Male urethral strictures - Treatment

Indications for consultation with other specialists

Occurs during the treatment of urethral strictures in patients with serious concomitant diseases that may affect the results of treatment of the stricture disease. These include diabetes mellitus, spinal cord diseases, severe concomitant infections, etc.

Non-drug and surgical treatment of urethral stricture in men

Treatment options for urethral strictures include:

1. observation;
2. bougienage;
3. internal optical urethrotomy;
4. resection of the urethra and urethrourethroanastomosis;
5. resection of the urethra and anastomotic plastic surgery;
6. substitution urethroplasty.

The first three approaches to treating urethral stricture in men are not curative. Observation is performed in patients with:

1. the absence or small number of symptoms that bother the patient;
2. maximum urine flow rate of more than 12 ml/s;
3. insignificant amount of residual urine (<100 ml);
4. absence of recurrence of infectious diseases of the urinary tract;
5. normal status of the upper urinary tract.

The proportion of patients meeting these criteria among men with strictures is about 3-4%; they require annual lifelong monitoring.

Bougienage

Bougienage is the oldest palliative method of invasive treatment of urethral stricture in men, considered as a periodically repeated and, as a rule, lifelong treatment. Discontinuation of bougienage contributes to the return of symptoms and objective signs of the disease, i.e. clinical progression of the disease.

The initial stage of bougienage is the most difficult, since gradual and repeated dilation of the urethra must be bloodless. The appearance of urethrorrhagia is an unfavorable sign indicating a new rupture of the mucous membrane.

Indications for bougienage:

• short strictures;
• long (up to 5-6 cm) strictures with uniformly narrowed lumen;
• absence of acute inflammation of the urethra;
• the possibility of inserting bougies without damaging the mucous membrane (urethrorrhagia);
• patient's refusal of surgical treatment of urethral stricture in men;
• somatic weakness of the patient with a high risk of complications during surgery;
• absence of complications from the kidneys and urinary tract;
• good compliance, i.e. subjective tolerance of probing.

Bougienage requires patience and accuracy from the patient and the doctor; the patient can be taught self-bougienage.

Internal optical urethrotomy Most modern urologists admit that internal optical urethrotomy is equivalent in its effectiveness to bougienage: 50% of patients after internal optical urethrotomy have such a progression of symptoms within 2 years that they require open surgery. It should also be taken into account that after internal optical urethrotomy, at least 3-6 months of bougienage is required, starting with several times a day and then reducing to 1-2 times a week. Experience has shown that the ineffectiveness of the first internal optical urethrotomy, manifested by an early relapse (after 2-3 months), as a rule, makes the second, and especially the third internal optical urethrotomy futile.

Currently, generally accepted indications for internal optical urethrotomy include:

1. short (<1.5 cm) traumatic strictures of the bulbar urethra;
2. even shorter (<1 cm) traumatic penile strictures of the urethra.

Internal optical urethrotomy can be successful only with minimal spongiofibrosis, when the dissection can reach normal spongy tissue, while with deep spongiofibrosis, relapse is inevitable.

Dissection of the stricture with a cold knife or laser gives identical clinical results. Removal of the catheter is advisable within 3-5 days. As studies have shown, a longer stay of the catheter in the urethra does not lead to a decrease in the frequency of relapses. Patients after internal optical urethrotomy and bougienage need monitoring of the urine stream (UFM) for life, since relapses, the maximum of which occurs in the first 2 years, occur after this period - after 5-10 years and later.

Attempts to improve the results of endoscopic dissection of urethral stricture by installing stents have not led to greater success. Stents have proven ineffective in severe spongio- and periurethral fibrosis: fibrous tissue grows into the internal space of the stent. Even with successful stenting, patients still have symptoms of urinary stasis, dribbling after urination, dysuria, impaired ejaculation and orgasm, signs of an infectious disease, discomfort and even pain in the stent area were added.
It is important to emphasize that the choice of treatment for urethral stricture in men in favor of a palliative approach should come primarily from the patient and less often from the doctor (only in the case of somatic weakness and a short life expectancy of the patient).

Experience shows that internal optical urethrotomy or bougienage can be implemented as a first step in the treatment of urethral tricture in men in approximately 10% of patients.

Resection of the urethra with end anastomosis can also be performed in case of a longer (2-4 cm) stricture of the bulbar urethra. If the distal part of the urethra from the stricture has a normal structure and elasticity, there will be no tension of the urethra in the anastomosis, which will ensure the success of the operation. However, if the penile urethra is affected by spongiofibrosis or the bulbar stricture is recurrent, then the circular urethra-retroanastomosis will have excessive tension, which will lead to a relapse of the stricture. At the same time, a wider mobilization of the penile urethra to reduce tension in the anastomosis will contribute to shortening of the penis or a decrease in the erectile angle (the angle between the axis of the penis and the anterior abdominal wall).

