BPH

Urethroplasty: An Overview

As we get older and the prostate increases in size, most men start experiencing urinary changes. One of them is a reduction in the flow of urine.

But besides benign prostate hyperplasia and prostate cancer, there are other causes to consider. One of them is a urethral stricture, and the treatment is entirely different. This problem is treated with urethroplasty surgery.

The urethra is a narrow tube where urine moves out of your body. It is longer for men because it passes through the penis. When this little tube is further narrowed, this is known as a urethral stricture. The problem is usually caused by scar tissue or another extra tissue, and it can be located in any part of the urethra.

The risk is a bit higher in men because they have a longer urethra. However, even male urethral stricture is relatively uncommon. It is often caused by urethral injury, chronic infections, or could be a congenital problem.

If you have this problem or your doctor recommended urethroplasty for another reason, this article is designed to answer some of your questions.

What is Urethroplasty?

Urethroplasty is a urethral reconstruction surgery recommended to repair the urethral canal. It is not the same as a urethral dilatation, which does not require a deep incision. This is a more advanced surgical procedure for anterior urethral stricture, and it is often used when the problem is recurrent.

It is an open surgery, which means that it requires anesthesia and incisions through your skin. For this reason, your doctor may consider several aspects and run tests beforehand (1). 

The cost and recovery of urethroplasty depend on every individual because different techniques can be used. So, your doctor will plan ahead your surgery after a proper physical exam and evaluating your particular problem.

During the diagnostic evaluation phase, you will know where is your urethral stricture located. You will also know how long is it and may ask your doctor for details about the procedure itself.

Types of urethroplasty

After the diagnostic evaluation phase, your doctor will talk about your available options. There are different types of urethroplasty, and choosing them depends on the length and location of urethral stricture.

You have an easier surgery in small stricture cases where you simply cut the damaged section and reconnect the urethra. In longer strictures, doctors can use a graft to connect both ends. And sometimes other complex methods are considered.

Here’s a useful list of urethroplasty types that your doctor may consider after studying your case (1):

  • Anastomotic urethroplasty: This is a simple approach for small-sized structures. It does not require multiple steps. The doctor would only make an incision to reach the urethra without damaging your blood vessels or nerves. After locating the defect, it will be cut, and the borders will be secured. Then, it is simply about stretching the borders together and sutured. Doctors will also apply some fibrin glue to prevent leaks. This procedure is quite simple and appropriate for strictures smaller than 2 cm (2).

  • Substitution urethroplasty (Graft urethroplasty): If your stricture is longer than 2 cm, your doctor may consider using a graft. The urethra stretches for anastomotic urethroplasty but has a stretch limit. So, the first part of the procedure is similar except that doctors will not join the borders. They are too far apart. Instead, they take tissue from other parts of your body to close the gap. This is called a graft and usually comes from your buccal mucosa or penile skin. In your buccal mucosa, the graft is taken from the inside of your cheek. In your penis, the graft is taken from the foreskin. After suturing the graft in place to close the gap, the surgeon will apply fibrin glue. The success rate is better when buccal mucosa grafts are used. However, penile grafts are considered more appropriate when the stricture is longer than 4 cm (2,3).

  • Johansen’s urethroplasty (Two-stage urethroplasty): When none of the above options gave a good result, a staged urethroplasty is considered. This is a more complex procedure and may require several surgeons to be completed. The surgery is conducted in two stages. In stage one, a buccal graft or skin graft is placed, similar to the above. But instead of closing the urethra, it is left open to heal. Meanwhile, the patient needs to urinate seated from a new pee hole near the scrotum. When the graft heals, stage two is programmed. This time, a new urethra is reconstructed using the healed graft. This is a very complicated procedure, only reserved for very severe urethral stricture (4).

The type of urethroplasty appropriate for you depends on several factors (1):

  • Your physical condition

  • The length of the problem area, if there are only one or multiple strictures

  • Where is the urethral stricture located (for example, the bulbar urethra, the anterior or posterior urethra), and the organs close to the defect

  • Postoperative complications from previous surgeries

  • The availability of autografts

  • Your doctor’s expertise with a given procedure

In complex cases, your doctor may consider different techniques at the same time.

