Urethral pathology and urethral stricture

Urology Treatments

Urethral pathology and urethral stricture

The male urethra can suffer from a host of diseases. Congenital and infectious are discussed in other chapters, and tumorous are included in penile tumors.

Urethral pathology and urethral stricture

Table of Contents

Definition

What is urethral pathology and urethral stricture?

The male urethra can suffer from a number of diseases. Congenital and infectious diseases are treated in other chapters and tumours are included in tumours of the penis. Therefore, we are going to focus on the description of urethral stricture, its causes, diagnosis and treatment, in order to give the reader a homogeneous content of this very frequent pathology, whose correct diagnosis and approach from the beginning will determine the subsequent evolution and the possibilities of successful treatment. Urethral stricture is a medium-prevalence disease that significantly alters the quality of life of those who suffer it. Therefore, the fundamental message will be the appropriate indication of the surgical technique to be used, avoiding starting with those (e.g., internal urethrotomy) which, although simple, are not exempt from complications that may jeopardize the subsequent success of a correct approach.

Urethral stricture is a medium-prevalence disease that significantly alters the quality of life of those who suffer it. Therefore, the fundamental message will be the appropriate indication of the surgical technique to be used, avoiding starting with those (e.g., internal urethrotomy) which, although simple, are not exempt from complications that may jeopardize the subsequent success of a correct approach.

La estenosis de la uretra es una enfermedad de prevalencia media que altera de forma importante la calidad de vida del que la sufre. Por tanto, el mensaje fundamental va a ser la adecuada indicación de la técnica quirúrgica que utilizar, evitando comenzar con aquéllas (p. ej., la uretrotomía interna) que no por sencillas están exentas de complicaciones que pueden hipotecar el éxito posterior de un correcto abordaje.

By consensus, the urethra is divided into two areas, and each of them into three others:

In this chapter, we will not deal with alterations of the prostatic urethra or bladder neck.

Lichen sclerosus

Healthy penis

Penis with Balanitis

Lichen Sclerosus (preferred name to balanitis xerotica obliterans) is an autoimmune disease of unclear aetiology, determined by a genetic predisposition (association to alopecia, vitiligo, diabetes and autoimmune processes). It is also related to local aggression (radiotherapy, vulvectomy, sunburn, urine extravasation by meatal stenosis) and may be related to an alteration of hormonal receptors and even infection. It is more frequent in women than in men and in the latter, it predominantly affects the foreskin and glans. Lichen sclerosus has been linked to the development of epidermoid carcinoma of the penis.1
Histologically, it is characterized by hyperkeratosis, parakeratosis, epithelial atrophy, hydropic degeneration of the basal lamina, lymphedema and decreased elastic fibres.
Clinically, the skin and mucosa become whitish, brittle, lose elasticity and often present small wounds, which usually occur during sexual intercourse. This leads to the development of phimosis and, in the case of urethral involvement, stenosis.
It most frequently affects the foreskin, glans, urethral meatus and fossa navicularis. When the disease is limited to the foreskin, circumcision can be a solution, although when there is already a meatus or fossa navicularis stenosis, a surgical approach should be performed, which will be detailed later. Affectation of the most proximal urethra should always be ruled out, in order to adapt the intervention type to the extent of the disease.

Urethral stricture

When we talk about urethral stricture, we do so by referring to the anterior urethra, and it is a process that affects the urethral epithelium and the underlying spongy tissue. It consists of a scar tissue that reduces the diameter of the urethral lumen.
Any process that results in damage to the urethral epithelium or spongy tissue can cause a stricture. The most frequent cause is traumatic. The incidence of lichen sclerosus is increasing and urethritis due to sexually transmitted diseases is no longer as frequent as the cause of urethral stricture.

Urethral stricture

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Diagnosis

Diagnosis of urethral stricture

The most common form of presentation is the obstructive symptomatology of the lower urinary tract, including from the decrease in the strength and amount of urine flow to acute or chronic urinary retention. It can also start with urinary infection, prostatitis or epididymitis. Frequently, the patient presents a progressive decrease in the strength of the urine flow over a long period of time, to which they become accustomed. It is well tolerated until the appearance of some complication.

The suspected diagnosis is fundamental, especially in older patients, in whom the symptoms are attributed to prostatic pathology, although they do not improve with medical treatment, and the problem arises during access to the bladder during the intervention. In order to choose an adequate technique for the surgical treatment of urethral stenosis, it is necessary to know the following data about it

The first three data can be known by means of one or more of the following techniques. However, the association of several of them is usually recommended in order to adequately plan the route of approach and the surgical technique.

