Urethral strictures

A detailed description on the management of or Urethral Strictures (Anterior part of the urethra).

1. Urethral strictures DR. M.YIGAH

2. INTRODUCTION A urethral stricture is a narrowing of the urethra caused by scarring of the epithelium and its surrounding corpus spongiosum. 2 nd commonest cause of Lower Urinary Tract Obstruction in Sub Saharan Africa . ( Mbibu et al 2002)

3. ANATOMY OF THE URETHRA

4. ANATOMY OF THE PENIS Glans penis is the expanded part of the Corpus spongiosum Corpus spongiosum is attached to perineal body The corpus cavernosum is attached to Ischiopubic rami

5. EPIDEMIOLOGY Prevalence in Sub Saharan Africa 2 nd commonest cause of lower urinary tract obstruction ( Mbibu et al, 2002) Hospital Prevalence – 4.2% in Ouagadougou ( Yameogo et al, 2017) Accounts for 14.3% of Acute Urinary Retention in South Africa– ( Stephan et al, 2011 ) Gender Differences Female Urethral strictures < 3% of all strictures ( Mugalo et al 2013) Age Peak age range – (20 and 39) years

6. EPIDEMIOLOGY Prevalence in Ghana Out of the 11,084 OPD visits to the urology clinic of KBTH in 2011, it accounted for 1015 (9%) of all diagnosis (Mensah et al 2013) Cape Coast Teaching Hospital Diagnosed 94 times out 173,507 OPD visits to the hospital Formal Cystostomy – 5 over the past 2 months 1 Urethroplasty over the past 3 months Urethroplasty – GH ₵4000

7. IATROGENIC CAUSES Urethral Instrumentation for diagnostic or therapeutic purposes Transurethral Catheterization Urethroscopy Transurethral Resection of the Prostate (TURP) or Bladder Tumors (TURBT) Urethral dilatation Internal Urethrotomy Genitourinary Surgery Radical Prostatectomy Hypospadia repairs Circumcision External beam radiotherapy or brachytherapy

8. TRAUMATIC CAUSES Blunt Injury Straddle injuries – e.g. falling onto a bicycle crossbar. Road Traffic Accidents and Industrial Accidents Penile fractures Constriction penile bands or rings Penetrating injury Gunshot wounds Stab wounds Penile amputation injuries

9. SOME CAUSES OF URETHRAL STRICTURES

10. INFLAMMATORY CAUSES Post-infectious inflammatory causes Gonococcal urethritis Non-specific Urethritis ( e.g Chlamydia sp.) Schistosomiasis Tuberculosis Non-infective inflammatory causes Lichen Sclerosis Allergic reactions – latex catheters Reiter’s syndrome

11. IDIOPATHIC & CONGENITAL Idiopathic strictures – Urethral strictures of unknown origin Absence of urethral inflammation, trauma, infection, and urethral manipulation . Congenital strictures Associated with other conditions Amniotic band syndrome Prune-belly syndrome

12. Epidemiology Developed Nations Idiopathic urethral strictures Iatrogenic stricture External trauma Post-infectious strictures Developing Nations Post-infectious strictures External trauma Iatrogenic urethral strictures Idiopathic strictures ( Irekpita & Udefiagbon , 2019)

13. COMMON SITE OF URETHRAL STRICTURES Bulbar urethra – 40.2% Membranous urethra – 35.57% Pendulous urethra – 14.43% Prostatic – 4.63% Female Urethra – 3.10% Fossa navicularis – 2.07%

14. PATHOGENESIS Strictures are the consequence of epithelial damage and spongiofibrosis Noxious stimulus (bacterial, chemical, physical) Squamous metaplasia Fissures develop in epithelium Extravasation of urine into corpus spongiosum Fibrosis develops in the corpus spongiosum Fibrotic plaques coalesce Contraction of this scar reduces the urethral lumen.

