The surgical procedure varies according to site, length and characteristics of the stricture.
Stricture involving the pendulous urethra
Many techniques have been described for repairing a stricture of the pendulous urethra. Here, patients can find some techniques that are commonly used in daily practice.
Meatotomy
Standard technique: The external urinary meatus and the navicularis urethra are fully opened ventrally, and the meatus is moved down in healthy urethral mucosa. Catheter is placed for 1-3 days.
Malone's technique: Minimal incision of the meatus on its ventral side, creating a small ventral meatotomy to assess the proximal extension of the narrowing. Another meatotomy in the dorsal face, deeper than the ventral, is done. The goal is to achieve a sufficient opening of the meatus.
Incisions are closed with 4/0 to 6/0 poligalactin interrupted sutures, opposing the urethral epithelium to that of the glans. A Relaxing glans incision in an “inverted V” shape, with the base of the V close to the proximal limit of the dorsal meatotomy, is also performed. Continuous polygalactin 4/0 to 6/0 suture opposing the internal borders of the V incision, forming the superior portion of the new meatus. Catheter is placed for 1-3 days.
Meatoplasty
The external urinary meatus and the navicularis urethra are fully opened ventrally, and the meatus is again moved up to the glans using graft or flap transposition. Catheter is placed for 7-10 days
Penile urethral marsupialization (i.e. Johanson urethroplasty or first stage)
The strictured urethra is fully opened ventrally along with the skin, leaving a wide meatus proximally to void through. The edges of the urethral plate are sutured with the surrounding penile skin using an absorbable suture polyglactin 5/0 or 4/0. A Foley 16 or 14Ch silicon catheter is inserted and keep in placed for 5 days.
Augmented penile urethroplasty
It can be performed as single stage, or more commonly, 6 months after the first stage (urethral marsupialization). The urethral plate is incised dorsally until the tunica albuginea is reached. A buccal mucosa graft, of the same length of the urethral stenosis, is harvested from the patient’s cheek and placed dorsally over the previous incision. The urethra is tubularized over a 14-16Ch catheter. Dartos and penile skin are closed in layers over the urethra. Instead of buccal graft, the preputial skin can be used. Alternatively, a penile skin flap can be mobilized from the side following the principles of the Orandi's technique.
Graft plus flap penile urethroplasty
This technique is reserved to those patients with a complete loss of long segments of pendulous urethra or when the urethral caliber of the stricture is below 3Ch for a long tract (several centimeters). Accordingly, the new urethral plate is reconstructed using a buccal mucosa graft dorsally and a penile fasciocutaneous flap ventrally. Firstly, fasciocutaneous flap is harvested from preputial or distal penile skin. Then, the urethra is fully exposed for the entire length of the stricture. A buccal mucosa graft is placed on the urethral bed dorsally and quilted to the corpora. The fasciocutaneous flap is then placed ventrally to reconstruct the anterior wall. A 14Ch silicon catheter is placed for 4-6 weeks.
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Stricture involving the bulbar urethra
The choice among different techniques is based upon patient’s characteristics such as BMI, history of previous transurethral prostate surgery and sexual function and also on the characteristics of the stricture. Except for traumatic etiology, anastomotic urethroplasty is not performed routinely due to the increased risk of post-operative voiding and sexual dysfunctions. Instead, augmented techniques are preferred.
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Dorsal onlay buccal mucosa graft augmented urethroplasty
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Urethral lumen above 7ch
This is the most versatile technique for bulbar urethral stricture with or without involvement of the pendulous urethra. Patients is under general anesthesia. He is placed in social lithotomy position.
Barbagli’s technique: A vertical incision is made on the midline of the perineum. The bulbospongiosus muscle is incised in the midline and opened to allow the identification of the corpus spongiosum and the urethra. The latter are circumferentially dissected from the two corpora cavernosa to expose the dorsal surface of the urethra.
Kulkarni’s technique: A vertical incision is made in the midline of the perineum. The bulbospongiosus muscle is identified and dissected on one side only, taking care to preserve vessels and nerves.
