URETHROPLASTY

1. Urethral Stricture Disease
DR. TALAL BALLOUT
UROLEGIST

2. Urethral Stricture Disease
• Definition: Scarring process of the anterior
urethral epithelium and/or spongy erectile
tissue of the corpus spongiosum.

3. Incidence/Prevalence1
• VA - 200-1200/100,000
• HCUP – 3.8/100,000
• Medicare outpatient –
21/100,000
• Outpatient visits
▫ 229/100,000 (National
Ambulatory Medical Care
Survey
▫ 312/100,000 (Medicare)
• Costs - $200,000,000/year

4. Risk Factors
• Any process that injures the urethral epithelium
▫ Trauma
 Straddle Injury
▫ Iatrogenic
 Catheter placement
 TURP
▫ Infection
 Gonorrhea/Chlamydia
 Lichen Sclerosis (BXO)
▫ Most patients will have no obvious etiology (50%)

5. Presentation
• LUTS
• Difficult Foley
• Urinary Retention
• Renal Failure

6. Diagnosis
• Non-Invasive2
▫ Uroflowmetry
• Invasive3
▫ RUG/VCUG
▫ Cystoscopy
▫ US

7. Diagnosis
• Non-Invasive2
▫ Uroflowmetry
• Invasive3
▫ RUG/VCUG
▫ Cystoscopy
▫ US

8. Ultrasound3

9. Treatment – Endoscopic
• Urethral Dilation
▫ Stretch scar
• Urethrotomy
▫ Cut Scar
▫ Re-epithelialization

10. • <50% success with DVIU4
▫ Longer strictures
▫ Dense spongiofibrosis
▫ Prior DVIU
• Most cost-effective strategy is DVIU then
urethroplasty
▫ Tailor based on above risk factors for failure

11. Urolume Placement5
• 5 year success – 60-70%5
• Failure – catastrophic
• DO NOT place these in the
anterior urethra

12. Urolume Placement

13. • Normal Urethra is
24-30 F
▫ Fossa Navicularis
▫ Bulbar Urethra
Urethral Anatomy6
Stratified
Squamous
Pseudostratified
Columnar
Transitional
Fossa
Navicularis
Penile
Urethra
Bulbar
Urethra
Membranous
Prostatic
Bladder Neck

14. Urethral Anatomy6

15. Urethral Blood Supply6

16. Urethral Blood Supply

17. Urethral Reconstruction
• Principles of Repair
▫ Remove diseased tissue (if possible)
▫ Tension free repair
▫ Water-tight closure
▫ Urethral Stenting (foley catheter – 3 weeks)
▫ Blood supply

18. Types of Urethroplasty
• Anastomotic
• Graft repairs
• Flap Repairs
• Two-stage repairs
• Combinations

19. Case #1
• 20 M - healthy college student falls at an Iowa
football game while intoxicated
▫ Unable to urinate
▫ Blood at meatus

20. RUG
• Management?
▫ Cystoscopy
▫ Foley Catheter
▫ Suprapubic Tube
• SP versus Foley Catheter8

21. Anterior Urethral Trauma
• Endoscopic Repair?
• Urethroplasty?

22. Intraoperative US

23. Anastomotic Repair
• Perineal Incision
• Max Length 2-3 cm
▫ Longer more proximally
• Spatulation
▫ Proximally – ventral
▫ Distally – dorsal
• Urethral mobilization
▫ Proximal – keep bulb a intact
▫ Distal – penoscrotal junction

24. Post-op

25. Case #2
• 67 M undergoing spinal surgery – unable to
place foley catheter
▫ Urology consulted – cystoscopy performed, unable
to place wire into bladder b/c of urethral stricture
▫ SP tube placed

26. Case #2
• Lumen size estimated to be
around 8-10 F
• Length – 3 to 4 cm
• Options?
▫ EPA
▫ Graft
▫ Flap

27. Case #2

36. Buccal Mucosal Urethroplasty

37. Dorsal Onlay

38. Case #3
• 67 M with long history of LUTS
▫ On flomax/finasteride without improvement
▫ Cystoscopy – urethral stricture

39. RUG

40. Augmented
Anastomotic Repair
• Combine the advantages
of the buccal graft with
the anastomotic repair

42. Augmented Anastomotic Repair
EPA AAR AAR

43. Case #4
• 56 M with BPH, underwent TURP and now
with post-op LUTS.
▫ Uroflowmetry – max flow rate 5.5 mL/sec,
obstructive pattern
▫ Cystoscopy – narrowing at penoscrotal
junction, unable to pass cystoscope
▫ SP tube placed
▫ RUG

44. RUG
• Options
• Two Stage Repair
• Single Stage?

45. Circular Penile Fasciocuatenous Flap

47. Outcomes of Flaps

57. Case #5
• 35 M with significant psych issues presents with
urinary difficulties
• Physical Exam reveals:

58. RUG
• Options?
▫ Buccal
▫ Flap
▫ Combination?
▫ 2-stage
▫ Other?

60. Perineal
Urethrostomy

61. Post-treatment monitoring
• Foley catheter for 3 weeks
• VCUG – replace if extravasation seen
• RUG/VCUG at 3 and 12 months (or cystoscopy)
• Uroflowmetry at every visit
• Repeat cystoscopy:
▫ UTI
▫ Elevated PVR
▫ Worsening symptoms
▫ Worsening uroflowmetry

62. Current controversies
• Underutilization of urethroplasty
• DVIU versus immediate urethroplasty
• Limits of anastomotic repairs
• Sexual dysfunction after urethroplasty
• Tissue engineering
• Long-term outcomes of flaps/grafts