Ideally, it should be carried out with a fine rigid cystoscope, with 0-30° optics or with a flexible cystoscope. In addition to being able to perform an approximate calibration, the appearance of the urethral mucosa can be seen. The more whitish it is, the more it points to a higher degree of spongiofibrosis.

It is advisable to perform this technique under the supervision of a urologist. At that time or previously (with a very thin catheter or through suprapubic cystostomy), the bladder must be filled with contrast. It consists of taking x-rays of different anterior pelvic oblique projections after introducing contrast through the urethra from the fossa navicularis in a retrograde way. In this way, we can obtain images of retrograde filling, voiding images and even images of urethrography combined with attempted voiding at the same time as the retrograde filling.

It is performed with Bougie-a-boules and is very useful in distal stenosis. It has the limitation that in case of long or multiple stenoses it is not very valuable since the most distal one usually conditions the study of the more proximal ones.

It is not usually used because it requires an experienced sonographer and the results are usually inconclusive.

An obstructive curve with "plateau" morphology points to urethra stenosis.

The degree of spongiofibrosis is usually really appreciated during the operation, although it can be suspected by the urethral aspect during endoscopy, by the bad distension during endoscopy, when retrograde urethrography is performed, by the existence of previous manipulations or interventions and, eventually, by ultrasound.

Technique and Treatments

Urethral stricture treatment

As a basis for the treatment, it must be stated that there is no technique that serves to resolve any type or location of the stenosis, so a selection of the procedure must be made based on the following factors in relation to it:

Location
Location

Cause
Cause

Length
Length

The number of strictures
The number of strictures

We have at our disposal certain less invasive treatments for stenosis, which in many cases do not provide a definitive solution to the problem, and even, if they are not correctly indicated, may risk the subsequent treatment.

Mucous sheet

Spongiofibrosis

Iris stenosis

Spongiofibrosis and perispongium

Full-thickness compromise, minimal spongy tissue fibrosis

Complete stenosis + fistula

· Endourethral treatments ·

Urethral dilation

This can be done using more or less rigid instruments of progressively larger calibres, such as dilator plugs (safer in the pendulous urethra), benches (for bulbar and membranous urethra) or by means of a dilator balloon inserted on a guide which is in turn placed under endoscopic control.
Dilation tears the narrowness, which frequently means the worsening of the stenosis as it is the cause of increased spongiofibrosis.

The best long-term indication for urethral dilation is membranous urethral stricture after prostate surgery, as this is the only technique in which the function of the external sphincter is not at risk, thus preventing incontinence.
Periodic self-catheterization with pre-lubricated catheters may also be used in patients with recalcitrant urethral strictures that are difficult to resolve surgically, especially in the elderly or those at high surgical risk.
In all other cases, it is a temporary solution.

Internal urethrotomy

It consists of opening the narrowness of the urethra by making an incision in it, transurethral. This involves separating the edges of the mucosa, allowing healing by second intention. A single incision can be made at 12 HC (at the most dorsal part of the urethra) or two lateral incisions at 10 HC and 2 HC.
Long-term studies indicate a failure rate of 58% to 84%,3 and results are worse in the penile urethra.
No greater efficacy of the technique has been demonstrated by repeating the procedure.

Therefore, the only reasonable indication for an internal urethrotomy would be a stricture of the following characteristics:

Thus, the possibility of success is around 75%, which contrasts with 10-15% in the case of long, multiple or penile stenosis, as well as in the case of a second internal urethrotomy.
Therefore, in the event of failure of an internal urethrotomy, a urethroplasty must be performed.

Laser urethrotomy

It consists of the vaporization of the tissue that grows towards the interior of the urethra. A type of laser that has little penetration into the underlying tissues should be used, in order to avoid an increase in spongiofibrosis. Its results are so far similar to those of internal urethrotomy.

Intraurethral prosthesis

They are placed endoscopically and should only be implanted in the bulbar urethra. They have frequent complications, such as post-void drip, infection, irritative symptoms, and intraurethral growth of fibrous tissue, often causing a new obstruction. This last complication is sometimes a difficult problem to solve since the removal of the prosthesis is complex and sometimes requires the excision of the treated urethral segment.
It may be indicated in older patients with bulbar stenosis with little fibrosis and not previously operated.