The urethra is opened dorsally at the level of the stricture to identify a normal urethral mucosa both proximally and distally to the stricture. The buccal mucosa graft is then fixed dorsally over the tunica albuginea of ​​the two corpora cavernosa and anastomosed proximally and distally to the normal urethra. The augmented urethra is tubularized onto a 14-20Ch silicone catheter, which is left in place for 4 weeks.
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Ventral onlay buccal mucosa graft augmented urethroplasty
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This technique is preferred in subjects with urethral stricture in the proximity of the external urethral sphincter where it would be better to avoid a dorsal urethrotomy. Patients is under general anesthesia. He is placed in social lithotomy position. A vertical midline incision is taken. Bulbospongiosus muscle is identified and dissected in the midline to expose the corpus spongiosum. The urethra is then opened ventrally along the entire length of the stricture. The buccal mucosa graft is placed ventrally to augment the urethral lumen. The proximal and distal anastomoses are performed and a 16-20Ch silicon catheter is placed. The corpus spongiosum is then closed and secured over the graft, along with the muscle.
Urethral lumen below 7ch
Non-transecting anastomotic urethroplasty (Andrich-Mundy’s technique)
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This technique is preferred in subjects with a short (<2cm), semi- or completely obliterative urethral stricture near the bulbo-membranous junction. The patient receives general anesthesia, and is placed in lithotomy position. A vertical incision is made in the midline of the perineum. The bulbospongiosus muscle is incised in the midline and opened to allow the identification of the corpus spongiosum and the urethra. The latter is circumferentially mobilized from the two corpora cavernosa to expose the dorsal surface. The urethra is then pulled on one side. A catheter is passed into the urethra to the distal end of the stricture and a dorsal urethrotomy is performed. The ventral hemi circumference of the urethra is sutured from within the lumen after removing any mucosal fibrosis. Finally, the dorsal longitudinal urethrotomy is closed transversely from the outside on a 14-20Ch silicone catheter.
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Augmented non-transected anastomotic urethroplasty (Welk-Kodama’s technique)
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This technique is preferred in subjects with a bulbar urethral stricture that presents a short (<1cm), semi- or completely obliterated segment. The patient receives general anesthesia, and is placed in social lithotomy position. A vertical incision is made in the midline of the perineum. The urethra is accessed either dorsally (Kulkarni or Barbagli approaches) or ventrally. After urethrotomy (either dorsal or ventral), the narrowest segment of the urethral stricture (mucosa and scarred portion of the corpus spongiosum) is resected using the blade and the two margins of healthy urethral mucosa are approximated using 5/0 polyglactin sutures. The opposite wall of the urethra (dorsal or ventral depending on the initial approach) is augmented with a buccal mucosa graft.
Double face urethroplasty (Palminteri’s and Gelman's techniques)
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This technique is preferred in subjects with bulbar urethral stenosis with a semi- or completely obliterated segment, which extends more than 1cm. Two buccal mucosa grafts are required here. The double face approach can be ventral or dorsal. In the ventral approach, the second buccal graft is placed on the dorsal surface of the urethra as described by Palminteri. In the dorsal approach, the second buccal mucosa graft is placed ventrally within the corpus spongiosum of the urethra as described by Gelman. The urethra is then tubularized onto a 14-20Ch catheter which is left in place for 6 weeks.
Gelman dorsal double face
Palminteri ventral double face
Augmented anastomotic urethroplasty (Long semi or complete obliteration of the urethra with narrow segment of approximately 15-20mm)
It is usually performed for traumatic etiology or failed anastomotic repair. The bulbar urethra is exposed through a vertical perineal incision. The level of the stricture is marked and the urethra is circumferentially mobilized after dissection of the bulbospongiosus muscle. The urethra is then opened on its dorsal surface at the 12 o’clock position, commencing at the distal end of the stricture and continuing the urethrotomy proximally through the strictured urethra until healthy, good caliber urethra is reached proximally. The urethra is transected and the stricture is excised. A buccal mucosa graft is placed dorsally and quilted to the corpora cavernosa to augment the anastomosis. A Foley catheter is left in place for 4-6 weeks.
