CUA 2020 Urethral Stricture Flashcards
what is a urethral stricture?
fibrosis of urethral epithelial tissue and corpus spongiosum which causes narrowing of the urethral lumen
What is the difference bw urethral stricture and stenosis
stricture: anterior urethra
Stenosis: posterior urethra
Increased likelihood of stricture with increasing age and decreases socioeconomic status
TRUE
Is urethral stricture a risk factor for fournier’s gangrene?
Yes
Should men with suspected urethral stricture undergo cystoscopy?
Yes
also suggest performing retrograde urethrography to further stage urethral stricture or refer to recon when recurrent stricture is suspected, recommend against use of MRI in routine initial diagnosis of suspected stricture.
What work up should be done in initial assessment of stricture?
H&P, physical exam, Cr, UA, IPSS, uroflow, US and PVR
In what situations may MRI be helpful in work up of urethral strictures?
Complex trauma, suspected urethral malignancy, RT induced stenosis or rectourethral fistula
Is DIVU superior to urethral dilatation
No evidence, No
who is a well selected patient for urethral dilatation/ DIVU?
(<1cm bulbar strictures with minimal spongiofibrosis and ≤2 prior dilations/incisions).
What situation is anastomotic urethroplasty good for?
anterior strictures, <2cm, in bulbar urethra.
do oral mucosal grafts and genital fasciocutaneous graft have similar success rates?
Yes, ( most urologists use oral mucosal as the primary source)
allograft, xenograft, synthetic material should not be used to perform urethroplasty
Correct
Should endoscopic management (dilation or direct vision internal
urethrotomy) compared to urethroplasty be used for men with the initial diagnosis of urethral stricture?
We suggest endoscopic management as the initial treatment of the
symptomatic undifferentiated stricture
Should urethroplasty compared to endoscopic treatment (either
dilation or dviu) be used for men with recurrent urethral stricture?
In the setting of men with recurrent urethral stricture failing prior endoscopic
treatment, we suggest performing urethroplasty rather than repeat endoscopic management
(DVIU or dilation)
In what patients should you not really attempt endoscopic management of urethral stricture?
strictures from failed hypospadias repairs, penile
urethral strictures, lichen sclerosis related strictures, trauma related urethral strictures, strictures
longer than 2 cm, and those with a completely obliterated lumen
How should trauma stenosis be managed
delayed urethroplasty at 3 to 6 months, very high success rates
How should patients with straddle urethral injury be treated
endoscopic realignment or SP– followed by urethroplasty
These are often transmural injury to Corpora spongiosa
what are the 4 classes of urethral strictures in patients with hypospadias?
1- long “pan-penile” stricture involving the majority of the penile urethra in the setting of
previous (and often multiple) hypospadias surgery
2- “junctional
stricture” which is a stricture of variable length at the junction of previous hypospadias repair
and native urethra
3- isolated bulbar urethral stricture after
hypospadias repair
4-urethral stricture developing in the setting of
previously untreated hypospadias
What are treatment options for hypospadias associated Urethral strictures?
urethroplasty, perineal urethrostomy,
Endoscopic management is not a great option
What are risk factors for developing bladder neck contracture?
low adenoma weight, unmanaged preoperative infections, long resection time, extensive resection of bladder neck, diabetes, smoking, cardiovascular disease.
What are treatment options for bladder neck contracture?
Urethral dilatation( first line), BNI+/- CIC to stabilize bladder neck, , permanent SP catheter, Open recon using Y-V plasty techniques
what is bladder neck contracture?
narrowing of the bladder neck following surgical
treatment of bladder outlet obstruction
What is Vesicourethral anastomotic stenosis
narrowing of the anastomosis after radical prostatectomy
What is a rare but serious complication of treating VUAS and how is it treated?
fistulation to the pubic symphysis
-This almost uniformly occurs in patients
with a history of radiation therapy, and in many cases, develops after endoscopic procedures to
treat VUAS. A patient will have severe pelvic pain, and an MRI of the pelvis should be done to
confirm the diagnosis. Treatment of this complication usually requires a urinary diversion
How is VUAS treated?
Observation,
If symptomatic and less than 14-F then dilatation –> laser/coldknife/hot knife incision of stricture
Radiation associated stenoses are usually refractory
to endoscopic techniques
correct,
urethroplasty in reasonably selected patients seems to be a good option.
but given advanced patient age some may prefer endoscopic treatment over surgery.
in case of radiation induced strictures in patients with patients with extensive prostate necrosis, cavitation,
prostatosymphyseal fistula, osteomyelitis or a small functional bladder capacity are best served by ….what?
by urinary diversion in lieu of urethral reconstruction
what is another name for Lichen sclerosis and what causes it
balanitis xerotica obliterans(no longer the accepted term). caused by lymphocyte mediated skin disease.
why is surveillance recommended in patients with lichen sclerosis
association with the development of squamous cell carcinoma which can occur in 2– 8% of men with lichen sclerosus
How is cutaneous LS treated
topical steroid cream for 8-12 weeks, dorsal slit or circ may be needed as well.
(True or False) Urethral strictures with LS are sporadic and self resolving.
Wrong. They are often progressive
what are some treatment options for LS associated isolated meatal stenosis
dilatation w or w/o intra-urethral steroid administration
how is Ls with longer urethral stricture treated?
Urethroplasty often requiring tissue transfer. Dont use genital skin as LS can reccur in it, oral mucosal graft is gold standard
