This document discusses stricture urethra and its management. It provides details on the epidemiology, etiology, clinical evaluation and surgical options for urethral strictures. Key points include that bulbar strictures are the most common, iatrogenic causes have increased in prevalence, clinical evaluation involves uroflowmetry, retrograde urethrogram and cystoscopy, and surgical options range from dilation and direct visual internal urethrotomy for short strictures to various types of urethroplasty using grafts or flaps for longer or complex strictures.
2. Moderators:
Professors:
⢠Prof. Dr. G. Sivasankar, M.S., M.Ch.,
⢠Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
⢠Dr. J. Sivabalan, M.S., M.Ch.,
⢠Dr. R. Bhargavi, M.S., M.Ch.,
⢠Dr. S. Raju, M.S., M.Ch.,
⢠Dr. K. Muthurathinam, M.S., M.Ch.,
⢠Dr. D. Tamilselvan, M.S., M.Ch.,
⢠Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2
4. Urethra
⢠Anterior Urethra âPenile and bulbar
urethra
⢠Posterior Urethra â Prostatic and
membranous urethra
Dept Of Urology, KMC and GRH, Chennai 4
5. ICUD Consensus 2010
⢠A urethral stricture is defined as a narrowing of the urethra
consequent upon ischaemic spongiofibrosis.
⢠Since only anterior urethra is covered by corpus spongiosum, the
terminology is used only for anterior urethra.
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6. Consensus Conference 2016
⢠Stricture- Associated with anterior urethra
⢠Distraction defects- Membranous urethra with pelvic fracture
⢠Stenosis- Associated with posterior urethra
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8. Epidemiology
⢠Prevalance 1-9 per 1000 population.
⢠Highest in developing countries.
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9. Anatomical Incidence
⢠Bulbar strictures - 44â67 %,
⢠Penile strictures - 12â39 %,
⢠Mixed (bulbar and penile)- 6â28 %,
⢠External meatal or submeatal - (0â23 %),
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10. Location and Mean Stricture Length
⢠Pendulous urethra - 6.1 cm,
⢠Bulbar urethra - 3.1 cm, and
⢠Fossa navicularis - 2.6 cm.
Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: etiology and characteristics. Urology.
2005;65(6):1055â8.
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14. Iatrogenic Stricture
⢠Transurethral resection (41 %),
⢠Prolonged catheterization (36.5 %), and
⢠Cystoscopy (12.7 %)
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15. Etiology
⢠Ischaemia due to
instrumentation at pressure
points and catheterization with
large lumen catheter.
⢠At points of bow string
compression.
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16. Risk Factors
⢠Advanced age,
⢠Sexually transmitted illness,
⢠Socioeconomic status,
⢠Race,
⢠Lichen sclerosus, and
⢠A history of prostate cancer treatment.
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17. Lichen sclerosis and Stricture Urethra
⢠Previously called Balanitis Xerotica Obliterans
⢠May be due to autoimmunity/oxidative stress
⢠Premalignant lesion â penile cancer changes 2.3 -9.3%
⢠Associated with anterior urethral stricture
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18. ⢠1991-2002 study
⢠925 patients underwent urethroplasty for anterior urethral stricture,
130 patients received the diagnosis of LS..
⢠14% had LS.
Barbagli et al 2004
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19. Lichen Sclerosis and Borrelia Burgdorferi-
Present Status
⢠Borrelia burgdorferi is not associated with genital lichen sclerosus in
men
Aberer E, Neumann R, Stanek G. Is localized scleroderma a Borrelia infection? Lancet. 1995;2:278.
Weide B, Waltz T, Garbe C. Is morphea caused by Borrelia burgdorferi? A review. Br J Dermatol.
2000;142:636â44.
Edmonds E, Mavin S, Francis N, Ho-Yen D, Bunker C. Borrelia burgdorferi is not associated with
genital lichen sclerosus in men. Br J Dermatol. 2009;160(2):459â60.
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20. Gonococcal strictures-Present Scenario
In the previous century more than 90 % of strictures were
inflammatory due to gonococcus.
At present, due to the development of antibiotics, the incidence has
decreased drastically.
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21. Mechanism
⢠Abscess in Paraurethral gland
⢠Rupture into corpus spongiosum
⢠Inflammation of corpus spongiosum
⢠Healing with fibrosis
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22. ⢠Urine extravasation
⢠Spongiofibrosis
⢠Further stricture upstream
Creep Up Phenomena
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25. Symptomatology
Common presentation
⢠Weak urinary stream,
⢠Straining to void,
⢠Urinary hesitancy,
⢠Incomplete emptying,
⢠Nocturia,
⢠Frequency, and
⢠Urinary retention
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26. Symptomatology
Less Common
⢠Post-void dribbling,
⢠Urinary tract infection,
⢠Genitourinary pain,
⢠Hematuria,
⢠Incontinence
Atypical
⢠Urethral cancer,
⢠Renal failure,
⢠Urethral abscess,
⢠Fournierâs gangrene,
⢠Ejaculatory dysfunction,
⢠Chordee
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27. Investigation- Aims
⢠Location of the obstruction,
⢠Length of the obstruction, and
⢠Associated urethral pathology
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28. Uroflowmetry
⢠Low Q max
⢠Saw toothed pattern
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29. Retrograde Urethrogram
⢠Dynamic retrograde urethrogram (RUG) - Reliable method to stage
and diagnose urethral stricture or stenosis.
