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Urethral stricture.pptx
- 1. A comprehensive reviewof male urethral stricture disease Sukhdev, CMC Vellore
- 2. Definition • Scar ofsubepithelial tissue of corpus spongiosum that constricts the urethral lumen • Applies only to anterior urethra • Elsewhere, stenosis or contracture would be the terms used
- 3. Aetiology • Idiopathic • Iatrogenic •Infection • Inflammatory • Trauma
- 4. • Young adults/adolescentswith a short focal stricture – idiopathic • High success rate
- 5. Iatrogenic • Catheterisation –‘pressure sores’ of urethra - ischemic • Post lower endourological procedures
- 6. • Catheter inducedstrictures will involve proximal penile and distal bulbar urethra • Post TURP strictures will involve proximal bulbar and membranous urethra
- 7. • Gonococcal strictureshave a long latency period ~20 years • Rare now
- 8. Lichen sclerosus • Oldname is Balanitis xerotica obliterans • Involves perineal skin • Extensive disease involving penile urethra. Rarely involves bulbar urethra • Commonest cause of stricture in young adults now • Starts at meatus and involves penile urethra
- 10. Prevalence Penile urethra • Inflammatory(40%) •Iatrogenic(40%) • Idiopathic(15%) • Trauma(5%) Bulbar urethra • Idiopathic(40%) • Iatrogenic(35%) • Traumatic(15%) • Inflammatory(10%)
- 11. Pathology • Urethra normallylined by pseudostratified Columnar epithelium • Noxious stimuli induces squamous metaplasia which easily fissures under stress • This leads to urine extravasation and spongiofibrosis
- 12. The metaplastic epitheliumhas wash leather appearance in cystoscopy
- 13. Natural history • VoidingLUTS • Trabeculated bladder with backpressure changes in kidneys • Acute retention • Prostatitis and EPO • Peri urethral abscess
- 14. Management • Uroflowmetry • Urethroscopy •MCU + RGU • USG • MRI
- 15. • Uroflowmetry • Plateaupattern – constrictive flow • Depending on the calibre of the stricture, the plateau can be higher or lower
- 16. Urethroscopy: • Can identifya stricture which can be ‘passed or not passed’ by cystoscopy • The proximal status not definable, unless a ureteroscope is used
- 17. MCU + RGU •Best imaging modality The patient should be positioned such that the obturator foramen is closed and oriented downwards This position will make the urethra parallel to the film If the urethra is not parallel, there can be under estimation of urethral stricture length The penis should always be kept in traction to avoid under estimating urethral stricture length
- 19. Instrumentation for RUG A foleys can be inserted into the urethra and balloon inflated to 2 ml in fossa navicularis Alternatively, a metal tip can be introduced into the urethra and a penile clamp can be used 20-30 ml of contrast has to be injected Contrast material, which is used for IV injection, should be used, because thicker contrast can increase urethral inflammation The imaging can be done as a static(under normal X ray unit) or as a dynamic procedure(Flouroscopy)
- 20. Urethral ultrasonogram • Urethraappears hypoechoic and stricture appears hyperechoic • Can comment on the length of the stricture, but not on the density/depth of spongiofibrosis • Continuous infusion of an irrigant should occur during the study which makes the study uncomfortable
- 21. Treatment • Dilatation • Incision •Excision • Substitution • Augmentation
- 22. Dilatation • Practised over3000 years • Almost 50% of soft, superficial, short bulbar urethral strictures can be cured by just dilatation • Successful dilatation – stretching the scar without further scarring • Bleeding after dilatation means there is going to be more spongiofibrosis
- 23. Meatus 8 mm Penileurethra 9-10 mm Fossa navicularis 10-11 mm Bulbar urethra 11-12 mm Membranous urethra 9 mm
- 24. Indications Contraindications • Strictureurethra • Strictureless urethra – prior to lower tract endourological procedures • Active urethritis • Urethral fistula
- 25.
- 26.
- 27. Incision - Urethrotomy •Blind urethrotomy Otis knife • Endoscopic internal urethrotomy Sachse knife Laser urethrotomy
- 28. Post urethrotomy • Willneed age old dilatation, but in the name of self calibration/intermittent self dilatation Complications of urethrotomy: • Recurrence • Bleeding • Extravasation of irrigation fluid into perispongiosal tissues • Cavernosal veno occlusive dysfunction
- 29. Excision and primaryanastomosis • Most useful for bulbar urethral strictures • Traumatic bulbar strictures are preferably treated by EPA because they have transmural fibrosis, unlike other aetiologies which have more superficial fibrosis
- 30. Urethroplasty – substitutionvs augmentation • Substitution – entire circumference of urethra is excised and substituting with a graft • Augmentation – lumen increased by stricturotomy(without excising the entire circumference of the stricture) and augmenting with a graft
- 31. General concepts ofurethroplasty Onlay procedures better than tubularised procedures Grafts are equal to flaps in success rates However, grafts are easier to perform Flaps are better for distal urethra because grafting if done in distal urethra ventrally, will not be adequately encompassed by corpus spongiosum(spongioplasty) and so graft fixation and blood supply to graft is not adequate Radiation strictures are the only place, where flaps are useful
- 32. Grafts • Ventral andDorsal onlay augmented Urethroplasty Can be harvested from: 1. Buccal mucosa 2. Bladder mucosa 3. Post auricular skin Types: 1. Barbagli 2. Asopa 3. Johanson 4. Kulkarni
- 33. Flaps Local penile skinflaps 1. Mcaninch 2. Orandi 3. Turner warwick 4. Johanson
- 34. Barbagli BMG dorsalonlay augmented urethroplasty
- 35. Asopa dorsal inlayaugmented urethroplasty
- 36. • Ventral urethrotomy •Dorsal urethrotomy • Graft quilted to corpora cavernosa • Dorsal urethrotomy sutured to graft edges • Ventral urethrotomy closed
- 37.