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Male Urethral Stricture Flashcards

1
Q

What is the mucosal histology of the posterior urethra, anterior urethra, and fossa navicularis?

A

posterior: transitional epithelium
anterior: pseudostratified columnar epithelium

fossa navicularis: stratified squamous epithelium

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2
Q

What are presenting features of urethral stricture?

A

decreased urinary stream
incomplete bladder emptying
UTI
epididymitis
rising PVR
decreased force of ejaculation
dysuria
spraying

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3
Q

What important factors are there to consider for positioning during urethral stricture repair?

A

high lithotomy
avoid pressure on calf muscles, peroneal nerve and ulnar nerve
use SCDs to prevent VTE

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4
Q

After a urethral repair, what follow up imaging is recommended?

A

urethrography or VCUG 2-3 weeks after
replace catheter if persistent leak to avoid inflammation, urinoma, abscess, and/or urethrocutaneous fistula

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5
Q

Clinicians SHOULD include urethral stricture in ddx of men who present with which symptoms?

A

GUIDELINE STATEMENT 1

decreased urinary stream
incomplete emptying
dysuria
UTI
rising PVR

*stricture characteristics (length, diameter, duration of obstruction) lend to sxs

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6
Q

Risk factors for forming urethral stricture?

A

hypospadias surgery
urethral catheterization or instrumentation
traumatic injury
transurethral surgery
prostate cancer
idiopathic
inflammatory disorder (LS)

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7
Q

What non invasive measures can be performed initially in a patient with suspected urethral stricture?

A

GUIDELINE STATEMENT 2

H&P
UA
Uroflow
PVR

*AUA-SS

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8
Q

What evaluations would be next step to confirm diagnosis of urethral stricture after non-invasive measures?

A

GUIDELINE STATEMENT 3

Cysto
RUG
VCUG
US urethrography
MRI (can provide detail in certain cases, e.g diverticulum, fistula, cancer)

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9
Q

In planning non-urgent intervention for known stricture what must be determined:

A

GUIDELINE STATEMENT 4

length and location

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10
Q

Patients with symptomatic stricture including urinary retention or need for catheterization, may undergo which procedures urgently?

A

GUIDELINES STATEMENT 5

DVIU
SPT
GUIDELINE STATEMENT 6

surgeons may place SPT prior to definitive urethroplasty depending on CIC Or foley

“urethral rest” 4-12 weeks

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11
Q

What is considered a short bulbar urethral stricture? What is an initial treatment options?

A

GUIDELINE STATEMENT 7

< 2 CM

DVIU or dilation

urethroplasty

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12
Q

What types of endoscopic treatment may be offered for urethral stricture? When may catheter be removed if uncomplicated procedure?

A

GUIDELINE STATEMENT 8

Dilation

DVIU

GUIDELINE STATEMENT 9

72 hours

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13
Q

For pts who are not candidates for urethroplasty, who have undergone DVIU, clinicians may recommend what at home activity?

A

GUIDELINE STATEMENT 10

self-catheterization to maintain temporary urethral patency

ranging daily to weekly > 4 mo reduces recurrence

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14
Q

For recurrent anterior urethral strictures, after failed dilation/DVIU, what management is recommended?

A

GUIDELINE STATEMENT 11

Urethroplasty

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15
Q

For surgeons who do not perform urethroplasty, what is an option?

A

GUIDELINE STATEMENT 12

refer to surgeon with expertise

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16
Q

Initial treatment of metal or fossa navicularis strictures?

A

GUIDELINE STATEMENT 13

dilation or meatotomy

as long as not associated with previous hypo repair, prior failed endoscopic treatment, previous urethroplasty, or LS

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17
Q

Recurrent metal or fossa navicularis strictures, should be treated with?

A

GUIDELINE STATEMENT 14

urethroplasty

*or associated with hypospadias or LS

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18
Q

Penile urethral strictures should be treated with?

A

GUIDELINE STATEMENT 15

urethroplasty due to high recurrence rates with endoscopic tx

19
Q

Patient with bulbar strictures > 2 cm should be treated with?

A

GUIDELINE STATEMENT 16

urethroplasty due to low success rate of DVIU/dilation

20
Q

Multi-segment strictures may be reconstructed utilizing what surgical technique and material?

A

GUIDELINE STATEMENT 17

One stage or multistage

oral mucosal graft, penile fasciocutaneous flap or combo

21
Q

what is a long term alternative for severe complex or length strictures?

A

GUIDELINE STATEMET 18

perineal urethrostomy

*recurrent complex anterior stricture, advanced age, medical co-morbidities, extensive LS, numerous failed urethroplasty, and patient choice

22
Q

What is the first choice when using grafts for urethroplasty? What materials/donor sites shouldn’t be used?

A

GUIDELINE STATEMENT 19

oral mucosa

*inner cheek, be careful of salivary gland

GUIDELINE STATEMENT 20

should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials

GUIDELINE STATEMETN 22

do not use hair-bearing skin

23
Q

What technique should not be performed by a single-stage?

A

GUIDELINE STATEMENT 21

tubularized graft urethroplasty

due to high risk of restenosis

24
Q

After pelvic fracture urethral injury (PFUI), planning a delayed repair, what testing should be done pre-operaitvely?

