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Urology > Strictures
Urethral Strictures
Article Last Updated: Jun 29, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction
Richard A Santucci is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Coauthor(s):
Joshua A Broghammer, MD, Resident Physician, Department of Urology, Wayne State University;
Jon Timothy Posey, MD, Staff Physician, Department of Urology, University of Miami School of Medicine;
Angelo Gousse, MD, Assistant Program Director, Assistant Professor, Department of Urology, Jackson Memorial Hospital, University of Miami School of Medicine
Editors: Daniel B Rukstalis, MD, Chief, Associate Professor, Department of Surgery, Division of Urology, Medical College of Pennsylvania-Hahnemann University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
Author and Editor Disclosure
Synonyms and related keywords:
urethral obstruction, urethral scar, anterior urethral stricture disease, scarring in the corpus spongiosum, internal urethrotomy, permanent urethral stents, primary repair, full-thickness skin graft, split-thickness skin graft, buccal mucosal graft, bladder mucosal graft, pedicled skin flaps, skin island onlay flaps, hairless scrotal island flap, skin island tubularized flap
Urethral strictures arise from various causes, and a patient can be asymptomatic or present with severe discomfort secondary to urinary retention. Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential. A urologic consultation should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease.
History of the Procedure
Urethral stricture disease has been cited as long ago as ancient Greek writings that report establishing bladder drainage with the passage of various catheters. Historically, the treatment consisted of urethral dilation with sounds. Hamilton Russell described the first surgical procedure for repair of a urethral stricture in 1914. In contemporary times, an array of surgical options is available.
Problem
- Urethral strictures can occur secondary to inflammatory, ischemic, or traumatic processes. These processes lead to scar tissue formation; scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance to the antegrade flow of urine.
- The term urethral stricture generally refers to the anterior urethra and is secondary to scarring in the spongy erectile tissue of the corpus spongiosum.
- A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and usually results from a distraction injury secondary to trauma or surgery, such as radical prostatectomy. The focus of this article is anterior urethral stricture disease.
Etiology
The most common causes of urethral stricture today are traumatic or iatrogenic. Less common causes are inflammatory or infectious, malignant, and congenital. Infectious urethral strictures typically are secondary to gonococcal urethritis, which remains common in certain high-risk populations of patients.
Pathophysiology
- Urethral strictures occur after an injury to the urothelium or corpus spongiosum causes scar tissue to form.
- A congenital stricture results from inadequate fusion of the anterior and posterior urethra, is short in length, and is not associated with an inflammatory process. This is an extremely rare cause.
Clinical
The most common presentation includes obstructive voiding symptoms, urinary retention, or urinary tract infections. Obstructive voiding symptoms are characterized by decreased force of stream, incomplete emptying of the bladder, urinary terminal dribbling, and urinary intermittency. These symptoms are progressive for many patients.
Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when conservative management fails.
- The urethra is divided into anterior and posterior segments. The anterior urethra (from distal to proximal) includes the meatus, fossa navicularis, penile or pendulous urethra, and bulbar urethra. The posterior urethra (from distal to proximal) includes the membranous urethra and the prostatic urethra.
- The urethra lies within the corpus spongiosum, beginning at the level of the bulbous urethra and extending distally through the length of the penile urethra. The bulbar urethra begins at the root of the penis and ends at the urogenital diaphragm. The penile urethra has a more central position within the corpus spongiosum in contrast to the bulbous urethra, which is more dorsally positioned.
- The membranous urethra involves the segment extending from the urogenital diaphragm to the verumontanum.
- The prostatic urethra extends proximally from the verumontanum to the bladder neck.
- The soft tissue layers of the penis, from external to internal, are skin, superficial (dartos) fascia, deep (Buck) fascia, and the tunica albuginea surrounding the corpora cavernosa and corpus spongiosum.
- The superficial vascular supply to the penis comes from the external pudendal vessels, which arise from the femoral vessels. The external pudendal vessels give rise to the superficial dorsal penile vessels that run dorsolaterally and ventrolaterally along the penile shaft, providing a rich vascular supply to the dartos fascia and skin.
- The deep penile structures receive their arterial supply from the common penile artery, which arises from the internal pudendal artery. The common penile artery gives off several branches that include the bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus spongiosum receives a dual blood supply via anastomoses between dorsal and urethral artery branches in the glans.
- The scrotum receives its vascular supply via branches from both the external and internal pudendal arteries.
