URETHRAL STRICTURES(male) : URETHRAL STRICTURES(male) Dr Mbute 20th Jan 2011
Grand round presentation introduction : introduction A narrowing of the urethra caused by injury or disease
Includes UTI’s and other forms of urethritis.
Above insults lead to scar tissue formation which contracts hence reducing the calibre of the urethral lumen.
End result is the resistance to ante grade flow of urine and semen. causes : causes Traumatic
Iatrogenic : post instrumentation(indwelling catheter, urethral endoscopy)
post operative eg open prostatectomy, amputation of the penis
Post infectious. Esp post gonococcal
Malignancies. presentation : presentation Obstructive voiding symptoms urine retention
(decreased force of stream , incomplete bladder emptying, dribbling intermittency.)
UTI’S complications : complications Retention of urine
Peri urethral abscess
Hernia , haemorrhoids and rectal prolapse management : management Principles of treatment
Proper understanding of the relevant anatomy
Skilled surgical technique anatomy : anatomy Making a diagnosis : Making a diagnosis Suggestive history
Findings on physical exam
Endoscopic techniques Radiographic imaging : Radiographic imaging Contrast studies achieved by retrograde and antegrade cystourethrograms
A transducer is placed longitudinally along the penis.
Can evaluate stricture length and degree and depth of spongiofibrosis. Endoscopic evaluation : Endoscopic evaluation Done using either rigid or flexible cystourethroscopy treatment : treatment NOTE:- NO MEDICAL THERAPY EXISTS FOR URETHRAL STRIC TURES. SURGICAL THERAPY : SURGICAL THERAPY Urethral dilatation
Permanent urethral stents
-tissue transfer repair techniques Urethral dilatation : Urethral dilatation The objective is to stretch the scar tissue without producingadditional scarring
Currative in patients with isolated epthelial strictures.
Its a blind procedure hence false passages can be created
Infection Internal urethrotomy : Internal urethrotomy Stricture is incised under direct vision using endoscopic equipment.
Objective is to incise the stricture and ensuring epithilialization before wound contraction reduces the lumen calibre.
Recurrence of stricture
extravasation of irrigation fluid into the perispongial tissues Permanent urethral stents : Permanent urethral stents Places endoscopically
Designed to be incorporated into the wall to provide a patent lumen
Most useful in short strictures located in the bulbar urethra and in elderly patients who can not withstand complex procedures. Slide 17: Draw backs
If placed distal to the bulbous urethra it can cause pain while sitting or during intercourse.
Migration of the stent
Contraindicated in patients with dense strictures or prior urethral reconstruction. Open reconstructiuon : Open reconstructiuon PRIMARY REPAIR
Gold standard against which other procedures are compared.
Involves complete excision of the stricture with re anastomosis.
Technical points to be observed
Complete excision of the area of fibrosis
Widely patent, tension free anastomosis Slide 19: Young patients have an additional benefit of having compliant tissues hence wide strictures can be safely excised and primary anastomosis done.
Post operative chordee
Decreased glans sensitivity. Slide 20: The repair is usually stented with a silicone catheter and urine diverted using a suprapubic catheter as healing takes place. Tissue transfer techniques : Tissue transfer techniques Reserved for patients in whom multiple procedures have failed.
Conducted as a two stage procedure
Success depends on the blood supply of the local tissues at the site of placement.
Graft is harvested from desired non hair bearing location eg buccal rectal or bladder. 1st stage : 1st stage Urethra is opened via a ventral midline incision ,and the scarred urethra is excised completely.
Dartos fascis is mobilised bilaterally and closed over the urethral bed.
Desired skin is harvested and then sutured to the dartos covered ventral urethral bed.
Catheter is placed for stenting 2nd stage : 2nd stage Takes place 6-9 months after the initial operation.
Skin strip is mobilised along the urethra that will be used to fashion a neo urethra.
Dartos fascia in not interfered with.
Must be water tight closure.
Catheter is left in situ for stenting purposes. complications : complications Post void dribbling
Post operative diverticulum
Skin retraction of the ventral skin of the penis
above can be minimised by having the appropriate experience and surgical technique
Oral complications :-pain ,persistent numbness,
Tightness or coarseness over donor site. Contraindications to surgery : Contraindications to surgery Active urinary tract infections
must have sterile urine before any operation is attempted
Must rule out malignancy
Endoscopic biopsy done in case of a luminal mass. prognosis : prognosis Prospective randomized comparison of internal urethrotomy and dilatation showed no significant difference in efficacy when used as the initial treatment.
Recurrence rate is directly propotional to the stricture length
Rates @ 12 months
2-4 cm- ----50% increased to 75% at 48 months.
>4 cm------80 % Slide 27: Stents
Long term success rate of 84 % at 5 years.
And increased patient satisfaction
North american study group 11 year data demonstrated an overall success rate of < 30 % Slide 28: Excision with primary anastomosis
Jordan and schlossberg (2007)deonstrated only 3 recurrences among 200 patients
Mundy (2006) analysis described a durable rate after primary anastomosis that does not deteriorate with time. Slide 29: Tissue transfer grafts
Have an overall success rate of > 95 % at one year
Mundy(2006) however showed that there is deterioration over time. THE END : THE END