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Urethral Stricture Surgery Treatment India

Urethral stricture is an abnormal narrowing of the tube that carries urine out of the body from the bladder (urethra). Urethral stricture is a narrowing or blockage of the urethra, through which urine exits the bladder. This narrowing is often due to build up of collagen fibers and cells called "fibroblasts". It is much more common in men than women. This condition can be congenital or acquired, through effects of infection (e.g. Gonorrhea), physical trauma (e.g. Pelvic fractures), a mass (e.g. Carcinoma of the urethra), and medical instruments (e.g. Indwelling catheter). A patient may experience urethral stricture after surgery, and this is most likely due to the placement of a catheter during the procedure and/or recovery.

In general, urethral strictures are divided into two main categories:

1. Anterior urethra (from the sphincter [control muscle] to the tip of the penis).

2. Posterior urethra (from the bladder to the urethral sphincter).

Causes

Urethral stricture may be caused by inflammation or scar tissue from surgery, disease, or injury. It may also be caused by pressure from an enlarging tumor near the urethra, although this is rare. Urethral strictures are generally caused by viral or bacterial infection of the tract, often caused by certain sexual transmitted diseases (STD), or by injury-related trauma to the tract. The body's attempt to repair the damage caused by the injury or infection creates a build-up of scar tissue in the tract resulting in a significant narrowing or even closure of the passage.

Instrumentation of the urethra, particularly before the advent of flexible uroendoscopy, was (and remains) an important causative event.

Short strictures in the bulbar urethra (near the bladder neck) particularly between the proximal 1/3 and distal 2/3 of the bulb, may be congenital (from birth). They probably form as a membrane at the junction between the posterior and anterior segments. It is not usually noticeable until later in life, as it fails to widen as the urethra does with growth, thus it only impedes urinary flow relative to the rest of the urethra after puberty. The urethra runs between the legs very close to the skin, leaving it vulnerable to trauma. Simply falling off a bike and injuring the area between the legs may result in the formation of scar tissue within the urethra tract. This condition is often not found until the patient has problems urinating because these are painless growths of scar tissue.

Passage of kidney stones through the urethra can be painful and subsequently can also lead to urethral stricture.

Risks

Other risks include:

• A history of sexually transmitted disease (STD)

• Any instrument inserted into the urethra (such as a catheter or cystoscope)

• Benign prostatic hyperplasia (BPH)

• Injury or trauma to the pelvic area

• Repeated episodes of urethritis

• Strictures that are present at birth (congenital) are rare. Strictures in women are also rare.

Signs and Symptoms

Symptoms may include decreased urine stream, spraying or double-stream, post-urination dribbling, increased frequency, mild dysuria (pain with urination), and chronic discharge. The presentation can be quite similar to BPH (benign prostate hypertrophy, or enlarged prostate). On physical exam,it may be  noticeable, a palpable mass, depending on the location of the narrowing. Blood in the urine is rare, but may be associated with a stricture.

Complications

This fibrosis can extend into nearby structures, including the corpus spongiosum of the penis. The condition can also cause problems upstream in the urinary tract, leading to prostatitis (inflammation of the prostate), hypertrophy of the bladder muscle (which overcompensates for the blockage with excess contraction), and incomplete bladder emptying. In severe, untreated cases, possible serious consequences include urine reflux, hydronephrosis (distention and dilation of the kidney), and even renal failure. Ineffective clearance of urine leads to increased likelihood of infection, and can cause fistulas and abscesses in the urinary tract.

Diagnosis

If signs and symptoms point to this diagnosis, urinary flow rates can be measured with urine collection. Another possible test is urine culture (to determine whether an infection is involved). Imaging studies may confirm the condition and its severity; useful tests include urethrogram, voiding cystourethrogram, and sonogram. A more invasive option for visualizing the urethra is urethroscopy. Other conditions that must be ruled out are BPH and prostate cancer. The diagnosis of urethral stricture begins with a history and physical exam.

