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.
When deciding the most appropriate form of treatment, it's important to take into account the stricture etiology, location, and severity, prior treatments, comorbidities, and patient preference. Physicians typically place a urethral catheter after urethral stricture treatment as it may serve as a stent around which the site of urethral intervention can heal.
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. A physician performs the procedure in the office under local anesthesia or in the operating room under general anesthesia. A health care professional gently inserts thin rods of increasing diameters into the urethra from the tip of the penis (meatus) in order stretch the narrowing without causing any further injury to the urethra. A health care provider typically places a catheter after the dilation and removes it approximately 72 hours after the procedure, if it was uncomplicated. It may be necessary to repeat this procedure from time to time, as strictures may recur. However, the AUA guidelines recommend urethroplasty instead of repeated endoscopic management for recurrent anterior urethral strictures following failed urethral dilation of direct vision internal urethrotomy. The shorter the stricture, the less likely it is to recur after a dilation procedure. Occasionally, physicians give patients instructions and dilation instruments (rods, lubricating gel, and anesthetic gel) to perform the urethral dilation at home as needed, particularly those patients who are not candidates for urethroplasty. 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 performed under general anesthesia. A physician inserts a thin tube with a camera (endoscope) into the urethra to visualize the stricture (as describe in earlier section). Then a physician passes a tiny knife through the endoscope to cut the stricture lengthwise to open up the stricture and widen the urethra. A physician then inserts a Foley catheter (urinary catheter), which is 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, as with urethral dilation, urethroplasty should be offered for recurrent anterior urethral strictures after failed DVIU.
Bladder neck contracture (vesicourethral stenosis) may occur after surgical management of prostate disease, including transurethral prostatectomy for benign prostatic hypertrophy (BPH) and radical prostatectomy for prostate cancer. Dilation or incision initially treats bladder neck contracture. Recurrent bladder neck contracture may require surgical reconstruction.
Urethral stent placement is another endoscopic procedure aimed at treating urethral strictures. Depending on the location of the stricture in the urethra, a health care provider may pass a closed tube (stent) through an endoscope to the area of the stricture. Once it reaches the proper location, a physician will open the stent to form a patent tube or conduit for urine to flow. This may be helpful in individuals who are too sick to undergo surgery that is more extensive. 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. Doctors may recommend different types of urethroplasty depending on the location and extent of the stricture. There are two types of urethroplasty techniques: tissue transfer procedures and non-tissue transfer procedures. Performance of tissue transfer procedures may require one stage or multiple stages (multi-stage) depending on the availability of tissue, extent, and location of the stricture.
Excision and primary anastomosis urethroplasty is a non-tissue transfer procedure: 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 left in place after the procedure allows 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 involves tissue transfer. For example, if the stricture is long and/or located in the penis, the stricture may be opened and a flap or graft of tissue is sewn on top of the opened urethra to increase the caliber of the urethra (single stage) 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) (multi-stage). In a multi-stage procedure, the scarred urethra is typically removed and a piece of tissue (graft of flap) is sewn into the area. Several months later the tissue is then made into a tube. 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. Individuals with lichen sclerosis related stricture disease should not use penile or genital skin for the urethroplasty due to possible involvement of this tissue with the lichen sclerosis. Erectile dysfunction may occur transiently after urethroplasty with resolution in nearly all affected individuals by six months postoperative. Ejaculatory dysfunction (pooling of semen, decreased ejaculatory force, discomfort with ejaculation, and decreased semen volume) is reported in up to 21% of men follow urethroplasty for bulbar urethral strictures.
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.
In select circumstances, a perineal urethrostomy may be preferred as a long-term treatment alternative to urethroplasty. A perineal urethrostomy involves making an incision into the urethra, urethrothrotomy, and opening the urethra and sewing it to the perineum (anterior to the rectum and behind the scrotum). With a perineal urethrostomy, the individual would sit on the toilet to urinate.
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.