To avoid such complications, after resection of the urethra (2-4 cm), it is necessary to perform spatulation of its ends and connect the ends of the urethra only along the dorsal or ventral semicircle, after which the free semicircle is replaced with a flap (free or vascularized). This surgical technique is called resection of the urethra and anastomotic urethroplasty.

The effectiveness of this procedure, as well as resection of the urethra with urethrourethroanastomosis, is 90-95% with observation for 10 years.

The result of resection of the urethra depends on a number of conditions:

1. vascularization of the tissues of the urethra (mucous membrane and spongy body) after excision of scars;
2. the degree of tension and the accuracy of tissue alignment in the anastomosis (excessive tension causes ischemia of the anastomosis, which leads to recurrence of the stricture);
3. sufficient density of the anastomosis zone presentation to the surrounding bed tissues (perimeter emptiness causes the development of stricture recurrence, and excessive density of presentation causes urethral fibrosis and compression of the urethra);
4. healing of perineal wounds;
5. thoroughness of hemostasis;
6. balance between granulation growth and the rate of epithelialization;
7. wound conditions (infectious factors contribute to the divergence of the edges of the urethra and recurrence of stricture);
8. reliability of bladder urine derivation.

The current understanding of the role of the urethral catheter in urethral resection is based on the recognition of the fact that the indwelling catheter itself is a potential source of penile and bulbar stricture formation due to provocation of infectious disease, inflammation and fibrosis. On the other hand, there is no absolute dependence between the healing of the urethral wound and the duration of the catheter, i.e. the duration of catheterization does not affect the outcome of the end anastomosis.

Thus, an “ideal” resection with end-anastomosis may not require a urethral catheter. Optimal urine drainage will be provided by a cystostomy for 10-12 days; by this time, epithelialization of the anastomosis is complete. A urethral catheter may be used as an additional means of hemostasis for the urethral wound; in this case, it is removed after 24 hours.

In anastomotic urethroplasty, the catheter plays an important role as a flap stabilizer for its tight contact with the bed tissues.
Resection of the urethra with anastomosis is the best way to treat urethral stricture in men, however, it is unacceptable for penile lesions, even extremely short ones, because it will be associated with shortening and curvature of the penis.

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Substitution urethroplasty

Substitution urethroplasty is the most complex operation, since many controversial issues arise during its implementation.

Indications for choosing replacement urethroplasty:

• long (>2 cm) strictures of the bulbous urethra;
• strictures of the penile urethra;
• strictures of the glans urethra.

The first stage of surgical treatment of urethral stricture in men is longitudinal urethrotomy on the ventral or dorsal surfaces. After this, a decision is made on the advisability of using the urethral "track" for flap plastic surgery or another option when the "track" must be excised, and then the urethral reconstruction becomes circular.

In addition, the choice of technique for urethral reconstruction depends on:

• from the localization of the urethra (capitate, penile bulbous);
• from the length of the stricture;
• from the condition of the skin itself on the penis, scrotum, perineum;
• from the presence of complications accompanying stricture (acute urethritis, fistulas, infiltrates, stones, etc.);
• from the experience of a urologist.

It is important to note that the treatment of urethral strictures in men (glans, penile, and long strictures of the bulbous part of the urethra) has its own technical features.

Strictures of the urethromeatus and navicular fossa

Strictures of the urethromeatus and navicular fossa are rarely congenital. They are usually associated with iatrogenic trauma (instrumental manipulations), but the most common cause is obliterating xerotic balanitis, which affects not only the skin of the foreskin and glans, but also the urethromeatus with the navicular fossa and even part of the penile urethra.

Surgical treatment of urethral stricture in men is carried out using the methods of Blendy, Coney, Brannen, Desi and Devin. The first four methods give good functional results, but a poor cosmetic effect - retraction of the external opening of the urethra. Devin's method provides a good cosmetic result, but it is not applicable to sclerotic atrophic lichen.

The general consensus is that Jordan's technique using a transverse vascularized cutaneous flap from the distal penile skin gives the best results, including cosmetic ones.

It is important that in case of capitate strictures, conservative tactics (bougienage) do not produce any effect; the earliest possible plastic surgery is indicated.

Penile strictures

The best way to treat urethral stricture in men is Orendi's vascularized skin island flap, a relatively simple and reliable one-stage technique. When there is insufficient skin in the genital area or it is scarred, it is possible to use the vaginal membrane of the testicle, cut out as a rectangular flap with preservation of the vascularized base.

