2. DEFINITION
• Urethral stricture: refers to anterior urethral disease, or a
scarring process involving the spongy erectile tissue of the
corpus spongiosum (spongiofibrosis)
• Term stricture is limited to the anterior urethra
• Posterior urethral “strictures” are not included in the common
definition of urethral stricture
3. • Posterior urethral stricture: an obliterative process in the posterior
urethra that has resulted in fibrosis interposed between distracted
ends of urethra and is generally the effect of distraction in that area
caused by either trauma or radical prostatectomy
• Distraction defects are those processes of the membranous urethra
associated with pelvic fracture
(Posterior pelvic fracture urethral distraction defect/ PFUDD)
• Urethral contractures or stenoses : stricture of prostatic urethra and
bladder neck
5. STRICTURE AETIOLOGY AND PREVALENCE
Site Cause Incidence %
Penile Iatrogenic 40
Inflammatory 40
Idiopathic 15
Traumatic 5
Bulbar Idiopathic 40
Iatrogenic 35
Traumatic 15
Inflammatory 10
Mundy et al, BJUI 2010, 107 , 6-26
6. Anatomy of anterior urethral strictures includes, in most cases, underlying spongiofibrosis
A, Mucosal fold
B, Iris constriction
C, Full-thickness involvement with minimal fibrosis in the spongy tissue
D, Full-thickness spongiofibrosis
E, Inflammation and fibrosis involving tissues outside the corpus spongiosum
F, Complex stricture complicated by a fistula. This can proceed to the formation of an abscess, or the
fistula may open to the skin or the rectum
8. CLINICAL EVALUATION
• Progressive symptoms of lower urinary tract obstruction:
• hesitancy
• a poor stream
• terminal dribbling
• and a feeling of incomplete emptying
• The strongest association of any of these symptoms with
stricture disease is a sensation of incomplete emptying
• AUA symptom score
• Physical examination- meatus, induration, sign of LS-BXO
• White rim to the meatus (pathognomonic of LS-BXO)
• DRE- evaluate position and characteristics of prostate
10. INVESTIGATIONS
• Urinary flow rate study
• Ultrasonography- thick walled bladder before voiding and PVR- both indicating long
term obstruction
• Retrograde urethrogram- if symptoms and a urinary flow rate study suggest a
urethral stricture, RGU is the next step to make the definitive diagnosis
• Voiding cystogram- show urethra proximal to stricture
• Flexible cystoscopy- stricture visualised & attempted guidewire placed under vision
• Sonourethrography / Ultrasonographic assessment of stricture - for distal bulbar
and penile urethra (7.5 MHz linear array transducer)
• MRI- for assessing post traumatic pelvic anatomy, length of prostatomembranous
defect,
should used in conjuction with RUG and VCUG to determine surgical approach
11. • For an appropriate treatment plan to be devised, it is important to
determine the location, length, depth, and density of the stricture
(spongiofibrosis)
• The length and location of the stricture can be determined with
radiography, urethroscopy, and ultrasonography
• The depth and density of the scar in the spongy tissue can be
deduced from the physical examination, the appearance of the urethra
in contrast-enhanced studies, and the amount of elasticity noted on
urethroscopy
• The depth and density of fibrosis are difficult to determine objectively
12. The typical long slow protracted flow pattern with a ‘plateau’
appearance (typically flat, box –shaped uroflow pattern) is
typical in a patient with a stricture
13. Technique for RUG
The patient is supine with the dependent thigh acutely flexed and pelvis tilted 45 degree.
The penis is on moderate stretch and the image obtained while injecting contrast
45 degree
Lauenstein position/
Right post. oblique
14.
15. Sonography accurately depicts bulbar urethral stricture length because the transducer is
positioned perpendicular to the diseased urethral segment
RUG routinely underestimates length of bulbar strictures because this area is frequently
aligned in oblique axis relative to the A-P radiograph beam. Bulbar urethra is fixed in
same axis as pelvis. As a result, an “END-ON” view of bulbar stricture is observed
16. • Sonographic staging is best used adjunctively to guide treatment
planning among patients known to have strictures on the basis of
RUG
• Stricture lumen size (in French) = 3 x sonographic diameter of
stricture (mm)
• Spongiofibrosis appears sonographically as thickened, irregular,
nondistensible tissue encroaching into the otherwise anechoic
urethral lumen
18. INDICATIONS FOR INSTRUMENTATION
• Curative
First time treatment of a short bulbar stricture
• Palliative
Further treatment of a short bulbar stricture
Treatment of any other stricture
• Dilatation or DVIU?
