Management of Urethral Strictures
URETHRAL STRICTURE (ENDOSCOPIC VIEW):
Treatment approach to Pre-TURP Urethral Strictures
- Incidental detection of significant urethral stricture – Re-assess need for TURP
- Meatal / sub-meatal stricture – Do a formal meatotomy instead of excess dialtion.
- Consider otis urethrotomy/VIU for distal, penile-bulbar urethral strictures instead of excess dialtion.
Tips to prevent post-TURP Urethral Strictures
- Restrict the time of TURP to less than 1.5 hours (for large gland use alternative energy source)
- Prefer Bipolar TURP, thin loops, pure cut option, minimise use of coagulation/ fulguration.
- Superior quality Foley’s catheter.
- Avoid excess / prolonged catheter traction.
PENILE STRICTURE (TUBULAR)
Treatment of Penile and Bulbar Strictures
- Visual Internal Urethrotomy (VIU)
1. Single stage patchy urethroplasty
Buccal mucosa graft (BMG) (Barbagli)
Penile / preputial skin viable patch
2. Two staged urethroplasty (substitution)
Penile / preputial viable skin tube
BMG tubed (post harvest)
PROSTATIC FOSSA STRICTURE
Management of Prostatic Urethral Stricture
- Endoscopic stricture resection
- Use of laser as an energy source
- Use of urethral stents
(Note: Risk of urethral perforation/renting of thinned/fibrosed prostatic capsule)+
UROLOME URETHRAL STENT
Need for surgical intervention (Especially in cases of long-standing prostatic urethral strictures associated with recurrent UTI and with significant scarring). Approach
-Hyperextended lithotomy to increase exposure to prostatic apex (Jordan and Mc’Aninch 1997)- mention with limitation.
-Partial excision of subpubic arch (LenziBarbagli)
-Abdominoperineal transpubic (Turner Warwich and Keith Water House, 1973)
- Laparoscopic/Robotic Assisted
PROSTATIC URETHRAL STRICTURE Excise/Bypass Strictured Prostatic Urethra
- End-to-end anastomosis if possible 9strictly tension free)
– Bladder neck to membranous urethra (as after radial prostratectomy).
– Bladder base mobilization to meet the urethra distally.
- Length supplemented by: – Bladder flap tubed to recontrsuct prostratic urethra (tanagho’s)
– Viable preputial/penile tubed skin
– BMG (Barbagli)- Limitation (needs to be harvested before being tubed)
- Possibility of stress incontinence due to loss of bladder neck support
- Retropubic space (void)to be filled with viable tissue. Eg Omentum, gracillis muscle.