15. NATURAL HISTORY A stricture narrows the lumen to (10–12 French) before significantly impairing urine flow Compensatory hypertrophy of the detrusor muscles Decreases compliance to filling of bladder Development of hydroureters and hydronephrosis due to vesico-ureteric reflux Urinary stasis can predispose infections and bladder stones Development of periurethral abscess leading to fistulation (Watering Can Perineum)

16. COMPLICATIONS Infections - Urinary tract infections, prostatitis, epididymo-orchitis Development of fistula Bladder calculi Diverticula Urinary Retention Renal failure

17. CLINICAL PRESENTATION Progressive worsening of symptoms of lower urinary tract obstruction . Frequency and Nocturia Feeling of incomplete emptying of urine Poor urine stream Straining Hesitancy Terminal dribbling .

18. CLINICAL PRESENTATION Complications especially in long standing cases or neglected cases Acute or Chronic Urinary Retention Infections – cystitis, prostatitis, epididymitis and pyelonephritis Urethrocutaneous fistulae – scrotal, perineal fistulae (Watering can perineum) Bladder stones Renal failure

19. FURTHER ENQUIRY ON HISTORY Onset, severity and rapid progression of the LUTS Post gonococcal strictures – can take up to 20 years to develop History of confirmed STD or past symptoms suggestive of STD Trauma – within 2 months Preceding trauma to the perineum or penis, RTA Lower abdominal pain, blood at the urethral meatus, inability to pass urine - PFUI

20. CLINICAL HISTORY Past Medical History History of a stricture and subsequent management – urethral dilatation, internal urethrotomy History of urologic surgeries – Hypospadia repairs, prostatectomy etc History of difficult urethral catheterization TB, Schistosomiasis, BPH, Diabetes mellitus Social History Smoking or chewing of tobacco.

21. PHYSICAL EXAMINATION General Ill-looking and febrile - infection Examining the oral mucosa for suitability for harvest of buccal or lingual mucosal graft Abdomen Lower abdominal pain in UTI, retention Bladder may be palpable in patient with urinary retention. Examining the hernia orifices DRE – for patient >40yrs and patients with PFUI

22. PHYSICAL EXAMINATION Genitalia and Perineum Palpation of the penis, scrotum, perineum and urethra for thickenings or Indurations Assess the urethral meatus for stenosis and bleeding Scrotal, Penile or Perineal hematoma Presence or absence of a fistula Presence of Chordie, Hypospadia and whether the patient has been circumcised

23. EXAMINATION OF THE GENITALS & PERINEUM

24. DIAGNOSTIC INVESTIGATIONS Imaging Studies Retrograde Urethrography (RUG) Voiding Cysto-Urethrography (VCUG) Urethrosonography MRI & CT Scan Urethrocystoscopy Urethral Instrumentation

25. RETROGRADE URETHROGRAPHY Gold standard for diagnosis and staging of urethral strictures since 1910

26. RETROGRADE URETHROGRAPHY A scout film should be taken before the contrast is injected

27. RETROGRADE URETHROGRAPHY Positioning of the patients Should be done (or supervised) by the treating Urologist Lateral Oblique (45 degrees) Gentle traction on the penis

28. RETROGRADE URETHROGRAPHY Contrast should be seen proximal to the stricture.

29. NORMAL RUG Well positioned patient. Good traction on the penis All parts of the urethra well delineated Contrast flowing into the bladder

30. POST-TRAUMATIC BULBAR URETHRAL STRICTURE

31. POST INFLAMMATORY PENILE URETHRAL STRICTURE

32. RECTO-URETHRAL FISTULA

33. LIMITATIONS OF RUG Difficult to assess distal urethral strictures (urethral meatus and fossa navicularis) Difficult assessing the proximal part of the urethra e.g Bladder neck Injecting of contrast can be very uncomfortable and predispose to UTI Reaction to contrast agent.

