Urethral stricture is a condition characterized by the narrowing of the urethra, which can cause difficulty in urination, recurrent urinary tract infections, and bladder dysfunction. This narrowing can result from trauma, infections, inflammation, or prior surgeries affecting the urethra. When conservative treatments such as dilation or intermittent catheterization fail to relieve symptoms, surgical intervention becomes necessary. Understanding the operation for urethral stricture, including its types, techniques, indications, risks, and recovery, is essential for patients considering this procedure.
Understanding Urethral Stricture
A urethral stricture occurs when scar tissue forms within the urethra, narrowing the channel through which urine passes from the bladder to the external urethral opening. The severity of the stricture varies, and it can affect different parts of the urethra, including the anterior or posterior sections. Symptoms often include weak urine stream, straining to urinate, incomplete bladder emptying, urinary retention, and in severe cases, kidney problems due to back pressure.
Causes of Urethral Stricture
- Trauma or injury to the pelvic area or perineum
- Infections, such as sexually transmitted infections or recurrent urinary tract infections
- Inflammation from conditions like lichen sclerosus
- Previous surgeries involving the urethra, prostate, or bladder
- Radiation therapy affecting the pelvic region
Indications for Surgery
Surgery is indicated when urethral strictures cause significant symptoms or complications that cannot be managed conservatively. Common indications include
- Recurrent urinary retention or incomplete bladder emptying
- Severe obstruction affecting quality of life
- Failure of minimally invasive treatments such as dilation or urethrotomy
- Recurrent infections due to stricture-related urine stasis
- Progressive kidney damage caused by obstruction
Surgical Techniques for Urethral Stricture
Various surgical approaches exist for treating urethral strictures, each chosen based on the location, length, and severity of the stricture. The main surgical techniques include
Urethral Dilation
Urethral dilation involves gradually stretching the narrowed portion of the urethra using dilators. This is often considered a temporary or initial measure for short strictures. While dilation can provide immediate relief, recurrence is common, necessitating more definitive surgery in many cases.
Direct Vision Internal Urethrotomy (DVIU)
DVIU is a minimally invasive procedure where a small incision is made in the stricture under endoscopic guidance. It is suitable for short strictures, usually less than 2 centimeters. Success rates are variable, and repeated procedures may be required if the stricture recurs.
Urethroplasty
Urethroplasty is considered the gold standard for definitive management of urethral stricture, particularly for longer or recurrent strictures. The procedure involves excising the scarred segment and reconstructing the urethra. Techniques include
- Excision and primary anastomosis Suitable for short bulbar urethral strictures, where the ends of the urethra are directly reconnected after removing the narrowed segment.
- Substitution urethroplasty Used for longer strictures; a graft or flap, often from the buccal mucosa, is used to reconstruct the urethra.
- Perineal or penile urethroplasty Choice of approach depends on stricture location and length, with perineal approach commonly used for bulbar and penile urethra reconstruction.
Preoperative Evaluation
Before surgery, comprehensive evaluation is essential to plan the optimal approach. Preoperative assessments include
- Uroflowmetry to measure urine flow rate
- Retrograde urethrography to visualize the stricture’s location and length
- Cystoscopy for direct visualization of the urethra
- Urinalysis and urine culture to rule out infections before surgery
- Assessment of comorbidities to reduce surgical risks
Postoperative Care and Recovery
Recovery after urethral stricture surgery varies depending on the procedure performed. General recommendations include
Catheterization
Following urethroplasty, a urinary catheter is typically placed to allow the urethra to heal. The duration ranges from 1 to 3 weeks based on the surgical technique and patient factors.
Pain Management
Postoperative pain is managed with analgesics, often including non-steroidal anti-inflammatory drugs or acetaminophen. Severe pain may require short-term use of stronger medications.
Monitoring for Complications
Patients are monitored for potential complications such as
- Urinary leakage or fistula formation
- Infection at the surgical site
- Bleeding or hematoma
- Recurrence of stricture
- Urethral diverticulum or abnormal scarring
Rehabilitation and Follow-Up
Follow-up visits typically involve clinical evaluation, uroflowmetry, and possibly imaging to assess urethral patency. Sexual function and urinary continence are also evaluated. Patients are advised to avoid strenuous activities and sexual intercourse until cleared by the surgeon.
Success Rates and Prognosis
Urethroplasty provides high long-term success rates, often exceeding 85% to 90% for suitable candidates. Shorter strictures treated with DVIU or dilation have variable outcomes, with recurrence rates up to 50% in some series. Patient factors such as stricture length, etiology, and comorbidities influence the prognosis. With proper surgical technique and adherence to postoperative care, most patients experience improved urinary function and quality of life.
Risks and Complications
As with any surgery, there are potential risks associated with urethral stricture operations. These include
- Recurrence of the stricture
- Infection of the urinary tract or surgical site
- Urethral fistula or abnormal connections
- Bleeding or hematoma formation
- Urinary incontinence
- Altered sexual function or erectile dysfunction in some cases
Operations for urethral stricture are a critical intervention when conservative treatments fail to relieve symptoms or prevent complications. Options range from minimally invasive procedures like dilation and internal urethrotomy to definitive reconstructive urethroplasty, tailored to stricture length, location, and patient factors. Understanding the surgical techniques, preoperative planning, postoperative care, and potential complications helps patients make informed decisions and achieve optimal outcomes. With skilled surgical management and diligent follow-up, most patients regain normal urinary function and significantly improve their quality of life.