Male Urethral Stricture Flashcards
What is the mucosal histology of the posterior urethra, anterior urethra, and fossa navicularis?
posterior: transitional epithelium
anterior: pseudostratified columnar epithelium
fossa navicularis: stratified squamous epithelium
What are presenting features of urethral stricture?
decreased urinary stream
incomplete bladder emptying
UTI
epididymitis
rising PVR
decreased force of ejaculation
dysuria
spraying
What important factors are there to consider for positioning during urethral stricture repair?
high lithotomy
avoid pressure on calf muscles, peroneal nerve and ulnar nerve
use SCDs to prevent VTE
After a urethral repair, what follow up imaging is recommended?
urethrography or VCUG 2-3 weeks after
replace catheter if persistent leak to avoid inflammation, urinoma, abscess, and/or urethrocutaneous fistula
Clinicians SHOULD include urethral stricture in ddx of men who present with which symptoms?
GUIDELINE STATEMENT 1
decreased urinary stream
incomplete emptying
dysuria
UTI
rising PVR
*stricture characteristics (length, diameter, duration of obstruction) lend to sxs
Risk factors for forming urethral stricture?
hypospadias surgery
urethral catheterization or instrumentation
traumatic injury
transurethral surgery
prostate cancer
idiopathic
inflammatory disorder (LS)
What non invasive measures can be performed initially in a patient with suspected urethral stricture?
GUIDELINE STATEMENT 2
H&P
UA
Uroflow
PVR
*AUA-SS
What evaluations would be next step to confirm diagnosis of urethral stricture after non-invasive measures?
GUIDELINE STATEMENT 3
Cysto
RUG
VCUG
US urethrography
MRI (can provide detail in certain cases, e.g diverticulum, fistula, cancer)
In planning non-urgent intervention for known stricture what must be determined:
GUIDELINE STATEMENT 4
length and location
Patients with symptomatic stricture including urinary retention or need for catheterization, may undergo which procedures urgently?
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
What is considered a short bulbar urethral stricture? What is an initial treatment options?
GUIDELINE STATEMENT 7
< 2 CM
DVIU or dilation
urethroplasty
What types of endoscopic treatment may be offered for urethral stricture? When may catheter be removed if uncomplicated procedure?
GUIDELINE STATEMENT 8
Dilation
DVIU
GUIDELINE STATEMENT 9
72 hours
For pts who are not candidates for urethroplasty, who have undergone DVIU, clinicians may recommend what at home activity?
GUIDELINE STATEMENT 10
self-catheterization to maintain temporary urethral patency
ranging daily to weekly > 4 mo reduces recurrence
For recurrent anterior urethral strictures, after failed dilation/DVIU, what management is recommended?
GUIDELINE STATEMENT 11
Urethroplasty
For surgeons who do not perform urethroplasty, what is an option?
GUIDELINE STATEMENT 12
refer to surgeon with expertise
Initial treatment of metal or fossa navicularis strictures?
GUIDELINE STATEMENT 13
dilation or meatotomy
as long as not associated with previous hypo repair, prior failed endoscopic treatment, previous urethroplasty, or LS
Recurrent metal or fossa navicularis strictures, should be treated with?
GUIDELINE STATEMENT 14
urethroplasty
*or associated with hypospadias or LS
Penile urethral strictures should be treated with?
GUIDELINE STATEMENT 15
urethroplasty due to high recurrence rates with endoscopic tx
Patient with bulbar strictures > 2 cm should be treated with?
GUIDELINE STATEMENT 16
urethroplasty due to low success rate of DVIU/dilation
Multi-segment strictures may be reconstructed utilizing what surgical technique and material?
GUIDELINE STATEMENT 17
One stage or multistage
oral mucosal graft, penile fasciocutaneous flap or combo
what is a long term alternative for severe complex or length strictures?
GUIDELINE STATEMET 18
perineal urethrostomy
*recurrent complex anterior stricture, advanced age, medical co-morbidities, extensive LS, numerous failed urethroplasty, and patient choice
What is the first choice when using grafts for urethroplasty? What materials/donor sites shouldn’t be used?
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
What technique should not be performed by a single-stage?
GUIDELINE STATEMENT 21
tubularized graft urethroplasty
due to high risk of restenosis
After pelvic fracture urethral injury (PFUI), planning a delayed repair, what testing should be done pre-operaitvely?
GUIDELINE STATEMENT 23
RUG + VCUG
and/or
Retrograde + Antegrade Cystoscopy
Other adjunctive tests include: pelvic CT or MRI to assess proximal extent of injury
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
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
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
Men who perform chronic CIC with strictures may be offered which treatment?
GUIDELINE STATMENT 29
urethroplasty
when causing problems with CIC
If alternative pathology is suspected in the urethra?
GUIDELINE STATEMENT 30
biopsy
for LS or suspected urethral cancer
Urethroplasty in a patient with LS, what is important to remember?
GUIDELINE STATEMENT 31
do not use genital skin
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
AUA SS includes which elements, plus bother:
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
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
Describe posterior urethral stricture repair?
- high lithotomy
- lamba incision in perineum
- divde bulbospongiosus muscle
- circumferentially mobilize urethra distally to penoscrotal junction and proximally to obliterated segment of the urethra
- excise intervening scar between distal urethral segment and apex of prostate
- 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
- Tension free anastomosis
- Foley
Etiologies of low Qmax and elevated PVR in a male?
NGB
BPH
urethral stricture
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)
Describe a bulbar EPA urethroplasty:
- vertical midline perineal incision
- dissect through Colles’ facia
- divide bulbospongiosus muscle
- circumferentially mobilize the urethral distally to penoscrotal junction and proximally towards membranous urethra after dividing central tenon
- ID stricture by cysto
- excise urethral stricture
- spatulate proximal and distal ends of urethral 1 cm on each side
- Distal spatulate ventrally
- proximal spatulate dorsally
- anastomosis with absorbable interrupted
- foley
- close
Describe substitution urethroplasty with buccal mucosa:
- vertical midline perineal incision
- dissect Colles’ facia
- sharply divide bulbospongiosus muscle
- ID stricture via cysto
- excise urethral stricture
- spatulate urethra dorsally 1 cm on each side, measure defect
- harvest buccal mucosa
- fenestrate for dorsal, don’t fenestrate for ventral
- lay graft on corporal bodies an secure with absorbable suture
- close lateral sides of buccal graft to native urethra with absorbable suture
- test anastomosis for water tightness with irrigation in urethra
- foley
- close
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
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
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
What is recurrence rate of DVIU at one year?
50% in 1 year
Follow with AUA SS, uroflow/pvr, cysto, RUG