· Urethroplasty ·

Urethroplasty with grafts and flaps

Urethroplasties in two stages (using scrotal flaps) and in one stage (using free preputial skin grafts) represented the first major advances in urethral surgery and gave a boost to reconstructive surgery in the middle of the last century.
But these methods, which were successful between the 1950s and 1970s, gave way to other techniques as a result of the constant search for the ideal technique. Genital skin flaps in islets with lateral, dorsal or ventral pedicles, based on increasingly accurate knowledge of the vascularization of the skin and fascia of the penis and scrotum. First Orandi in England in 1968, then Hinderer in Spain in 1971 and then Standoli in Italy described various forms of islet genital skin flaps, which, once mobilized with their vascular connective pedicle, can reach all segments of the urethra to replace it totally or partially. The definitive popularization of islet flaps corresponds to Duckette in the field of pediatric surgery and Quartey in adults.

Since then, in the last 20 years of the last century, the use of islet skin flaps has been the basis for reconstructive surgery of the pendulous urethra and the anterior bulbar urethra. But, like all methods, urethroplasty with genital skin have limitations imposed precisely by the availability of donor areas. There are subjects who, because they are surrounded and/or have been operated on several occasions with poor results (urethral invalids), lack suitable skin for reconstruction. And it is also known that free extragenital total skin grafts do not provide predictable or reliable results. Therefore, dispensing with the preputial mucosa graft (which is one of the best in urology), other grafts have been used such as the bladder mucosa and oral mucosa grafts, which constitute the latest advance in the evolution of urethral reconstructive surgery. Both epitheliums had been used more than 100 years ago in urology, but without achieving good results. More modern surgeons, with more complete training, a more refined technique and the possibility of antibiotic treatment were the ones who managed to consolidate them, first in the field of reconstructive surgery of congenital anomalies and later in that of urethral stenosis.

The grafts can be classified according to their origin in:

The skin or mucosa graft is a fragment of skin or mucosa that is totally disconnected from its location to be transferred to another remote place where it will develop a new vascularization.
The skin houses the skin attachments, which include the sweat glands, sebaceous glands, hair follicles and the hair erector muscle. These elements are practically absent in the skin and preputial mucosa and are one of the reasons why it is so suitable for urethral reconstructive surgery.

Once the graft has been obtained and placed in contact with the place where we intend to attach it, it begins to adhere by means of the fibrin. It is important that, previously, all the fat and connective tissue adhered to the dermis have been removed, to facilitate the survival of the graft.
During the first 3 days, the graft is nourished by plasma imbibition. Between the third and fifth day, the revascularization begins. After 4-7 days, both, blood and lymph circulation of the graft, has been restored. Between the fourth and eighth day, the epidermal proliferation is activated again and there is also a replacement of almost all the collagen tissue. Tissue reinnervation, on the other hand, is slow and takes between 1 and 2 years.
The correct placement of the graft, the use of pads or small cushions that compress the graft against its recipient tissue and loose points that fix the central part of the graft to the underlying tissue are very useful. During the first 5 days, the mobilization of the patients should be, therefore, low to avoid breaking the very small neoformed capillaries.
Among the causes that facilitate the necrosis of the graft, the most common is the formation of a seroma or hematoma between the graft and its bed. It may also be due to poor immobilization of the graft and the third cause of necrosis is infection.
For urethroplasty, full-thickness skin grafts can be used, which include the entire dermis and epidermis. By including the reticular dermis, which contains a large amount of collagen and elastic fibres, it allows for extensibility and decreases the possibility of retraction. Likewise, it allows better sensory reinnervation, which recovers progressively during the first 2 years. As it is very thick, it gets attached if the local conditions are optimal: absence of contamination and very well-vascularized bed. If the donor skin has lymphedema (as it happens, for example, in patients with lichen sclerosus), the graft will have dilated and malfunctioning lymph nodes, and will continue with lymphedema. These are grafts with an appearance similar to normal skin, both in texture, pigmentation, presence of skin adnexa and sensitivity. The usual donor areas for full-thickness grafts are the retro auricular region, inguinal and foreskin since they are areas with thin skin thickness. They contract approximately 20%. In urology, the ideal grafts, both of skin and mucosa, are those of the foreskin. They are very elastic, do not retract almost anything and are very resistant to moisture. All the fat underlying the graft must be removed, once obtained, to facilitate its neovascularization.
The oral mucosa has multiple advantages over the bladder: easy to obtain, less morbidity, more manageable and less hospital stay. In addition, the success rate is higher because it has its own thin lamina and a great richness in vascular spaces in the submucosa, which facilitates the inosculation of the graft with new vessels. However, within the enthusiasm that has been aroused, there are different opinions. While there are authors who use these grafts at all levels of the anterior urethra (bulbar, pendulous and glandular), others prefer to use them only in the portion of the urethra that allows spongioplasty and coverage with the bulbocavernous muscles. The results are so good at this level that the current trend is to consider oral mucosa-free grafts the first option for treating bulbar urethral strictures (when excision and reanastomosis are not feasible). Furthermore, instead of grafting them onto the ventral side of the urethra, dorsal urethrotomy, first proposed by the Belgian Monseur in 1980 and then by Barbagli et al in 1995, is used to maximize the chances of success. This assertion is valid for oral mucosa free grafts, as well as for those of bladder and preputial mucosa or penile skin.
In conclusion, as Jordan says: “In 40 years, methods of urethral reconstruction have progressed from grafts to flaps and back to grafts. What has become clear during this time is that it is beneficial to have more than one option available to us and that surgeons undertaking urethral reconstruction must master the full range of techniques available and understand the characteristics of the replacement tissues”.

