Urethral Stricture Repair

 Unfortunately, many strictures are long, have dense scar tissue, or have failed either dilation or VIU.  Those strictures are best managed by open urethroplasty.  Repeated dilation or incision of a urethral stricture causes scar tissue proliferation and decreases the success rate of the inevitable open surgical repair.  Urethroplasty is a surgical procedure where we incise the skin over the scarred urethra, usually below the scrotum, and expose and reconstruct the urethra.  Urethral reconstruction may be accomplished by either removing the scar tissue and bringing the remaining urethral ends together, or rebuilding the urethra with tissue taken from some other site in the body.  The lining of the inside of the mouth is the most common site where tissue is taken for urethroplasty.  This tissue, called buccal mucosa, is the optimal thickness, produces good results, and the donor site in the mouth heals well, usually leaving no lasting effect.

Overview

A urethral stricture is an area of scar tissue that causes the urethra, or urine tube, to narrow.  Urethral strictures begin with an injury of some type.  The mechanism of that injury may be known or unknown.  An example of a known injury is a car crash causing a pelvic bone fracture and tearing of the urethra.  Many urethral strictures do not have a known cause, however.  A patient may have hit the underside of the scrotum on a bicyle seat at a young age for example.  The injury may not have been severe enough to seek medical attention, but may lead to scar that becomes a problem years later. 

Scar tissue all over the body contracts when it matures. A scar from a cut on ones arm may shrink over 6-12 months as the scar matures.  While good in many parts of the body, contraction of scar tissue in the urethra leads to narrowing of the urethral tube.  This can become so severe that a patient may not be able to urinate and may need to seek emergency treatment.

Treatment Options

Urethral strictures can be addressed by dilation, cutting of the scar tissue through a small telescope passed through the urine tube, or by making an incision in the skin over the urethra and rebuilding the damaged portion.

Urethral dilation is the least invasive and also the least effective treatment.  It is very useful, acutely when a patient is unable to urinate and can be used with some success on short urethral strictures.  Cutting the stricture through a small telescope passed through the urethra, or visual internal urethrotomy (VIU), is more effective than simple dilation, but must be performed in the operating room.  VIU is also most successful in short soft urethral strictures that have not recurred in the past.

Urethroplasty (Most Definitive Repair)

Most patients with urethral strictures in our practice have long dense strictures that require open repair.  We perform buccal mucosa urethroplasty as described above, pedicle flap onlay urethroplasty and anastomotic urethroplasty where the scar containing portion of the urethra is removed and the two ends are sewn together.  We usually determine which of these procedure to perform during the evaluation in our office.  That work-up usually involves an x-ray test called a retrograde urethrogram (RUG) and by looking into the urethra with a small telescope called a  cystoscope.  There are times, however, when situations that can only be determined in the operating room require a change in the planned procedure.

Urethroplasty is performed under magnification and is a delicate surgical procedure.  All our urethroplasty procedures are performed in the Main operating rooms at Vanderbilt Hospital and involve an overnight hospital stay.  After surgery, patients spend about 1.5 hours in the recovery room before returning to the room where they will spend the night.  Please review the Overnight Surgical Stay page for further details.

Urethroplasty patients leave the hospital with a urethral catheter through the penis.  The duration of catheterization varies with the type of surgery performed.  Most patients require a catheter for 2 to 3 weeks.  Specific post-op instructions for urethroplasty patients can be obtained by clicking here.  Patients return to the office one month after the catheter is removed in order to assess how well the urethra has remained open.  Patients should come to the office with a full bladder and will be asked to urinate into a special machine that determines the urinary flow rate and plots a flow rate curve.  We will also have the patient fill out a questionaire about their urinating symptoms (AUA/IPSS).  Most patients return again for reevaluation 3 months later.  Further follow-up is determined by the findings at the one month and three month visits.

This x-ray shows a substantial defect in the distal bulbar urethra.  The bladder and proximal urethra has been filled with x-ray contrast through a small tube into the bladder.  The radiologist has also filled the distal urethra with contrast by injecting backward through the penis. The defect between the two sides is dense scar tissue that must be removed in the operating room. The two good ends of the urethra are then sewn together.

Onlay Urethroplasty

The urethra has been opened in the midline and a nice buccal mucosa donor graft is being sewn over the defect.  A white urethral catheter can be seen under the graft.  Vascular muscle tissue seen to each side of the urethra will be closed over the graft providing oxygen and nutrients to the graft tissue for the 5 or so day period during which new blood vessels are growing into the buccal graft.

Anastomotic or End to End Urethroplasty 

Anastomotic (end to end) urethroplasty is seen here.  A green guidewire can be seen entering the opening (lumen) of each urethral segment.  We have removed the section of the urethra containing dense scar tissue.  Both ends of the urethra now have supple tissue with normal blood supply.  The blood visible on the right urethral segment indicates that the scar tissue has been removed and that the existing tissue has normal blood supply.  Removal of all scar tissue and preservation of blood supply are 2 of the 3 most important predictors of success.  The third important step to maximize the chance of success is putting the two ends together so that they are not under tension.  That was relatively easy to do in this case. The image from another operation shown below was taken after the first two sutures were placed connecting the back wall of each segment.  Eight sutures are typically used to bring the edges of the urethral lining together.

 Endoscopic Incision of Stricture

Patients often ask why we don't look into the urethra and cut the stricture.  We do.  The problem is that each time the scar tissure is cut, the body forms even more scar tissue than was present in the first place.  Research done by others has shown that repeated incision of urethral strictures decreases the chance of success when open urethroplasty is performed.  We will often give incision of a stricture one chance, but if the stricture is longer than one centimeter and has been previously incised, the best results are achieved by open urethroplasty.

This photo demonstrates a green safety guidewire through the stricture.  The LASER fiber with the blue sheath is shining red LASER light on the top of the stricture. The LASER light will cut through the scar tissue opening the urethra.  Unfortunately, the body will likely  heal by forming more scar tissue.