Dilatation- Meatal / fossa navicularis strictures
Sphincter strictures
Easy strictures
DVIU- Difficult strictures needing a guide-wire
Mundy et al, BJUI 2010, 107 , 6-26
19. DILATATION
• Oldest and simplest treatment
• May be curative in patient with an epithelial stricture without
spongiofibrosis
• Goal - stretch the scar without producing more scarring
• If bleeding occurs during dilation, the stricture has been torn
rather than stretched, possibly further injuring the involved area
• Safest method - use of urethral balloon-dilating catheters
20. INTERNAL URETHROTOMY / DVIU
• Described by Sachse in 1972
• A single cut made at 12 o'clock position in the scar tissue, till the scar
is incised completely
• Aims to separate the scarred epithelium so that the healing occurs by
secondary intention
• The Sachse urethrotome is 21 F calibre (Urologie A 1978:17:177-81)
• No reported difference in the outcome of single versus multiple
incisions (J Urol 2010:183:1859-62)
• The narrower the percent of narrowing, the worse the outcome,
with a cutoff of 74% narrowing (Dubey 2005)
21. Indication for DVIU
• Bulbar urethral strictures of <1 cm and minimal spongiofibrosis
• A second urethrotomy may be indicated in patients who have a
recurrence after 6 months or depending on patient preference
Extremely poor long-term outcomes after DVIU
• Strictures >1 cm
• Multiple strictures
• Pendulous urethral strictures
• Bulbar strictures with significant spongiofibrosis
• Recur within the first 3 months
Dubey (Ind J Urol 2011)
22. • The data show that strictures at the bulbous urethra < 1.5 cm
and not associated with dense, deep spongiofibrosis (i.e.,
straddle injuries) can be managed with internal urethrotomy,
with a 74% moderately long-term success rate (Campbell 10th/972)
23. • As yet there is no convincing evidence that extending the
duration of catheterization has an impact on the outcome
• Albers et al. reported that leaving the urethral catheter in place
for 3 days or less is associated with lower recurrence rates
(34%), compared to leaving it for 4-7 days or >7 days
(recurrence rates of 43% and 65%, respectively) (J urol 1996)
• Most studies have reported catheterization duration of 1-4 days
24. • Intralesional injection corticosteroids and mitomycin and
intraurethral captopril gel have been used in an attempt to
decrease the fibrotic response after DVIU; however, no long-
term followup data are available to determine the true benefit of
such strategies
• Colchicine, because it binds and block tubulin, possibly block
wound contracture has been used along with internal
urethrotomy for better results
25. Complications after DVIU
• Recurrence of stricture (MC)
• Bleeding
• Extravasation of fluid into the perispongiosal tissues
• Creation of a fistula and cavernosal veno-occlusive dysfunction
26. Factors associated with stricture recurrence:
• Stricture length - high recurrence for stricture > 1 cm
• Stricture diameter and spongiofibrosis, infection and duration of
catheterisation
75% narrowing on RUG predicted stricture recurrence with a
probability of 78%
• Stricture site- The Bulbar urethra has better vascularity than the
pendulous urethra and has lower recurrence rates in
comparison to more distal ones
27. • Repeat urethrotomy has no role when stricture recurrence
occurs within 3 months of the DVIU or recurs after a second
urethrotomy
• There is no level I evidence to support the use of clean
intermittent catheterization following DVIU
• Based on the existing literature, it is reasonable to recommend
a trial of ISD, not more than once weekly to be continued at
least for a year. There is no role for short-term ISD following
urethrotomy (Ind J Urol 2011)
28. URETHRAL STENTS
• Removable or Permanently implantable
• Used in opposing the forces of wound contraction after internal
urethrotomy or dilation
• 2 types
UroLume which is incorporated into the urethral wall
(permanent)
Memokath which is not (removable stent made of nitinol)
29. • Stent is best employed for relatively short strictures of the