⢠Sensitivity - 75â100%
⢠Specificity of 72â97%.
Angermeier KW, Rourke KF, Dubey D, Forsyth RJ, Gonzalez CM. SIU/ICUD consultation on urethral strictures:
Evaluation and follow-up. Urology 2014;83 3 Suppl: S8-17.
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30. Cystoscopy
⢠Cystoscopy - most specific test to diagnose a urethral stricture and
adjunct test for staging.
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31. USG /Sonourethrographyâ Current Status
⢠Can augment contrast-enhanced studies
⢠Accurate in determining the length of narrow-caliber annularity
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32. Conclusion:
USG is equally efficacious to RGU in detecting anterior urethral
strictures.
However, further characterization of strictures in terms of length,
diameter, etc can be performed with relatively greater sensitivity using
USG.
Choudary et al, 2004
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33. Male Urethral Stricture
Guidelines â 2016
⢠< 2 cm stricture - urethral dilation, direct visual internal urethrotomy
(DVIU), or urethroplasty for the initial treatment.
(Conditional Recommendation; Evidence Strength Grade C)
⢠âĽ2cm stricture â should offer urethroplasty as the initial treatment
(Moderate Recommendation; Evidence Strength Grade C)
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34. ⢠Older surgeons
⢠Following âreconstructive
surgical ladderâ.
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36. Stricture Excision and Primary Anastamosis
⢠Ideally suited for bulbar strictures 1â3 cm long,
⢠Can also be successful in some selected cases with proximal bulbar
strictures up to 5 cm in length.
⢠Not suitable for penile urethra.
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39. Oral Mucosal Graft Urethroplasty
⢠Suitable for penile stricture
⢠May be ventral or dorsal onlay technique
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40. Penile Skin Vs Mucosal Graft
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41. Dorsal Onlay Vs Ventral Onlay
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42. Lingual Grafts
BMG long term problems
⢠Persistent perioral numbness,
⢠Salivatory changes, and
⢠difficulty in opening the mouth
⢠Other complications are bleeding, scarring, and lip deviation or
retraction.
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45. ⢠Success rate of
100% in penile
strictures.
⢠Success rate of
81.3% in bulbar
strictures.
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46. Augmented Anastomotic urethroplasty
⢠A combination repair that incorporates the principles of excision and
substitution urethroplasty.
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51. Penile skin flaps
⢠Can provide upto 15 cms of length.
⢠But
⢠Avoid in cases of compromised blood flow (smoking history,
peripheral vascular disease, diabetes, radiation therapy).
⢠Avoid in old age, even though the results are comparable with young
adults.
⢠Avoid in penile skin with Lichen sclerosis changes.
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52. Longitudinal Vs Transverse - Longitudinal
Pros
⢠Easy placement
⢠Ability to tailor length and width
in a straightforward manner.
⢠Minimal amount of dissection
required to cover the urethra
Cons
⢠Longer strictures, proximal
penile skin with hair must be
used.
⢠This can lead to infection, stone,
and obstruction.
⢠Flap length is contingent on
penile length.
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53. Longitudinal Vs Transverse-Transverse
Pros
⢠Upto 15 cm length
⢠Excellent cosmesis
⢠Broad based blood supply
Cons
⢠More challenging dissection
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54. Proximal Vs Distal
⢠Distal skin is preferred over proximal skin due to the absence of hair.
⢠It is accustomed to moist environment
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55. Penile skin flap techniques
⢠Longitudinal Ventral Penile Skin Flap with a Lateral Pedicle (Technique
of Orandi)
⢠Longitudinal Ventral Penile Skin Flap with a Ventral Pedicle (Technique
of Turner-Warwick)
⢠Transverse Circular Penile Skin Flap with a Primarily Dorsal Pedicle
(Technique of McAninch)
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59. Patient reported outcome measures (PROMs)
To measure the outcome of the procedure from Patientâs perspective.
⢠American Urological Association Symptom Index(Also Known as IPSS)-
For LUTS
⢠International Index for Erectile Dysfunction â For Erectile dysfunction
⢠Male sexual health questionnaire â For Ejaculatory dysfunction
⢠An index purely for stricture urethra is yet to be constructed.
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