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1. URETHRAL STRICTURE
DR KRISHAN SUYAL
MODERATOR : DR SWATANTRA RAO
BLK-MAX HOSPITAL

2. ANATOMY
• Skin
• Dartos fascia
• Bucks fascia
• Urethra

3. • AANATOMY

4. Layers of anterior urethra
• Inner to outer layer
• 1 Urethral epithelium
• 2 Lamina propria
• 3 Corpus spongiosum
• 4 Tunica albuginea
• 5 Bucks fascia

5. • PLANES OF CLEAVAGE
• Skin and subcutaneous tissue
• Subcutaneous tissue and bucks
fascia
• NO PLANE between bucks and
tunica albugenia

6. Superficial Arterial Supply

7. DEEP ARTERIAL SYSTEM
• Dual Blood Supply of CS
• Internal pudendal artery-
-- Common penile artery.
• Proximal – bulbar,
circumflex cavernosal
• Distal – dorsal , cavernosal

8. • SUPERFICIAL DEEP

9. Lymphatics
• Prostatic urethra and Bulbomembrenous
- Obturator and external iliac LN.
Penile urethra- Superficial inguinal LN.

10. Etiology and pathophysiology
• Etiology:
• 33% idiopathic, 33% iatrogenic, 19% traumatic, 15% inflammatory
• Bulbar strictures are the most common (44–67 %)
• penile strictures in 12–39 %
• mixed (bulbar and penile) in 6–28 %
• external meatal or submeatal (0–23 %)
• membranous (0–20 %) and prostatic (0–4 %)

11. Urethral strictures
• STRICTURE URETHRA term refers to anterior urethral stricture, Posterior urethra
narrowing term as stenosis or contracture
• Injury to epithelium or CS – scarring
• Incidence 200-1200/lac
• Anterior (92.2%) ---- Bulbar (46.9%)
Cause of anterior urethral stricture
Infection- gonorrhea, NGU- unclear
Imflammatory- BXO
Traumatic- straddle injury, iatrogenic
Idiopathic

12. Post TURP STRICTURE
• Trauma induced by resectoscope
• Bulbar urethra > penoscrotal junction
• Fixation at penoscrotal junction act as Fulcrum

13. General Concepts

14. Location of ischemic urethral stricture.

15. Devine clas.

16. USG CLASSIFICATION-McAninch

17. USG CLASSIFICATION-modified by Chiou
• 1. Short stricture (<2.5 cm) with minimal spongiosal tissue
involvement
• 2. Short stricture with moderate (some normal spongiosal tissue in
the periphery) spongiosal tissue involvement.
• 3. Short stricture with extensive (full thickness) spongiosal tissue
involvement.
• 4. Long (>2.5 cm) or multiple strictures with moderate spongiosal
tissue involvement.
• 5. Long (>2.5 cm) or multiple with extensive spongiosal tissue
involvement

18. Stricture vs Stricture disease

19. Posterior urethral stricture (Post operative)
• ClASSIFICATION ( Pansadoro)
Type 1- fibrous tussue involved BN.
Type 2- Stricture localised to median part of prostatic fossa with open
BN and spared verumontanum.
Type 3- Complete prostatic urethral obliteration

20. CLINICLE FEATURES
• Obstructive/Oviding LUTS- thin stream urine, straining, dribbling
• Prostatitis
• Epididymitis
• UTI
• Urinary retention

21. Evaluation and diagnosis –
• Physical examination – depth and density of scar
• RGU – Under estimates bulbar stricture length, no info on fibrosis
• USG – accurate length, spongiofibrosis
• Endoevaluation – peads scope
• No intervention 3 mo before definite surgery, may need SPC 6-12 weeks
before

22. RGU

23. • INDICATION
Pelvic trauma, suspected urethral injury
Stricture- pre op evaluation
Urethral diverticula
Suspected FB, Fistula
Congenital anomaly
• Complications- contrast extravasation, urethral rupture, uti

25. TREATMENT
• Urethral dilatation
• Internal urethrotomy
• Urethral stent
• Laser

26. Urethral dilation
• Palliative treatment
• It is only for pure epithelial stricture
• Aim- Radial uniform stretching of scar tissue without producing more
scarring.