bulbous urethra associated with minimal spongiofibrosis in
patients >50 years with serious comorbidities
• Stents must be placed only in the bulbous urethra
• C/I of UroLume- Prior substitutional urethral reconstruction
Pelvic fracture urethral distraction defects and
straddle injuries associated with deep fibrosis
30. • Lasers used for the T/T of urethral stricture disease (isolated and short
stricture) include carbon dioxide, argon, KTP, Nd : YAG, holmium : YAG,
and excimer lasers
• Ideal laser
- That totally vaporizes tissue
- Exhibits negligible peripheral tissue destruction
- Not absorbed by water
- Easily propagated along a fiber
• Although the carbon dioxide laser appears to be ideally suited, it must be
used with a gas cystoscope, which carries the potential threat of a
carbon dioxide embolus
31. EXCISION AND PRIMARY ANASTOMOSIS
• Has proved to be the “gold standard” form of repair for anterior
urethral strictures
• From a strict anatomic perspective, only short strictures (<2 cm)
located between the suspensory ligament and the membranous
urethra are amenable to excision
• For best results-
- Area of fibrosis is totally excised
- Urethral anastomosis is widely spatulated, large ovoid and
tension free
32. • Exaggerated lithotomy position
• Vertical midline incision / lambda incision / inverted ‘‘Y’’ incision
• Midline fusion of bulbocavernosus muscle is divided to expose bulbospongiosum
• Vigorous mobilisation of urethra/ corpus spongiosum from penoscrotal jn to
membranous urethra
• Mobilization beyond the suspensory ligament (penoscrotal jn) increases the risk
of post-operative chordee
• Dissection of Buck fascia from distal urethra
• Development of the intracrural space by dividing triangular ligament
• Detachment of the bulbospongiosus (bulb of urethra) from the perineal body
• 1-2 cm spatulation of the proximal urethra dorsally and the distal urethra ventrally
ensures an oblique anastomosis and reduces the risk of recurrent stricture from
contraction at the anastomosis
• High success rate of 95% in short stricture of bulbar urethra (Santucci et al,
Int.braz j urol 2007)
33.
34. •Bulbospongiosus released from its attachment to perineal body and arteries to bulb not divided
•This technique allows the urethra to be mobilized distally
•This technique combined with development of the intracrural space can shorten the path of the
urethra by approximately 1 to 1.5 cm
35.
36. SUBSTITUTION URETHROPLASTY
• Free graft / Flap
• Indications for free graft reconstruction include
- Bulbar urethral stricture >2.5 cm in length
- Presence of balanitis xerotica obliterans (BXO)
- Absence of suitable penile skin for other complex urethral
reconstructions
Urol Clin N Am 29 (2002) 381–387
37. • The graft can be applied ventrally or dorsally or dorsolaterally with
comparable success rates
• For dorsal and dorsolateral onlay tunica albugenia of corpora provide the
firm vascular bed where the graft can be spread fixed
• As in the bulbar urethra, spongioplasty maneuver is not possible in
pendulous urethra and dartos fascia forms the bed for ventral onlay
• Dorsolateral onlay requires unilateral mobilization of urethra; and
therefore avoids the devascularization of the urethra due to
circumferential mobilization
38. Diagram of various techniques of graft onlay
A, Ventral onlay with spongioplasty
B, Lateral onlay with quilting to the ischiocavernosus muscle
C, Dorsal onlay with spread fixation of the graft
39. DORSAL FREE GRAFT (BARBAGLI)
• The dorsal approach to treating strictures of the bulbar urethra
is anatomically more sound than the ventral approach because
- it requires less extensive opening of the spongy tissue
because of urethral lumen is located dorsally in this tract
- avoids significant bleeding from the corpus spongiosum and
better graft take and
- mechanical weakening of the graft is unlikely (reduced
incidence of diverticulum formation)
40. Technique of dorsal graft onlay popularized by Barbagli
A, The corpus spongiosum is detached from the triangular ligament and corpora cavernosa.