When should a urethroplasty be performed?

This is a reconstructive surgery commonly used to manage urethral stricture. However, it is not recommended in every case of urethral structure. It is more appropriate in recurrent cases with symptoms that keep coming back. In these cases, urethroplasty has better long-term results with limited side effects and risks.

There are no official guidelines as of yet by health authorities such as the European Association of Urology. However, the European Association of Urology recommends urethroplasty for recurrent urethral stricture. So, it is actually a second-line treatment after other less invasive modalities are considered and failed.

They also recommend urethroplasty as the first-line treatment in other conditions, especially hypospadias. Actually, Johansen’s urethroplasty was originally designed to treat hypospadias. This is a structural problem of the urinary meatus in which the pee hole is located where the penis frenulum should be. 

However, there’s some discrepancy about exactly when to use urethroplasty. According to the European Association of Urology, it should be used in every case of recurrence. If you had a previously failed attempt to improve the defect and failed, the next step is a urethroplasty. But the Société Internationale d’Urologie recommends using urethrotomy and urethral dilation in some cases of recurrence. So, urethrotomy would be the third attempt to correct the problem.

Since there is no consensus, your doctor may give you a recommendation based on your particular case and his clinical experience. They may or may not recommend endoscopic urethrotomy before trying a urethrotomy. In each case, there are benefits and risks to consider (5).

How much pain is experienced after surgery?

In most cases, postoperative pain is not severe during recovery. In some cases, there is swelling in the scrotum and some pain. If that’s the case, it goes away after a few days. However, you may feel soreness in your mouth if you had a buccal mucosa graft taken out. Pain medication will be given, though, and pain will dissipate after a few days.

Urethral stricture has several symptoms, including a decreased urinary stream, spraying of urine, and difficulty to start urinating. This condition also causes significant pain when urinating. The risk of urinary tract infection is higher, and that means more pain and discomfort.

How useful is this surgery to control urinary pain? Is recovery painful?

These are prevalent questions before surgery. The answer is that most patients are delighted after urethroplasty. After urethroplasty, most patients report a significant improvement in urinary pain. If your main comes from the penis, the urethra, or the bladder, it will likely resolve. These patients also have significant relief of other urinary symptoms and fewer activity restrictions.

The only symptom that sometimes stays is perineal pain. Perineal pain may become more frequent or severe in some cases. According to recent studies, this is relatively common. It is experienced by around 14% of patients, and it is often a transient symptom. In other words, you can start feeling pain around the scrotum or in your pelvic floor. In most cases, this pain will go away by itself. However, other studies show that some patients still report this problem after one year (6, 7).

But this pain is not severe and nothing compared to the symptoms of urethral strictures. The patient’s satisfaction level in studies is not compromised by perineal pain. 87% of patients choose the option “satisfied” or “very satisfied” with the results of urethroplasty in surveys (8).

Why would you feel scrotal or perineal pain after urethroplasty? The answer is not yet clear, and researchers have not found risk factors to predict when it may develop. However, there are a few theories around it:

Pain may come from nerves such as the lateral femoral nerve or the pudendal nerve. They have a long trajectory and go through the inner thigh and buttocks toward the scrotum and the perineum. Following this trajectory, those nerves may become injured when surgeons are retracting the penile urethra during surgery. Another theory is that those nerves become entrapped during surgery or injured during incision. 

What are the risks?

Every surgery has a risk, and that’s why you need to run several tests before coming to the operating table. If you have a high risk of complications during surgery or right after, your doctor will probably recommend other options. But when the benefits overlap the risks, you’re good to go.

Even so, that doesn’t mean that everything will work out correctly. Even in perfectly healthy patients with no risk factors, there are certain complications. 

Complications of urethroplasty depend on the type of procedure. Substitution urethroplasty has two types, as shown above. When the graft is taken from the buccal mucosa, it is known as buccal graft urethroplasty. This type has the least risk of complications. When the graft is taken from the penile skin, it is known as fasciocutaneous urethroplasty. This one has significant complications, but it is sometimes the only option.

