Urethral Stricture under Dr. Soumyan Dey:
What are the symptoms of urethral stricture?
- lower urinary tract symptoms (LUTS) like:
- poor stream
- Intermittent urine
- Straining while passing urine
- Increased frequency of passing urine
- Recurrent urinary tract infection
- Retention of urine
How does an urologist diagnose a urethral stricture?
- Clinical examination, urinanalysis, serum creatinine, cbc, fasting blood sugar are the initial tests done
- Uroflowmetry: it shows a flat low flow uroflow graph
- Ultrasonography abdomen pelvis with post void residual urine
- Retrograde urethrogram (rgu) and sometimes micturating cystourethrogram (mcu)
What can causes urethral stricture
- Inflammatory strictures: bxo/ recurrent balanoposthitis as in diabetes
- Injury or trauma to external genitalia, perineum or pelvis, causing trauma to urethra followed by healing with scaring.
- Damage from previous endoscopic procedures of urinary tract like turp.
- Foley catheterisation, long term intermittent
- Infections of urinary tract:
- Sexually transmitted infections like gonorrhea and chlamydia.
- Radiation to pelvic organs
When patient presents with retention of urine: catheterization. Inserting a small tube (catheter) into the bladderto drain urine is the usual first step for treating urine
Definitive treatment of stricture
Endoscopic urethrotomy (viu/oiu)
Viu (visual internal urethrotomy) or oiu (optical internal urethrotomy): here an endoscope is inserted into urethra so as to visualise the stricture segment, and then the scar tissue is cut at 12 o clock position with a holmium laser or cold knife
Unless it’s used for small segment soft stricture of bulbar urethra, this treatment is associated with high failure rates.
Quite often it does not provide a definitive treatment for stricture urethra.
Often frequent long term self calibration and multiple viu treatment is required, leading to poor quality of life, high net cost of treatment.
End to end anastomotic urethroplasty
This involves surgically removing the narrowed section of the urethra, and then re-suturing the healthy ends over a foley catheter. This is usually used in treatment of traumatic urethral strictures.
Buccal mucosa graft urethroplasty
sometimes, the stricture is longer, and end-to-end repair is not possible by excising the long stricture segment, then the narrowed segment is surgically widened using tissue patch known as grafts. The procedure involves harvesting tissues from other areas of the body, usually the oral mucosa and sometimes the preputial or penile skin, which is then used as a patch to enlarge the narrowed segment of urethra. The results of urethroplasty are very good and the recurrence rate of urethral stricture after this surgery is very low.
Two stage urethroplasty
This is seldom used today. This usually involves laying open the diseased segment urethra, till its proximal normal portion, in the first operation and laying down a graft on the base of the opened urethra so as to form a wider plate of urethra. This wide plate is then allowed to get adequate blood supply from penile tissue and heal for 3 months. During this period the patient usually passes urine from a point at shaft of penis below the normal external urethral meatus and sometimes even, sitting down, if the urethral segment involved is at level of scrotum o below
The second stage operation is then carried out after 3 months, where the wide urethral plate created in first operation is closed and a wider urethral tube is thus formed, with the distal end of the tube opening to the tip of the penis. So the patient can now pass urine again in standing position from tip of penis
- Usually 72 hours, following which patient is taught self calibration which he has to continue thereafter
- Most patients are discharged on day 3 or 4 after surgery. Some pain may be there in the surgical site till day 5, which can be easily controlled with paracetamol
- The oral mucosa heals very fast , they can take non spicy liquid fron 1st post operative day, soft diet from day 5 , and normal diet in about 10 days
- Swelling in the check can take an week to subside
- They can take a shower after discharge from hospital
- They can do most simple activities with the catheter on.
- We do not put any removable stitches on the oral mucosa or perineum
After an urethroplasty, a urethral catheter is left inside urethra for two to three weeks ,the patient then returns to the radiology opd/ clinic for removal of catheter and a repeat of rgu test to document proper healing. Self calibration is not required post urethroplasty.
it’s very rare after a buccal mucosa graft urethroplasty and is more frequent after a anastomotic urethroplasty used for treatment of traumatic urethral strictures. Ed after urethroplasty may be due to damage to the erectile nerve, and deterioration of the flow of the bulbar artery. Many a times it’s psychogenic and responds to treatment with sildenafil.
Secondly, another important benign mass which needs to be treated is a ANGIOLIPOMA, its easily diagnosed radiologically due to presence of fat( finding 20 pixels with attenuation less than -20 HU , or 5 pixels with attenuation less than -30 HU ,on a CT scan is a diagnostic hallmark). MOREOVER AML always indents into the renal parenchyma, whereas liposarcomas will only extrinsically push the renal parenchyma. 30 to 50% of these tumor can present with a haemorrhage or life threatening bleeding, especially if more than 4 cm.
Treatment of AML : in setting of acute haemorrhage, selective angioembolisation is first line therapy.
In other situations, for AML going to 4 cm or more, as best treated with a partial nephrectomy , as embolisation has drawbacks in form of a high rate of secondary procedures, extended follw up , and risk of contrast induced renal damage during angio-embolisation
Thirdly , another important but uncommon benign tumor is a JG CELL tumor or Reninoma, which presents with uncontrolled hypertension and hypokalemia. Surgical removal with a partial nephrectomt treats this issue.
However when cost is not the issue , i shall do a robotic procedure, as its less stressful for me..
However when cost is not the issue , Dr. Soumyan Dey shall do a robotic procedure, as its less stressful for him..
Tamoxifen 10 mg twice daily for 6 months post-viu can to be effective in reducing the recurrence of urethral stricture post-viu. There was a significant improvement of the clinical outcome regarding maximum flow rates and alleviation of luts, after tamoxifen adjuvant therapy as per some scientific studies.