Urethroplasty is an open surgical procedure to correct an obstruction in the urethra due to scar tissue (urethral stricture).
Urethral scarring may be related to previous trauma (fall astride injury, pelvic fracture), previous instrumentation or catheter insertion, infection, failure of surgery for congenital urethral problems such as hypospadias or as in after the case, no clear cause can be identified.
Urethroplasty is performed when simple procedures (urethral dilation, optical urethrotomy) have failed or when the urethral stricture is too long or too dense for simple procedures to have any chance of controlling the problem.
The extent and location of the stricture is usually defined by a urethrogram – an X-Ray where dye is injected via a small catheter introduced into the urethral opening at the tip of the penis.
Patients with urethral strictures usually present with weak or fine urinary stream, forking or spraying of the stream, often accompanied by frequency and urgency. There may be irritation in the urethra. Urethral strictures may be complicated by infection (urine infection or infection locally in the urethra), peri urethral abscess, urinary retention, bladder and urethral stones and rarely squamous cell carcinoma of the urethra.
Diagram: Anatomy of the urethra.
The type of urethroplasty preformed will be determined by the site and length of the stricture. Most urethroplasty surgery is performed as a single operation but sometimes it is necessary to do a staged operation (usually 2 stages). The surgery will be discussed with you as is relevant to your specific problem.
Common types of urethroplasty
This operation is used for short strictures (˂ 2cm) located in the bulbar or bulbomembranous urethra where the scar can be excised and there is still sufficient urethral length and elasticity to re-join the urethra with a spatulated anastomosis.
The operation is performed through a perineal incision. Patients will have a urethral catheter and suprapubic catheter (draining the bladder through the abdominal wall) for three weeks after the surgery at which stage a further urethrogram will be performed to check healing before removing both catheters.
This operation is used for longer bulbar urethral strictures not suitable for anastomotic urethroplasty and for strictures of the penile urethra. The most commonly used patch is the lining of the inside of the cheek (buccal mucosa). Less commonly, a pedicle patch will be used (penile shaft skin or foreskin with its underlying blood supply). Or other free grafts (skin from penile shaft, skin from behind the ear or other non-hair bearing thin skin from other sites). Sometimes patch urethroplasty in the penile urethra will need to be performed as a 2 stage procedure. Patients having patch urethroplasty will also have urethral and suprapubic catheters for 3 weeks. Patients who have had buccal mucosa graft will have antiseptic mouth wash and local anaesthetic gel to apply to the graft donor site.
Complications of urethroplasty
- Recurrence of stricture (5-20%). There is a higher chance of failure with longer dense, more complicated strictures or if there have been previous surgery or if the sticturing is caused a condition called balanitis seratia obliterans or lichen sclerosus
- Urinary tract infection
- Urine leak
- Erectile dysfunction
- Post micturition dribble
You will be admitted on day of surgery. Prior to admission you are required to have blood and urine tests as arranged by your doctor. Your doctor will check these before admission and arrange appropriate antibiotics if an infection is detected in your urine.
- You will be in hospital between 3-5 days.
- You will have a drain tube which will be monitored and checked by your doctor and the nursing staff. The drain tube will be removed by nursing if no drainage (may take 1-2 days).
- You are strictly advised not to sit in an upright position. You must remain resting in bed until advised by your doctor. Once you are allowed to mobilize out of bed, you are able to shower, walk gently but not sit in a chair. You are required to eat your meals in a semi upright position in bed. This is to prevent any pressure on the surgical site.
- You will have a dressing on your perineal wound. This dressing will be monitored and changed if required.
- It is important you avoid constipation. Please ensure a high fibre diet with adequate fluids. If aperients are required, these will be given to you to prevent any straining.
- You are required to wear anti embolic stockings throughout your admission. Nursing staff will advise you on how to remove and put back on. You will also have a daily injection of clexane to prevent blood clots forming in your legs.
- If you have had a buccal mucosa graft, you will be given a mouth wash and numbing gel such as bonjella to help with the pain. The buccal mucosa graft can cause some discomfort. Please ensure you attend to regular mouth washes, take regular pain relief and use numbing gel. You will be able to drink and eat as directed by the nursing staff on the ward.
- Following your surgery, you will have two catheters. The urethral catheter will be spigotted and will be secured firmly to prevent any traction along the urethra. Your suprapubic catheter will be attached to a drainage bag and staff will monitor your urine output throughout your admission. Before discharge home, you will be taught how to manage your supra pubic catheter, leg bag and overnight drainage bag. The urethral catheter must remain spigotted and must be free from traction at all times.
- Before discharge you will be given an appointment for a wound check in the room in one week.
- You will return to the rooms for a wound check by your doctor and the Practice Nurse. Your perineal dressing will be removed if you have had an anastomic urethroplasty. If you have had a patch urethroplasty, the wound will be reviewed and redressed. At this appointment, staff will provide you with a date to have your catheter removed.
- On the day your Trial of void has been scheduled, you are required to attend the Radiology Department for a voiding cystourethrogram. Your doctor will check the results and will authorise staff to proceed with your trial of void. Initially, you will have your suprapubic catheter spigotted and the urethral catheter removed. You will be required to pass urine 2-3 times. Each time you pass urine you will have an ultrasound performed by the nurse to check you have emptied your bladder.
- If your trial of void has been successful, your suprapubic catheter will also be removed and a waterproof dressing will be applied to the suprapubic catheter site. You will be discharged from the hospital and you will be given an appointment to see your doctor 3 weeks later. At this appointment, you are required to have a flow test and ultrasound residual on arrival. Please arrive in the rooms with a comfortably full bladder and inform the nurse if you require to sit to pass urine.
- Ongoing follow up will be arranged as required and specific to your needs.
You are required to call the rooms and speak to the Practice Nurse if you develop any of the following symptoms:
- Offensive urine
- Presence of blood or sediment in your urine
- Feeling unwell
- Slow stream
- Feeling of incomplete emptying/frequency