27. • Filiforms and followers- false passage or urethral stricture suspected
• Metal sound or Bougies
• Urethral catheter of increasing size
• Teflon dilators
• Inflatable balloon dilators

28. DIRECT VISION INTERNAL URETHROTOMY
(DVIU)

29. Endoscopic - DVIU/Dilation
• Dilation (endoscopic/fascial/balloon) = DVIU
• Concept of dilation and OIU
• Full thickness incision through
the scar at 12 oclock –
open to 24 Fr
• For initial treatment of short
(<1.5 cm) bulbar stricture.
Healing by 2nd intention,

30. Endoscopic - DVIU/Dilation
• Balloon dilation – safer – eccentric forces
• Post op PUC – no consensus
• Self dilation reduces restricture at a price
• MMC(0.4mg/ml) or Triamcinolone – of benefit

31. Endoscopic – Success rates
• Overall – 30-50% (best 50-70%)
• <2cm – 60%, 2-4cm – 50%, >4cm – 20%
• >15Fr – 69% vs < 15Fr – 34%
• Bulbar – 42%, penile- 16%, memb -11%
• Greater the spongiofibrosis or number of strictures – less success
• Recurrence after 1 yr- 50-60 %, after 5 yrs- 74-86 %

32. Efficacy of repeat urethrotomy
• Remain stricture free after 3 month-
• First procedure- 55-60 %
• Second procedure- 30-50 %
• Third procedure – 0%
• Recurrence common B/W 3-12 month
Prevention -
• Hydraulic self dilatation
• Intermittent self catheterisation

33. CONTRAINDICATION TO DVIU
• Long segment stricture >2 cm
dense fibrosis
more then 1 attempt previously failed VIU
UTI
Coagulopathy

34. Otis urethrotome
• Commonly used to incise a narrow urethra.
• Use for managing urethral stenosis in females
• Shaft is 16 cm in length and house a hub/groove for passage of knife
• Shaft on dorsal aspect –
Calibrating device max can dilate
urethra to 15-45 fr
Min diameter of urethra should be 16
Fr.

35. LASER URETHROTOMY
• Laser for DVIU – KTP, Nd: YAG, Ho:YAG
• Circumferential laser ablation provide better result.
• Low energy setting – 5Hz 0.5J
• Advantage -
Laser vaporize the stricture ( no necrosis)
no bleeding
less injury to cavernosa
Disadv- Cost and availability.

36. Urethral stents
• Easy, LA
• 0.5cm away from EUS, several, bulbar urethra stricture
• Recurrent bulbar, minimal fibrosis, unfit old pts
• Permanent – metallic (urolume, memotherm)
• Temporary stents – polyurethane
• Recommendation – not for fit pts
• Mostly abandoned

37. GRAFTS AND FLAPS
• FUNDAMENTALS AND PRINCIPLES

38. GRAFTS - composition
SKIN BUCCAL MUCOSA BLADDER EPITHELIUM

39. GRAFTS - vascularity
• SKIN BUCCAL MUCOSA BLADDER EPITHELIUM

40. • STSG
Exposes intradermal plexus
Brittle and contracts
• FTSG
Exposes subdermal plexus
Contracts less and is durable
Genital FTSG Wolffe graft

41. Oral mucosal graft
• Pan-laminar plexus
• Advantages over skin – easy handling, better vascularity, similar to
urothelium, good bacterial defense, less scarring when comes in
contact with urine, wet surface
• Preferred for BXO, Bulbar urethra (by many), re-do cases

42. Oral mucosal graft
• Results of BMG, LMG or lip graft are same
• BMG is almost similar to LMG
• Lip grafts are significantly thinner than BMG and thus are difficult to
handle

43. Principles of Grafting
• Take – 2 phases
• Denser the plexus and thinner the tissue better the take
• Avoid – Hematoma, Friction, Infection, Undue pressure
• By day 5 – becomes clear
• Use FTSG whenever possible

44. Principles of Grafting
• Grafts best used in Bulbar urethra
• Patches better than tubes (3x re-stricture rates)
• Graft – ventral, lateral or dorsal
• (ventral/lateral in previous OIU, stent or obese)
• If using ventral graft – buccal mucosa better

45. Flaps
• Classification
• Vascular supply - Random / axial
(direct cuticular / musculocut / fasciocut)
• Elevation tech - Peninsula / island / free
• Skin island / skin paddle verses true island flap

46. Genital flaps - fascio-cutaneous axial
peninsular flaps
• Penile flaps – tunica dartos Scrotal flaps – tunica dartos

47. General tech of elevating a genital flap

48. Genital flaps - penile
1.Dorsally oriented
Easily reach penile shaft
Difficult to reach perineum
May result in torsion of penis
2.Ventrally oriented
Easily reach perineum

49. Genital flaps - scrotal
• Septal vessels
Midline hairless scrotal island
elevated on septal vessels
• Post scrotal vessels - lateral
Midline hairless scrotal island elevated on tunica dartos mobilized laterally
• Strict attention to tailoring - diverticula
• Hirsute skin – midline or epilate
• When no other appropriate genital donor source

50. Principles of genital flap elevation
• Use non hirsute redundant genital skin
• Ventral flap – 7-9cm (transverse/longitudinal/hockey stick)
• Dorsal flap – 3-5cm (transverse)
• Circular - 13-15 cm (ventrally/dorsally based)