B, A dorsal urethrostomy is performed. The graft is spread fixed to the corpora cavernosa
C, The edges of the stricturotomy are then sutured to the graft as well as to the corpora
cavernosa
41. VENTRAL ONLAY
• Long-term, stricture-free outcomes equal to dorsal onlay
• Provides easy exposure of the stricture, an excellent graft bed
• Complete circumferential mobilization is not necessary for a
ventral onlay technique, thus preserving arterial and venous
connections to the corpora cavernosa
• Ventral onlay has been criticized because of excessive blood
loss and a high incidence of diverticulum formation due to
mechanical weakening of unsupported graft on ventral urethral
surface
42. Limitations to ventral onlay urethroplasty
• Severe spongiofibrosis due to prior failed urethroplasty or pelvic
irradiation and strictures of the distal penile urethra.
Spongiosum is not abundant, and spongioplasty is difficult to
achieve. In these cases a penile skin flap, staged procedure, or
potentially dorsal onlay is indicated
43. DORSAL FREE GRAFT URETHROPLASTY BY
VENTRAL SAGITTAL URETHROTOMY APPROACH
(ASOPA TECHNIQUE)
• Urethra was not separated from the corporal bodies (urethra not
mobilised) and was opened in the midline over the stricture
• Good results in long and multiple strictures of anterior urethra
• Easy to perform b/c urethra not mobilised
• Sizing of graft accurate, so pooling of semen and urine minimised
• The risk to the blood supply of the two halves of the bivalved
urethra is less because it derives adequate blood supply from the
corpora and from the circumflex arteries
UROLOGY 58: 657–659, 2001
44. • Laying open stricture ventrally and then incising the urethra dorsally
without mobilizing it to expose the tunica albuginea
• Margins of incised dorsal urethra dissected from tunica albuginea
without lifting two halves of bisected urethra, this provide an elliptical
raw area upto 2 cm over tunica albuginea between incised dorsal
edges of urethra
• Incised dorsal free margins of the urethra are anchored by interrupted
sutures to the tunica albuginea
• Free full thickness graft of preputial or buccal mucosa placed over
the raw area of the incised dorsal urethra
• Retubularization of the urethra in one stage
• Catheter removed after 3 weeks
UROLOGY 58: 657–659, 2001
45. (a) Separation of margins of dorsal urethrotomy
from corporal bodies
(b) Securing of free margins to tunica albuginea
(c) Fixation of dorsal free graft
(d) Retubularization of urethra
Cross-section of penis showing arterial
supply of urethra on right and venous
drainage on left, along with dorsal free
graft and retubularized urethra
46. AUGMENTED ANASTOMOSIS WITH GRAFT ONLAY
A, Corpus spongiosum is detached from triangular ligament and corpora cavernosa and area of
narrowest caliber stricture is excised. The urethral ends are then spatulated on dorsum.
B, A two-layer floor strip anastomosis is performed and the graft is spread fixed to corpora
cavernosa. Note the pie-crusting incisions and the mattress sutures.
C, The edges of the stricturotomy are then sutured to the graft as well as to the corpora
cavernosa
Indication- Nearly or totally obliterating segment of urethra
47. BUCCAL MUCOSA
• Most popular substitute, readily available and easily harvested
from cheek or lip
• More reliable re-vascularisation as a result of thin and highly
vascular lamina propria (Panlaminar vascular plexus)
• Hairlessness
• Compatibility in a wet environment
• Its early in-growth and graft survival
• Less contracture
• Thicker and the density of elastic fibers is higher than that of
preputial skin and will probably therefore be more resistant to
mechanical weakening over time (Thick elastin rich epithelium)
48. Flaps
• Random flap (No identifiable vessels at its base, its survival
depends upon dermal and intradermal plexuses and ratio of
length to width
• Axial flaps (have an identifiable vessels at their base)
Musculo-cutaneous flaps
Fascio- cutaneous flaps
49. McAninch flap (Penile circular fasciocutaneous skin flap)
• provides an adequate length (usually 13–15 cm) of hairless genital
skin that can be used throughout the entire anterior urethra
Singapore flap / Perineal artery flap / Pudendal medial thigh skin flap
• type of fasciocutaneous flap used in complex proximal stricture
• This is a vascularised flap that can be transferred across trans-
sphincteric segment of urethra where free grafts have poor take and
where a muscle flap is too bulky
Gracilis muscle flap
• based on medial circumflex femoral artery (branch of profunda femoris
artery) and obturator branch of femoral artery
• Gracilis is accessory thigh adductor and knee flexor
50. STAGED URETHROPLASTY
• Described in 1914 by Russell
• Refined and popularized by Johanson and later modified by
Turner-Warwick, Blandy, Leadbetter, and Gil-Vernet, Schreiter,
Mundy
• Concept of exposing the diseased urethra to the outside world
