Urethral strictures in men: treatment

Indications for consultation of other specialists

Occur in the treatment of urethral stricture in patients who have serious congenital diseases, which can affect the results of treatment of stricture. This includes diabetes, spinal cord diseases, severe co-infections, etc.

Non-drug and surgical treatment of urethral stricture in men

The treatment options for urethral stricture include:

1. observation;
2. bougie;
3. internal optical urethrotomy;
4. resection of the urethra and urethrourethanastomosis;
5. resection of the urethra and anastomotic plastic;
6. replacement urethroplasty.

The first three approaches to the treatment of urethral stricture in men are not curing. Observation is performed in patients with:

1. absence or small number of disturbing sick symptoms;
2. the maximum flow rate of urine is more than 12 ml / s;
3. an insignificant amount of residual urine (<100 ml);
4. no recurrence of infectious diseases of the urinary tract;
5. normal status of the upper urinary tract.

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

Buzhirovanie

Buzhirovanie - the oldest palliative method of invasive treatment of urethral stricture in men, considered as a recurrent and, as a rule, lifelong medical treatment. Termination of the bougie facilitates the return of symptoms and objective signs of the disease, i.e. Clinical progression of the disease.

The initial stage of bougie is the most difficult, since a gradual and repeatedly repeated dilatation of the urethra should be bloodless. The appearance of urethrorrhagia is an unfavorable sign indicating a new rupture of the mucosa.

Indications for bougienage:

• short strictures;
• Long (up to 5-6 cm) strictures with a uniformly narrowed lumen;
• absence of acute inflammation of the urethra;
• the possibility of holding buzha without damaging the mucous (urethrorrhagia);
• refusal of the patient from surgical treatment of urethral stricture in men;
• somatic weakness of the patient with a high risk of complications during the operation;
• absence of complications from the kidneys and urinary tract;
• good compliance; subjective tolerance of bougie.

Buzhirovanie requires patience and accuracy from the patient and the doctor; the patient can be taught self-immolation.

Internal optical urethrotomy Most modern urologists recognize that internal optical urethrotomy is equal in its effectiveness to bougie: 50% of patients after internal optical urethrotomy within 2 years have such a progression of symptoms requiring open surgery. It should be taken into account and that. That after internal optical urethrotomy requires at least 3-6 months of bougie starting from several times a day and then cutting down to 1-2 times per week. Experience has shown that the ineffectiveness of the first internal optical urethrotomy, manifested by early relapse (in 2-3 months), as a rule, also infects the second, and even more so, the third internal optical urethrotomy unpromising.

At present, to the generally accepted indications for internal optical urethrotomy include:

1. short (<1.5 cm) traumatic strictures bulboznogo department of the 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 succeeds in reaching a normal spongy tissue, with deep spongiofibrosis a relapse is inevitable.

The dissection of stricture with a cold knife or laser produces 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 optic urethrotomy and bougie need to monitor the urinary stream (UFM) for life, since relapses, the maximum of which occurs in the first 2 years, occur after this period - 5-10 years later.

Attempts to improve the results of endoscopic dissection of urethral stricture by stent placement did not lead to greater success. Stents were ineffective in severe spongio- and periurethral fibrosis: fibrous tissue sprouts into the internal space of the stent. Even with the success of stenting, the patients had symptoms of stagnation of urine, dribbling after a micture, dysuria, ejaculation and orgasm, signs of an infectious disease, discomfort and even pain in the stent area.
It is important to emphasize that the choice of the method of treatment of urethral stricture in men in favor of the palliative approach should primarily come from the patient and less often from the doctor (only in case of somatic weakness and short life expectancy of the patient).

Experience shows that internal optical urethrotomy or bougie can be realized as the first step in the treatment of urethral urethral stricture in men in approximately 10% of patients.

