slowly narrow the urethral canal for decades after traumatic catheterization. Almost 50% of men after radical abdominal and cardiovascular surgeries due to wearing a catheter have problems urinating due to damage to the urethra.
Infection can cause inflammation of the tissues in and around the urethra. It is treated with antibiotics and usually leaves no consequences, but if the inflammation is not treated properly, or not treated at all, a scar remains at the site of inflammation, which if it affects a large enough part of the urethra causes blockage of the canal. Infection can develop after long-term use of a catheter or as a result of a sexually transmitted disease.
Lichen sclerosis is a progressive disease that, when it affects the urethra, leads to a narrowing of its outer opening. Classical treatment consists of violent dilation of the urethral canal. If the disease continues, and leads to the formation of a long urethral stenosis, doctors usually surgically open a small part of the urethra and continue with the protocol of dilatation of the urethral canal, so-called urethral dilation, with rough instruments until the urethral wall opens and urine flows out again. The problem with this type of treatment is that the narrowing of the urethra inevitably returns after a short period of time, when the narrowing becomes longer, the opening of the urethra becomes narrower, and the symptoms of difficult urination become more severe.
Injuries to the urethra, whether from a fall and a direct blow to the crotch, a pelvic fracture or due to numerous medical interventions, lead either to a direct interruption of the urethra or to the formation of a scar which can lead to narrowing of the urethra and difficulty urinating after several years.
Injuries to the urethra in severe traffic accidents, in which there was a complete separation of the urethral canal from the prostate and bladder, are the most complicated to treat.
In traffic injuries, a fracture of the pelvic bones, an injury to the bladder and vital organs are almost always associated with an injury to the urethra. The injured person is in danger of death at that moment, and surgeons are trying to save the injured person's life. The urethra is usually neglected during that initial surgical procedure. Men are then usually left to fend for themselves, with a catheter placed over their abdomen and with no hope of returning to normal life.
Dr. Nikola Stanojevic and his team of reconstructive urologists - andrologists, successfully treat such extensive urethral injuries in one surgery. Postoperative recovery is common as in all other forms of urethroplasty, about 2 to 3 weeks, after which patients begin normal urination.
Helping a person return to normal life after severe urethral injury is a mandatory task of every genitourinary reconstructive surgeon.
How do I know if I need surgery?
Surgical treatment of urethral stenosis is planned when the patient has difficulty urinating, when straining to urinate or cannot urinate at all, if a significant amount of urine remains in the bladder after urination, if there are more serious problems with the bladder or kidneys, if recurrent urinary tract infections, or if unbearable pain is present when urinating.
How is urethral narrowing diagnosed?
There are several tests that urologists use to diagnose strictures: Your doctor - urologist - andrologist will suggest that a contrast imaging - urethrography - be performed whenever there is a suspicion of urethral stenosis. Ultrasound examination of the urethra can show the length of the scar that interferes with the flow of urine. Urethroscopy includes a visual examination of the patency of the urethra using a particularly thin instrument - an endoscope. The flow test (Uro Flow) is an estimate of how much urine is wet per second.
How is narrowing treated? The doctor advised me dilation instead of surgery - what should I do?
Urethral dilatation (urethral calibration) is always counterproductive. Narrowing of the urethra almost always returns after a short period of time and in a much serious form than before the beginning of dilatation of the urethra. Usually, the patient is subjected to this very aggressive, painful and unsuccessful method for many years before seeking the help of one of the experts for the treatment of urethral stenosis. Urethral surgery in patients who have been treated with dilation is more difficult due to the serious scars that occur after each session of urethral dilation.
Endoscopic resection of the narrowing of the urethra (direct vision internal urethrotomy - DVIU with a resectoscope) is a very popular method in urological circles. It should be used only once in very short forms of narrowing of bulbar urethra (less than 5-10 mm) and if it does not give results after the first resection, the same method should not be tried further. The use of lasers to cut the narrowing of the urethra is an equally unsuccessful method. After failure, if the urologist decides to repeat the endoscopic resection of the urethral stenosis, each subsequent urethrotomy leaves even bigger scar and a longer narrowing of the urethra.
The long-term success of the method after the first resection is 30% and after the second resection the success is less than 10%.
Urethral stent placement is a proven unsuccessful concept for the treatment of urethral stenosis. Urethral stents present serious complications without obvious long-term benefit.
What is the best method to treat urethral stricture?
Open urethral reconstruction (urethroplasty) is the only option that gives over 95% success in the treatment of urethral narrowing. The techniques of joining the cut ends (anastomosis of the urethra) differ from the techniques of enlarging the internal canal (augmentation of the urethra). In our practice, we encounter very severe cases of narrowing of the urinary tract and the most commonly performed procedure is the reconstruction of the canal using a buccal mucosa graft placed dorsaly.
