1. Urethral Stricture Ali Bin Mahfooz, MD, FRCS(C)
King Faisal Specialist Hospital and Research Center, Riyadh

2. Urethral Reconstruction
Anatomy of urethra.
Mechanism of injury.
How did I do it, why?
Conclusion

3. Anatomy of urethra
Sound easy but in reality challenging!

4. Correct Treatment? Consideration: Length. Location. Diameter.
Patient desire.
Experience & treatment bias of urologist.

5. Surgical Treatment of Anterior Stricture
Bulbar:
Short (<2.5cm):
Excision & primary anastomosis (EPA).
Long (>2.5cm):
Graft “Penile skin, Buccal mucosa”
Penile skin flap
Hairless scrotal island flap.
Staged repair “meshed, buccal mucosa”

6. Surgical Treatment of Anterior Stricture
Penile:
Penile skin flap.
Buccal mucosa graft.
Staged repair.

7. Principle of anterior Urethral Stricture Repair
Transect urethra fully at stricture point.
Excision fibrotic urethra & spongy tissue.
Spatulate proximal & distal end.

8. Jorden et al on J uro 2004
207 patients with bulbar urethral stricture.
Age
All done by (EPA).
Etiology:
61% idiopathic.
17% straddle.
12% trauma.
10% Instrumental.
Stricture length:
Rang cm
Follow-up monthes

9. Jorden et al on J uro 2004
Cure defined as needing no further treatment and no indicating for dilatation.
97.7% no recurrence.
All failure in 1st 25 patients ??
3 patients no cure:
2 patients have stricture at anastomosis site → internal urethrotomy.
1 patient has recurrant stricture need monthly dilatation.

10. Jorden et al on J uro 2004 Complication: No. of patients Complication10
Febrile UTI 4 ED 2
Wound infection
Persistent pain

11. Summary: Anterior Urethral Reconstruction
EPA is extremely reliable with excellent outcome in patients with short bulbar stricture.
Complication are minimal.
Good long term results.
EPA is better than endoscopic procedure.

12. Posterior Urethral Stricture Reconstruction
Like repair of common bile duct.
Do it right, or leave it for expert.
Mechanism of injury:
Pelvic fracture:
5% incidence.
Higher in bilateral pelvic injury.

13. Posterior Urethral Trauma
Pelvic fracture 98%.
Blood at meatus 37-93%.
Scrotal hematoma.
Perineal hematoma.
Unable to void.
Bladder distension.
Unable to pass catheter.
High riding postate.

14. Classification of Prostatic Urethral Injury
Type I
Type II
Type III

15. Main Management
Primary realignment.
Delayed reconstruction.

16. Primary Realignment Limited associated injuries.
Optimal endoscopic equipment & fluoroscopy.
Hemodynamic stable.

17. S.Wolf J.Trauma (36-40) 36-40 2001 ER catheter & stenting (???)
10 patients, successful in 8 patients.
Realignment over a catheter.
Outcome:
Stricture 69%.
Impotence 44%.
Incontinent 20% wesber J. urol , 1982

18. Bartchet al J.urol 157( 499-505) 1992 Early realignment.
Half need urethrotomies
40% success at 3 years follow up.

19. Delayed Reconstruction
Suprapubic cystostomy.
Repair the defect at 3-4 monthes or after.
Associated with other injury.

20. Pre-op studies Urethrogram.
Cystogram + simultaneous up/down urethrogram.
Penile duplex U/S.
MRI

21. Intra-op High lithotomy. Midline perineal incision. Excise fibrosis.
Spatulation.
Epithelium to epithelium anastomosis 5-0 (maxon, PDS, Monocryl).
16Fr foley’s catheter 2-4 weeks.

22. Successful Points Step to achieve tension free anastomosis:
Good urethral mobilization.
Split scrotal bodies.
Partial pubectomy.
Re-route urethra.
Webster et al J.urol (1991).

23. Post op success Normal voiding. No dilatation.
No self cath/dilatation.

24. Deferred Urethral Repair
Author
Success
No of pt
Mundy 1996
88% 82
Turner-Warwick 1989
5y 95%
10y 93%
600
Marberger 1986
70% 90
Webster 199
96% 74
Mc Aninch 2002
118

25. Post Traumatic Stricture
Lack of experience.
Delayed repair 97%.
Primary realignment 53% stricture
56% impotence.
21% incontinence
Koratin et j urolgy 1996

26. Summary Compare Management
Deferred Repair
Primary Realignment
Need SPC, (???), void short term morbid
Need optimal condition & technical experience
Always results in stricture
Shorten “stricture” ultimate repair easier
Stricture is longer & difficult to repair
Potential short term morbid “infection, hematoma”
Lower long term morbidity
Possible long term morbid “ED, incontinence”
Repair success 90-95%
Rarely definitive treatment alone, need CIC or urethroplasty

27. Recommendation If pt stable try once to place an aligning catheter.
Minimal disruption of pelvic hematoma.
Refer pt to specialized center.

28. Delayed Endoscopic Management
Cut-to-the light procedure.
Poor control.
Need redo, fibrosis persist.
You will give other colleague hard case.

29. Take Home Massage for Posterior Urethral Injury
An apparently short stricture does not mean easy repair.
Complexity of repair related to length of defect.
Staging the lengthen defect is challenging but important.
Initial intervention is important for the following treatment outcome.
I like prenieal approach, but be ready for transpubic.

30. Why Buccal Mucoa?
More data to support its superior to other graft.it thick,non-keratinized epithelium make it easy to handle and suture
Could be used on onlay (ventral or dorsal).
Enough tissue, easy to handle.
Plastic surgeon may help.

31. Complex Urethral Stricture
BXO:
Meatus & F.N are usually involved & most problematic.
Best manage by complete excision & re-surfacing with Buccal mucosa.
If not re-surface use steroid.
Use 20-24Fr catheter.
Best replaced to coronal & subcoronal, not to gland tip.
Leave buccal mucosa everted at meatus.
Preserve the meatus or neomeatus.

32. Post Radical Prostatectomy
Endoscopic incision has high failure.
Redo the anastomosis is the best.
If small bladder neck contracture they do well with BNI.

33. Post Radiation Urethral Stricture
Usually membranous urethra involved after brachytherapy.
Very difficult to repair.
Most of cases they need a flap rather than graft because radiation effect the blood supply.

34. The Caveats (???) Very little data. Small numbers.
Little personal opinion.

35. Conclusion
Urethral surgery is very complicated, please do it right or leave it for expert.

36. Conclusion Key points to success:
Tension free anastomosis.
Water tight.
Be ready for alternative approach.
match size of needle to suture. (???)
Good Abx coverage post-op, till catheter removed
Leave foley’s catheter for 2-3 weeks.,on lower abdomen.
Silicon catheter is better.
If post op leakage on urethrogram wait for 5-6weeks; remove the catheter. Think that this is a failure.
Staged repair did not mean that you are not good surgeon

37. THANKS