Urethroplasty

Surgical urethrotomy / Perineal urethrostomy
Surgical urethrotomy / Removal of urethral stone by incision
Other local excision or demolition of lesion or urethral tissue / Urethrectomy
Closure of ureterostomy
Closing of urethral fistula
End-to-end urethral anastomosis
Repair of urethrocele

Definition: Urethroplasty is the urethral repair surgery whose purpose is:

• solve the obstacle to the emptying of the bladder, determined by the stenosis (or narrowing) of the urethral canal;
• repair a urethral fistula or a urethrocele (diverticular sac of the urethra);
• remove a urethral stone and repair the urethra.

Indications:
Stenosis of the anterior urethra: bulbar or penile urethral tract.
Stenosis of the posterior urethra: prostatic and membranous urethral tract.
Urethral fistula.
Urethrocele.
Urethral stone.

Description of the technique:
urethroplasty consists of surgical repair of the urethral canal. In relation to the characteristics of the lesion (length and cause of the stenosis, fistula or urethrocele, presence of urethral stone) and to the local tissue conditions, the surgeon reserves, during the intervention, the possibility to choose from a range of different techniques the surgical solution more suitable to the case:

A) URETHROPLASTY IN SINGLE TIME

• End-to-end anastomosis: full section of the urethra, resection of the fibro-sclerotic tissue, cause of the narrowing of the urethral canal, and rejoining of the two urethral stumps.
• Urethral enlargement urethroplasty with the use of skin or mucous tissue transplants.

B) URETHROPLASTY IN TWO TIMES
The repair of the urethra occurs in two interventions separated by a variable time interval depending on the evolution of the stenosing urethral pathology (usually more than 10 months).

• Urethroplasty 1st part: it consists of the opening of the urethral canal (surgical urethrotomy) and the deviation of the urine through the formation of a new urinary meatus at the perineum (perineal urethrostomy) or along the ventral surface of the penis (penile urethrostomy). In cases characterized by severely damaged urethral tissues and with suspicious dysplastic lesions, this intervention allows to heal the diseased urethral tract (through partial urethrectomy) and to deviate the urine while waiting for the tissues to heal and to subsequently reconstruct the continuity of the urethral channel.
• Urethroplasty 2nd part: it consists of the surgical closure of the aforementioned urinary deviation (perineal or penile urethrostomy) with consequent reconstruction of the continuity of the urethral channel. In the end, therefore, the patient returns to urinate by the original urinary meatus.
  In the interval between the 1st and the 2nd part of a two-stage urethroplasty, it may be necessary to resort to urethral revision surgery due to the progression of the underlying urethral stenosing pathology. These revisions can correspond from a surgical point of view to an actual urethroplasty.

It is not advisable to perform the 2nd surgical part of the urethroplasty before a period of at least 12 months has passed free of stenosing relapses, in which it is not necessary to perform any maneuver on the urethral canal.
All urethroplasty, except the end-to-end anastomosis, provide for the possibility of having to resort to the use of tissue transplants lacking their own vascular support (grafts) or with a vascular support (flaps).
The grafts generally consist of skin taken from the prepuce (via circumcision or not) or from other extragenital cutaneous regions, or mucosa generally taken from the inside of the cheek or lip.
The flaps, on the other hand, consist of preputial skin areas with their own vascular peduncle.
All surgical operations on the urethra provide for the possibility of carrying out histological examination of the urethra sample in order to highlight diseases that require further treatment or careful monitoring over time.
Stenosis of the posterior urethra (prostatic or membranous) is generally of a post-traumatic nature (trauma of the pelvis). Compared to anterior urethral repair, urethroplasty in the posterior urethral tract is a more complex and invasive procedure. In some cases it may be necessary to resort to a double surgical access (perineal and abdominal with bladder opening) since the urethral area located behind the pubis is difficult to reach. The patient must know that the operation can damage the erectile function and urinary continence (functions already partially compromised by the pelvic trauma) because the surgical repair involves the erectile nerves and the sphincter-urinary apparatus.