Resection of the urethra with terminal anastomosis can be performed with a longer (2-4 cm) stricture of the bulbose department of the urethra. If the part of the urethra distal from the stricture has a normal structure and elasticity, then the tension of the urethra in the anastomosis will not be, which will ensure the success of the operation. However, if the penile section of the urethra is affected by spongiofibrosis or bulbous stricture is recurrent, the circular urethro-retroanastomosis will have excessive tension, which will lead to a recurrence of the stricture. At the same time, a wider mobilization of the penile section of the urethra to reduce tension in the anastomosis will help to shorten the penis or reduce the angle of the penis (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), sputulate its ends and connect the ends of the urethra only along the dorsal or ventral semicircle, after which the free semicircle should be 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 urethrourethanastomosis. Is 90-95% when observed for 10 years.

Result of resection of the urethra depends on a number of conditions from:

1. vascularization of the tissues of the urethra (mucous membrane and spongy body) after excision of scars;
2. the degree of tension and accuracy of the comparison of tissues in the anastomosis (excessive tension causes ischemia of the anastomosis, which leads to a recurrence of the stricture);
3. sufficient density of presentation of the anastomosis zone to the surrounding tissues of the bed (perimeter void causes the development of a stricture recurrence, and excessive presentation density - urethral fibrosis and compression of the urethra);
4. healing of perineal wounds;
5. thoroughness of hemostasis;
6. balance between the growth of granulations and the rate of epithelialization;
7. the state of the wound (the infectious factor contributes to the divergence of the edges of the urethra and the recurrence of the stricture);
8. reliability of bubble derivation of urine.

The modern understanding of the role of the urethral catheter in resection of the urethra is based on the recognition that a permanent catheter is in itself a potential source of formation of penile and bulbous strictures due to provocation of an infectious disease, inflammation and fibrosis. On the other hand, between the healing of the urethra wound and the length of the catheter's stay, there is no absolute dependence, i.e. The duration of catheterization does not affect the outcome of terminal anastomosis.

Thus, an "ideal" resection with a terminal anastomosis may not need a urethral catheter. Optimal drainage of urine will provide cystostom for 10-12 days; by this time the epithelization of the anastomosis is completed. The urethral catheter can be used as an additional means of hemostasis for the urethra wound; in this case, it is removed after a day.

With anastomotic urethroplasty, the catheter plays an important role of the flap stabilizer for its intimate contact with the tissues of the bed.
Resection of the urethra with the application of anastomosis is the best way to treat urethra stricture in men, but at the same time it is unacceptable for penile lesions, even extremely short. Will be associated with a shortening and a curvature of the penis.

[1], [2], [3], [4]

Replacement urethroplasty

Replacement urethroplasty is the most difficult operation, because in the process of its implementation there are many controversial issues.

Indication for the choice of replacement urethroplasty:

• long (> 2 cm) strictures bulboznogo department of the urethra;
• stricture of the penile section of the urethra;
• stricture of the head of the urethra.

The first stage of surgical treatment of urethral stricture in men is longitudinal urethrotomy along the ventral or dorsal surfaces. After that they decide whether to use the urethral "path" for scrappy plastic or another option, when the "path" should be excised, and then the urethral reconstruction becomes circular.

In addition, the choice of techniques for the reconstruction of the urethra depends on:

• from the localization of the urethra (capitate, penile bulbose);
• from the extent of stricture;
• from a condition of a skin actually on a sexual member, a scrotum, a perineum;
• from the presence of complications accompanying the stricture (acute urethritis, fistula, infiltrates, stones, etc.);
• from the experience of the urologist.

It is important to note that the treatment of urethral stricture in men with capitate, penile and long strictures of the bulbose department of the urethra has its own technical features.

Structures of the urethromeatatus and scaphoid fossa

Structures of the urethromeatatus and scaphoid fossa are rarely congenital. They are usually associated with iatrogenic trauma (instrumental manipulation), but the most common cause is obliterating xerotic balanitis, affecting not only the skin of the foreskin and the head, but also the urethromeatatus with the navicular fossa and even part of the penile section of the urethra.

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

By all accounts, Jordan's plastic with the use of a transversal cutaneous vascularized flap of disgalic penile skin gives the best results, including cosmetic.

