URETHRAL STRICTURES(male)

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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 Congenital Malignancies.

presentation : 

presentation Obstructive voiding symptoms urine retention (decreased force of stream , incomplete bladder emptying, dribbling intermittency.) UTI’S

complications : 

complications Retention of urine Urethral diverticulum Peri urethral abscess Urethral fistula Urethral calculi Hernia , haemorrhoids and rectal prolapse

management : 

management Principles of treatment Proper understanding of the relevant anatomy Accurate diagnosis Skilled surgical technique

anatomy : 

anatomy

Making a diagnosis : 

Making a diagnosis Suggestive history Findings on physical exam Radiographic imaging Endoscopic techniques

Radiographic imaging : 

Radiographic imaging Contrast studies achieved by retrograde and antegrade cystourethrograms Ultrasonography 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 Internal urethrotomy Permanent urethral stents Open reconstruction -primary repair -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. Drawbacks Its a blind procedure hence false passages can be created Recurrence rate 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. Complications Recurrence of stricture Bleeeding 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. Complications Post operative chordee Penile shortening Ejaculatory dysfunction 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 Urethrocutaneous fistula 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 2cm-------- 40% 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 most successful 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