Preparation:
Antibiotic and antithrombotic prophylaxis is recommended. The use of oral mouthwashes in the pre- and post-operative, even if not necessary, could improve oral hygiene in relation to the buccal mucosa collection.

Duration of the procedure:
the duration of the intervention varies according to the surgical technique chosen by the operator and of the stretch (length and location) of the urethra affected by the lesion. Typically urethroplasty 1st part lasts between 1 and 2 hours, urethroplasty 2nd part lasts 1.5 hours. Single-time urethroplasty lasts between 2 and 3 hours for anterior urethral stenosis and between 3 and 5 hours for posterior urethral stenosis.

Type and duration of hospitalization:
in anterior urethral stenosis the intervention should preferably be performed under general anesthesia. The repair of posterior urethral stenosis is performed under general anesthesia. Sometimes during surgery, a wound drainage tube is left and will be removed after a few days. A bladder catheter is applied during the procedure. In some cases (especially in posterior urethroplasty) a bladder catheter is also applied by suprapubic route.
In the post-operative period, the patient will have to stay in bed for a few days:
1 day after end-to-end anastomosis, 2-3 days after urethroplasty 1st part, 3 days after urethroplasty using grafts (to allow engraftment of transplanted tissues), 2-3 days after posterior urethroplasty.
Afterwards, the patient will be advised caution in the movements, for about 15 days, in order to minimize the possible trauma on the perineum, on the genitals and on the urethra: in this perspective it will be useful to use tight underwear and keep the penis up, overturned onto the abdomen.
The duration of the hospital stay and the maintenance of the catheter depends on the type of urethroplasty.
In urethroplasty 1st part of the bulbar urethra (perineal urethrostomy) the catheter is removed approximately after 6 days and the average hospital stay is 7 days. In urethroplasty 1st part penile urethra (penile urethrostomy) the caterer is removed after 1 day and the average hospital stay is 2 days.

In urethroplasty 2nd part the hospital stay is 3-4 days and the catheter is removed after 7-21 days. In urethroplasty single-time the average hospital stay is 4-5 days and the catheter will be removed after 15 days in case of end-to-end anastomosis, after 21 days in case of enlargement urethroplasty with skin or mucosa grafts.
In all cases the variation in catheter maintenance time will depend on the complexity of the urethral reconstruction that will vary from case to case.
Before the catheter is removed, the bladder is filled with contrast medium and, once the catheter is removed, the urethral canal is radiologically controlled while the patient urinates (urinary cystourethrography).
In cases where the buccal mucosa is used, the patient will have to feed on a cold liquid diet only on the first postoperative day, subsequently re-starting the normal diet.

Results

A. Symptomatology:
after the removal of the catheter, the improvement of the symptomatology consists in an increase in the force of the urinary flow, disappearance of the sensation of obstacle to the emptying of the bladder and during ejaculation, reduction of the post-urination residue, progressive reduction and disappearance of the repeated urinary infections. However, it must be pointed out that in long-established stenosis, the resumption of the original contractile bladder capacity will be gradual and slow.

B. Objectives Results:
single-time urethroplasty has a success rate between 70 and 98%: 98% in end-to-end anastomosis, 90% in enlargement urethroplasty with skin or mucosal grafting.
2-times urethroplasty has a 76% chance of success.
In reality the result depends on the evolution of the stenosing urethral pathology: the fibro-sclerotic process at the scar may reactivate and, furthermore, the extra urethral tissues involved in urethroplasty are subject to a progressive deterioration over time.
The success rates of the urethrotomy (30%), which consists in the endoscopic treatment of the stenosis, are significantly lower than those of the urethroplasty (above average 85%): open surgical repair therefore represents the treatment of choice for urethral stenosis.

Advantages:

• Better and more lasting results in the treatment of urethral stenosis.
• The only therapy possible in the case of long and complex urethral stenosis, or of fistula or urethrocele.
• Execution of complete histological examination.
• Overall costs not high.

Disadvantages:

• Long surgical procedure in two-time urethroplasty. After the 1st part of the urethroplasty the patient will have the discomfort due to the leakage of urine and sperm from the neomeatus of the urinary deviation (penile or perineal urethrostomy) with consequent need to urinate in sitting position and impotence generandi: it will still be preserved erectile function of the penis and the ability to maintain sexual activity.

