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Urethroplasty

What is a “Urethroplasty”?

Urethroplasty is a word that refers to an open surgery to repair a urethral stricture. This can also be referred to as a urethral reconstruction. When a urethroplasty is performed, in contrast to internal dilations or incisions of the stricture which is done through the penis, there is actually an open operation with an incision of the skin and a repair of the urethral stricture.

How is a Urethroplasty Performed?

Many men who contact us seeking a urethroplasty often ask: “What is the recovery or the cost of a urethroplasty”? These are reasonable questions, but the answer is: “It depends”. If the surgery were a circumcision, then those and similar questions would be easier to answer because there is generally 1 way to do a circumcision. There are 2 separate circular incisions made in the skin towards the head of the penis, the foreskin in between the 2 incisions is removed, and the skin is then put back together. However, there are many operations that can be performed to cure urethral stricture disease. Which surgery is most appropriate depends on the length of the stricture, the location of the stricture, and other factors, especially when there has been prior failed treatment. When patients are asked if they know how long or exactly where their stricture is, most often, they are not sure. This is because they have not had proper diagnostic imaging even if they were treated 1 or more times previously without success. When we see new patients, the first step is to define the stricture. Subsequently, we review options, and if the plan is urethroplasty, we can then review the details and what is involved with that particular urethroplasty. The following is a basic overview of urethroplasty options, and additional information related to particular urethroplasty options can be found in separate sections including, bulbar strictures, pelvic bone fractures, lichen sclerosus, and recurrent and complex strictures.

A urethroplasty to definitively repair a short urethral stricture may involve surgery to remove the involved segment and re-attach the two normal ends. This is called excision and primary anastomosis. It is also called an anastomotic urethroplasty. This procedure is best suited for short strictures involving the urethra deep to the penis more towards the prostate in portions of the urethra called the bulbar or membranous urethra in particular. Fortunately, the urethra has some elasticity and ability to stretch, and so if a short segment removed, the ends can reach and be brought together without undue tension. Details about anastomotic urethroplasty can be found in the sections on bulbar strictures and pelvic bone fractures.

However, this elasticity has limits, and when the stricture is longer, the ends simply can’t be brought together. One advantage of first accurately defining the length of the stricture is to know before beginning the surgery if the stricture will or will not be short enough to be amenable to anastomotic urethroplasty. When an anastomotic urethroplasty (splice by cutting out the bad part and re-connecting the healthy ends) is not possible, tissue can be transferred to augment and therefore widen the narrow segment to a normal caliber. It you take a narrow urethra tube and cut it along the length, it becomes a strip. If you then close it back, it again becomes a narrow tube. However, if you open the narrow urethra tube to make s strip and then add a patch of tissue, it becomes a wider urethra tube. For example, the urethra can be augmented (made wider) 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) during a second surgery. The choice of repair is individual and influenced by the length and location of the stricture, the availability of local tissue, and other factors.

Urethroplasty Recovery

Subsequent to urethroplasty surgery, the length of hospitalization varies but generally does not exceed 1-5 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 called 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.

Follow-up after Urethral Stricture Repair

Our patients return 4 months after surgery for a urethroscopy to gently measure the size of the urethra under direct vision. We use a camera and a monitor so that our patients can see the inside of their urethra after surgery in comparison to before 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.

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