51. Grafts VS Flaps
• Grafts
Quick and easier
Less reliable
Commonly the procedure of choice
• Flaps
Tedious and time consuming
Scarring and loss of contour of penis
BETTER IF:
• Revision surgery
• Infection
• Vascularity compromise

52. Harvesting BMG
• Inner cheek and/or lower lip
• Respect – stensons duct, angle of mouth, outer lip
• 1:1,00,000 LA+adr submucosally
• Graft lifted submucosally over buccinator muscle
• Dimensions 1-2cmx6-8cm

53. Sutures : material and needles
• Absorbable is the rule
• Material : Vicryl, monocryl or PDS
• Caliber : smallest possible, no need to be stronger than the tissue
• 4-0 to 6-0 for penile strictures – flap & graft
• 3-0 for bulbar - EPA
• Needles – taper RB-1, TF or SH-1
• No specific suture is best, but vicryl is most resilient to effects of
human urine in terms of loss of tensile strength

54. Concepts of urethroplasty - general
• Adequate mobilisation
• Resection upto healthy CS
• Spatulate 1-2cm
• Account for 20-30% contraction of graft
• Non overlapping suture lines
• Interpose subcut tissue / tunica dartos between
• Suture :
• EPA : interrupted
• Graft/Flap : interrupted running or running
• Skin - interrupted

55. Penile urethral strictures
• One stage - Graft
Ventral onlay – FTSG/BMG
• Longitudinal incision
• Ventral placed graft
• Tunica dartos coverage

56. One stage - Graft
• Dorsal onlay
• Circumferential mobilisation
• Dorsal incision
• Graft placement

57. One stage - Graft
• Asopas dorsal inlay
Needs normal CS – rarely used in penile strictures

58. One stage - Flaps
• Orandi – Devine penile flap
• Longitudinal or hockey shaped flap on ventral surface
• Short pedicle – only rotated
• Cover the sutures with tunica dartos

59. One stage - Flaps
• Quartey`s penile flap
• Transverse penile skin flap – dorsal
• Long pedicle

60. One stage - Flaps
• Penile skin flaps
• Can be taken to bulbar urethra
• Used as dorsal or ventral onlay

61. One stage - Flaps
• McAninch – penile circular flap
• 13-15cm long foreskin or loose penile skin
• Divided in mid ventral plane
• Can be taken to bulbar urethra

62. One stage - Flaps

63. One stage - Flaps
• Turner-Warwick
• Longitudinal ventral penile skin flap
• Ventrally based pedicle

64. 2 stage procedures
• Indications- unhealthy urethral plate
• BXO – diseased urethra excised
• Extensive stricture disease
• Chronic inflammation
• Fistula / abscess
• Radiation
• multiple failed repair
• Used : significant scar tissue, repeated prior surgeries - absent healthy genital
skin

65. • 22.5% revision rate of the 1st stage
• 10-40% show contraction due to scarring - chordee
• 2nd stage - 25-30mm width of neourethra
• 15% may not opt for 2nd stage
• Principles
• Full thickness prepuce/penile or STSG
• Meshed and sutured to marsupialized urethra
• 6mo later, ample healthy hairless skin

66. • 2 stage procedures – Bengt Johanson
• 1st stage
• Graft - uncircumcised – foreskin, circum -STSG
• Mesh the graft – 1:1.5
• Lay the penile skin and stricture open

67. • 2nd stage
• 6m0 after FTSG, 1yr after STSG – longer the better
• Wide peritomy of graft – 30mm
• Mobilization directed laterally
• Interrupted running sutures

68. • 2nd stage – skin coverage
• Byars asymmetrical advancement flap

69. • 2 stage – Brakka
• When urethral plate absent or completely removed
• 1st stage – excise, use BMG or STSG or FTSG
• 2nd stage – 3-6 months, peritomy of graft

70. • Points of technique
Interpose dartos between graft and albugenia
STSG – shrink, should be thin and translucent
FTSG- adequate defatting
By 5th day – graft is either taken or sloughed

71. Points of technique
• Quilt the graft
• Mesh the graft
• Incorporate tunica dartos laterally
• Oval urethra – less risk to vascularity
• Stitches through the dermis
• Overlap suture line with dartos

72. Dressing – 1st stage of mesh graft
• Goals
• Good contact with covering tissue
• No friction
• no contact between 2 grafted sites
• Gentle pressure
• No change before 5-7days

73. Urethral stents
• Easy, LA
• 0.5cm away from EUS, several, bulbar urethra
• Recurrent bulbar, minimal fibrosis, unfit old pts
• Permanent – metallic (urolume, memotherm)
• Temporary stents – polyurethane
• Recommendation – not for fit pts
• Mostly abandoned