It is important that. That with cervical strictures conservative tactics (bougienage) do not give effect, it is shown as early as possible an earlier plastic.

Penile strictures

The best way to treat the urethral stricture in men - plastic skin by an isocular vascularized flap of Orendi - is a relatively simple and reliable one-step technique. When the skin of the genital area is not enough or it is scarly altered, it is possible to use the vaginal envelope 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. A number of researchers in cases of deficiency of the penile skin recommend the use as a flap of free skin extragenital grafts taken from the back of the auricles. This skin is easy to climb. Has a small layer of fat, thin, which allows it to get well after the transplant. The disadvantage is that. That this skin is not always enough for plastics.

In the last decade there has been an interest in the plastic of the urethra of the mucous lips or cheeks as free grafts. Extensive literature data and own experience show that the buccal mucosa can be successfully used to replace one of the walls of the urethra in both single-stage and multi-stage plastics. In the latter case (circular reconstruction of the urethra) buccal mucosa is the material of choice.

Two-stage operations are performed when the urethral "path" has to be excised and its place may be occupied by buccal mucosa; at the second stage, the surrounding skin is folded into the tube according to Brown. Unfortunately, circular reconstruction in one stage is associated with a significantly large (up to 30%) failure rate. That is why two-stage, and sometimes three-stage, four-stage plastic surgery is necessary for the guaranteed success of the final result.

Long bulbous strictures

Experience has shown that there is no better plastic material for urethroplasty than your own urethra. Within 5 years after dermal urethroplasty bulboznogo department of the urethra occurs up to 15% restenosis, and after terminal anastomosis - less than 5%. That's why there. Where it is possible and permissible, it is necessary to perform a resection with an anastomosis. In cases where this is not possible, it is advisable to replace the bulbous section of the urethra with a vascularized island of penile skin, transversely taken on the ventral surface, or buccal mucosa located in the dorsal position according to Barbagli (1994).

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

Usually preference is given to sewing the tissues of the urethra with vascularized patches with separate absorbable threads, and with loose flaps with a continuous suture. The urethral catheter with vascularized grafts is removed for 6-7 days, and for free - for 14-20 days.

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

If we talk about that. That it is better to use the skin, the vaginal membrane or buccal mucosa, it is worth noting that it is definitely better to have a "moist" and elastic tissue, without infection and hair follicles. In this sense, the vaginal membrane and buccal mucosa have advantages, and in addition, they are easily taken away and easily manipulated. Not all authors recommend using the scrotum skin and split skin grafts for plastic surgery.

Long strictures and obliteration of the prostatic urethra

Long strictures and obliteration of the prostatic section of the urethra are the result of operations on the prostate (adenomectomy, TUR, including with the use of high modern technologies) and complicated surgery for traumatic membranous strictures of the urethra.

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

With long obliteration (> 2 cm), an open surgery is necessary in the form of resection of the scar and urethrocystoanastomosis, when the bulbous section of the urethra is connected to the neck of the bladder.

At the time of this operation, the patient is already, as a rule, affected by the neck of the bladder 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, the original technique of urethrocystoanastomosis was developed, which reduced the incontinence frequency to 2-3%. It goes without saying that after the urethrocystoanastomosis, the penis appears shortened. The next stage of plastic surgery assumes its rectification by proximal movement of the urethromeatatus, then the circular plastic of the penile section of the urethra is performed by known methods.

Approximate terms of incapacity for work

When performing palliative treatment of urethral stricture in men, the patient's ability to work is not impaired, even with outpatient performance of internal optical urethrotomy.

The optimal length of stay of a patient in a hospital in the process of his open surgery on the urethra is 9-14 days maximum.

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

[5], [6], [7],

Further management

Patients with urethral stricture, including after open surgery, need lifelong monitoring in the urologist due to the real risks of the disease profession and its complications. Especially important is the period of the first five years after performing a reconstructive plastic surgery. At this time, control of urination and infection of the urinary tract and genitals, as well as in a number of patients for sexual function and fertility, is necessary.