· General indications for urethroplasty ·

There are multiple factors that determine the choice: age, patient’s general conditions, aetiology, location, number, degree of spongiofibrosis, length, the existence of complicating factors such as fistulas and untreatable infection, and the primary or secondary nature of the operation. All of these factors must be taken into account and it is therefore very difficult to make simple and comprehensible flow charts or algorithms. Authors advise basing the choice, above all, on spongiofibrosis and location:

Very short, annular stenosis

They occur at any level of the urethra in cases of mild fibrosis, internal urethrotomy under vision.

Traumatic disruptions of the membranous urethra

Excision and bulboprostatic reanastomosis.

Short (<1-2 cm) bulbar urethral stenosis

Excision and reanastomosis (termino-terminal urethroplasty)

Bulbar urethra stenosis >2 cm

Preputial Mucosa Graft (oral mucosa in circumcised patients):

  •       Proximal half of the bulbar urethra. The graft is sutured in a ventral position, covered by a spongioplasty.

      Distal bulbar urethra. Near the penoscrotal angle, it is preferable to suture the graft in a dorsal position, since the shortage of urethral spongy tissue doesn't allow that a spongioplasty that completely covers the graft can be performed.

Multiple, long stenosis with great fibrosis and/or active infection in the anterior urethra

Two-stage urethroplasty, which can replace damaged portions of the urethra with preputial mucosa grafts or, failing that, oral mucosa or retro auricular skin grafts. In cases of balanitis xerotica obliterans, it is important not to use preputial skin for reconstruction and to completely replace the last centimetres of the urethra with oral mucosa or retro auricular skin grafts.

Uncomplicated penile urethral stenosis

Transverse flap in preputial mucosa islet. In circumcised patients, a circumferential flap of distal penile skin or a longitudinal flap of ventral penile skin can be used. In cases where the urethral stenosis is not very closed, a urethroplasty with dorsal preputial mucosa or oral mucosa graft can be chosen.

· Types of graft ·

For a century, the search for the ideal substitute for the male urethra has been unceasing. It has not yet been found. However, at present, autologous epitheliums of genital and extragenital origin allow urethral reconstructions in a single time with great reliability. Among all of them, penile skin stands out (in particular, preputial mucosa), either in the form of pedicle flaps in islets or in the form of free full-thickness grafts; due to its versatility, wide availability, lack of hair, tolerance to humidity, flexibility and low tendency to retraction. Hence, it is still considered the first option when it is available. Occasionally, however, there may be a deficit of penile skin and, then, other places must be resorted to in order to obtain tissue. Free extragenital full-thickness skin grafts, in the long term, give results that are far from satisfactory. That is why in complex situations free grafts of bladder or oral mucosa have been used.

Preputial mucosa

Devine and Horton were the first to use foreskin grafts for hypospadias reconstruction. Later, Kaplan modified the technique. He used a tubulate preputial graft to reconstruct the urethra and then covered the ventral skin defect with a foreskin flap. He saw that there was no difference in results between preputial flaps and grafts, always trying to direct the suture of the tubulate tissues towards the albuginea.