(Marsupialization of the diseased urethra), thus allowing
inflammation and infection to subside before undertaking an
extensive urethroplasty (delayed reconstruction)
51. Indications for staged urethroplasty
• Strictures that are associated with chronic inflammation,
radiation, spinal cord injuries, spina bifida, fistula, false
passage, urethral stones, urethral diverticula, abscess, and
failed prior repair
52. BUCCAL MUCOSA URETHROPLASTY FOR ADULT
URETHRAL STRICTURES
• Buccal mucosa graft (BMG) was first described for urethral
reconstruction by Humby in 1941
• Standard bulbar urethroplasty using buccal grafts should have a
lifetime success rate approaching 92%
• BMG may offer advantages over genital skin, with fewer cases
of penile scarring, penile/ glans torsion, and chordee. BMG also
may offer an inherent resistance to LS
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
53. • Uses of buccal grafts in two places-
• MC for ventral-onlay buccal urethroplasty for bulbar stricture
• Less commonly use buccal grafts to augment an inadequate
urethra plate during first stage Johanson urethroplasty, usually
for penile stricture (BMG as a dorsal onlay, if urethral plate and
penile skin is inadequate and 3 cm urethral plate for
tubularisation is not obtain in second stage)
• Buccal-augmented Johanson urethroplasty especially useful in
patients with lichen sclerosis and strictures after childhood
hypospadias repair
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
54. • In the penile urethra, most experts would place BMG dorsally. In
the bulbar urethra, many experts place it ventrally, or mix
ventral, dorsal and even lateral placement as the clinical
situation warrants
• Multiple studies have shown that both dorsal and ventral-onlay
BMG has good blood supply and mechanical support
• Barbagli et al. showed that success rates are equal between
dorsal and ventral BMG (85-100%)
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
55. • In patients with LS, Kulkarni proposed several criteria for
determining the appropriate surgical approach:
• One-stage repair patients should be <70 years with slight to
moderate LS should be seen on histology and only focal
involvement of the glans, penile skin, and meatus. Finally, a
visible/salvageable urethral plate is mandatory
• Otherwise, all other patients should undergo a two-stage repair
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
56. • Follow-up for VCUG and urinary catheter removal, usually after
7 days to 2 weeks
• If no extravasation occurs, the catheter will remain out. If
extravasation is found, a 14 or 16 French coudé catheter is gently
replaced, and the VCUG will be repeated in another week
• Follow-up at 4, 8, and 12 months with questioning for obstructive
voiding symptoms, uroflow, and a PVR measurement
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
57. OVERVIEW OF URETHRAL STRICTURE M/M
Urethral stricture type Surgical management
Bulbar Ventral or dorsal buccal mucosa onlay urethroplasty
Penile First-stage Johanson with or without buccal grafts in
first stage
Alternatively, dorsal onlay buccal urethroplasty
Pan First-stage Johanson with or without buccal grafts in
first stage
Alternatively, double dorsal buccal onlay urethroplasty
versus mixed techniques of buccal and
Fasciocutaneous urethroplasty
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
58. FLOW CHART OF SURGICAL STEPS IN BULBAR
URETHROPLASTY
Mundy et al BJUI 2010
59. FLOW CHART OF SURGICAL STEPS IN PENILE
URETHROPLASTY
Mundy et al BJUI 2010
60. M/M OF PANURETHRAL STRICTURE
• Main causes of panurethral strictures are previous
catheterization, urethral surgery, and lichen sclerosus
• Laying-open of the urethra (two-stage surgery)is better in-
- Significant narrowing with unsalvageable urethral plate
- Multiple failed previous repairs
- Stricture associated with complications like abscess and stone
- Complex stricture associated with adverse local conditions,
such as extensive scarring, fistula or infection
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
61. Panurethral strictures are considered difficult to treat due to several
reasons-
• Long length of narrowing/stricture
• Insufficient donor tissue for flap and graft
• Significant spongiofibrosis, poor bed for graft especially in
penile urethra
• Frequent association with lichen sclerosus
• Association with complications
62. Using flap for reconstruction-
McAninch flap (Penile circular fasciocutaneous skin flap)
• most well-described and popular
• reliably provided 12-15 cm of length for reconstruction
• major advantage - its versatility, since it can be used in all areas of
urethra from the membranous area to the meatus
Q-flap
• modification of the McAninch flap and is so called because it
incorporates an additional midline ventral longitudinal penile extension,
thus resembling the letter Q
