Urethroplasty

Definition

Urethra = the tube in the penis through which one urinates

Plasty = to cut and open or reconstruct to a new shape

This procedure is done to open up and remove a stricture (scar tissue that narrows a passageway) in the urethra. The most common reasons to have a stricture are:

• a history of prior cystoscopy (putting a scope in the urethra) or other urethral procedure
• an old injury or trauma to the urethra
• history of gonorrhea or other urethritis (infection involving the urethra)

Soft strictures and those scars that are very short may respond to simple office dilatation(gentle spreading with specialized instruments). Other strictures may need to undergo a more formal procedure to maximize results and reduce the incidence of recurrent scar formation. A minimally invasive procedure, termed an “internal optical urethrotomy (IOU)” can be done through a small telescope placed in the urethra. For strictures that have failed a prior IOU procedure, or for those that are too long to yield acceptable results from an IOU, an open operation might be suggested. Strictures can occur in different places throughout the length of the urethra. They may also range in length. Increased success of the procedure depends on the location of the stricture, shorter scar length, and fewer number of failed prior procedures. Re-do procedures have a higher failure rate.

The symptoms characteristic of a urethral stricture are those of an obstructive urination pattern. The most common symptoms are:

• straining (need to push to begin urination)
• hesitancy (delayed onset of urination following the urge to urinate)
• slow or diminished force of stream
• a thin or split (sometimes called “forked”) stream
• intermittence (urine stream that starts and stops)
• sensation of incomplete emptying of the bladder after urination is complete

Other symptoms that may be present are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).

Preparation

There is no particular preparation for this procedure. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. It may be uncomfortable while you are healing. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema before bed the night before your procedure.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from one to several hours depending on the length, density, and location of the stricture. You will be placed in the lithotomy position (lying down on your back with your legs fairly elevated in holsters called stirrups). Prior to beginning, we may want to repeat a special x-ray (urethrogram). This is an x-ray of the urethra using an injection of contrast dye through a catheter. In very complex strictures, or those in which the urethra was actually divided (most commonly from a car accident in which there was a severe fracture of the pelvic bones), we may need to do the x-ray from two directions. In order to accomplish this, we would need to place a suprapubic catheter (SP tube) into the bladder through a tiny hole into the abdomen.

A urethroplasty is most commonly done through an incision in the perineum (the area between the scrotum and anus. In fewer instances, it may be done through an incision in the lower abdomen. Occasionally, combinations of the two incisions are used. Once the urethra is approached and separated from surrounding tissue, dead scar tissue is removed. With short strictures, the two healthy ends may be anastomosed (sewn together) without much manipulation. In other situations, there are numerous surgical maneuvers the surgeon can use to help bring the ends closer. This is important so that there is no tension on the edges that are sewn together. In rare instances, tissue may need to be harvested (taken from somewhere else on your body) to make up for a large gap between the ends. A catheter is placed across the repair and into the bladder. Once the urethral edges are repaired, the incisions are closed and a bandage is applied.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged home or admitted to the hospital. Your age and medical health, as well as the length of your procedure will determine whether or not you need to remain in the hospital.

It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients, this dissipates within a couple of hours, but could last until the catheter is removed. *The catheter may remain for anywhere from 1-3 weeks (or longer).Some patients require medications to help relax the bladder while the catheter is still in. Your catheter will be attached to a bag. The urine will either be clear or minimally tinged with blood. If you are being discharged, the bag can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. We assure you that it is quite simple. You will also be given a large bag for overnight use that you will hang off the side of the bed. You should not use the leg bag overnight while sleeping.

There may be small blood staining on the bandage. If the dressing becomes soaked, however, or if you see active blood oozing under the bandage, please contact us immediately. We ask that you refrain from any strenuous activity until your follow-up office visit. Every patient has some degree of swelling and bruising. It is important to apply ice compresses intermittently to the incision area (behind the scrotum) for the first 12 hours. This may help reduce any of the expected swelling. When you sit, you may want to put a soft pillow down on the chair. Your surgeon will have discussed bathing with you. Some physicians ask that you only shower (no baths) in the first few days while others may request that you take warm baths by the second or third day.

