Management of Urethral Strictures

Management of Urethral Strictures

Amod Tilak

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)

PENO-BULBAR STRICTURE

BULBAR STRICTURE

Treatment of Penile and Bulbar Strictures

• Visual Internal Urethrotomy (VIU)
• Endocotie
  -Urethroplasty
  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
• TUR
• Use of laser as an energy source
• Endocotie
• 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

1. Open
   -Perineal
   -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)
2. Laparoscopic/Robotic Assisted

PROSTATIC URETHRAL STRICTURE

Excise/Bypass Strictured Prostatic Urethra

1. 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.
2. 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)

Note

• Possibility of stress incontinence due to loss of bladder neck support
• Retropubic space (void)to be filled with viable tissue. Eg Omentum, gracillis muscle.

TANAGHO’S PROCEDURE