• Possible complications of the urethral-genital apparatus.
• The buccal hematoma, the external hematoma of the cheek or lip, the discomfort for the possible removal of the buccal mucosa (they resolve, however, in a few days).

Complications:

• Postoperative hemorrhage: the need for hemotransfusion is very rare in the repair of anterior stenosis, but rare in the repair of posterior urethral stenosis.
• Urinary infections and epididymitis: they gradually resolve upon removal of the catheter.
• Compartment syndrome (due to prolonged intraoperative lithotomy position): very rare. The use of particular leg straps and the surgeon’s attention in positioning the patient has almost completely eliminated this complication.
• Urinary incontinence: may occur after anterior urethroplasty in patients already undergoing prostate surgery and with urethral stenosis involving the residual distal urinary sphincter. This possibility is reduced by certain technical precautions during the intervention. The repair of posterior urethral stenosis may be more frequently due to a lesion of the urinary sphincter apparatus already damaged by the pelvic trauma.
• Postoperative erectile impotence: it is very rare but documented in the surgical repairs of the proximal bulbar urethral tract, near the distal urinary sphincter where surgical maneuvers could potentially damage the nerves of the erection. The integrity of the latter is more frequently at risk in the repair of posterior urethral stenosis.
• Perineal pains in the wound site: they reduce and disappear after the intervention.
• Hematoma and edema of the genitals or perineum: it is not very rare but it is gradually reabsorbed.
• Dehiscence of the wound: healing by secondary intention.
• Penile scar, Penile curvature, Glans rotation: sometimes a subsequent corrective surgical action may be necessary.
• Urethra fistula: in most cases it resolves with an extension of catheter stay after surgery.
• Urethrocele (diverticular sac of urethra at urethral repair): may require surgical repair if it causes post-urination dripping and repeated urethritis.
• Temporary paraesthesia of the lip or cheek from which the sample was taken.
• Recurrence of urethral stenosis: see what has been said previously about the success rates of urethroplasty. Surgical correction may be necessary.

Attention at discharge:
urinary antiseptic therapy until the third day after catheter removal.
In the 45 days following the discharge, a sober period of life is suggested: reducing physical stress, avoiding sexual activity. The introduction of oral fluids should be normal.
In the 12 months following the intervention, every possible traumatic action on the genito-perineal region should be avoided: avoid the use of cycles, motorcycles, tractors, horse; avoid prolonged sitting, especially on rigid seats; avoid contact sports that can cause trauma in the affected region; follow dietary rules (avoid white wines, sparkling wines, beer, spicy foods).

How to behave in case of complications at home:
in case of blood leakage between urethral meatus and catheter, lie in bed with a compressed ice bag on the perineum and on the penis: if the bleeding persists and tends to increase, consult the urologist.
In case of purulent secretion leakage between the urethral meatus and catheter, help the pus exit by squeezing with the fingers on the urethral canal from the perineum on the scrotum and on the penis in the direction of the meatus. In case of painful erections, wet the penis with cold water or place the ice bag on the penis.
If the bladder catheter malfunctions (obstruction), perform saline-supported washes with a 60 cc wide-spouted syringe.

In case of accidental leakage of the catheter before the established time, try to reposition with “extreme delicacy”, and without forcing the obstacle, a soft Foley bladder catheter 14ch: in case of failure of this maneuver a suprapubic cystostomy has to be put in place.
In case of acute retention of urine after the pre-established removal of the catheter, try to reposition with a “extreme delicacy” a soft or single-use rigid Foley catheter 8-10 ch (in case of failure of this maneuver a suprapubic cystostomy has to be put in place) and contact the urologist who performed the operation.

Checks:
the first postoperative check (urination cystourethrography) is performed at the time of catheter removal: in the 1st time urethroplasty (perineal or penile urethrostomy) it is not necessary to perform radiological inspection after removal of the catheter. Then 2-3 or more clinical checks will be performed in the 1st year.