- Urinary tract infections should be adequately treated prior to treatment.
- Malignancy should be ruled out.
Imaging Studies
- Diagnosis is made based on a suggestive history, findings on physical examination, and radiographic or endoscopic techniques.
- The entire urethra, both proximal and distal to the strictured area, must be evaluated endoscopically and/or radiographically prior to any surgical intervention.
- Radiographic evaluation of the urethra with contrast studies is best achieved by retrograde urethrogram or antegrade cystourethrogram if the patient has an existing suprapubic catheter. Retrograde urethrograms and antegrade cystourethrograms are usually obtained through the radiology department, although they can be performed by the urologist directly. These studies can be used to diagnose and define the extent of the urethral stricture. Accurately documenting the extent and location of the stricture is important so that the most effective treatment options can be offered to the patient.
- The technical aspects of a retrograde urethrogram involve placing a nonlubricated 8F or 10F urethral catheter into the fossa navicularis and inflating the balloon with 1-3 mL of sterile water until the balloon occludes the urethral lumen. A scout film is obtained. Approximately 10 mL of iodinated contrast media then is injected into the catheter under fluoroscopy, and images of the anterior urethra are taken. Extreme pressure during the injection phase can lead to extravasation and should be avoided. Do not mistake the membranous urethra for a stricture. On a retrograde urethrogram, the membranous urethra lies between the distal end of the verumontanum and the conical tip of the bulbous urethra.
- An antegrade cystourethrogram involves distending the bladder with water-soluble contrast media via a suprapubic tube or urethral catheter. A scout film is taken before administration of contrast material. Once the bladder is fully distended with contrast media, the suprapubic tube is clamped or the urethral catheter is removed and the patient is asked to void. Spot films are taken before, during, and after the voiding phase. This study can help delineate the posterior urethral anatomy.
Diagnostic Procedures
- Endoscopic evaluation can be conducted by flexible or rigid cystourethroscopy. Flexible cystourethroscopy can be performed with little discomfort to the patient using only local anesthesia, such as 2% lidocaine jelly intraurethrally.
Medical therapy
Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial strictures (no involvement of corpus spongiosum).
Surgical therapy
Internal urethrotomyInternal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision allows release of scar tissue. Success depends on the epithelialization process finishing before wound contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the 12 o'clock position with a urethrotome. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction. Complications include recurrence of stricture, which is the most common complication, bleeding, extravasation of irrigation fluid into perispongial tissues, and increasing fibrotic response. The curative success rate is reported as 20-35%, with no increase in the success rate with a second internal urethrotomy procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates; however, strictures typically return once the patient stops.
Permanent urethral stentsPermanent urethral stents are endoscopically placed. Stents are designed to be incorporated into the wall of the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing the patient pain while sitting or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated in patients with dense strictures and in patients with prior substitution urethral reconstruction because it elicits hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo lengthy open urethral reconstruction procedures.
Open reconstructionPrimary repair Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis. The key technical points that must be followed include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. Primary repair typically is used for stricture lengths of 1-2 cm. With extensive mobilization of the corpus spongiosum, strictures 3-4 cm in length can be repaired using this technique. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter. Repairs utilizing tissue transfer techniques
- Technical points for free graft repair
- Success depends on the blood supply of local tissues at the site of placement.
- Pendulous urethral strictures may be repaired with the patient in the supine or split-legged position. Bulbar or membranous urethral strictures are repaired with the patient in the exaggerated lithotomy position.
- The urethra is exposed through a penile or perineal incision.
- The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from the desired non–hair bearing location, bladder epithelium, or buccal mucosa. The graft is sutured to the edges of the urethrotomy. The graft is covered by the dartos fascia of the pendulous or bulbous urethra. Incisions are closed in 2 layers with an absorbable suture, and a Penrose drain is placed through a separate incision in the suprapubic or perineal areas.
- Full-thickness skin graft: Non–hair-bearing skin should be utilized. It is most successful in the bulbous urethra area.
- Split-thickness skin graft: The split-thickness skin graft is not preferred with single-stage repair because of the contraction characteristics of the graft. It typically is reserved for use in patients for whom multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is conducted as a 2-stage procedure.