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Graft plus flap urethroplasty (Long semi or complete obliteration of the urethra with narrow segment ≥20mm)
The bulbar urethra is mobilized on one side. In those cases where the stricture involves the penile urethra, the penis is invaginated through the scrotum in order to have full exposure of the anterior urethra. Dorsal urethrotomy is performed and the urethra is opened across the stricture. The portion of urethra with complete loss of native urethral plate is marked. A buccal or skin graft is placed dorsally and quilted to the corpora cavernosa to reconstruct the dorsal plate of the neourethra. A fasciocutaneous penile flap is harvested from the prepuce or distal penile skin and transposed with its vascular pedicle to the perineum, from the left side of the patient, and placed ventrally. A 14-20Ch catheter is placed and the urethra is tubularized.
Single-Stage preputial spiral graft urethroplasty
​​A midline incision is made until the perineal fascia is reached. The perineal fat is dissected, exposing the bulbospongiosus muscle and bulbar urethra with the Turner–Warwick retractor. The muscle is then dissected on one side to expose the corpus spongiosum following the Kulkarni technique. The penis is invaginated into the perineum via the scrotum to expose the anterior urethra. The urethra is dissected on one side, from proximal to distal. A dorsal incision in the urethra is made at the 12-o'clock position, and a urethrotomy is performed along the stricture until healthy tissue is found. A spiral preputial graft is harvested from the foreskin, creating a helicoidal-shaped graft of up to 20 cm. Circumferential incisions are made, and the skin is separated from the dartos fascia to extract a cylindrical graft, which is then cut into a 2-cm-wide spiral graft. The spiral graft is sutured to the meatus and inserted into the urethra. The penis is reinvaginated for full exposure, and the graft is anastomosed at the bulbo-membranous junction. The neo-urethra is tubularized, a catheter is placed, and the muscle is reconstructed. Incisions are closed, and the catheter remains until day 30 post-surgery
Post-traumatic stricture with obliteration
Anastomotic urethroplasty
Vertical perineal incision is taken. Bulbospongiosus muscle is identified and dissected in the midline to allow the exposure of the corpus spongiosum and the urethra. A bougie dilator is retrogradely passed inside the urethra until the level of the stricture, which is marked. The urethra is circumferentially mobilized proximally and distally to the stricture. The urethra is then transected and the strictured segment is excised. The two urethral ends are spatulated and subsequently joined together with 6 interrupted stitches to allow a tension-free anastomosis. Catheter is kept in placed for 4 weeks.
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Female urethral strictures
Compared with male urethra, the female urethra is much shorter and so, surgical options are less. When the urethral stricture is diagnosed, patients are advised about the available treatment options, which include periodic dilatations, DVIU, or open surgery (urethroplasty).
For open urethroplasty many techniques have been described. Among all, three approaches have become more popular because of higher success rates.
Anterior onlay
The patient is under general anesthesia in social lithotomy position. Labia minora are retracted with stay sutures to facilitate the exposure of the urethra. An integument deep hemi-circle incision is given surrounding the upper half of meatus. The distal half of urethra and the vestibular bulbs (equivalent of bulb of penis and corpus spongiosum in males) are easily separable from the cavernosal bodies which run superiorly and laterally. Followed proximally, the plane of dissection enters the sub-sphincteric plane, thereby preserving the external sphincter as well. Incision is given at the 12 o’clock position to open the urethra along the entire longitudinal length of the stricture and 5 mm beyond it. Care must be taken to avoid the incision of the bladder neck. The buccal mucosa graft is then parachuted above the opened urethra to reconstruct the augmented lumen. A few quilting sutures are taken to fix the graft to the corpora cavernosa and avoid any dead space. A 20Ch Foley catheter is left in place for 4 weeks.
Posterior inlay
The patient is under general anesthesia in social lithotomy position. Labia minora are retracted with stay sutures to facilitate the exposure of the urethra. The urethral mucosa and periurethral tissue are incised at 6 o’ clock position for the entire length of the stricture, until normal urethral caliber is reached. The lumen should be wide enough to allow a 30Ch bougie dilator to reach the bladder. The incision is restricted to the periurethral tissue as cutting any deeper would lead to an opening of the vaginal wall, creating a fistulae. The buccal mucosa graft is place in the urethral gap (inlay) and sutured to the edges of healthy mucosa. Few quilting sutures are used to fix the graft and avoid dead space. A 20Ch Foley catheter is left in place for 4 weeks.