A

GUIDELINE STATEMENT 23

RUG + VCUG

and/or

Retrograde + Antegrade Cystoscopy

Other adjunctive tests include: pelvic CT or MRI to assess proximal extent of injury

25
After PFUI with urethral obstruction/obliteration due to pelvic fracture, what type of repair should be done? When?
GUIDELINE STATEMENT 24 delayed urethroplasty GUIDELINE STATMENT 25 only after major injuries have stabilized and patients can be safely positioned
26
What are treatment options for bladder neck contracture after endoscopic prostate procedure?
GUIDELINE STATEMENT 26 Dilation Bladder neck incision transurethral resection of bladder neck contracture
27
What are treatment options for bladder neck contracture post prostatectomy for vesicourethral anastomotic strictures? What is performed for recalcitrant stenosis?
GUIDELINE STATEMENT 27 dilation vesicourethral incision transurethral resection \*lower success in cases of radiation GUIDELINE STATEMENT 28 open reconstruction of bladder neck \*may need sphincter
28
Men who perform chronic CIC with strictures may be offered which treatment?
GUIDELINE STATMENT 29 urethroplasty when causing problems with CIC
29
If alternative pathology is suspected in the urethra?
GUIDELINE STATEMENT 30 biopsy for LS or suspected urethral cancer
30
Urethroplasty in a patient with LS, what is important to remember?
GUIDELINE STATEMENT 31 do not use genital skin
31
Follow up of urethral strictures?
GUIDELINE STATEMENT 32 monitor for symptomatic recurrence following dilation, DVIU, and urethroplasty utilize AUA SS, uroflow, pvr \*can occur at any time \*risks for recurrence failed tx, tobacco, DM, increasing length, LS, hypo. graft/flap
32
AUA SS includes which elements, plus bother:
33
In the setting of a prior urethral stricture dilation, with pelvic trauma/fracture and blood at the meatus, what is the significance of a butterfly hematoma?
urethral injury contained in Colles' facia superiorly the extravasation can extend to clavicles where Scarpa's facies the abdominal extension of Colles' facia attaches
34
Describe endoscopic realignment in patient with urethral disruption for whom you have placed a SPT:
2 surgeons flexible/rigid cystoscopy via urethra and SPT to try to pass a wire across the defect with fluoroscopy prolonged attempts should not be performed
35
Describe posterior urethral stricture repair?
1. high lithotomy 2. lamba incision in perineum 3. divde bulbospongiosus muscle 4. circumferentially mobilize urethra distally to penoscrotal junction and proximally to obliterated segment of the urethra 5. excise intervening scar between distal urethral segment and apex of prostate 6. identify prostatic apex, if cannot reach → separate corpus cavernosum in midline, if cannot reach → perform pubectomy (give additional length), if still cannot reach → re-route urethra under ones side of corpus cavernosum 7. Tension free anastomosis 8. Foley
36
Etiologies of low Qmax and elevated PVR in a male?
NGB BPH urethral stricture
37
List risks of urethroplasty:
bleeding infection DVT nerve damage (peroneal) rectal injury testicular injury stricture recurrence ED EjD urethrocutaneous fistula formation penile chordee altered penile sensation post void dribbling mouth scarring (buccal) obstruction of salivary duct (buccal)
38
Describe a bulbar EPA urethroplasty:
1. vertical midline perineal incision 2. dissect through Colles' facia 3. divide bulbospongiosus muscle 4. circumferentially mobilize the urethral distally to penoscrotal junction and proximally towards membranous urethra after dividing central tenon 5. ID stricture by cysto 6. excise urethral stricture 7. spatulate proximal and distal ends of urethral 1 cm on each side 8. Distal spatulate ventrally 9. proximal spatulate dorsally 10. anastomosis with absorbable interrupted 11. foley 12. close
39
Describe substitution urethroplasty with buccal mucosa:
1. vertical midline perineal incision 2. dissect Colles' facia 3. sharply divide bulbospongiosus muscle 4. ID stricture via cysto 5. excise urethral stricture 6. spatulate urethra dorsally 1 cm on each side, measure defect 7. harvest buccal mucosa 8. fenestrate for dorsal, don't fenestrate for ventral 9. lay graft on corporal bodies an secure with absorbable suture 10. close lateral sides of buccal graft to native urethra with absorbable suture 11. test anastomosis for water tightness with irrigation in urethra 12. foley 13. close
40
What is blood supply to penis?
Internal iliac artery Internal pudendal artery Common penile artery Bulbourethral artery → corpus spongiosum Dorsal artery of penis → glans Cavernosal artery → corpus cavernosa Circumflex artery → crus of corpus cavernosa
41
What is blood supply to urethra?
dual blood supply Proximal: bulbourethral artery → proximal corpus spongiosum Distal: dorsal artery of penis → via communicators to glans penis
42
What questions do you ask a patient with suspect urethral stricture?
History of perineal/scrotal trauma prior UTIs/STIs Sexually active, ED, EjD length of time of sxs episodes of retention hx of catheterization or difficulty with cath hematuria AUA SS
43
What is recurrence rate of DVIU at one year?
50% in 1 year Follow with AUA SS, uroflow/pvr, cysto, RUG

ABU Oral Boards (36 decks)

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