- First stage: The urethra is opened via a ventral midline incision down to the level of healthy urethra. The scarred urethra is excised completely. The dartos fascia is mobilized bilaterally and then closed in the midline over the scarred urethral bed. A split-thickness skin graft is harvested from a desired non–hair bearing location. The graft is transferred to the ventrum of the penis and sutured to the dartos-covered urethral bed, and the proximal aspect is anastomosed in a spatulated fashion to the proximal urethral stump. Xeroform gauze and Dacron padding are used to cover the graft and are secured with supporting sutures. A 14F soft silicone catheter is placed into the urethra and bladder for stenting. Urine is diverted with a suprapubic tube. The Dacron and Xeroform padding is removed after 5-6 days. The suprapubic tube is removed after 2 weeks.
- Second stage: Closure takes place in 6-9 months if the graft has succeeded. A 3-cm-wide strip of skin is marked along the ventrum of the penis, which is to be used as the neourethra. A superficial, skin-deep incision is made along the marked lines. Care must be taken to spare the underlying dartos fascia. The skin strip is developed using the tissue plane between the penile skin and dartos fascia. The skin strip is fashioned into a neourethra as it is inverted using interrupted absorbable sutures. This is followed by a watertight closure using absorbable sutures in a running fashion. A small suction drain is left in the periurethral area, and the skin is closed. The drain is removed on postoperative day 3. A 14F soft silicone catheter is passed through the reconstructed urethra for stenting purposes. Urinary diversion is accomplished via suprapubic tube for 3 weeks.
- Buccal mucosal graft: The tissue is resistant to infection and trauma. The epithelium is thick, making it easy to handle. The lamina propria is thin and highly vascular, allowing efficient imbibition and inosculation. Harvesting is easier than other free grafts or pedicled flaps. A 15- to 20-mm graft is harvested from the oral mucosa. The graft is sutured to the edge of the urethra. A Penrose drain is left in the incision bed for 24 hours to allow drainage. A 16F urethral catheter is left for 7 days. Suprapubic urinary drainage is continued for 2 weeks. The suprapubic tube is removed in 2 weeks, after voiding cystourethrogram demonstrates no extravasation of urine. The graft may be placed as a ventral or dorsal onlay.
- Bladder mucosal graft: It is not as popular as other free tissue grafts because of difficulty in harvesting and handling the tissue.
Pedicled skin flaps These procedures are based on the principal of mobilizing an island of epithelium-bearing tissue with a pedicle of fascia to provide its own blood supply. Penile skin represents an ideal tissue substitute because it is thin and mobile and has an excellent blood supply.
- Skin island onlay flaps: Transverse, longitudinal, and circumferential island flaps refer to the type of skin incision made to fashion the tissue flap. Dorsal and ventral onlay refer to the position in which the flap is sutured to the edge of the incised urethra, as in the dorsal or ventral position with respect to the urethra and corpora cavernosa. Penile incision is carried out through the skin, dartos fascia, and down to the Buck fascia. A skin island flap is elevated on the penile dartos fascia, which serves as the vascular supply. A lateral urethrotomy is made along the course of the strictured area. The skin island flap then is transposed to the incised strictured area, oriented into proper position, and sutured to the edges of the urethrotomy incision with an absorbable monofilament suture. A watertight subepithelial suture line should complete the flap placement. The skin is closed with interrupted sutures.
- Hairless scrotal island flap: A non–hair bearing area of skin in the midline of the scrotum is used. The tunica dartos of the scrotum is used as the vascular pedicle. This procedure typically is used in complex urethroplasty procedures and is combined with penile skin island flaps to provide additional vascularized tissue for reconstruction.
- Skin island tubularized flap: It can be used in combination with onlay flap when a large obliterated segment of urethra is present. It involves tubularizing the pedicled skin flap over a sound and anastomosing the tubularized edge to the native urethral stump.
Preoperative details
The patient should be evaluated and deemed medically stable for the selected procedure. Urine culture should be sterile. Urethral stricture disease should be thoroughly evaluated with radiographic and/or endoscopic techniques. The procedure selection should be discussed thoroughly with the patient in advance, and the discussion should include information on the risks and benefits of the procedure and postoperative care. Risks include, but are not limited to, bleeding, infection, recurrence of stricture, and urethrocutaneous fistula formation.
Intraoperative details
- Position the patient in the supine, split-legged, or exaggerated lithotomy position.
- For open repair procedures, shave and prepare the perineum, penis, and scrotum.
- Administer intravenous antibiotics prior to making the incision.
