Urethral strictures are strictures in the urinary tract from the bladder to the outer part of the urethra. It is mostly seen in men because the urethra is longer in men. This discomfort can be seen in different parts of the urethra. Strictures in the posterior parts of the posterior urethra are more complex in terms of treatment. So-called stenosis may be due to many reasons such as trauma, infection, medical interventions.

There are different treatment options according to the width and location of the narrow part. Open urethral surgeries performed in patients with urethral strictures are called “urethroplasty” surgery. Since we have been dealing with urethral stricture surgery for a long time, in this article I will give general information about urethroplasty with our own experience and current literature.

What is the urethra?

The urethra is the part of the urethra after the bladder. The urethra has only one function. Acting as a transit for urine to be expelled from the bladder.

The length of the urethra varies with gender. The average length of the urethra in women is 4-5 cm, in men it is 18-20 cm. In men, part of the urethra remains inside the prostate. This part is called the prostatic urethra. The length of the prostatic urethra is 3-4 cm on average.

What are the parts of the urethra / anatomical structure of the urethra?

The structure of the urethra differs in men and women. In men, the urethra is longer. The urethra is anatomically grouped differently. In general, the urethra consists of two anatomical parts. Anterior urethra and posterior urethra.

• Anterior urethra (anterior urethra): The anterior urethra consists of the penile urethra and the bulbar urethra.
• Posterior urethra (posterior urethra): The posterior urethra consists of the membranous urethra, prostatic urethra, and bladder neck.

The structure and parts of the male urethra are shown in the figure below.

What does urethral stricture mean?

Urethral stenosis is a stenosis that occurs in any part of the urethra from the bladder to the part where the urinary canal opens out and prevents the urine flow. Depending on the location and degree of the stenosis, the patient has difficulty urinating.

What are the types of urethral stricture?

Urethra stenosis is divided into types according to the location of the stricture. In general, urethral stenosis is divided into two main groups:

• Anterior urethral stricture: Strictures in the region up to the membranous urethra are classified as anterior urethral stricture (anterior urethral stenosis),
• Posterior urethral stricture: Strictures higher than the membranous urethra are classified as posterior (posterior) urethral stenosis. Treatment planning differs according to the location of the stenosis.

What are the causes of urethral stricture?

Urethral stenosis can occur due to many reasons. These include a broad spectrum from trauma to infection. We can list them as follows:

• Previous urethral surgeries
• Urethral interventions (cystoscopy, endoscopic interventions)
• Urethral catheter insertion
• Sexually transmitted diseases (urethritis)
• Balanitis xerotica obliterans (BXO)
• •Traffic accidents
• Pelvis (hip) bone fractures
• Falling astride from height
• Penetrating and cutting tool injuries

What are the symptoms of urethral stricture?

Symptoms of urethral stricture vary according to the extent of the lesion. Patients with severe stenosis have more complaints. These complaints are:

• Decrease in urine pressure, inability to pass away, urinating drop by drop and forcefully
• Thin and forked urination
• Constant need to urinate
• Feeling of incomplete emptying of the bladder
• Frequent recurrent urinary tract infections
• Swelling and pain in the lower abdomen
• Deterioration in kidney functions in advanced periods

How is the diagnosis of urethral stricture made?

In order to diagnose the disease, detailed patient questioning, urological examination and radiological examinations are used.

• Detailed questioning of the patient
• Patient’s complaints
• Uroflowmetry test: Urine flow rate is low in patients with stenosis.
• USG: Bladder and kidneys are evaluated with USG. If there is stenosis and it is severe, urine remains in the bladder after micturition, enlargement of the kidneys and deterioration in kidney functions occur in the following periods.
• Urethrography: The location, length and degree of stenosis are shown with contrast agents given from the urethra.
• Cystourethroscopy: Endoscopic urethral stricture is seen.

To whom / to whom is urethroplasty surgery performed?

Before performing this surgery, the patient should be evaluated in detail. Open urethroplasty surgery should be performed in the following cases:

• If there is urethral stenosis: If the patient has severe and frequently recurring urethral stricture, then urethroplasty surgery should be performed.
• If there is epispadias or hypospadias: Sometimes surgery is required to stretch the urethra to its normal shape in cases where the urinary canal is opened from above or below (hyopadias or epispadias).
• If the length of the stenosis is greater than 2 cm
• Patients who have had 2 or more closed surgeries and have relapsed
• Frequent recurrent strictures that occur in patients who have undergone radical prostatectomy for prostate cancer
• Patients with serious urethra damage due to traffic accident
• Patients who had a stent placed due to urethral stricture but failed
• Patients who need bougie dilatation due to frequent stenosis

Urethral stricture surgery in women

Urethral stricture is usually seen in men. Female patients may also have urethral stricture. The reason for the rare occurrence of stricture in women is that the urethra is shorter than in men. Treatment depends on the degree of stenosis and whether it recurs frequently. Endoscopic treatment may be sufficient in small and infrequent cases. If the stenosis recurs frequently and is complicated, then urethroplasty surgery is appropriate.

What are the success rate and advantages of urethroplasty?

The most important advantages of Nu surgery are the high success rate and the extremely low recurrence rate. The success rate is 80% and above. In some cases, it is possible to achieve over 90% success after surgery, depending on the location and length of the stenosis. We have similarly high success rates in our own surgeries.