According to studies, possible complications after urethroplasty include (9):

Early complications

  • Scrotal swelling: This is quite common shortly after surgery. It is the effect of inflammation in the tissue and a temporary blockage in the lymph drainage. It goes away by itself after a while. However, you need to inform your doctor if it’s severe or doesn’t go away.

  • Scrotal ecchymosis: It means redness in the scrotum, and it is also a common side effect. In most cases, it goes away without any significant complications.

  • Urinary urgency: After urethroplasty, there’s significant irritation in the lower urinary tract. This often leads to urinary urgency, primarily if the defect was located near the bladder.

  • Rectal injury: In this case, the complication is due to a technical problem during surgery. It is a more severe complication and needs special attention. But the patient usually recovers with appropriate treatment.

  • Urosepsis: It is systemic inflammation triggered by infection of the wound or internal organs. This is a very severe complication and may require hospitalization. Luckily, it is very rare.

Late complications

  • The sensation of tightness: Patients often report a sensation of wound tightness. It doesn’t compromise mobility but feels a bit uncomfortable.

  • Scrotal numbness: This happens due to minor nerve injury leading to reduced sensation in the scrotum. It may remain untreated as long as no pain is triggered.

  • Perineal pain: In some cases, patients report perineal or scrotal pain instead of numbness. This is a possibility but not the most common complication.

  • Urine spraying: In most cases, all urinary symptoms are solved, including urine spraying. But when they remain, urine spraying is the most common.

  • Erectile dysfunction: Some patients report different degrees of erectile dysfunction months after surgery. This is a more severe and fairly uncommon side effect.

  • Chordee: This is a downward curvature of the penis gland. It is often more visible during an erection. It is not very common, either.

  • Fistula formation: This is probably the most severe late complication. Fistulas are small passages that connect two organs. They may also connect an organ to the outside.

What are the benefits?

As noted above, you will be programmed for surgery only if the benefits outweigh the risks.

Only a patient with a urethral stricture knows how bothering his symptoms are and how they affect their quality of life.

Living without urinary symptoms is a dream come true for these patients. That’s why they come to the operating room, and most of them are very satisfied with the results (8).

They feel happy and satisfied because:

  • They are now able to urinate without straining or making special efforts.

  • Starting to urinate is not a problem anymore.

  • After voiding, they feel more satisfied because no leftover urine is left in the bladder.

  • They no longer experience as many recurrent lower urinary tract infections.

  • Pain or a burning sensation when urinating goes away.

The only symptom that sometimes stays is urine spraying, and this only happens to a minority. So, the overall results are excellent, and the quality of life improves significantly.

The list of early and late complications above looks very long, but we cover all the possibilities. Only 3% of patients have major early complications. Even if late complications (perineal pain or erectile dysfunction) are a bit more common, patients are usually very relieved from urinary symptoms and disregard the rest as secondary (8,9).

How long is the hospital stay?

There are three types of urethroplasty and different types of patients. However, in most cases, it is done as an outpatient procedure. You may not need to stay the night in the hospital or have a very short stay. Still, you will leave the operating table with a Foley catheter placed through the penis.

Every instruction about how to use it and keep it clean will be given to you before discharge. After two or three weeks, the urethral catheter will be taken out. Throughout that time, you will be given antibiotics and need to take them as instructed.

There is a short hospital stay of 1, 2, and up to 5 days in some cases. This time is taken particularly when the procedure was difficult to ensure proper recovery. However, most patients do not have significant swelling or pain and will be discharged very soon.

You will need to go back to the hospital to take out the urinary catheter. It is usually removed after 2 or 3 weeks. Before taking out the catheter, your doctor will perform a particular test known as voiding cystourethrogram. In this exam, your bladder will be filled with contrast, and you will be asked to void. A post-void X-ray is taken, and it will reveal how the urethra is healing. If your urethra is completely healed, the catheter will be taken out.

When can I resume day-to-day activities?

