Urethral Stricture after Prostate Surgery or Radiation
Urethral stricture disease (other than bladder neck contracture) is uncommon after radical prostatectomy. However, when urethral strictures occur as a complication of prostate surgery, the most common location is the fossa navicularis, the portion of the urethra near the tip of the penis. This is likely related to the urethral catheter that is required during and after prostate surgery. Although the catheter passes through the entire urethra, the fossa navicularis is particularly susceptible to narrowing. This is not a common complication. However, when there is a stricture, the narrowing is usually severe and not cured with dilation. Our preferred treatment is a urethral reconstruction using a small amount of penile skin (as a flap) as a patch to widen the narrow urethra. To date, we have had uniform success with this treatment, first published by Dr. Gelman’s mentor, Dr. Gerald Jordan.
After radiation, the most common location of a urethral stricture is the membranous urethra. When patients are referred to the Center for Reconstructive Urology with proximal strictures (other than bladder neck contractures), they are often diagnosed with bulbous urethral strictures based on cystoscopy. Bulbous strictures are easily repaired. However, when we evaluate the urethra using the more accurate urethral imaging we perform, the strictures are actually not limited to the bulbar urethra, but are instead in the membranous urethra adjacent to the prostate. This makes sense because radiation effects generally extend beyond the prostate, and the membranous urethra is next to the prostate. Membranous strictures after radiation are difficult problems because when the scar is excised the connection is not healthy tissue to healthy tissue, but rather fairly healthy tissue to radiated prostate. However, we have had good success with surgery to repair radiation membranous strictures when the remainder of the urethra is normal and the bladder neck is without damage. However, we believe that the recurrence risk may be higher in these cases than when urethroplasty if performed for stricture disease in the absence of prior radiation.
This is the retrograde urethrogram (RUG) of a patient with a membranous stricture. This study confirms a normal anterior urethra. This study does not diagnose narrowing of the membranous urethra because this portion of the urethra is normally closed when a patient is not urinating, and during a RUG, the patient is not urinating.
During voiding, the voiding cystourethrogram (VCUG) shows that the bladder neck opens normally. However, there is severe narrowing of the membranous urethra. The patient had radiation and recurrent stricture disease after numerous dilations.
This is the VCUG after open repair, urethroplasty, with excision of the narrow area and reanastomosis. His surgery was 8 years ago, and his urethra remains patent without the need for dilations or other treatment (most recent follow-up 12/3/10)
Mr. H. S. is the man whose urethral imaging is shown in the previous films. In this video, he details his experience with the complications from his prostate cancer treatment, and the subsequent care he received by Dr. Gelman at the Center for Reconstructive Urology.