How long is the type of anesthesia, hospital stay and operation time?

This surgery is usually performed under spinal or general anesthesia. The duration of the operation varies according to the location and width of the stenosis and the technique to be applied. It takes 2-3 hours on average, sometimes 5-6 hours. Patients stay in the hospital overnight. He is discharged the next day with a catheter.

What is urethroplasty surgery, which doctor does it?

Urethroplasty surgery is a surgical intervention to correct the deterioration of urinary flow as a result of strictures in the urethra due to various reasons such as trauma and infection. If this operation is performed by an experienced urologist in urethral surgery, the success rate is higher. We have been doing this surgery successfully for a long time.

What are the pre-operative procedures?

Since this operation will be performed under general or spinal anesthesia, routine tests are required before the operation. If the tests are normal, he is taken to surgery.

• Required surgical preparations for general or spinal anesthesia
• Patients stop eating and drinking by mouth 5-6 hours before the surgery.
• Patients using blood thinners should stop one week in advance.
• Patients taking heart, blood pressure and diabetes medications continue to take these medications.
• On the day of the operation, hospitalization is made, necessary forms are filled and signed, patients are informed about the subject.

What are the treatment methods of urethral stricture?

Treatment of urethral stenosis depends on the location of the stricture, its frequent recurrence, and the length of the narrowed part.

• Endoscopic internal urethrotomy (closed stenosis surgery): If there is a short narrow segment and it has not recurred frequently, then endoscopic treatment (internal urethrotomy) is possible. In internal urethrotomy surgery, the narrow part is cut by entering the urinary canal under endoscopy and a catheter is inserted into the patient. It remains in the patient for up to 1 week. Later, urethral dialtation is performed with special bougies so that the stenosis does not recur.
• Urethroplasty surgery: If the stenosis is long and recurs frequently, the most ideal treatment for these patients is open urethroplasty surgery.

How is urethroplasty surgery performed?

Open urethroplasty surgery varies according to the width of the stricture. After the scar tissue in the narrow part is removed, different surgical methods are applied according to the length of the distance. We can summarize them as follows:

• End-to-end anastomosis: The stenosis is completely removed. After the scar tissue is removed, parts of the intact urethra are exposed. An end-to-end anastomosis is performed if the intact parts are in a position to fit comfortably and end-to-end without tension. If the narrow part is too long for end-to-end anastomosis, then a piece of tissue taken from another place is used to correct the narrow part.
• Graft method: After the narrow part is removed, if the distance is long and end-to-end anastomosis (connection) cannot be made, then the tube (graft, patch) formed from the skin part taken from the genital area (usually the penile skin) is placed in the narrowed part. In these surgeries, parts taken from different parts of the body are used depending on the length of the narrow segment. The textures we frequently use for this purpose are:
• Cheek mucosa (buccal mocosa): The stenosis is corrected by patching the long stenosis on the part of the cheek mucosa taken from the inner part of the mouth.

What are the risks/complications of the surgery?

As with any surgery, there may be some complications in these surgeries. Most of these are simple complications. We can list them as follows:

• There may be complications related to anesthesia

• There may be a wound infection
• Catheter-related infection may develop
• In some cases, the stenosis may recur, albeit rarely.
• There may be numbness in the temporary leg nerves depending on the operating position.
• There may be pain due to surgery
• There may be erection problems. Sometimes in severe stenosis, this situation can be seen due to the effect of penile nerves. The majority of these resolve in 18 months or less.

Does urethroplasty surgery affect sexuality negatively?

Urethroplasty surgery does not have any direct negative effect on sexuality. Although this condition develops temporarily in some patients, it improves over time and with medication. If the penile nerve is damaged in serious injuries due to traffic accidents, these patients may have erection problems. It has nothing to do with surgery directly.

After the surgery, the doctor should be called in the following cases

The postoperative course is generally uneventful. In some cases, it is necessary to communicate with the doctor. In the following cases, the doctor who performed the surgery should be contacted:

• If there is a high fever
• If there is discharge or bleeding from the wound
• If there is very severe pain,
• If the probe is clogged or dislodged

What should be considered after the operation?

There are some issues that patients should pay attention to after surgery. If these are taken care of, the success rate will increase. The points to be considered after the surgery are:

• Patients are discharged after one day in the hospital.
• Antibiotics and painkillers are started against infection.
• Shower can be taken after 4-5 days
• For the first week, it is recommended that patients do not move as much as possible and rest.
• Heavy lifting, cycling, heavy sports activities should not be done for 4 weeks.
• After 4 weeks, sexual activity can be done
• Prolonged sitting and driving should be avoided until the Foley catheter is removed.
• Heavy sports and sexual intercourse should be avoided for 4-6 weeks.

In summary: The treatment of urethral stricture is possible with surgery. Endoscopic opening of the stenosis is an effective treatment method in small and non-recurring strictures. If the stricture recurs frequently and involves a long part of the urethra, endoscopic treatment is insufficient. In these cases, urethroplasty surgery is required. In urethroplasty surgery, if the normal urethra ends are end-to-end after the narrow part is removed, an end-to-end anastomosis is performed. If this distance is long and end-to-end anastomosis cannot be performed, grafts or patch methods from the oral mucosa are used. Success rate is high in experienced hands. Appropriate patient and an appropriate treatment method are very important in success.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- Turkey