What surgical options are available for urethral strictures?
There are several surgical treatments available for treating urethral strictures, some are more invasive than others. The treatment recommended may vary with the location, length, and severity of the stricture as well as an assessment of the risks and benefits of the procedure.
The common procedures include
- urethral dilation,
- direct vision internal urethrotomy (DVIU),
- urethral stent placement, and
- open urethral reconstruction.
Urethral dilation is a commonly attempted technique for treating urethral strictures. The goal of urethral dilation is to stretch the scar tissue without injuring the lining of the urethra. This procedure may be done in the office under local anesthesia or in the operating room under general anesthesia. Thin rods of increasing diameters are gently inserted into the urethra from the tip of the penis (meatus) in order stretch the narrowing without causing any further injury to the urethra. This procedure may need to be repeated from time to time, as strictures may recur. The shorter the stricture, the less likely it is to recur after a dilation procedure. Occasionally, patients are given instructions and dilation instruments (rods, lubricating gel, and anesthetic gel) to perform the urethral dilation at home as needed. A risk of urethral dilation is the risk of making the stricture worse over the long term.
Direct vision internal urethrotomy (DVIU) is an endoscopic procedure that is typically done under general anesthesia. A thin tube with a camera (endoscope) is inserted into the urethra to visualize the stricture (as describe in earlier section). Then a tiny knife is passed through the endoscope to cut the stricture lengthwise to open up the stricture and widen the urethra. A Foley catheter (urinary catheter) is then inserted and kept in place for a few days to a week while the urethral incision is healing. For individuals with a soft stricture that is short, <1 cm long, located in a segment of the urethra called the bulbar urethra, DVIU has a stricture-free rate of 50%-70%. The success of DVIU in other locations and more dense strictures is often less. Complications after DVIU include bleeding, pain, urinary tract infection (UTI), troubles with erections, and recurrent stricture. Use of the laser to open up the scar tissue does not appear to be any better than using the knife. DVIU may be repeated if the stricture recurs, however, after the third treatment or recurrence of the stricture less than three months after the procedure, repeat DVIU offers no long-term success.
Urethral stent placement is another endoscopic procedure aimed at treating urethral strictures. Depending on the location of the stricture in the urethra, a closed tube (stent) can be passed through an endoscope to the area of the stricture. Once it reaches the proper location, then the stent can be opened to form a patent tube or conduit for urine to flow. This may be helpful in individuals who are too sick to undergo more extensive surgery. Information on long-term success rates of urethral stents is lacking. Complications of urethral stent placement include pain, dribbling after urinating, change in position of the stent (stent migration), stent malposition, and blockage of the stent.
Open surgery, urethroplasty, is the gold standard. It has better long-term success rates than other therapies. Depending on the location and extent of the stricture, different types of urethroplasty may be recommended.
Excision and primary anastomosis urethroplasty: This procedure involves open surgical removal of the scar and reconnection of the urethra. This procedure works well for short strictures (< 2 cm) located in a special area of the urethra, the bulbar urethra. A catheter is left in place after the procedure to allow the area to heal. The duration of the catheter will vary with surgeon preference. The success rate of this procedure is up to 90%. Risks of this procedure include risks of infection, bleeding, pain, recurrent stricture, and fistula (a communication between the urethra and the skin), and dribbling after urination.
Augmented urethroplasty: If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). To allow the tissue to heal and minimize urine leakage during healing, a catheter is left in place. The duration of the catheter may vary with the extent and location of the stricture and whether the procedure is being performed in a single stage or in two stages.
Pelvic fractures may results in urethral injury and subsequent stricture. The risk of developing a stricture is related to the initial treatment of the injury. If a suprapubic tube is placed at the time of the pelvic injury, there is a high likelihood that a stricture will form. The stricture is repaired when the patient has healed from the other injuries and is treated with excision of the stricture and reapproximation of the ends of the urethra. In some cases, a catheter is able to be passed through the urethral injury into the bladder (primary realignment) at the time of injury, and the urethra is allowed to heal over the catheter. This realignment of the urethra decreases the risk of urethral stricture formation by about 30% and makes surgery for repair of the stricture, if it occurs, easier. Success rates with repairs of urethral strictures from pelvic fractures is about 90%-98% with excision of the stricture and bringing the ends of the urethra together (reapproximation). Complications of pelvic fractures include bleeding, infection, and erectile dysfunction. Complications of the urethral stricture repair include bleeding, infection, and urinary incontinence.
The treating urologist would recommend the procedure that would be the best option for each individual. As with any medical procedures, there are some degrees of risks and complications associated with any of these operations.