Once the stenotic urethra has been opened until it has reached a healthy urethra, the length of the stenosis and its width are measured and the profile of the graft is drawn on the preputial mucosa extended and stretched over the albuginea of the penis. Given the elasticity of the preputial mucosa and in order to avoid over-dimensioning the graft, its length must be equal to or slightly less than that of the stenosis. The width of the graft, which is transversely oriented on the foreskin, should be between 1.5 and 2 cm, although it depends on the severity of the urethral stenosis. At this point, it should be remembered that the sum of the width of the stricken urethra and that of the graft in millimetres is equal to the Charriere scale calibre of the future reconstructed urethra. The incision of the preputial mucosa must be shallow. It is then freed from the subcutaneous tissue with scissors, taking care to dissect the mucosa with as little underlying connective tissue as possible (fig. 115-2). The preputial wound is closed with short-lived loose resorbable stitches without completing the circumcision, in case another preputial graft needs to be obtained in the future. The graft is then extended and fixed with the help of insulin needles on a sterile splint. While an assistant irrigates the graft with saline solution and antibiotics to prevent drying out, the surgeon removes any remaining submucosa connective tissue attached to the graft. At the end of the preparation, the graft should be virtually transparent (fig. 115-3). At this point, it is convenient to give the graft 4 cardinal points of support, to facilitate its manipulation and transposition to the urethra. The graft is sutured with loose stitches to the urethra, using a Foley 22 ch probe as a tutor. If the stenosis is located in the middle or proximal bulbar urethra, it is preferable to suture the graft in ventral position, since it can be completely covered by a spongioplasty, which not only guarantees a good vascular bed but also immobilizes the graft. The stitches include only the urethral mucosa and the graft, and a second plane of the closure of the urethral sponge must be given (spongioplasty). If it is distal bulbar urethra stenosis we open the urethra dorsally and fix the graft to the albuginea of the corpora cavernosa according to Barbagli's technique. The albuginea provides a good bed to hold the graft and allows it to be immobilized while extended, thus avoiding possible folds and blood collections that may hinder the inosculation of the graft. The points of the urethroplasty include the urethral mucosa with its spongy tissue on one side, and the corpora cavernosa's albuginea and the graft on the other. At the end of the repair, the urethra is intimately connected to the corpora cavernosa. This technique should be applied with caution for pendulous urethral stricture in potent men since it can produce incurvation of the penis in erection. To avoid this, very fine suture material (5/0) should be used and a small amount of albuginea should be taken with the stitches to avoid puckering or pleating. On the other hand, if the graft is sutured ventrally in this portion of the urethra, the scarce thickness of the urethral sponge prevents it from being sutured above the graft, having to resort to nearby subcutaneous flaps to cover the graft and to provide an adequate vascular supply to facilitate its neovascularization. This is why in the pendulous urethra it is preferable to use penile skin flaps rather than grafts, except for the glandular urethra, where there is spongy tissue to cover the graft.

Fistulas or stenosis occur with foreskin grafts in 28% of cases (103 out of 368). Stock et al had 16% of complications (44 tubulates with 20% of complications and 33 patches with 9% of complications).

Bladder mucosa

The penis’ skin, in particular the mucous membrane of the foreskin, is hairless, thin, very elastic and resistant to moisture; it is therefore still the favourite for reconstructing the urethra. But when as a result of unfortunate interventions the entire skin of the penis has been consumed, or there is a sclero-atrophic lichen (balanitis xerotica obliterans) that has made it useless, the reconstructive surgeon must turn to other graft donation sites, usually extragenital skin of full-thickness, without hair, following Horton and Devine. The results, however, are not always satisfactory when using extragenital skin, because of the unpredictable, unpleasant and unacceptable contracture of the graft, which appears in 5 to 50% of the cases. This led, as we commented before, to the rediscovery of bladder mucosa grafts in the early ’80s.
Bladder mucosa is used if the abdomen has to be opened at the same time to correct another problem or if the stenosis to be repaired is very long and the oral mucosa is not enough. The danger in all these cases is that the grafts will not fasten properly due to the existence of abundant scar tissue. It is very important that there is no preoperative urine infection that can contaminate the graft. To avoid the problem of mucosa protrusion into the meatus, the most distal area of the urethra near the meatus can be reconstructed with preputial or penile skin. The bladder mucosa is used in re-operated cases with little penile skin available and no foreskin, although in these cases the oral mucosa is the first possibility if there is enough availability.

