- May 31, 2020
- Posted by: Prof Dr Coşkun Şahin
- Category: Urethral Stricture
What is Urethral Stricture?
Urethra is 20 cm in male and 4 cm in female. It is an event of narrowing of the canal for any reason and difﬁculty in urination.
In the photo, we see the narrowed urethra in the section we call ‘Bulbous Urethra’. This part is the most frequently narrowing part of the Urethra and it usually occurs after trauma.
Why does the Urethra is narrows?
The most common cause is endoscopic urological surgeries and interventions. The second frequent accidents are falling from height, compression between two objects and pelvic bone fractures. Infections create other causes. Sometimes a reason cannot be found.
How do I suspect Urethral Stricture?
A patient who has been exposed to the above procedures should be suspected if there is a ﬁne, non-pressured urination, a weak urination, a feeling of not fully ejaculating, a drop-invoiding urine. At ﬁrst, blood may have come from the tip of the penis.
How is urethral stricture diagnosed?
First, a detailed inquiry is made. On examination, the outer mouth of the urinary canal is examined. Previous surgical scars are sought. Then voiding test (uroﬂowmeter) is done. Urethra ﬁlm called retrograde urethrography is made. In necessary cases, MR, ultrasonography and urine culture are performed.
You can click here to read the letters from my patients
How to take retrograde urethrography (Narrow ﬁlm)?
Retrograde urethrography should deﬁnitely be done on the ﬂuoroscopy table. On the traditional X-ray tables, the graphics that are blindly given by contrast should not be preferred. If possible, the procedure should be performed by the physician who will perform the operation. There are two important reasons for this. First, a physician who has followed his patient will better adjust the rate of administration of contrast media since he knows the degree and location of the stenosis. Thus, it will prevent possible high pressure pain and urethro-vascular backﬂow. The second reason is that the physician, who personally monitors ﬂuoroscopic control, will be able to decide whether the procedure is sufﬁcient or not and whether an angegrade voiding cystouretrography is required. The ﬁrst impressions of the operation will be obtained at the scope of the scope. The patient should be in the right side position on the ﬂuoroscopy table. While extending the lower leg straight,
Patient position on retrograde urethrography. The patient should be in the right side position, the leg on the top should be taken to the side as much as possible. If this position cannot be achieved, the true length of the urethral stenosis can be misinterpreted and the surgery plan can be made wrong.
Voiding cysto-urethrography (graph during voiding) shows that the anterior urethra is narrow, from the tip of the penile, where the posterior urethra is enlarged. Closed surgery is not useful in this patient. Open surgery is essential.
Patient with posttraumatic posterior urethral complete rupture. This patient was completely ruptured after a trafﬁc accident. Closed surgery is not useful in this patient. As a matter of fact, with open surgery, both ends were mutually sutured and completely healed.
This patient has a 3-4 cm stenosis. Urethra was repaired in the form of a patch from the inside of the mouth and completely recovered.
This patient is in another hospital with a urethral stent due to urethral stenosis. However, in this patient, the narrow urethra should be repaired by performing urethroplasty.
This patient was a patient who had prostate cancer due to prostate cancer and developed stenosis and underwent closed operations in many hospitals. In this patient, we mutually healed the bladder to the urethra and added an artiﬁcial urine retention valve for urinary incontinence, thereby enabling it to be completely healed.
Why do closed surgeries fail in Urethral Stricture?
Closed surgery can be attempted once in patients with short stenosis and intact urinary integrity. If it repeats, it is now known that these strictures will always recur, and if closed surgery is performed again, we will accept this result in advance.
How is Closed Surgery Performed ?: It is an easy method that requires 1-day hospitalization lasting 15-45 minutes under anesthesia. The chance of success is between 30-70%. Success is high in short (smaller than 1cm) stenoses. Failure is inevitable in patients who has long strictural tissues. (100% failure).
The urethra, which is narrow in closed surgery with a cold knife, is cut at 12 o’clock and opened and placed at the end. The process is simple. It ends in 15 – 20 minutes. The success rate is low.