34. VOIDING CYSTO-URETHROGRAM (VCUG/MCUG)

35. BULBAR STRICTURE RUG BULBAR STRICTURE ON MCUG

36. URETHRO-CYSTOSCOPY Gold standard for determining the presence or absence of stricture Enables biopsy of suspicious lesions which may be a carcinoma Permits visual inspection of the bladder - bladder calculi, tumors or diverticula

37. URETHROSONOGRAPHY Used to stage the stricture - location, length and caliber. Best used for penile urethral strictures compared to the bulbar portion. Limited by the stricture location and its is operator dependent

38. MRI & ct scan Best ancillary imaging modality for assessing post-traumatic pelvic anatomy. Evaluate the configuration of any pelvic fractures 3 Dimension Spiral CT Cystourethrography (CTUG) – Novel technique

39. SUPPORTIVE INVESTIGATIONS Post Void Residual Urine Measurement Uroflowmetry urethral obstruction – PFR < 15ml/sec and plateau curve profile American Urological Association Symptom Score (or IPSS) Questionnaire used to quantify the severity of the subjective voiding symptoms in both sexes Urinalysis BUE and Cr

40. FINAL DIANOSIS Confirm the stricture and its characteristic Cause of the stricture Site of the stricture Length of the stricture Complete or Incomplete (Caliber of the stricture) Density and depth of the spongiofibrosis Complication of the stricture e.g. Bladder calculi, Renal failure Associated urological pathology that might affect LUTS

41. TREATMENT OPTIONS Temporary Measures Supra-pubic catheterization – Formal or Stab Cystostomy Definitive Treatment Dilation Endoscopic Direct Vision Internal Urethrotomy Urethroplasty

42. Indications for Temporary Treatment Complications of Urethral strictures – Urinary retention, Fistula, Uraemia etc. Unfit for surgery – Old age, Bleeding disorders Lack of funds for definitive treatment Lack of expertise and facilities for open or endoscopic surgery

43. DEFINITIVE TREATMENT

44. URETHRAL DILATION Goal: Stretch the scar without injuring the urethra to produce more scars A palliative treatment for most patients A potential curative treatment for well selected patients Short (< 2 cm) incomplete epithelial stricture with no (or minimal) spongiofibrosis Frequency of dilation Increasing intervals e.g. 2 weeks, 1 month, 3months and 6months and continued indefinitely

45. Flexible filiform bougies & followers CURVED STEEL BOUGIES

46. Flexible filiform bougies and followers

47. Complications of urethral Dilation Bleeding, Clot Retention, Urethral rupture, Infections - Prostatitis, Cystitis, Epididymo-orchitis, Pyelonephritis, Bacteraemia Rupture of prostate (BPH)

48. ENDOSCOPIC DIRECT VISION INTERNAL URETHROTOMY ( dviu ) Internal Urethrotomy is any procedure that opens the stricture by incising through the scar transurethrally to release the contraction to allow the lumen to heal enlarged. Direct Vision Internal Urethrotomy (DVIU) was introduced in 1974 by Sachse. The urethra is then splinted with an indwelling catheter for about 2 – 7 days (14 – 21 days for difficult strictures)

49. ENDOSCOPIC DIRECT VISION INTERNAL URETHROTOMY 1 st line therapy Short < 1 cm bulbar stricture > 15F in calibre in the absence of dense and deep spongiofibrosis . A stricture-free rate (SFR) of up to 50%–70%

50. The case for patient selection Pansadoro and Emiliozzi 1996 Stricture Location Bulbar Penile Peno -scrotal Success Rate (SFR) 42% 16% 11% Stricture Length < 1cm > 1cm Success Rate (SFR) 71% 18% Diameter > 15 FR <15 FR Success Rate (SFR) 69% 34% No of Strictures Single Multiple Success Rate (SFR) 50% 16% Primary or Repeat Treatment Primary Repeat Success Rate (SFR) 47% 0%

51. ATTEMPTS TO IMPROVING THE OUTCOME OF DVIU Long term continuous catheterization – i.e for 6 weeks Intermittent self or office catheterization Urethral dilation Pharmacological management Colchicine Mitomycin C Triamcinolone Laser therapy

52. Contraindications to DVIU Stricture Characteristics Long strictures (> 4cm) Complete stricture Strictures with dense spongiofibrosis 2 previous failed DVIU Recurrent strictures that occur <3 months after DVIU Complications of strictures: Untreated urinary tract infection, Fistula etc Coagulation disorders