Combined anterior onlay and posterior inaly
When the stricture is more severe and the urethral lumen is very narrow (below 7Ch), a double face augmentation is required. This technique simply follows the principles of the two previously described operations. Thus, two grafts are required, and the time of the operation will be longer.
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Precautions after urethroplasty
Hospital stay can last from one to three days after urethroplasty. The dressing is usually removed before discharging the patient along with any drains. The patient is discharged with the bladder catheter. It is important not to pull or remove the catheter until the established date. At home, the patient can have a normal life avoiding strenuous physical activity and sporting training until the catheter is removed. He/she should follow a diet rich in fiber (fruit and vegetables) to facilitate intestinal motion. It is mandatory to take at least 2L of water per day. Cranberry or red fruit juices are also useful to prevent urinary tract infections. The urine bag should be emptied regularly but should not be changed frequently in order to avoid bacterial contamination. The patient will have to take the therapy prescribed by the physician. This may include antibiotic therapy, heparin antithrombotic prophylaxis, and/or anticholinergic therapy to prevent from catheter-induced bladder spasms (solifenacin 5mg). The prescription of these medications will be decided by the treating physician based on the risks and benefits, and it can therefore vary considerably from patient to patient.
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Buccal mucosa graft harvesting
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The Buccal mucosa graft is used in many reconstructive operations due to its versatility and intrinsic ability to substitute the urethral mucosa. The buccal graft is usually harvested from the mucosa of the inner cheek (left or right). Other sites of the oral cavity can be used to harvest the graft whether the mucosa of the inner cheek on both sides is unsuitable. These sites include the lower surface of the tongue or the inner face of the lower lip. However, harvesting the graft from these sites might have some cons including shorter length of the graft and higher comorbidities for the patient. From the day before surgery, the patient is advised to start mouth washing with chlorhexidine. It works by decreasing the amount of bacteria in the mouth, helping to reduce the risk of infection and bleeding during graft harvesting. The patients should rinse the mouth with the solution after brushing the teeth, usually twice daily (after breakfast and at bedtime). It should be continued for 3-4 weeks after surgery.
Surgical procedure
Patients is usually under general anesthesia. Nasal intubation is not mandatory but it is useful especially in patients with a limited mouth opening. A Kilner-Doughty mouth retractor is placed to facilitate the dissection. Three stay sutures are placed along the edge of the mouth to stretch the oral mucosa. The Stensen’s duct is marked to avoid its dissection or cauterization during surgery. When the Stensen’s duct is not visible, a gentle compression on the upper portion of the mandibular ramus can stimulate secretion from the parotid gland. The graft is designed on the mucosa of the inner cheek according to cheek size and stricture length. Ten ml solution with bupivacaine hydrochloride 2.5 mg/ml and epinephrine acid tartrate 0.0091 mg (0.005 mg epinephrine) are injected below the layer of graft mucosa to facilitate hemostasis and dissection. The graft is dissected in the plane below the mucosa leaving the buccinator muscle untouched. The donor site is accurately examined and bleeding is controlled with electrocautery. The donor site can be closed with running 5/0 polyglactin sutures or left open and packed with gauze. The donor area is usually left open when the size of the graft is too large to allow a tension-free closure or the oral cavity is too small to avoid deformity upon closure. Instead, the closure of the donor site is preferred when it is not possible to control the bleeding or the patient require anticoagulation after surgery. Leaving the donor site open also can facilitate the harvesting of another buccal graft from the same site in the future.
Post-operative care
On first postoperative day, the patient is asked to follow a fluid diet that avoids hot liquids to prevent from pain on the harvesting site. Instead, cold fluid or ice-cream are encouraged to reduce post-operative pain. A soft diet without spicy or chilly food is advised from the second postoperative day. The patient usually returns to a normal diet after 7 days. When the donor site is left open, a new layer of mucosa will grow over the raw area in about 3 weeks. The patient is also encouraged to practice a mouth physiotherapy, which includes stretching exercises such as blowing with closed mouth to increase cheek distension and prevent from retraction and fibrosis. These exercises should be carried during the first month after the operation. Oral morbidity and complications are rare but they may include pain, bleeding, swelling, numbness, alteration of salivation and taste, as well as impairment of mouth opening, smiling, whistling, diet, and speech.