74. Excision and primary anastomosis
• Heusner (1883)
• Indication : <2cm, bulbar, with failed DVIU
• Closer the stricture to memb urethra – longer it can be and still be
EPA
• Success rates: 90-95%
• Failures if – inadequate excision, tension

75. EPA : Principles

76. EPA : Principles

77. EPA: Principles

78. Bulbar strictures : tissue transfer - grafts
• Used
• Longer >2cm
• Graft
• Preputial skin
• Buccal mucosa
• Dorsal graft onlay
• Monseur`s technique
• Barbagli`s technique

79. Bulbar strictures : tissue transfer - grafts
• Ventral graft onlay
• Success rates
• 85-90%

80. Bulbar strictures : tissue transfer - grafts
• DORSAL ONLAY
Urethra placed dorsally
Mechanically sound
Multiple DVIU affects dissection and take
Difficult in obese
• VENTRAL ONLAY
• Increased blood loss
• Sacculations (lesser with BMG)
• Easy exposure
• Circumferential mobilisation not required
• If necrosis – fistula

81. Bulbar strictures : tissue transfer - grafts
• Augmented ansatomosis
• Small segment of very dense stricture - excised
• Dorsal or ventral onlay

82. Bulbar strictures : tissue transfer - flaps
• Indicated – recurrent, ischemic urethral disease
• Site – prepuce, penile or scrotal skin
• Dorsal onlay – preferable
• Augmented anastomosis is possible

83. Bulbar strictures : tissue transfer
• GRAFTS
Easy and quicker to harvest
Less reliable
Commonly of 1st choice
• FLAPS
More morbidity
Technically complex
Higher sacculation rates
Better if
• Revision surgery
• Poor vascularity of bed

84. Bulbar strictures : 2 stage procedure
• Complete obliteration of long segment
• USE : meshed prepuce FTSG or STSG

85. Pan anterior urethral strictures
• One stage
• Preservable urethral plate
• No infection or inflammation on the plate
• Two stage
• If urethral plate unhealthy – excised
• 1st stage – new urethral plate created
• 2nd stage – healthy plate tubularised
• Cause – BXO, catheterization, instrumentation

86. 2 stage procedures
• 2 stage :lay open (Johanson) + meshed graft
• 1st stage
• Lay open entire urethra
• Stitch the side of scrotum
• STSG – meshed or foreskin

87. 2 stage procedures
• 2nd stage
• Peritomy of graft + open lateral scrotal sutures
• Avoid too wide cut in bulbar region
• Inverting interrupted running sutures
• Asymmetrical sliding skin flap

88. One stage
• Dorsal onlay – flap + graft or graft + graft

89. Post op period
• Bulbar urethral stricture – flap or graft
• Bed rest for 5-7 days
• Avoid bowel movement 5-7 days
• Penile strictures – flap or graft used
• Bed rest for 5-7 days
• Avoid bowel movement 5-7 days
• In flaps or graft – don’t open dressing 5-7 days

90. Post op period
• Meatus and fossa navicularis
• PUC removal after 10 days
• Grafts and flaps
• MCU after 3-4 weeks – if no leak PUC removal

91. Uncommon flaps

92. Uncommon flaps - Singapore
• Perineal artery fascio-cutaneous flap
• Proximal bulb and posterior urethra

93. Uncommon flaps – muscle assisted
• Combined onlay BMG/skin and gracilis muscle

94. Uncommon flaps - prefaricated

95. • Startergies to optimise graft take –
• Bulbar urethra
• BMG
• dorsal
• After incising the stricture – see widht of urethral plate – if small – 2
stage may be req
• If very dense stricture – excision may be req with dorsal strip
anastomosis ( augmented)

96. • BMG – 6cm on each side – jennings cheek retractor – a 2cm wide
graft is usually adequate
• 30Fr normal –
• 10Fr symptoms occur
• our goal 24-26 Fr
• take 2-2.5cm wide graft

97. • 2 stage – Bengt Johanson procedure – scrotal or perineal skin – to
reconstruct – this is suitable for all types of strictures
• Gluteus maximus assisted flaps – prone position for fistulas in
prostatic and BMJ region. Incision from coccyx to perianal region.
Excise the fistula. Apply BMG. Mobilise medial part of gluteus
maximus over inferior gluteal artery and buttress over the BMG.

98. Tips and tricks
• Always prepare the strictre until healthy tissue is reached
• Mobilise urethra widely over the length of stricture
• Rgu underestimates the length of stricture
• Free transplant graft has 30% shrinkage
• Dressing 5th day after 1stage and 10 th day after 2 stage
• Simple strictures of penile urethra best treated as one stage flaps

99. • Posterior auricular graft – wolffe
2x5cm centered over post auricular groove
Full thickness
Separated from underlying fascia and bone