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Technical aspects

The bladder approach is performed by Pfannenstiel incision, the bladder is filled with saline solution and the detrusor muscle is incised until it reaches the mucosa, which is dark blue. A strip of bladder mucosa is then dissected, separating the detrusor to the sides. If the mucosa is accidentally opened, dissection becomes much more difficult, as the bladder is emptied and the mucosa does not remain distended. Before incising the bladder mucosa, the graft to be taken is marked with support stitches and then removed. In cases of a complete replacement, the graft is tubulated over a probe with continuous suture in the central area and loose stitches at the ends, to facilitate spatulation and finishing of the ends. The suture of the graft is oriented towards the albuginea to decrease the possibility of fistulas and is sutured to the ends of the open urethra with spatulation and loose stitches. The graft is covered with well-vascularized tissue.

From a behavioural point of view, bladder mucosa grafts are similar to full-thickness grafts. They shrink a little and are usually well-vascularized, although when used to reconstruct the urethra they tend to dilate easily as soon as there is some area of relative stenosis, forming pseudo-diverticula with some frequency. 

Meatal stenosis and the proliferation of exposed bladder mucosa are common problems of this technique, which have led to the proscription of glandular urethra reconstruction with bladder mucosa. Currently, in those cases where it is necessary to reconstruct up to the meatus, mixed grafts are used, with penile skin or buccal mucosa for the most distal section. The main disadvantage of using the bladder mucosa is, however, the need to open the abdomen to obtain the graft, which implies greater morbidity, risks and inconvenience for patients, who require postoperative analgesia and longer hospital stays. All this, together with a complication rate of more than 30%, led to a continued search for new tissue for replacement urethroplasties. Hence, in the late 1980s and early 1990s, oral mucosa grafts were rediscovered, abandoned due to septic complications since Humby tried to popularize them in 1941.

Oral or buccal mucosa

The oral or buccal mucosa is one of the favourite grafts of reconstructive urologists, second only to the preputial mucosa when it is available. The buccal mucosa has a stratified, non-keratinized squamous epithelium and a lamina of its own with a thickness of 0.5 mm. The epithelial cells of the intermediate spinous layer and the superficial layer are firmly attached to each other and make the epithelium quite impermeable to urine. The mucosa is richly vascularized, which facilitates rapid regeneration and good inosculation. Within 25 days the epithelium can be completely regenerated. The lamina itself is rich in elastic fibres, with good elasticity, which is necessary for changes in the volume of the cheek. The sensitivity of the mucosa depends on sensitive branches of the trigeminal nerve and the motor innervation of the buccinator muscle of the facial nerve. The graft can be obtained from the inner portion of each cheek and from the inner portion of the upper and lower lips. The length of the inner cheek grafts is usually 6 × 2 cm and the inner lip grafts are 4 × 1.5 cm. The length of the cheek graft can be increased by extending the graft to the lip, and it can be up to 10 cm. The oral mucosa usually does not elongate or contract after it is removed from the oral cavity, which allows the measurement made in situ in the mouth to be maintained during preparation.
Usually, the transverse diameter of the graft is not enough to make a tube and is often used as a patch or tile. In very long urethral stenosis almost the entire urethra can be reconstructed with bladder mucosa, using oral mucosa to reconstruct the last few centimetres and the meatus, in order to avoid ectropion and metaplasia suffered by the bladder mucosa in the urethral meatus.

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Technical aspects

The ideal intubation during anaesthesia is the nasotracheal; although the orotracheal, displacing the tube laterally, may also allow access to one cheek and lips. Antibiotic coverage should be as for contaminated intestinal surgery: amoxicillin + aminoglycoside + metronidazole. The mucosa of the cheek is thicker than that of the lip, but the result for urethroplasties is probably the same. To obtain cheek mucosa it is better to put in a mouth opener with a tongue retractor. For the lower lip, it is very useful to give 2 traction points on each end of the lip to properly expose its inner part. If the cheek graft is removed, it is convenient to mark the Stenon's duct with a dermographic pencil or nylon thread at the height of the second upper premolar. It is recommended to infiltrate with 1% lidocaine with 1:200,000 of adrenaline and wait 7 minutes before starting the dissection. This is done with scissors, trying to avoid the extraction of fat and buccinator muscle. The defect is sewn with short 4/0 resorbable stitches. When the graft is obtained from the lower lip, more care must be taken, since the mucosa is thinner and tears more easily. A useful technique is to make only the longitudinal incisions and dissect underneath with scissors the subepithelial space between the two incisions, as if making a submucosal tunnel, leaving the graft held by the mucosa at its ends until the dissection is finished. The lip defect can be left without sutures and in 3 weeks the healing will be perfect. It is preferable to stitch it up as long as it is estimated that no lip asymmetries will occur. Once the graft is obtained, it is immersed in saline solution and the whole team changes gloves. The graft is fixed with insulin needles and all the submucosal tissue is removed. We also take advantage of this moment to regularize the edges and ends of the graft. As previously indicated, the graft is usually used as a patch and when you want to make a tube, you have to complement it with a second graft or coil it around a catheter. Immobilization of the graft is essential, which is achieved with proper surgical technique, a good dressing and proper urinary diversion. The urethral catheter must be fixed and in and out movements must be avoided, as well as leakage of urine, which can wrinkle the graft during the first days. In the first 48 hours of the postoperative period, bed rest is recommended, provided that the graft is located in the pendulous urethra. If the graft is sutured in the bulbar urethra, the patient can move around the day after the surgery. One of the advantages of the oral mucosa over the bladder mucosa is that it does not generate problems in the urethral meatus such as metaplasia, incrustation and overgrowth. The main disadvantage of oral mucosa is its relative scarcity.