In Laser Uretrotomy, the same process is performed with laser energy .
Is it cold knife or laser? In fact, there is no difference in success rates. It happens with both. It is the character of the stricture that determines success.
IMPORTANT NOTE: Closed surgeries are an operation that should be performed only in elderly patients who do not want open surgery with a stenosis less than 1 cm. The probability of recurrence is between 30-100%.
Why do patients have a lot of surgeries?
Among the patients who applied to us were patients who had closed surgery 50 times. The reason for this is that urologists do not inform strangers about open surgery and the success of open surgery and do not refer patients to necessary centers. It is clear which strictures will repeat in the urethra ﬁlm to be shot.
Urinary tract in patients with broken Patients who have had multiple closed surgeries and urethral stricture recurred In patients with stenosis longer than 2 cm open surgery should be done.
How is open surgery performed in Urethral Stricture?
Generally, surgery is performed with a 5 cm incision inserted through the appendage. The procedure takes 1-3 hours. The patients lie in the hospital for 1 day. The probe is withdrawn after 2-3 weeks. When done in suitable centers, the success rate is quite high, such as 95% . It saves patients from subscribing to their doctor. In some patients, the surgery is performed by cutting the narrow part and sewing the healthy ends end-to-end with 6 stitches. In some patients, repair is performed by removing patches from the skin of the penile or oral mucosa.
Repair with tip-to-tip stitching technique: It is the most suitable form of surgery in patients with short stenosis and in patients with broken urinary tract after trauma.
In this technique, the narrow urethra is cut and thrown, and the healthy urethra ends are sewn together.
Patch-style surgeries that expand the urethra : These surgeries can be performed in all urinary tract stenosis (shortest to longest). It is done using the hairless skin of the penis or the oral mucosa.
In this technique, the narrow urethra is not removed, it is drawn across and a patch is added to the ﬂoor or ceiling of the urethra.
Is there a risk of open surgery in Urethral Stricture?
There is no risk if it is done meticulously and in accordance with anatomical rules. Urinary incontinence and loss of sexual function are rare. None of our patients had urinary incontinence and loss of sexual function. In our series of 270 patients, 7% stenosis was repeated and successfully treated with secondary treatments.
Is open surgery also possible in women?
It is possible. It is easier. The same success rate is also found in female urethral strictures. Only 12 of my more than 260 urethroplasty experiences are female patients. Because the urinary tract is short in female patients, the frequency of stenosis is also low. All of these patients improved. No second surgery was required. It was not necessary to use a probe by itself.
Why is open surgery performed so little while it is so successful?
This is all about surgical experience. Closed surgeries are easy and performed by almost any urologist. Open surgery requires personal skill and experience. Patients cannot reach their doctor who will perform open surgery. He is unaware that there are other forms of treatment than recommended to him. Sometimes, in the ﬁrst center he is treated, the patient’s eyes are intimidated by the side effects of open surgery. Urinary incontinence and loss of sexual function due to surgery did not occur in any patient with whom we performed open surgery. The complaints of very few patients with sexual dysfunction were due to bone fractures at the time of the ﬁrst accident or the ﬁrst surgery they caused cancer.
Will the success achieved in open surgery last a lifetime?
Yes it takes.
Who should be especially open surgery?
- Anyone with recurrent stenosis is an open candidate for surgery
- There is no age limit.
- Patients who expand on their own or with spark plugs in the hospital
- Patients who have had more than two closed operations and failed
- Patients with a urethral stent and fail
- Patients with accidentally broken urethra
- Patients with radical prostatectomy and recurrent stenosis
What do you think about urethra stents?
It should only be applied in very few patient groups. It should be used in patients who want to keep the urinary tract open in a short and simple way, with the elderly short-lived. Patients who have had permanent stents in the past travel around in the middle as a urethra injury. In 7 such patients, we had surgeries that removed the stent and repaired the urinary canal, and we were successful in all of them.
When can I go to work?
Normally, work starts after 1 week. However, since catheter removal time can be up to 3 weeks, the catheter can be returned to work.