What is Urethral stricture?
Refers to anterior urethral disease, or a scarring process involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis).
In contrast, posterior urethral “strictures” are not included in the common definition of urethral stricture. Posterior urethral stricture is an obliterative process in the posterior urethra that has resulted in fibrosis and is generally the effect of distraction in that area caused by either trauma or radical prostatectomy
Important causes of urethral stricture?
- Trauma - most common cause
- Inflammatory strictures - gonorrhea (rare)
- Lichen sclerosus - behave like inflammatory strictures.
Treatment of urethral stricture?
Dilatation - The goal of this treatment, a concept that is frequently forgotten, is to stretch the scar without producing more scarring. The least traumatic method to stretch the urethra is to use soft techniques over multiple treatment sessions.
Location of internal urethrotomy?
Although the most common location for the incision in the past has been at the 12-o’clock position, it should be realized that there is little corpus spongiosum dorsally there in the area of the bulbous urethra. Therefore, incisions at 10 o’clock and 2 o’clock (± 6 o’clock) or some minor variation thereof have been described as a means of ensuring that the incision extends through the depth of the scar into healthy spongy tissue
Indication of internal urethrotomy?
Strictures at the bulbous urethra that are less than 1.5 cm in length 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.
Methods of open reconstruction?
Excision and Reanastomosis.
Principles of excision and reanastomosis?
- Area of fibrosis is totally excised
- Urethral anastomosis is widely spatulated, creating a large ovoid anastomosis;
- Anastomosis is tension free
Length that can be repaired in reanastomosis?
1-2 cm are generally easily excised with reanastomosis. In some cases, strictures as long as 3 to 5 cm can be totally excised and a primary reanastomosis of the anterior urethra performed.
As a rule, the closer the stricture is to the membranous urethra, the longer it can be and still be reconstructed with anastomotic techniques.
Grafts for urethral stricture?
- Full-thickness skin graft
- Bladder epithelial graft
- Oral mucosal graft
- Rectal mucosal graft.
- Oral mucosal grafts can be taken from the cheek (buccal), the lip (labial), and the undersurface of the tongue (lingual).
- Split-thickness skin grafts have been used for staged anterior urethral reconstruction
Onlay or tubularized graft?
Onlay procedures (graft or flap) are attended with a higher success rate than tubularized grafts or tubularized skin islands
Tubularized grafts and skin islands should therefore be avoided, if possible.
When tubularized segments cannot be avoided, the length of these segments can be limited by combining aggressive mobilization and excision.
Without question, tubularized flaps provide better results than tubularized grafts.
Unique feature for BXO urethral stricture?
Because LS-BXO is a skin condition, the use of skin as a flap, single-stage graft, or staged graft does not preclude involvement of the skin with the inflammatory process.
Thus surgeons at a number of centers believe that staged oral graft techniques should be employed for reconstruction of strictures associated with LS-BXO.
Principles of urethroplasty? [Brandes]
- Define the healthy urethra above and below the site of the injury of the surrounding fibrosis and perform a spatulated end-to-end anastomosis.
- Tension free anastamosis
What is “transperineal progression approach"?
This sequence of mobilization proceeding to crural separation when necessary, proceeding to inferior wedge pubectomy when necessary,proceeding ultimately to re-routing of the urethra around the shaft of the penis when necessary,is known as the “transperineal progression approach”.
What is Gapometry index?
- Length of urethral gap divided by the bulbar urethral length.
- Bulboprostatic urethral gaps shorter than a third of bulbar urethral length are usually corrected by a simple perineal operation. For longer gaps an elaborated perineal or transpubic procedure is usually done.
Types of Urethroplasty?
- Dorsal inlay buccal mucosal graft (Asopa) urethroplasty for anterior urethral stricture - when the urethral plate is ≥1 cm in width.
? Barboglie jQuery112403006440077063741_1527441752613
Prof Anthony Mundy, also called Tony Mundy
Complex urethral reconstruction, Reconstructive urology
What diameter to augment? diameter to replacejQuery112403599521018854652_1532392899759
- ? if a guidewire can be passed - can be augmented ?
- Upto 16F diameter, does not need further treatment
If complete occlusion, ? Perineal Urethrotomy and two procedures ??