1. Urinanalysis: performed to rule out hematuria (blood in the urine), infection or other urinary abnormalities.

2. Urine culture: studies the urine for evidence of infection, which may occur in some people with a urethral stricture.

3. Uroflowmetry/Peak flow urine study: individuals are asked to void into a special toilet, which measures the speed at which urine flows from the bladder to the end of the urethra. Many individuals with a stricture will have a diminished rate of flow.

4. Post-void residual urine study: an ultrasound of the bladder is performed, measuring the amount of urine that remains after a "normal" void.

5. Retrograde urethrogram (RUG) with voiding cystourethrogram (VCUG): X-ray constrast (dye) is used to fill the urethra and bladder as images are obtained, identifying the level of blockage. Patient is then asked to void (VCUG) and again x-rays are taken to better outline the level of stricture.

6. Cystoscopy: using a fiber optic telescope the urinary tract from the tip of the penis to the bladder can be inspected. This can help rule-out other causes of obstruction or allow the urologist to better characterize the stricture.

7. Sonourethrogram: This test is usually done in the operating room as part of the pre-operative surgical planning. It uses an ultrasound probe to image the stricture, measure its length and assess for the degree of scarring.

Most patients will have a urinalysis, urine culture, uroflowmetry, post-void residual study and a RUG/VCUG. Cystoscopy may not be required and its need will be determined by the doctor.

Prognosis and treatments

If symptoms are severe, initial treatment may include dilation, which provide temporary relief, but will likely not be curative because of the build-up of scar tissue. Another treatment option is endoscopic lysis with a knife; this is safe and effective in the long-term, but does not prevent recurrence. Finally, surgical correction is a more risky but potentially necessary option. This condition must be monitored for at least a year after treatment to ensure that it does not recur.

How can urethral strictures be prevented? 

The most important preventive measure is to avoid injury to the urethra and pelvis. Also, if a patient is performing self-catheterization they should exercise care, to liberally instill lubricating jelly into the urethra, and to use the smallest possible catheter necessary for the shortest period of time.

Acquired strictures may be a result of inflammation caused by sexually transmitted diseases (STDs). Although gonorrhea was once the most common cause of inflammatory strictures antibiotic therapy has proven effective in reducing the number of resulting strictures. Chlamydia is now the more common cause, but strictures caused by this infection may be prevented by avoiding contact with infected individuals or by using condoms.

What are some treatment options?

Treatment options for urethral stricture disease are varied and selection depends upon the length, location and degree of scar tissue associated with the stricture. Options include enlarging the stricture by gradual stretching (dilation), cutting the stricture with a laser or knife through a telescope (urethrotomy) and surgical removal (excision) of the stricture with reconnection and reconstruction with grafts.

Dilation

This is usually performed in the urologist's office under local anesthetic and involves stretching the stricture using progressively larger dilators called "sounds." Alternatively, the stricture can be dilated with a special balloon on a catheter. Dilation is rarely a cure and needs to be periodically repeated. If the stricture recurs too rapidly the patient may be taught how to insert a catheter into the urethra periodically to prevent early closure.

Pain, bleeding and infection are the main problems associated with dilation procedures. Occasionally, a "false passage" or second urethral channel may be formed from traumatic passage of the "sound."

Urethrotomy

This procedure involves use of a specially designed cystoscope that is advanced along the urethra until the stricture is encountered. A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing. A catheter may be placed into the urethra to hold the cleft open for a period of time after the procedure to allow healing in the open position. The suggested length of time for leaving a catheter tube draining after stricture treatment can vary.

Urethral Stent

This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The stent is placed into the urethra through the penis using a specially designed cystoscopic insertion tool after the urethra is widened. The stent expands within the widened stricture and prevents the urethra from closing. The lining of the urethra eventually covers the stent, which remains in place permanently. This treatment has the advantage of being "minimally invasive." However, it is only suited to very select strictures and frequently causes significant swelling around the device. Removal of these devices is very difficult and may result in a more significant stricture.

