URETHRAL STRICTUREAli Bin Mahfooz, MD, FRCS(C)

King Faisal Specialist Hospital and Research Center, Riyadh

URETHRAL RECONSTRUCTION

1. Anatomy of urethra.2. Mechanism of injury.3. How did I do it, why?4. Conclusion

ANATOMY OF URETHRA

Sound easy but in reality challenging!

CORRECT TREATMENT?

Consideration: Length. Location. Diameter. Patient desire. Experience & treatment bias of urologist.

SURGICAL TREATMENT OF ANTERIOR STRICTURE

Bulbar: Short (<2.5cm):

Excision & primary anastomosis (EPA). Long (>2.5cm):

Graft “Penile skin, Buccal mucosa” Penile skin flap Hairless scrotal island flap. Staged repair “meshed, buccal mucosa”

SURGICAL TREATMENT OF ANTERIOR STRICTURE

Penile: Penile skin flap. Buccal mucosa graft. Staged repair.

PRINCIPLE OF ANTERIOR URETHRAL STRICTURE REPAIR

Transect urethra fully at stricture point. Excision fibrotic urethra & spongy tissue. Spatulate proximal & distal end.

JORDEN ET AL ON J URO 2004

207 patients with bulbar urethral stricture. Age 11.6-77.7 All done by (EPA). Etiology:

61% idiopathic. 17% straddle. 12% trauma. 10% Instrumental.

Stricture length: Rang 0.8-4.5 cm Follow-up 7-12.4 monthes

JORDEN ET AL ON J URO 2004

Cure defined as needing no further treatment and no indicating for dilatation.

97.7% no recurrence. All failure in 1st 25 patients ?? 3 patients no cure:

2 patients have stricture at anastomosis site → internal urethrotomy.

1 patient has recurrant stricture need monthly dilatation.

JORDEN ET AL ON J URO 2004

Complication:

ComplicationNo. of patients

Febrile UTI10

ED4

Wound infection2

Persistent pain2

SUMMARY: ANTERIOR URETHRAL RECONSTRUCTION

EPA is extremely reliable with excellent outcome in patients with short bulbar stricture.

Complication are minimal. Good long term results. EPA is better than endoscopic procedure.

POSTERIOR URETHRAL STRICTURE RECONSTRUCTION

Like repair of common bile duct. Do it right, or leave it for expert. Mechanism of injury:

Pelvic fracture: 5% incidence. Higher in bilateral pelvic injury.

POSTERIOR URETHRAL TRAUMA

Pelvic fracture 98%. Blood at meatus 37-93%. Scrotal hematoma. Perineal hematoma. Unable to void. Bladder distension. Unable to pass catheter. High riding postate.

CLASSIFICATION OF PROSTATIC URETHRAL INJURY

Type I Type II Type III

MAIN MANAGEMENT

Primary realignment.

Delayed reconstruction.

PRIMARY REALIGNMENT

Limited associated injuries.

Optimal endoscopic equipment & fluoroscopy.

Hemodynamic stable.

S.WOLF J.TRAUMA (36-40) 36-40 2001ER CATHETER & STENTING (???)

10 patients, successful in 8 patients. Realignment over a catheter. Outcome:

Stricture 69%. Impotence 44%. Incontinent 20% wesber J. urol 130-898,

1982

BARTCHET AL J.UROL 157( 499-505) 1992

Early realignment. Half need urethrotomies 40% success at 3 years follow up.

DELAYED RECONSTRUCTION

Suprapubic cystostomy.

Repair the defect at 3-4 monthes or after.

Associated with other injury.

PRE-OP STUDIES

Urethrogram.

Cystogram + simultaneous up/down urethrogram.

Penile duplex U/S.

MRI

INTRA-OP

High lithotomy. Midline perineal incision. Excise fibrosis. Spatulation. Epithelium to epithelium anastomosis 5-0

(maxon, PDS, Monocryl). 16Fr foley’s catheter 2-4 weeks.

SUCCESSFUL POINTS

Step to achieve tension free anastomosis:

Good urethral mobilization. Split scrotal bodies. Partial pubectomy. Re-route urethra.

Webster et al J.urol (1991).

POST OP SUCCESS

Normal voiding.

No dilatation.

No self cath/dilatation.

DEFERRED URETHRAL REPAIR

No of pt

SuccessAuthor

8288%Mundy 1996

6005y 95%10y 93%

Turner-Warwick 1989

9070%Marberger 1986

7496%Webster 199

11896%Mc Aninch 2002

POST TRAUMATIC STRICTURE

Lack of experience. Delayed repair 97%. Primary realignment 53% stricture 56% impotence. 21% incontinence

Koratin et j urolgy 1996

SUMMARY COMPARE MANAGEMENT

Primary Realignment

Deferred Repair

Need optimal condition & technical experience

Need SPC, (???), void short term morbid

Shorten “stricture” ultimate repair easier

Always results in stricture

Potential short term morbid “infection, hematoma”

Stricture is longer & difficult to repair

Possible long term morbid “ED, incontinence”

Lower long term morbidity

Rarely definitive treatment alone, need CIC or urethroplasty

Repair success 90-95%

RECOMMENDATION

If pt stable try once to place an aligning catheter.

Minimal disruption of pelvic hematoma.

Refer pt to specialized center.

DELAYED ENDOSCOPIC MANAGEMENT

Cut-to-the light procedure.

Poor control.

Need redo, fibrosis persist.

You will give other colleague hard case.

TAKE HOME MASSAGE FOR POSTERIOR URETHRAL INJURY

1. An apparently short stricture does not mean easy repair.

2. Complexity of repair related to length of defect.

3. Staging the lengthen defect is challenging but important.

4. Initial intervention is important for the following treatment outcome.

5. I like prenieal approach, but be ready for transpubic.

WHY BUCCAL MUCOA?

More data to support its superior to other graft.it thick,non-keratinized epithelium make it easy to handle and suture

Could be used on onlay (ventral or dorsal).

Enough tissue, easy to handle.

Plastic surgeon may help.

COMPLEX URETHRAL STRICTURE

BXO: Meatus & F.N are usually involved & most

problematic. Best manage by complete excision & re-

surfacing with Buccal mucosa. If not re-surface use steroid. Use 20-24Fr catheter. Best replaced to coronal & subcoronal, not to

gland tip. Leave buccal mucosa everted at meatus. Preserve the meatus or neomeatus.

POST RADICAL PROSTATECTOMY

Endoscopic incision has high failure.

Redo the anastomosis is the best.

If small bladder neck contracture they do well with BNI.

POST RADIATION URETHRAL STRICTURE

Usually membranous urethra involved after brachytherapy.

Very difficult to repair.

Most of cases they need a flap rather than graft because radiation effect the blood supply.

THE CAVEATS (???)

Very little data.

Small numbers.

Little personal opinion.

CONCLUSION

1. Urethral surgery is very complicated, please do it right or leave it for expert.

CONCLUSION

1. Key points to success: Tension free anastomosis. Water tight. Be ready for alternative approach. match size of needle to suture. (???) Good Abx coverage post-op, till catheter

removed Leave foley’s catheter for 2-3 weeks.,on lower

abdomen. Silicon catheter is better. If post op leakage on urethrogram wait for 5-

6weeks; remove the catheter. Think that this is a failure.

Staged repair did not mean that you are not good surgeon

THANKS