Definition and Overview
Urethroplasty is the surgical treatment of urethral strictures. The urethra is part of the urinary system that transports urine to the bladder. It can be injured and its walls can narrow due to many factors including underlying disease, trauma, and congenital conditions.
A urethra reconstruction surgery can be performed using different approaches such as buccal mucosal onlay graft, flap surgery involving the penis and scrotum, and Johansen’s urethroplasty. The choice depends on several factors such as the patient’s health, the cause of the condition, the availability of graft material, and possible risks and complications.
Who Should Undergo and Expected Results
A urethra reconstruction surgery is performed on patients who suffer from urethral constriction, which can be caused by:
Congenital defect – Some patients are born with an underdeveloped or narrowed urethra that forces urine to go back up or create an obstruction in the area.
Injury – Injury to the urethra may happen as a consequence of a regular activity or routine like straddling a bicycle or playing contact sports that can potentially hit the lower regions of the body such as the scrotum and the bladder.
Infection – Certain types of infection, especially sexually transmitted diseases, can inflame the walls of the urethra. In such cases, the infection is treated first with antibiotics before urethroplasty is performed.
Tumour – Tumours that develop in the bladder or the penis can place undue pressure on the urethra, causing its walls to get damaged.
Poor insertion of the catheter – A urinary catheter is a long thin transparent tube that is surgically attached to the bladder to drain or collect urine directly from the bladder. When not done correctly, the procedure can injure the urethra.
Depending on the severity and the overall health impact of the urethra stricture, the urologist may try cystoscopy first, a minor outpatient procedure that involves using a cystoscope to check on the bladder’s condition and if needed, perform corrective techniques. Another option is the placement of a stent in a manner similar to an angioplasty with stenting (percutaneous coronary intervention with a stent to dilate stenotic cardiac arteries).
If these options fail to correct the condition, the diagnosis is a long stricture, or there’s a scar present, any of the urethral reconstructive approaches is performed.
When it comes to success rate, the anastomotic urethroplasty is considered as one of the best while a penile island flap is the least preferred, although it is the most ideal for strictures measuring at least four centimeters.
How Does the Procedure Work?
Urethra reconstruction surgery may be anastomotic, island flap or graft of the penis and scrotum, Johansen's urethroplasty, or buccal mucosa onlay graft.
The anastomotic urethra reconstruction surgery is performed on strictures in the bulbar urethra, which is found in the perineum and the scrotum, and if the stricture is no more than 3 centimeters. It involves disconnecting the urethra from the cavernosum, widening the urethra, and then connecting both ends of the urethra.
The flap procedure that involves the scrotum and the penis is very similar to the buccal mucosa graft. The biggest difference is the graft material, in which the extra skin found in the penis and/or scrotum is used and sutured. Because of the source, this technique is best done on patients who are uncircumcised.
The Johansen’s urethroplasty is a two-stage process and is recommended for patients with complex urethra strictures.
In buccal mucosa onlay graft, two procedures are done simultaneously. While the urologic surgeon begins with the urethroplasty, a specialist in oral surgery such as a maxillofacial or an ENT surgeon removes a part of the cheek to be used as a graft. The graft or cheek tissue is used to create a diversion away from the stricture and permit the flow of urine. The graft is sutured and glued to prevent any leak.
The reconstructive surgery of the urethra is a major operation that takes at least 3 to 4 hours. Patients are given general anaesthesia and are positioned lying on the back with feet placed in the stirrups. An incision is made to access the urethra and the stenotic area and the scarred tissue are removed. A catheter is then left in place for at least 3 weeks to a month.
Possible Risks and Complications
Complications associated with urethra reconstruction surgery are many, but they are rare, occurring in less than 10% of the patients. These include urinary incontinence, fistula, infection, erectile dysfunction, bleeding, and injury to the surrounding blood vessels and organs.
Snodgrass WT. Hypospadias. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 130.
Elder JS. Disorders and anomalies of the scrotal contents. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 539.
Kraft KH, Shukla AR, Canning Da. Hypospadias. Urol Clin North Am. 2010;37:167-181.