Comparing oral mucosa urethroplasties together with the other free grafts, it seems that the former provide better results and are exposed to fewer complications. The graft that comes out worse is the one with bladder mucosa, due to the double or more urethrocutaneous fistulas and the problem of ectropion of the external meatus, which does not exist for other epithelia.

Comparando en conjunto las uretroplastias con mucosa oral con los otros injertos libres, parece que las primeras proporcionan mejores resultados y están expuestas a menos complicaciones. El injerto que sale peor parado es el de mucosa vesical, debido al doble o más de fístulas uretrocutáneas y al problema del ectropión del meato externo, que no existe para otros epitelios.

Extragenital skin graft

When oral mucosa cannot be used and neither foreskin nor sufficient penile skin is available, due to previous reconstructive surgery or lichen sclerosis, extragenital skin can be used as a graft. It can be obtained from the inner arm, groin area or retro-auricular region.
As a general rule, grafts used to partially reconstruct the urethra, such as urethral floor or roof, in a patch or tile shape, go better than when used to reconstruct the entire circumference of the urethra, in a tube shape. It is more difficult for the entire surface of the tube to be covered and in contact with well-vascularized tissue to ensure inosculation of the graft, and partial graft necrosis is more likely to occur. After full-thickness preparation of the graft, removing fat and subepithelial connective tissue, the graft should be almost transparent.
One of the most frequent indications for using such a graft is balanitis xerotica obliterans. In these cases, the affected distal urethra must be removed and reconstructed in 2 stages with oral or bladder mucosa grafts, to prevent the disease from reproducing. When oral or bladder mucosa cannot be used, the best alternative is extragenital skin. When the urethra has to be reconstructed around its entire circumference, relatively extensive grafts are required and, although the ideal thing is to use mucosa, retro-auricular skin grafts behave as well in the long term as mucosa, although they are easier to obtain.

Mesh skin graft

It is a partial thickness skin graft obtained from the inner thighs, buttocks, abdomen or inner arms. Usually, the graft is meshed with a mechanical mesh at 1:1.5. It is an ideal graft to reconstruct scrotum, more than the urethra since meshing gives it a wrinkled, almost physiological aspect. These grafts tend to retract and must be greatly over-dimensioned. After 2 weeks the area is completely epithelialized and after 8-12 weeks the epithelial surface is resistant and stable. Regarding this type of graft, a series of precautions must be taken into account. It should only be used for 2-stage techniques. In hypospadias surgery, the graft should not be placed directly against the albuginea, since it makes body with the latter and when it retracts it produces ventral incurvation when erect. Subcutaneous tissue that serves as a bed should always be interposed and you must ensure that the graft is not thick. After fixing the graft with loose resorbable stitches, it must be covered with tulgrasum, trying to introduce part of it in the neo-meatuses to avoid synechiae. Dry gauze and an elastic bandage slightly compressed in X are placed on top of the tulgrasum. The patient remains in bed for 7 days and is prohibited from sitting for another 7 days. The dressing is changed after 5-6 days, once the initial neovascularization has been established.