Open surgical urethral reconstruction

Many different reconstructive procedures have been used to treat strictures, some of which require one or two operations. In all cases, the choice of repair is influenced by the characteristics of the stricture, and no single repair is appropriate for all situations. Open reconstruction of a short urethral stricture may involve surgery to remove the stricture and reconnect the two ends (anastomotic urethroplasty). When the stricture is too long and this repair is not possible, tissue can be transferred to enlarge the segment to normal (substitution procedures). Substitution repairs may need to be performed in stages in difficult circumstances.

Anastomotic Procedures

These are usually reserved for urethral strictures of two centimeters or less where the urethra can be reconnected after removing the stricture. This procedure involves a cut between the scrotum and rectum. This is usually performed as an outpatient procedure or with a brief hospitalization. A small, soft catheter will be left in the penis for 10 to 21 days and removed after an X-ray is performed to ensure healing of the repair.

Substitution Procedures

• Free Graft Procedures: Strictures significantly longer than two centimeters may be repaired with a free graft procedure to enlarge the urethra. The graft may be skin (usually removed from the shaft of the penis) or buccal mucosa removed from inside the cheek. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.

• Skin Flap Procedures: When a long stricture is associated with severe scarring and a free graft would not survive, flaps of skin can be rotated from the penis to ensure survival of the newly created urethra. These procedures are complex and require a surgeon experienced in plastic surgery techniques. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.

• Staged Procedure: When sufficient local tissue is not available for a skin flap procedure and local tissue factors are not suitable for a free graft, a staged procedure may be required. The first stage in a staged procedure focuses on opening the underside of the urethra to expose the complete length of the stricture. A graft is secured to the edges of the opened urethra and allowed to heal and mature over a period of three months to a year. During that time, patients urinate through a new opening behind the stricture, which in some cases will require the patient to sit down to urinate. The second stage is performed several months after the graft around the urethra has healed and is soft and flexible. At this stage the graft is formed into a tube and the urethra is returned to normal. A small, soft catheter will be left in the penis for 10 to 21 days.

What are the possibilities of recurrence?

Because urethral strictures can recur at any time after surgery, patients should be monitored by a urologist. After removal of the catheter, followup of the repair should be performed intermittently with physical examination and X-ray studies being performed as necessary. Sometimes, the doctor will perform urethroscopy to evaluate the repaired area. Some patients will have recurrence of stricture at the site of the prior repair. These are sometimes mild and require no intervention, but if they cause obstruction they can be treated with urethrotomy or dilation. A repeat open surgical repair may be needed for significant recurrent strictures.

Frequently Asked Questions:

Can urethral strictures be treated with medicine?

No. 

What can occur if no treatment is taken?

The patient would have to continue to tolerate problems with urination. Urinary and/or testicular infections and stones can develop. Also, there is a risk that urinary retention may occur which can cause the bladder to enlarge and also lead to kidney problems.

Is there a risk of infecting others with urethral strictures? 

Urethral strictures are not contagious but the underlying cause, like an STD, may be contagious.

Treatment for Urethral Stricture at Delhi, Mumbai, Chennai, Hyderabad, Banglore, India

The urethra may be widened (dilated) during cystoscopy by inserting a thin instrument to stretch the urethra while you are under local anesthesia. You may be able to treat your stricture by learning to dilate the urethra at home.

If urethral dilation is not possible, you may need surgery to correct the condition. Surgical options depend on the location and length of the stricture. If the stricture is short and not near the urinary sphincter, options include cutting the stricture via cystoscopy or inserting a dilating device.

An open urethroplasty may be done for longer strictures. This surgery removes the diseased part or replaces it with other tissue. The results vary depending on the size and location, the number of treatments you have had, and the surgeon's experience.

In cases of acute urinary retention, a suprapubic catheter may be placed as an emergency treatment. This allows the bladder to drain through the abdomen.

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