Postoperative details
- Patients are placed on bedrest for 24-48 hours, depending on the extent of the procedure.
- Intravenous antibiotics are continued for 24 hours and then followed with oral culture-specific antibiotics or antibiotics with good gram-negative coverage.
- Anticholinergics are used to prevent bladder spasms.
- Drains, ef necessary, typically are removed on postoperative day 1-3.
- Wounds should be washed with soap and water daily after drains are removed.
- The patient may be discharged when afebrile; ambulatory; tolerant of a regular diet; and competent in managing drains, catheters, and wound care.
Follow-up
- Patients undergoing internal urethrotomy should return to the outpatient clinic for catheter removal on postoperative day 3-5.
- Patients undergoing open repair should return to the outpatient clinic on postoperative day 3 for wound evaluation and removal of drains.
- Prior to removal of the suprapubic catheter, a voiding cystourethrogram is conducted with contrast, instilled through the suprapubic tube. If no evidence of contrast extravasation occurs and the suture line is intact, then the urethral catheter is removed and the suprapubic tube is capped.
- If the patient continues to void well, the suprapubic catheter is removed after 1 week.
- When all tubes are removed and no evidence of infection is present, antibiotics may be discontinued.
- Urethral evaluation should be conducted with retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively.
- Urinary tract infection
- Wound infection
- Wound dehiscence
- Urethrocutaneous fistula
- Recurrence of urethral stricture
Urethral dilation and internal urethrotomy
Steenkamp and colleagues (1997) conducted a prospective, randomized comparison between internal urethrotomy and urethral dilation for male urethral strictures. They found no significant difference in efficacy between the 2 procedures when used as initial treatment. Recurrence rates increased as the length of the stricture increased. Recurrence rates at 12 months were 40%, 50%, and 80% for stricture lengths of less than 2 cm, 2-4 cm, and greater than 4 cm, respectively. The recurrence rate for strictures 2-4 cm long increased to 75% at 48 months of follow-up.
Permanent urethral stents
Milroy and Allen (1996) report an 84% long-term success rate and high level of patient satisfaction with as long as 5 years of follow-up. Failures typically occurred in patients with extensive stricture disease. Morgia and colleagues (1999) reported on the short- and long-term complications in a multicenter study of 94 cases. Short-term complications in 7-28 days included perineal discomfort (86%) and dribbling (14%). Long-term complications included painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%).
Free graft repair
These procedures have an overall success rate of 84.3%.
Pedicled skin flaps
The overall success rate is 85.5%. Skin island onlay flap with preservation of the urethral plate provides better success rates than the tubularized flap. Tubularized island flaps have lower success rates than skin island onlay flaps secondary to stricture formation at the site of anastomosis with the native urethra.
Many techniques are available for the treatment of urethral stricture disease. Based on the literature, each technique clearly cannot be applied successfully to every situation. The urologist who treats patients with urethral strictures must be experienced in several techniques. Each technique has advantages and disadvantages. Recently, buccal mucosa free graft urethroplasty has received favorable attention secondary to its excellent early results and decreased level of difficulty compared to pedicled skin flaps. So far, a prospective, randomized study comparing free grafts and tissue flaps has not been conducted.
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Urethral strictures. Cross-sectional diagram of the penis. |
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| Media file 2:
Urethral strictures. Schematic of penile anatomy. |
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| Media file 3:
Retrograde urethrogram demonstrating bulbar urethral stricture. |
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Urethral strictures. Retrograde urethrogram demonstrating complete obliteration of the bulbous urethra. |
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Retrograde urethrogram demonstrating pan-urethral stricture disease. |
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Urethral strictures. Retrograde urethrogram demonstrating patent urethra after buccal mucosa urethroplasty. |
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Urethral strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary anastomosis. |
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Urethral strictures. Photograph of a permanent urethral stent. |
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Urethral strictures. Photograph of open urethroplasty depicting the pedicled flap and urethrotomy. |
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Urethral strictures. Photograph depicting pedicled flap anastomosed to the urethra. |
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- Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P. Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures. J Urol. May 1999;161(5):1501-3. [Medline].
- Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: a prospective, randomized comparison. J Urol. Jan 1997;157(1):98-101. [Medline].
- Wessells H, McAninch JW. Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction. World J Urol. 1998;16(3):175-80. [Medline].
Urethral Strictures excerpt Article Last Updated: Jun 29, 2006
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