· General factors influencing the final outcome of urethroplasties ·

Previous surgery is one of the factors that most conditions the outcome of urethroplasties, which are obviously better in untreated patients. They are also better in stenoses than in hypospadias. Within stenoses, those of traumatic origin behave better, followed by inflammatory and ischemic ones (due to instrumentation or catheterization). Regarding location, greater stability and the existence of well-vascularized beds mean that bulbar urethral stenosis evolves better than penile stenosis. Younger patients evolve slightly better than older ones and, logically, patients with urinary infection have a higher risk of failure. With regard to post-operative urinary diversion, it is recommended that the urethral tutor be maintained for 3 weeks in all types of free grafts. Then an attempt at urinary urethrography can be made with the catheter in place, being helpful to slightly mobilize the balloon so that it does not rest on the bladder neck. If there is no contrast leakage, the catheter is removed and the urethrography is completed. If there is a leakage, the catheter is kept in place for at least another week. In the case of termino-terminal urethroplasties, the control can be done two weeks after the operation, as well as in the case of pedicle grafts.

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Medical evaluation

Andrological aspects of urethral stenosis and its treatment

Urethral stenosis, insofar as it can affect the portion located in the penis and that both its symptoms and its treatment can have andrological implications, must be assessed and treated with these aspects in mind. Its fundamental implications will be reviewed below, and are also analyzed in the chapters corresponding to erection and ejaculation disorders.

Voiding disorders

Urethral stenosis, both in terms of its cause and evolution and after treatment, may, in addition to manifesting a decrease in urinary flow, have associated urinary infections, irritative symptoms, urethral or bladder lithiasis. The discomfort that all of this generates, together with the psychological implications that patients may have, may have a negative influence on the patient’s sexual life.

Ejaculation disorders

Urethral stenosis may cause difficulty in ejaculating, and the patient may have a significant decrease in the flow of the seminal fluid (asthenic ejaculation). This can occur whether the stenosis is proximal or distal to the bulbar urethra. Painful ejaculation can also occur, usually as a result of urinary infection, especially prostatitis.

Erectile disorders

It is not uncommon for a patient with urethral stenosis to come in with associated erectile dysfunction. This can have the same cause as stenosis, especially in the case of severe pelvic trauma affecting the erector nerves or penile vascularisation. It may also be a consequence of the surgical intervention aimed at resolving the urethral stenosis. In this sense it is important, whenever possible, to avoid injuring the penile innervation (especially in post-traumatic stenosis of the membranous urethra) and vascularization of the penis, respecting, for example, the bulbar arteries whenever reasonably possible when releasing the proximal bulbar urethra.
On the other hand, excessive release of the urethra with the aim of attempting a termino-terminal urethroplasty at all costs instead of using grafts in a too-long stenosis can lead to ventral penile incurvation during traction erection of the shortened urethra.

The use of dorsal free grafts in the pendulous urethra can also cause penile incurvation, especially in very young patients, since this graft remains intimately attached to the corpora cavernosa. To avoid this, very fine suture material (5/0) should be used and a small amount of albuginea should be taken with the stitches to avoid puckering or pleating.

Patients with advanced lichen sclerosis may progress to the destruction of the glans and to a buried penis due to the progressive retraction of the penile skin

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Conclusion

Urethral stenosis is a relatively frequent and potentially disabling entity that must be addressed by properly planning the technique and assessing the best options based on its cause, type, location and extent. A hasty choice of an apparently simpler technique (for example, an internal urethrotomy in a young patient with a 1 cm bulbar urethral stenosis with spongiofibrosis) may limit the outcome of a urethroplasty performed later, which, if indicated at the time of diagnosis, would have a greater chance of success. The continuous training of the urologist, as well as the creation of reconstructive urology units in urological services, can significantly help patients suffering from this pathology.

Psychological disorders

Urethral stenosis may cause difficulty in urination or ejaculation, or urine infections, and even coexist with erectile dysfunction of organic origin, especially in cases of post-traumatic stenosis. All this can continue to occur after an operation or as a consequence of it. This, together with the frequent need for multiple interventions throughout life and not infrequently from childhood, the presence of urethral or suprapubic catheters in the short or long term, and aesthetic alterations of the genital area may lead the patient to need support and even treatment from the psychological and even psychiatric point of view. These disorders can create a vicious circle that, especially in the case of erectile dysfunction, makes its treatment much more complex.

Dr. Natalio Cruz

Author

Dr. Natalio Cruz


El Dr. Cruz, con 25 años de experiencia médica, ha sido hasta 2016 Jefe de la Unidad de Andrología en el Servicio de Urología del Hospital Virgen del Rocío de Sevilla, Coordinador Nacional de Andrología de la Asociación Española de Urología (AEU) y Secretario General de la ESSM, cargos que ha delgado para centrarse de lleno en el ilusionante proyecto de ofrecer una consulta médica privada de alto nivel en Sevilla.

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