• Provided a pedicled strip of skin with a mean (range) length of 17 cm
(15-24)
• Provides longest vascularised skin pedicle for single stage urethroplasty
• Hairless, versatile and reliable
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
63. • Flaps should not be >20 mm wide when performing onlay
reconstruction to prevent pseudodiverticulum formation
• After the flap the urethral lumen should be approximately 26F in adults
Biaxial epilated scrotal flap
• For reconstruction of the whole anterior urethra from the
bulbomembranous portion to the meatus, 20 × 2.5 cm central skin flap
drawn on the biaxial scrotal flap that is extended on the anterior and
posterior scrotal faces
• Indicated where penile skin is of poor quality due to repeated
traumatic and infectious processes caused by urine collection devices
(like in men with paraplegia)
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
64. • Although flaps can be applied dorsally or ventrally, it is generally
believed that the results in terms of postvoid dribbling of urine,
ejaculatory dysfunction, and flap outpouching or
pseudodiverticulum formation are better with dorsal flap
placement
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
65. Using grafts for reconstruction-
• Most popular method of urethroplasty
• Gupta et al. described dorsal graft placement by a ventral sagittal
urethrotomy and minimal access perineal approach (BJUI 2004)
• Kulkarni et al. reported a new dorsal onlay graft technique called the
one-sided anterior urethroplasty (BJUI 2009)
• LS is a skin disease, any skin graft used for repair may also become
diseased in due course and therefore skin graft should be avoided in
• Dorsal graft placement, especially in the pendulous urethra, is
associated with better results as compared to ventral graft placement
(Dubey et al)
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
66. Using combined tissue transfer techniques for reconstruction
• Sometimes sufficient length of skin may not be available
especially in circumcised men or men with LS to make a long
flap. Therefore, a good treatment option is combining a (shorter)
flap with a graft with the graft placed proximally in the bulbous
urethra
Indian Journal of Urology, Jul-Sep 2011, Vol 27, Issue 3
67. Two-stage urethroplasty
• Most anterior urethral strictures managed with single-stage but 10%
patients have at least one complicating factor that precludes safe one-
stage surgery
• One-stage reconstruction should be done only if stricture caliber is
>6Fr and it appears feasible that the urethral plate would accept a flap
or graft as an onlay (Dubey et al)
• First-stage - creation of a urethrostomy proximal to the coronal margin
• Second stage - tubularization of the urethra distal to the urethrostomy
created in the first stage
• Urinary diversion via a perineal urethrostomy avoids continuous
urine extravasation into the corpus spongiosum and facilitates
urethral tissue healing
68. M/M OF STRICTURE OF FOSSA NAVICULARIS
AND PENDULOUS URETHRAL STRICTURES
• Stricture of fossa navicularis is most often caused by lichen
sclerosus et atrophicus (LSA-BXO) and instrumentation
• Posthypospadius repair strictures differ from other anterior
urethral strictures because of the presence of more densely
scarred, immobile, hypovascular tissue, lack of spongiosum,
shortened penis, and chordee
• MCU is helpful in the evaluation of fossa navicularis and for
delineation of urethra proximal to impassable stricture
69. M/M OF FOSSA NAVICULARIS STRICTURE
Urethral dilatation- Simple stricture without much spongiofibrosis
• can potentially exacerbate the inflammatory process in LSA-BXO
stricture
Direct visual internal urethrotomy (DVIU)-
• Technically difficult in fossa navicularis and distal pendulous
strictures due to poor fulcrum and lack of leverage needed to
incise the scar
• This makes any cutting motion awkward, and inadvertent incision
into the glans penis or corpora cavernosa can cause significant
hemorrhage and possibly erectile dysfunction
70. Dorsal or ventral meatotomy
• Urethra is incised and mucosal edges are sutured
• Ventral meatotomy produce a small degree of hypospadius and
splaying of urinary stream that is preferable to a dorsal incision,
which can result in significant bleeding by cutting into the
vascular glans penis
71. Reconstructive procedures- Flaps and Grafts
• Use versatile flap (distal penile transverse ventral fasciocutaneous island
flap) based on robust and broad dartos pedicle
• Glans wing glanuloplasty - flap is sutured to the urethra as ventral onlay
after splitting the glans. Glans wing is created and closed over the flap
• Glans cap glanuloplasty similar flap but preserving the glans
- Glans was elevated off the glanular urethra and onlay flap was tunneled
under the glans, bringing it out through the meatus and avoiding the
direct incision over the glans.