Several aspects can change after surgery, even if you underwent an outpatient procedure. Here’s the breakdown of what to expect after urethroplasty in different day-to-day activities:

  • Dietary habits: Since urethroplasty surgery is an outpatient procedure, there are not many limitations to what you can do. Actually, there is no particular diet after surgery, and you can go back to your usual diet instantly. The only recommendation would be to follow a soft diet for a few days if your doctor took a buccal mucosa graft. If this is your case, you will see a yellowish or white film developing. Do not pick at it.

  • Urination: You will also resume normal urination after a while. The urinary catheter will be there for 2 or 3 weeks. After that, and only when doctors ensure urethral healing it will be taken out. You will probably notice a completely different sensation when urinating after the catheter is out.

  • Showering and self-care: There’s no limit to self-care and showering. You can shower when you get back home. Just be gentle when washing the incision area and only use soap and water. You may want to use some ointment in the glans to lubricate the catheter and feel more comfortable. Oral hygiene is fundamental if a buccal mucosa graft was taken.

  • Driving: The recommendation is not to drive for 24 hours after the procedure. If you’re taking opioid medications for the pain, you may be restricted from driving while taking them. Pre-arrange someone else to take you back home after the procedure is done.

  • Drinking alcohol: It is not recommended to drink any alcohol for a minimum of 24 hours. After that time, you may resume drinking alcohol, but that depends on the antibiotics you’re taking. Thus, be sure to talk to your doctor about this.

  • Physical activity: You can walk and resume day-to-day physical activities right away. Strenuous or aerobic exercise should be restricted for 6 weeks. Stretching your legs in a straddle position and using a bicycle or motorcycle will be off-limits for a long time. Ask your urologist when it is appropriate to resume this type of activity.

  • Sexual activity: You can resume sexual activity after 6 weeks. There is no problem if you have an erection. Just do not act on it.  

Conclusion

Urethroplasty is a reconstructive urologist procedure for the recurrent stricture of the urethra. There are different variations of the procedure depending on the stricture length and where the defect is located. For example, it is a bulbar stricture when it’s located in the anterior urethra or the bladder neck.

In long or complicated penile urethral stricture, urethroplasty may require a buccal mucosa graft or a penile skin graft to reconstruct the urethra. The procedure is superior to a urethral dilatation, and most patients experience an impressive recovery from urethral stricture disease. Some risks should be considered and informed to the patient. But the procedure is only made available when the benefits outweigh the risks.

Sources

  1. Andrich, D. E., & Mundy, A. R. (2000). Urethral strictures and their surgical treatment. BJU international, 86(5), 571-580.
  2. Mundy, A. R. (2005). Anastomotic urethroplasty. BJU international, 96(6), 921-944.
  3. Rosenbaum, C. M., Schmid, M., Ludwig, T. A., Kluth, L. A., Dahlem, R., Fisch, M., & Ahyai, S. (2016). Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes. BJU international, 118(5), 797-803.
  4. Secrest, C. L. (2002). Staged urethroplasty: indications and techniques. The Urologic clinics of North America, 29(2), 467-75.
  5. Stephenson, R., Carnell, S., Johnson, N., Brown, R., Wilkinson, J., Mundy, A., … & Pickard, R. (2015). Open urethroplasty versus endoscopic urethrotomy-clarifying the management of men with recurrent urethral stricture (the OPEN trial): study protocol for a randomised controlled trial. Trials, 16(1), 1-13.
  6. Evans, P., Keihani, S., Breyer, B. N., Erickson, B. A., Hotaling, J. M., Lenherr, S. M., & Myers, J. B. (2018). A prospective study of patient-reported pain after bulbar urethroplasty. Urology, 117, 156-162.
  7. Granieri, M. A., Webster, G. D., & Peterson, A. C. (2014). Scrotal and perineal sensory neuropathy after urethroplasty for bulbar urethral stricture disease: an evaluation of the incidence, timing, and resolution. Urology, 84(6), 1511-1515.
  8. Jackson, M. J., Chaudhury, I., Mangera, A., Brett, A., Watkin, N., Chapple, C. R., … & Mundy, A. R. (2013). A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. European urology, 64(5), 777-782.
  9. Al-Qudah, H. S., & Santucci, R. A. (2005). Extended complications of urethroplasty. International braz j urol, 31(4), 315-325.

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