53. OUTCOME OF DVIU/DILATION Best Outcome A stricture-free rate (SFR) - 50%–70% (for well selected patients). Recurrence of stricture Recurrence at < 3 months – SFR is 0 % after 2 years for the 2 nd attempt Recurrence at > 6 months - SFR is 40% after 2 years for the 2 nd attempt Repeated DVIU/dilation Patients undergoing a third incision or dilation have a 100% recurrence rate (palliative)

54. Complications of INTERNAL URETHROTOMY Recurrence of stricture, Urethral haemorrhage Clot retention Erectile dysfunction UTI

55. Urethral stenting The concept of urethral stenting dates back to at least 1969 Championed by Milroy et al. in 1988. Criteria for using Permanent Stent Short, incomplete and recurrent bulbar stricture who are medically unfit for urethroplasty cannot tolerate intermittent self-catheterization/dilation

56. URETHROPLASTY Gold standard for management of urethral stricture and stenosis. Indications All forms of stricture and stenosis Failed Urethral Dilation or DVIU Complex strictures – Long and Multiple, Pelvic Fractures Associated urologic conditions – e.g. Hypospadia Associated complication – False passages, Fistulae, Calculus, urethral diverticula .

57. TYPES OF Open Urethroplasty Excision and Primary Anastomosis Substitution (Augmentation) Urethroplasty Techniques Augmented anastomotic procedure. Onlay Augmentation Procedure Tube Augmentation

58. Excision and Primary Anastomosis The most dependable technique of short anterior urethral reconstruction High success rate – 90 – 95% (G. Barbagli et al 2008; Santucci et al 2007) Patient selection Short (<2cm) especially in the anterior bulbar urethral Dense bulbar strictures (obliterative and near obliterative)

59. Excision and Primary Anastomosis The best results are achieved when the following technical points are observed: The area of fibrosis is totally excised; the urethral anastomosis is widely spatulated creating a large ovoid anastomosis anastomosis is tension free Techniques Vessel‐sparing excision and primary anastomosis Non-vessel sparing technique

60. Vessel‐sparing excision and primary anastomosis

61. Vessel‐sparing excision and primary anastomosis

62. Vessel‐sparing excision and primary anastomosis

63. Vessel‐sparing excision and primary anastomosis

64. Excision and Primary Anastomosis Complications Ejaculatory dysfunction Erectile dysfunction Chordie Penile shortening Stricture recurrence

65. SUBSTITUTION URETHROPLASTY Strictures too lengthy for tension free EPA Substitutes – Grafts and Flaps Various grafts have been used for reconstructing the Urethra. STGF or FTSG – Penis, Post-auricular region Oral Mucosal Grafts - buccal, lingual, labial Bladder Epithelial Graft, Rectal Mucosal Graft. Acellular collagen matrix

66. DONOR SITES FOR GRAFT BUCCAL POST-AURICULAR LINGUAL

67. SUBSTITUTION URETHROPLASTY One-stage Graft Techniques An augmented anastomotic procedure Excision of stricture and restoration of roof or floor strip of native urethra with a graft On-lay Augmentation Procedure To incise the stricture and carry out a patch augmentation Tube augmentation . To excise the stricture and put in a circumferential patch

68. The augmented anastomotic urethroplasty Combination Excision and Substitutional Urethroplasty Bulbar strictures deemed too long for straight forward primary anastomosis.

69. Dorsal Onlay augmented anastomoSIS For short distal Bulbar strictures ≤ 2cm Superior spread-fixation (reduces graft shrinkage) Enhances graft take due to vascular corporal body,

70. VENTRAL Onlay augmented anastomoSIS Short proximal bulbar strictures ≤ 2cm A risk of graft shrinkage Prone to diverticulum

71. ON-LAY (NON-TRANSECTING) AUGMENTATION URETHROPLASTY

72. Ventral OnlaY NON-TRANSECTED Augmentation Urethroplasty For Proximal Bulbar Stricture that are > 2 cm. Inferior graft take compared to dorsal version Prone to graft contraction Prone to diverticulum