Urologist-Andrologist Dr. Nikola Stanojevic is internationally recognized expert in the field of reconstructive uro-genital surgery. Dr Nikola applies the most successful surgical techniques for the treatment of urethral narrowing.
What is a graft and what is a buccal mucosa?
A generally accepted standard in the treatment of complicated urethral stenoses is an operation called - augmentation urethroplasty using a buccal mucosa graft. Proven to be the most successful approach in the treatment of urethral stenosis involves transplanting a piece of tissue (graft) from the inside of the cheek (mucosa) into the area of the urethral narrowing. In that way, the capacity of the urethra is permanently increased and it enables unhindered urination. This approach is technically demanding but the only one that offers good long-term results.
Opening of the urethra to the skin below the scrotum - perineostomy
In extremely rare cases, when the surgeon assesses that there are no conditions for urethral reconstruction, he may decide to form a perineostomy, an opening of the urethra on the perineum behind the scrotum. This is a permanent solution that allows you to urinate in a sitting position.
Who should I contact for help?
Due to its specific pathology and special approach to treatment, urethral stricture is treated only by specially trained urogenital reconstructive surgeons. The hospital department of classical urology is dedicated to solving the most dangerous urological problems - prostate cancer, bladder tumors and kidney tumors. Doctors in large urological hospitals are maximally dedicated to the treatment of these dangerous diseases. A patient suffering from urethral narrowing in such environment can hardly find a properly educated specialist who would dedicate himself to the delicate problem of urethral narrowing.
The classic urological approach to the treatment of urethral stenosis is reduced to dilation - urethral calibration, and endoscopic resection - internal urethrotomy. These methods have been unsuccessful in the long run.
The safest and only permanent solution is open urethral reconstruction surgery, urethroplasty.
What is the procedure before and after the surgery?
How long is the recovery?
After diagnostic measurements of urethral damage and a definitive diagnosis of narrowing, your doctor may decide to insert a urinary catheter through your abdomen to rest the urethral tissue and prepare it for surgery. During this period, you may receive medication to control your urinary tract infection. On the day of the surgery, you are accommodated in a hospital apartment, where your surgeon - andrologist - urologist will talk to you once again so that all the details of the procedure are as clear as possible.
You must not eat or drink for six hours before the surgery. The surgery itself is usually performed under general anesthesia, but if necessary, or at your request, it can also be done in regional, spinal anesthesia. The surgery usually lasts up to two hours, after which you wake up in a hospital apartment where your urologist will explain what was done during the surgery and what the expected result is.
Dr. Nikola Stanojevic applies minimally invasive microsurgical technique which does not reduce the safety of a good result, but reduces tissue trauma during the intervention, which is why patients recover faster and the wound heals better.
You can expect to leave the hospital the day after the urethral surgery. You must stay in close contact with the doctor and come for regular scheduled check-ups. The catheter that is worn after the surgery stays for about two weeks, after which it is removed and you then start urinating unhindered naturally on the urethra.
Is there a risk that my erection will be destroyed by surgery?
When can I go back to work?
Urethral surgery, if performed correctly and carefully, has no effect on the quality of the erection and does not reduce male fertility. In some cases, urethral stenosis itself is the cause of male infertility, so by treating the narrowing, fertility returns to normal. The return to normal physical activities is, as with any surgical procedure, gradual. Depending on the type of work you do, you can start working as early as 7 days after the surgery. With heavy physical work or weight exercise, you can return about 20-30 days after the surgery. Return to normal sex life usually occurs 30 days after surgery.
Can my constriction return?
By applying micro-surgical methods, excellent precision in urethral reconstruction is achieved. In this way, excellent long-term treatment results are achieved and the return of urethral narrowing is avoided. Riding a bicycle, motorcycle, moped, horseback riding or any other activity of a similar type in the first few months of surgery can lead to poorer tissue healing and recurrence of urethral stricture. It is important that you are in constant contact with your surgeon until the wound is completely healed.
Publikacije
The effect of annual hospital volume (AHV) on perioperative outcomes after urethroplasty - The Journal of Urology 04/2019; Francesco Montorsi, Nikola Stanojevic, Vladislav Pesic, Salvatore Sansalone, Marco Bandini, Rados Djinovic
Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in proximal hypospadias: A feasibility, safety and protocol compliance assessment study - European Urology Supplements 03/2019; M. Bandini, N. Stanojevic, V. Pesic, M. Slavkovic, A. Briganti, A. Salonia, F. Montorsi, R. Djinovic
Treatment of penile urethral stricture in patients with failed hypospadias repair using buccal mucosa grafting - Journal of Sexual Medicine 04/2017; N. Stanojevic, A. Ruffo, G. Di Lauro, L. Romis, G. Romeo, F. Iacono
Penile stricture and lichen sclerosus: One-stage urethroplasty with buccal mucosa graft - European Urology Supplements 09/2018; N. Stanojevic, A. Ruffo, M. Franco