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The open reconstruction of urethral stricture disease, also called urethroplasty, may involve surgery to remove the involved segment and re-attach the two normal ends. This is called excision and primary anastomosis. This procedure is best suited for short strictures involving the bulbar or membranous urethra in particular. When this repair is not possible, tissue can be transferred to augment and therefore widen the narrow segment to a normal caliber. For example, the urethra can be augmented using penile skin. Other tissues that can be used to reconstruct the urethra include a graft of buccal mucosa (skin inside the cheek). When the above procedures are not an option, alternatives include a two-stage repair where a buccal mucosa and/or a split-thickness skin graft is placed along the undersurface of the penis, and later rolled into a new urethra (neo-urethra). The choice of repair is individual and influenced by the length and location of the stricture, the availability of local tissue, and other factors.
Subsequent to surgery, the length of hospitalization varies but generally does not exceed 5 days. Patients seldom have any significant pain or swelling in the penis or scrotum. However, if a buccal mucosa graft is harvested from the inside of the cheek, it is not uncommon for the mouth to be sore. This slowly resolves day by day, and pain medications are given as needed. Patients can immediately resume a normal diet after surgery. However, patients who undergo buccal mucosa graft harvests generally prefer a soft diet initially. When patients are discharged, they are encouraged to remain inactive for several weeks. Often, catheters remain for 2-3 weeks. We then remove the catheters after filling the bladder with x-ray contrast. Then, as the patient voids, a film is taken. This is a voiding cystourethrogram (VCUG). If the urethra is nicely healed, the patient leaves the office "tube free" and resumes normal urination. The vast majority of patients report a "night and day" difference in their stream, and often compare their stream to a "fire hose" as the change is often dramatic.
Our patients return 4 months after surgery for a urethroscopy to assess the caliber of the repair under direct vision. We use a camera and a monitor so that our patients can see the inside of their urethra before and after surgery. The size of the scope is 16 Fr (16mm circumference) and when we repair a stricture, we strive to achieve a 30 Fr caliber. It is quite possible for the caliber to slightly decrease as the urethra heals, but the caliber of the urethra should certainly be greater than the caliber of the scope. When the urethra is widely patent 4 months after surgery, this confirms a technical success of the surgery and the patient can be assured that it is likely that he will never have a problem with stricture disease in the future. However, late recurrences are possible, especially when the surgery is a "re-do" repair, or tissue transfer is required. Patients with Lichen Sclerosis in particular are at risk for late recurrence. Therefore, we recommend that patients have follow-ups annually by their local referring Urologist (or at our institution) indefinitely. Our protocol is an annual assessment of any symptoms or problems, an exam, urinalysis, Uroflow assessment of flow rate, and ultrasound check of post-void residual volume. If there is any suggestion of a problem, we advise cystoscopy to definitively evaluate the caliber of the urethra.