73. DORSAL Onlay NON-TRANSECTED Augmentation Urethroplasty For longer (> 2cm) middle and distal bulbar strictures. Superior graft coverage Superior graft take. Less prone to graft sacculation or diverticulum

74. ASOPA TECHNIQUE NON-TRANSECTING augmented URETHROPLASTY Variant of dorsal onlay for penile and bulbar strictures Urethra plate > 1 cm No circumferential mobilization of the urethra Preserves the perforating neurovascular structures

75. Kulkarni Non-transecting augmented URETHROPLASTY For Penile or Peno-bulbar stricture Suitable for pan urethral strictures Eliminates the need for full circumferential mobilization Preserves the perforating neurovascular structures and Bulbospongiosus muscle

76. PALMINTERI NON-TRANSECTING AUGMENTED URETHROPLASTY For very narrow strictures where a single graft would not be sufficient to obtain adequate lumen width The strictured urethra is incised in the midline and augmented dorsally and ventrally using two oral grafts Preserves sexual function

77. MULTI-Staged URETHROPLASTY Staged reconstruction is planned repair strategy characterized by more than one operation and inherent free tissue transfer. INDICATIONS , Multiple prior urethroplasty failures Long obliterative strictures Failed Hypospadia repairs Urethral reconstruction after failed urethral stent placement Presence of diverticulum or fistula Strictures caused by lichen sclerosis

78. MULTI-Staged URETHROPLASTY 1st Stage of urethroplasty Marsupialization of the urethra Placement of FTSG, STSG or buccal grafts over the dartos fascia 2 nd stage of Urethroplasty Tubularization of the graft. Time between the 1 st and 2 nd surgery --- 6 -12 months.

79. Techniques OF MULTI-Staged URETHROPLASTY Staged oral mucosa graft urethroplasty Johanson’s technique Mesh graft urethroplasty

80. FLAP Urethroplasty The flap can be harvested from the penis or scrotum Techniques of flap urethroplasty Quartey’s penile flap – bulbar or pendulous strictures Jordan’s ventral transverse skin island flap procedure – fossa navicularis strictures Ventral longitudinal island flap (Orandi) – strictures of the pendulous urethra Dorsal transverse preputial island flap (Duckett) – pendulous and distal bulbous urethra Hairless scrotal island flap (Jordan) for bulbo-membranous stricture.

81. Quartey’s Penile flap urethroplasty

82. Orandi flap Ventral longitudinal island flap for long penile strictures

83. FLAP VS GRAFT There is no advantage of a flap over a graft in terms of stricture recurrence rate. Flap are technically more challenging and have more complications Wound infections Penile hematoma and Seroma Skin necrosis Urethrocutaneous fistula Higher risk of sacculation (diverticulum formation )

84. POST OPERATIVE EVALUATION There is not even a standard definition of what constitutes post-operative success or a recurrent urethral stricture. Commonly Used Assessment Tools RUG, VCUG, Urethro -cystoscopy urethral calibration, AUA-SI, uroflowmetry & PVR,

85. COST EFFECTIVE WAY OF MANAGING STRICTURES For the management of short bulbar urethral strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails . For longer strictures, in which the success rate of DVIU is expected to be < 35%, urethroplasty as primary therapy is cost effective. (Wright et al, 2006)

86. TAKE HOME MESSAGE The BEST WAY to treat a stricture is to PREVENT IT Gentle urethral instrumentation Public education on STD and the use of condoms Complying with all industrial and road safety measures

87. References Campbell-Walsh Urology Textbook 11 th Edition. An International Consultation on Urethral Strictures - Marrakech, Morocco, October 13-16, 2010. Anthony R. Mundy and Daniela E. Andrich, 2010, Urethral strictures BAJA’ Principles and Practice od Surgery Vol II Onyeanunam N Ekeke 2017, African Journal of Urology Eshiobo I, Ernest U. A Review of the epidemiology and management of urethral stricture disease in Sub-Saharan Africa. Curr Med Issues 2019;17:118-24. Mensah et al.-2013-Contemporary Evaluation and Treatment of Male Urethral Stricture Disease in West Africa

88. THANK YOU