Urethral stenosis is one of the most common diseases, especially in men. If left untreated, it causes serious health problems up to kidney failure in progressive cases. Depending on the condition of the stenosis, the treatment method changes. Treatment is generally surgery, that is, surgery. The surgery can be either endoscopic (closed) or open surgery, depending on the condition of the stenosis. In this article, I will talk about the endoscopic treatment of urethral stricture (endoscopic internal urethrotomy, internal urethrotomy).

What is the urethra?

The urethra is the tube-shaped structure that extends from the bladder to the end of the urethra and through which the urine passes. It is 18-20 cm long in males and 4-5 cm in females. Because the urethra is long in men, urethral stricture is more common than in nannies.

What does urethral stricture mean?

Urethral stenosis means stenosis that occurs at any level in the urethra from the bladder to the last part of the urinary canal.

What kind of complaints occur in urethral stenosis?

The most common complaints in urethral stricture are:

• Frequent urination
• Urinating by force or straining
• Thin, forked urination
• Inability to urinate in severe cases

How is the diagnosis of urethral stricture made?

The diagnosis of ureteral stricture is not difficult. The diagnosis of urethral stricture is easily made by detailed questioning of the patients and by radiological methods. The location and length of the stricture are clearly shown by urethrography. In this way, the operation is entered in a more prepared way.

What is an internal urethrotomy?

Internal urethrotomy or internal urethrotomy performed under direct endoscopic view is the endoscopic (closed surgery) operation of urethral stricture. No incision is made in this procedure.

Who is internal urethrotomy performed for?

Endoscopic urethral stricture surgery is not suitable for every patient. The patient group for whom closed urethral stricture surgery is suitable:

• Patients with stricture in a short segment of the urethra. 1.5-2 cm narrowness is most suitable.
• Primary patients that do not recur frequently.

What are the advantages of internal urethrotomy?

Endoscopic, that is, closed way, urethral stricture surgery has some advantages. These:

• No need for open surgery
• The risk of infection is low
• You can be discharged from the hospital on the same day.
• Complications are less
• It can also be done under local anesthesia.

What are the alternatives to internal urethrotomy?

There are other alternatives to internal urethrotomy (urethrotomy intern). If internal urethrotomy cannot be performed in a patient with urethral stricture or if the patient does not want it, then there are some options. These options are:

• Balloon dilatation: These are systems specially developed for urea stenosis. The balloon is inflated in the urethra where the stenosis is, and it is removed after waiting there for a certain period of time.
• Urethral dilatation: Urethral dilatation is an alternative method to internal urethrotomy. It is made with special metal spark plugs. These spark plugs are designed in different thicknesses and in accordance with the inclination of the urethra. The urethra is enlarged in a sterile manner with local anesthesia, starting from small diameters. We use this system extensively in practice. Dilatation with this is also applied to prevent recurrence after stenosis surgeries.
• Open urethroplasty surgery: With this surgery, the narrowed urethra part is removed and if the removed part is short, the normal urethra parts are sutured end to end. Different urethroplasty techniques are used in longer and more complicated strictures. These are patch methods taken on different parts of the body. The patch method, which is taken from the oral mucosa, is most often used. These procedures are special surgeries that require experience. We do these methods for our patients as necessary.

What are the pre-operative preparations?

Patients who are diagnosed with urethral stricture and undergo internal urethrotomy surgery are evaluated in detail beforehand.

• If patients use blood thinners such as aspirin, they should stop 1 week in advance.
• Necessary tests are taken for general or spinal anesthesia
• Patients stop eating and drinking orally 4-5 hours before the operation.
• Patients are asked to read and sign consent forms for the surgery before the surgery.

How is internal urethrotomy done, what kind of anesthesia is given?

Patients are prepared in the lithotomy position under general or spinal anesthesia. Endoscopically, the tip of the penis (urethra) is entered and the narrow part is reflected on the screen with the camera. The narrow one is cut open with the definitive closed method, and it is checked whether the urethra is open up to the bladder, and the inner part of the bladder is also evaluated (cystourethroscopy). A Foley catheter (urethral catheter) is inserted into the urethra so that the narrow part that is opened is not closed again. This catheter stays in the urethra for 7-10 days.

How long is the hospital stay?

Patients who have undergone internal urethrotomy stay in the hospital for 1 day or are discharged the same day after the patients recover and the effect of anesthesia wears off.

How is the follow-up after the surgery?

It is very comfortable after the surgery. Patients are discharged with painkillers and antibiotic treatment. The catheter (urethral tube, catheter) inserted after the surgery stays in the patient for 7-10 days. After the catheter is removed, the patients are called for control at regular intervals. In the early stages, urethral dilatation is performed with sterile urethral bougies at regular intervals. In this way, recurrence of stenosis is prevented.

