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The history of patients urinary symptoms, a description of any prior treatment, and general information such as medical illnesses, any prior surgeries and urethral dilation or urethrotomy, or urethroplasty surgeries in particular, allergies etc is important for diagnosis making. Most of the patients have thin stream and difficulties in passing urine. We encourage patients to hand carry their medical records to their initial appointment. During the complete physical exam, particular attention is made for assessment of the appearance of the penile skin and the urethral opening. In some cases, an option for urethral reconstruction can be a repair using the penile skin as a “patch”, and when indicated, is performed when a man is uncircumcised with normal skin or is circumcised with some redundancy of the skin (extra skin). The appearance of the urethral opening (called the urethral meatus) is also important. At Precision Urology, every patients of urethral structure undergo RGU/ MCU and diagnostic urethroscopy as part of pre operative planning.
For short strictures that involve the bulbar urethra (the part of the urethra under the scrotum and up to the prostate), a segment of the scarred urethra can be completely excised. The two cut ends of the urethra are then sewn together.Excising a short segment of urethra and sewing the ends together typically has the best long term surgical results – which approach 95%.Stricture excision cannot be performed in the penile urethra or for long strictures of the bulbar urethra because there will be too much tension when trying to bring the two cut ends together. Tension on the suture line leads to surgical failure, and potentially to penile shortening and curvature.
A graft is a piece of tissue that is transferred from one part of the body to another. A graft does not have its own blood supply, so it relies on the blood supply of the host (where it was transferred to) to survive. Grafts are used to increase the size of the narrow urethra by patching it, rather than a total replacement.
Typical grafts that are used to reconstruct the urethra are harvested from the extra-genital skin or from the inner lining of the mouth. The mouth graft is known as a “buccal graft”.
The lining of the mouth (cheek) is a wet and pliable tissue that makes an excellent substitute urethra. A sliver of tissue can be easily removed with no consequences. Pain is minor and feels the same as when one accidentally bites his inner cheek. The mouth heals very quickly – usually in less then 1 week.
Grafts are highly successful in the bulbar urethra as an onlay or patch technique. The lining of the cheek is typically used as a patch graft because it is easy and quick to harvest, has a hidden suture line, does not contract much, and can result in durable success rates that approach 80-85%.
Skin grafts used in urethral reconstruction can shrink as much as 50 percent, and thus result in lower success rates then the buccal graft. Penile skin should be avoided as a graft when the penile skin is not very redundant and elastic, or when the penis is affected by Lichen Sclerosus (a skin disease).
A flap is a transfer of tissue from one part of the body to another, where the donor blood supply is left intact. Penile flap urethroplasty uses a flap of penile skin to reconstruct a urethral stricture that does not rely on the scarred urethra for its survival. Penile skin flaps are good for reconstructing long strictures of the penile urethra. Penile skin flaps are versatile and are used as a patch to the narrow urethral segments. Success rates in the short term approach 80-85%. Flaps that are rolled into a tube have nearly a 50 percent failure rate – so flaps are reserved for patching and not replacement.
Skin flaps from the scrotum should be avoided in urethroplasty, as their complication rate is high and their success rates poor.
For patients who have failed prior urethroplasties, or where the urethra and local skin are severely scarred, a staged urethroplasty is usually indicated.
Here, the scarred urethra is typically surgically excised, and in its place, a buccal or skin graft is placed. This replaced urethra is left open to the air to heal over the next few months. The meatus (pee hole) is often placed in front or under the scrotum causing patients to sit to urinate for a few months. Once the graft is soft and well healed, the patient undergoes a second (‘staged”) surgery to roll the graft up into a tube to reconstruct the urethra. A staged urethroplasty can require more than two steps and more than one phase of grafting. Staged urethroplasty is typically reserved for the worst urethral strictures.
Before any urethroplasty, the scar should be stable and no longer contracting. Thus, it is preferred that the urethra not be dilated or cut for three months before planned definitive surgery. If the stricture patient goes into urinary retention prior to his surgery date, a suprapubic tube is typically placed. A suprapubic tube, also known as a SP tube, is a small tube that is placed through the skin and straight into the bladder. The tube is typically 2 to 3 cm above the pubic bone.
As with most surgeries, the pain is worst in the first 12 hours and then gradually subsides. By the morning after surgery, you should feel pretty comfortable. The pain is typically just a constant ache that lasts a few days. If you experience sudden pain in the penis, pubic bone or lower abdomen, this is “bladder spasm” or pain from the catheter. This is not pain from your surgery. To treat the “bladder spasm” pain you can take medicines that calm the bladder down, like Ditropan, Levsin or Detrol.
Surgery time varies because each surgery and patient is unique. In general, the procedure takes three hours, but it can range from 2 to 5 hours, depending on the severity of the scar tissue and the extent of the reconstruction.
Most of the patients are evaluated for surgery and are given appointment for the day of surgery. Patients are called nill orally for 6-8 hours prior on the day of surgery. Surgery generally is carried under spinal anaesthesia and last around 3-4 hours. They are kept in post operative recovery room for 1 day before being shifted to room on first post op day. Patient are generally discharged from the hospital on 6th or 7th post operative day. Patient undergoing end to end or BMG urethroplasty are discharged with catheter in situ. They are given proper post operative instructions to maintain and clean the catheter. The urethral catheter is left in for two to four weeks depending upon the type of surgery that was performed. It is important to limit activities after urethroplasty until adequate healing has occurred. This means no heavy lifting, strenuous exercise, or work for at least two- four weeks. When patients return to clinic the bladder is filled with X-ray contrast and the catheter is gently removed. While X-rays are being taken, the patient voids and the area of the surgery is evaluated. If the area of surgery is healed, then the catheter is left out and patients begin to void normally. Patients are seen every three to six months in their first year after surgery.
Patients seldom have any significant pain or swelling in the penis or scrotum. However, if a graft is harvested from the lining of the inside of the cheek (a buccal mucosa graft), it is not uncommon for the mouth to be sore following the procedure. The pain slowly dissipates day by day, with pain medication given as needed.Patient are usually comfortable on post operative day 3. There are no diet restrictions following urethroplasty surgery, and patients can immediately resume their normal eating habits after the surgery. However, patients who undergo buccal mucosa graft harvests generally prefer a soft diet initially, since the inside of their mouth may be sore.
Erections will typically not injure or compromise the surgery, as most people will lose the erection as soon as they have pain. However, if the erections keep waking you from sleep or cause a lot of pain, then medicine can be prescribed to suppress erections.
We recommend that you allow 3 to 4 weeks off from work, especially if you do manual labor or lift heavy objects for a living. In general, it is safe to go back to work once the catheter is removed. If you have a desk job, however, you can probably return to work after 1 to 2 weeks post catheter removal. We suggest that you consider working shorter days the first week you return to work.
Different surgeries have different success rates. Generally, strictures can be resolved in 75–85 percent of cases. If strictures come back, only about one half cause symptoms. In other words if a stricture comes back, it has to be very tight to cause blockage of urinary flow, just like the original stricture.If patients have symptoms, then an internal cutting surgery with a scope is usually tried (direct vision internal urethrotomy). If this doesn’t work, then patients may need additional surgery, which is a rare circumstance.