We strongly encourage you to take approximately one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a lying down position. Periodic walking is encouraged. Some patients have almost no discomfort while others are somewhat uncomfortable for several days. Severe pain is unlikely but possible. We may provide you with a prescription for pain medication to alleviate most of the discomfort. An antibiotic prescription may also be given and should be taken until completion. If any side-effects occur, contact our office immediately.

Expectations of Outcome

Most patients are very satisfied after the procedure. The improvements that are typically noted immediately after the operation are:

• Stronger force of stream
• Decreased standing around waiting for the urination to commence
• Decreased need to push
• Loss of forking (splitting) of the urine stream as well as a wider stream
• Loss of intermittence (i.e. where the flow used to start and stop and start, etc.)
• Loss of the sensation that you are “not really emptying your bladder”

In rare instances, it may be difficult to control the urine for a couple of weeks. You may notice that you are still voiding frequently and with some urgency (sensation that forces you to get to the bathroom quickly). These symptoms may take a long time to disappear. In patients that were significantly obstructed for a prolonged period, these symptoms may never fully resolve. Nocturia (getting up at night to urinate) is typically the last symptom to resolve. In many instances, it may become less frequent, but never fully disappear. The reason is that nocturia can be due to several other physiological issues and also because the night-time ritual becomes somewhat habitual.

*Uncommonly, the stricture cannot be repaired. In instances where there was complete urethral separation, it may not be possible to bring the two ends together in a satisfactory manner. If there is too much tension on the repair, it is certainly doomed for failure. If this is the case, the suprapubic tube would remain temporarily until further management is discussed with you in the office. Please refer to the literature on suprapubic catheter placement.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Wound Infection: As with any operation, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics and local wound care. In some instances, a small area of the superficial (upper layer) incision needs to be opened for adequate drainage. Infections are more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. If the infection enters the bloodstream, you may feel very ill. This is termed “sepsis”. This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. A septic patient may need a short hospitalization for intravenous antibiotics, fluids and observation.
• Urinary Tract Infection or Urosepsis: It is possible for you to acquire a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This may not be readily apparent in the period that you have a catheter in place, as the catheter itself may cause these symptoms. The infection will usually resolve with a few days of antibiotics, and sepsis (infection in the bloodstream)is rare in this instance. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Recurrent Urethral Stricture: A recurrence of the stricture can occur weeks, months, or even years after this sort of procedure. The chance of recurrence is proportional to the length of the stricture as well as the number of prior procedures that a patient had. In rare instances, however, even a first-time operated, short stricture can recur.
• Urinary Incontinence: If your bladder was obstructed for years by a stricture, it may have learned to over-compensate by squeezing with more force. The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or even longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel. Additionally, if the stricture involves the portion of the urethra where the continence sphincters are located, total incontinence (continuous dripping of urine) may result on a short term or even permanent basis.
• Bleeding/Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The human body normally reabsorbs this collection over a short period of time. Intervention or surgical drainage is rarely necessary.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Urinary Leak and Fistula: If the repair of the urethra heals poorly or comes apart, urine can leak from the area and come out through the incision. This abnormal connection is called a “fistula.” In most instances, this will heal by replacing the catheter. In other instances, the urine may need to be diverted out through a suprapubic tube (see above) for some time. An open repair may be necessary.
• Urinary Retention: Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If you presented with long-standing urinary retention (complete inability to urinate), this may not resolve following a urethroplasty procedure. You may need to be taught to catheterize yourself after the procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
• Injury from Suprapubic Tube: If a suprapubic tube is being placed (again when access to the urethra is needed from above), it can rarely puncture a structure adjacentto the bladder. Although rare in any instance, the small intestine is the most commonly involved organ. When recognized, a general surgeon may need to be consulted. Surgery on the small intestine may be necessary.
• Erectile Dysfunction: Because the nerves stimulating erections run alongside certain portions of the urethra, they can be injured despite all attempts to void them during dissection. Following nerve injury, a patient may have partial or complete inability to achieve an erection. Often, the injury or infection that caused the stricture will also have already caused injury to these nerves as well. In that case, many patients will have partial or complete erectile dysfunction (impotence) prior to the surgery.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.