• With a severely diseased or flattened glans, creating glans wings is
preferable because this allows the excision of all fibrotic tissue with
anatomic resculpturing of the glans
72. MANAGEMENT OF PENDULOUS URETHRAL
STRICTURE
Direct visual internal urethrotomy
• Pansadaro reported a recurrence rate of around 84% for penile and
89% for penobulbar stricture after DVIU (J UROL 1996)
Anastomotic urethroplasty
• possible only when the stricture segment is very short (<1 cm) and
both the ends can be brought together without causing tension and
chordee
Substitution urethroplasty
• Graft or flap, whenever feasible should be used as onlay rather than
tube to avoid high rate of stricture recurrence
73. ANASTOMOTIC STRICTURE AFTER RADICAL
PROSTATECTOMY
• Dilatation
• Cold Knife incision
• Endoscopic resection of anastomotic stricture
• Optical urethrotomy and long term self dilation
• Urethral stent (UroLume)
• Anastomotic urethroplasty
• Tissue transfer (vascularised flap recommended over free grafts
b/c of blood supply of graft bed can be tenuous)
74. STRICTURE AFTER TRANSURETHRAL
RESECTION
• Post –TURP strictures occur soon after surgery , usually within 6
months (UCNA 2002,417-27)
• After TURP, stricture occur anywhere in urethra, but commonly
bladder neck contracture
• Classification of post-TURP strictures (iatrogenic posterior urethral
strictures) proposed by Pansadoro et al
• Type I only the bladder neck is strictured
• Type II the midpoint of the prostatic fossa is strictured
• Type III the entire prostatic fossa is replaced by stricture
• This classification appears to be functionally significant and cure rate
is more for type 2
75. • Dilatation
• Bladder neck incision
• Transurethral resection of bladder neck contracture
• Open repair (anastomotic urethroplasty)
76. POSTERIOR PELVIC FRACTURE URETHRAL
DISTRACTION DEFECT (PFUDD)
• Bulbomembranous junction is the weak spot at which posterior urethra
is prone to injury
• Delayed management of posterior urethral distraction defects:
- Endoscopic procedures and open surgical repairs
• Procedure selection will be dictated by the nature of the urethral
defect (obliterative or non-obliterative), length of the defect, presence
of complicating factors (eg, urethral cavitation, fistulae)
• Generally, a period of 3 to 6 months is allowed to pass following the
initial injury and SP tube placement. This allows for the resorption of
the retropubic hematoma and descent of the bladder and prostate
77. Open urethoplasty (Perineal anastomotic urethroplasty):
• One stage anastomotic repair
• Through a perineal incision the urethra is circumferentially mobilized
and released from its posterior attachments to the perineal body
• Further circumferential mobilization of the distal urethra as far as the
suspensory ligament of the penis (2-3 cm, 8%)
• Separation of the proximal 4 to 5 cm of the corporal bodies beginning
at the level of the crus distally, dissecting in the relatively bloodless
plane between them (1-2 cm, 41%)
• Inferior pubectomy A 1.5 to 2 cm wide wedge of bone can be excised
from the inferior surface of the pubis exposed by corporal separation
(1-2 cm, 28%)
• Supra-crural re-routing urethra can be re-routed around the lateral
surface of a corporal body (1-2 cm, 23%)
• Excellent with success rate >90%
78.
79. Abdominoperineal approach
• involves both perineal and retropubic exposure of the urethra and
prostate with removal of a segment of pubic bone to facilitate
exposure.
Indication
• to improve visualization
• to facilitate the removal of fistulous tracts and periurethral
epithelialized cavities, the excision of scar tissue at the prostatic apex
• performance of a tension-free anastomosis