Why is an internal urethrotomy performed?

Endoscopic internal urethrotomy is performed to open the urethral stricture. The stenosis in the urethra is opened with a closed, that is, endoscopic method. This method is not a treatment method for every patient. It is a procedure with few side effects, which is applied to suitable patients.

Is internal urethrotomy a major surgery?

Internal urethrotomy is not a major urological surgery. It is a simple operation performed endoscopically. To be able to perform this operation, it is necessary to be experienced in endoscopic urological surgery. It is one of our routine surgeries.

How long does an internal urethrotomy take to heal?

Internal urerotomy surgery is an operation that takes about 20-30 minutes. The recovery period is not long. The Foley catheter is removed for about a week and the patients urinate normally. Healing occurs after about 3-4 weeks. However, as the stenosis may recur, patients should come for regular check-ups.

The age of the patient and the presence of systemic diseases such as diabetes delay the healing process. In addition, the recurrence rate is higher in these patients.

What are the complications of internal urethromy?

Internal urethrotomy surgery is a procedure with very few complications. It should be performed by a Urologist with endoscopy experience. In our surgeries we have done for many years, our results are very good and complications are almost non-existent.

Complications that can be seen due to internal urethrotomy surgery, although rare, are as follows:

• There may be complications related to anesthesia
• Sometimes there may be bleeding from the urethra
• Infection may develop
• There may be pain while urinating in the early postoperative periods.
• There may be injuries and perforations in the urethra
• Stenosis may recur
• There may be pain in the penis
• Erectile dysfunction (erectile dysfunction, impotence) is extremely rare
• Recurrence of stenosis: 30-40% recurrence has been reported after long-term
• Edema in the penis

Does internal urethrotomy surgery affect erectile function negatively?

No, this post-operative erection is not adversely affected. In the early stages, there may be problems due to the psychological effect of the surgery.

Is recurrence common after internal urethrotomy surgery?

Recurrence may occur after endoscopic urethral stricture surgery. It may be related to the body of these people. In addition, many factors such as the length of the narrow part, the experience of the surgeon, and the method of operation affect the recurrence of the disease.

Is it possible to prevent recurrence after internal urethrotomy?

It may not always be possible to prevent recurrence after endoscopic urethral stricture surgery. In the literature, it has been shown that the administration of certain drugs to the surgical field to prevent recurrence seriously affects the recurrence rates. We also apply such supportive treatments to our eligible patients.

In the following cases, a doctor should be consulted

In patients who have undergone urethrotomy, if the following conditions occur after surgery, the doctor who performed the surgery should be consulted.

• If there is severe pain
• If the catheter is not working
• If there is fever, chills, shivering
• If excessive blood is coming from the urethra

What should be considered after the operation?

As in any surgery, there are situations that need attention. Conditions that patients who have undergone internal urethrotomy should pay attention to:

• Do not lift too much weight for 2 weeks
• Antibiotics and painkillers should be used
• Oral water intake should be increased
• You should not have sexual intercourse for up to 1 week
• Do not take a shower, swim in the pool or the sea while the catheter is in place.

In which cases internal urethrotomy is not performed?

Internal urethrotomy surgery is not suitable for every patient with urethral stricture. This surgery is decided according to the questioning of the patients and the condition of the stenosis seen as a result of the radiological tests. In the following cases, endoscopic internal urethrotomy surgery is not performed, but open urethroplasty surgery is performed instead.

• In recurrent strictures: If the patient has had recurrent closed urethral stricture surgery at different times, other methods should be applied to these patients, because the recurrence rate in such cases is quite high.
• In stenosis due to pelvic trauma: Today, pelvic traumas occur mostly due to traffic accidents and falling from a height. The urethral strictures seen in these patients are more complicated and associated with bone fractures. The preferred treatment method in these is open urethroplasty surgery at the appropriate time after emergency intervention.
• In case of infection: It is not appropriate to perform internal urethotomy in patients with active urinary tract infection. It is more appropriate to perform the surgery after the infection has been treated with effective antibiotics.
• In long segment strictures: The length of the narrow urethra segment is very important for performing internal urethrotomy surgery. In general, the most suitable cases for endoscopic surgery are patients 1.5-2 cm and below the stenosis in the urethra. The success rate is low in patients with longer stenosis. These cases relapse in a short time. We explain these situations in detail beforehand to our patients who will undergo surgery.

In summary; Endoscopic internal urethrotomy is a closed method (endoscopic) urethral stricture surgery that is preferred in patients with primary and 1.5-2 cm urethral stenosis, with extremely few complications and a high success rate.

Prof. Dr. Emin ÖZBEK

Urology Specialist