Introduction. Etiology. Incidence 2/18/17

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1 Introduction Urethral stricture refers to narrowing of the urethral lumen from scar tissue. Usually used for anterior urethral disease Posterior Urethral strictures usually is a stenotic process after trauma or surgery. Bladder neck contracture or Pelvic fracture urethral distraction defect (PFUDD) Etiology Any process that cause injury to the urethral epithelium Usually as a result of trauma, infection and rarely congenital Incidence 0.6% in the U.S. male population in 2000 with a peak incidence of urethral stricture in men age 55 years. Between 2007 and 2012 an estimated 1.2 million patients sought medical care for stricture disease. Trauma to the urethra often is unrecognized until pt presents with symptoms Infection: STDs Lichen Sclerosis Chronic Inflammatory skin disease 1

2 Length : Average cm Penile and Bulbar: cm Membranous: cm Prostatic: 2-3 cm Anatomy Diagnosis and Evaluation Symptoms: Hesitancy Decreased forced stream Recurrent UTI Urinary retention Renal Insufficiency Other GU infection: Prostatitis, epididymitis Uroflow Diagnosis and Evaluation For an appropriate plan it is important to determine: Location Length Depth* Density (spongiofibrosis)* 2

3 Diagnosis and Evaluation Length and location: Cysto/Urethroscopy Retograde urethrograhpy (RUG) / VCUG Ultrasound Depth and Density: Deduced from physical exam Apperance on contrast studies Amount of elasticity on cystourethroscopy RUG/VCUG 3

4 Treatment In the past: reconstructive ladder Simple procedure first before moving to a more complex approach Both the patient and physician should discuss goal of treatment before treatment choice is made. Dilation Oldest and simplest treatment Goal is to stretch the scar Least traumatic method is to stretch the urethra with soft techniques over multiple treatment sessions. Dilating techniques: Urethral balloon Urethral dilators/sounds Efficacy rates can be equal to DVIU in selected patients (retrospective data) Internal Urethrotomy Incision done transurethral Classically done at 12 0 clock Cold knife, lasers Factor that contribute to success: Length <1.5cm Location: bulbous urethra No spongiofibrosis Primary vs Recurrent Single vs Multiple Time to stricture recurrence 4

5 Open Reconstruction AKA: Urethroplasty Types: Excision and Reanastomosis Graft or Flap reconstruction Staged urethroplasty Excision and Primary Anastamosis Gold standard for anterior urethral strictures 2cm? Technical points: Area of fibrosis is completely excised Urethra is widely spatulated Large ovoid anatamosis Tension FREE The closer the stricture is to the membranous urethra, the longer it can be reconstructed with anastomotic techniques 5

6 Longer Than 2cm? If EPA not possible then repair needs to consist of flaps, graft and/or combinations Ventral vs Onlay graft Placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique (Barbagli et al 2005) 6

7 Buccal 4cm x 2.5 cm It can stretch up 6cm Lingual 2 nd choice after buccal Grafts Lower lip Not recommended, too thin, too morbid Posterior Auricular Full thickness / Dermal graft 7

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9 Posterior Urethra MC: Related to pelvic fracture Pelvic Fracture Urethral Distraction Defect (PFUDD) If immediate exploration is not indicated, posterior urethral disruption can be managed in a delayed primary fashion. Primary realignment requires placement of a suprapubic tube at the time of initial injury, with realignment undertaken when the patient is stable. This usually takes place within 7 d when most patients are stable and most pelvic bleeding has resolved. Internal realignment aims to correct severe distraction injuries rather than prevent a stricture. Vesicourethral Distraction Defects AKA: Bladder neck contractures TX options: DVIU at 5 0 clock and 7 o clock and +/- Mitomycin SP tube Diversion Redo Vesicourethral Anastamosis Perineal vs Perineal / Abdominal Approah Patients will need AUS 6 months after successful patency due to urinary incontinence 9

10 Case Introduction 31 year old male presents to your office with voiding LUTS and clear urethral discharge Next step? 10

11 History PMH: Chlamydia 10 yrs ago, no hx urethral stricture, no hx of SI PSH: none Office eval Unremarkable physical exam Uroflow: Meds: None All: none FamHx: unremarkable Social Hx: denies toxic habits AUA-SS: 20/35 Treatment U/A: RBC: 0, WBC: 6-8, Bac: none Culture: no growth Buccal urethroplasty Urethral swab: negative for GC and chlamydia Cystoscopy: pinpoint stricture at bulbar urethra RUG: 2.5 cm stricture at bulbar urethra 11

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