The effectiveness of the above techniques is 85-90% or more in the absence of complications. In cases of penile skin deficiency, a number of researchers recommend using free extragenital skin grafts taken from the back of the ears as a flap. This skin is easily taken, has a small layer of fat, is thin, which allows it to take root well after transplantation. The disadvantage is that this skin is not always enough for plastic surgery.

In the last decade, there has been interest in plastic surgery of the urethra using the mucous membrane of the lip or cheek as free transplants. Extensive literature data and our own experience show that buccal mucous membrane can be successfully used to replace one of the walls of the urethra in both single-stage and multi-stage plastic surgery. In the latter case (circular reconstruction of the urethra), buccal mucous membrane is the material of choice.

Two-stage operations are performed when the urethral "track" has to be excised and its place can be taken by the buccal mucosa; at stage II, the surrounding skin is folded into a tube according to Brown. Unfortunately, one-stage circular reconstruction is associated with a significantly higher (up to 30%) failure rate. This is why two-stage, and sometimes three- or four-stage plastic surgeries are necessary to guarantee the success of the final result.

Long bulbous strictures

Experience shows that there is no better plastic material for urethroplasty than the patient's own urethra. Within 5 years after cutaneous urethroplasty of the bulbous urethra, up to 15% of restenoses occur, and after end anastomosis - less than 5%. That is why, where possible and acceptable, it is necessary to perform a resection with anastomosis. In cases where this is not possible, it is advisable to replace the wall of the bulbous urethra with either a vascularized island of penile skin, taken transversely on the ventral surface, or buccal mucosa, placed in the dorsal position according to Barbagli (1994).

Complex inflammatory strictures of the bulbous section of the urethra with its complete excision are reconstructed by three-, four-stage operations using a circular technique. Buccal mucosa increased the success rate of treating complex bulbous strictures of the urethra to 90%, even in cases of circular urethroplasty. The main condition is good fixation of the free flap to healthy vascularized underlying tissue. Thus, circular plastic surgery in one stage in the bulbous section is possible and with a full effect, but in the penile section the same technique will lead to inevitable complications.

Usually, preference is given to suturing the tissues of the urethra with vascularized flaps using separate absorbable threads, and with free flaps using a continuous suture. The urethral catheter is removed on the 6th-7th day with vascularized flaps, and on the 14th-20th day with free flaps.

The question often arises: which is better - a free or vascularized flap. It is believed that theoretically it is better to use a vascularized flap, but in practice the level of unsuccessful operations and complications is the same when compared (15%).

If we talk about what is better to use skin, vaginal membrane or buccal mucosa, it is worth noting that "wet" and elastic tissue, without infection and hair follicles, is definitely better. In this sense, the vaginal membrane and buccal mucosa have advantages, and in addition, they are easy to take and manipulate. Not all authors recommend using scrotal skin and split skin flaps for plastic surgery.

Long strictures and obliterations of the prostatic urethra

Long strictures and obliterations of the prostatic urethra are the result of prostate surgery (adenomectomy, TUR, including the use of high modern technologies) and complicated surgeries for traumatic membranous strictures of the urethra.

In these cases, endoscopic circular excision of the scar tissue of the prostate and bladder neck is justified, if only this is technically possible.

In case of long obliterations (>2 cm), open surgery is required in the form of resection of the scar zone and urethrocystoanastomosis, when the bulbar part of the urethra is connected to the neck of the urinary bladder.

At the time of this operation, the patient usually already has some degree of damage to the bladder neck and urethral sphincter, so after excision of scar tissue and urethrocystoanastomosis there is a high risk of postoperative urinary incontinence.

In order to prevent it, an original technique of urethrocystoanastomosis has been developed, which has reduced the frequency of urinary incontinence to 2-3%. It goes without saying that after urethrocystoanastomosis, a shortening of the penis occurs. The next stage of plastic surgery involves its straightening by proximal displacement of the urethromeatus, then circular plastic surgery of the penile section of the urethra is performed using known methods.

Approximate periods of incapacity for work

When performing palliative treatment for urethral stricture in men, the patient's ability to work is not impaired, even when performing internal optical urethrotomy on an outpatient basis.

The optimal length of a patient's stay in hospital when undergoing open surgery on the urethra is a maximum of 9-14 days.

Temporary disability after discharge from hospital is on average 14-20 days.

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Further management

Patients with urethral stricture, including those after open surgery, require lifelong monitoring by a urologist due to the real risks of the disease and its complications. The first five years after reconstructive plastic surgery are especially important. During this time, it is necessary to monitor urination and urinary tract and genital infections, as well as sexual function and fertility in some patients.