Definition:
Urethroplasty is the surgical repair of the urethra whose purpose is:
- to solve the obstacle to the bladder emptying, determined by stenosis (ie narrowing) of the urethral canal;
Indications:
Front urethral stenosis: urethral bulbous or penile tract.
Technique description:
Urethroplasty is the surgical repair of the urethral canal. Depending on the characteristics of the lesion (length and cause of stenosis, fistula or ureterocele, urethral stones) and conditions of local tissues, during the surgery the surgeon will be able to decide the most suitable surgical solution to the case from a range of different techniques:
A) URETHROPLASTY IN SINGLE TIME
- End-terminal anastomosis: a full-thickness section of the urethra, fibro-sclerotic tissue resection, causing of the narrowing of the urethral canal, and the rejoining of the two urethral stumps.
- Urethroplasty of urethral light amplification with the use of transplants of skin or mucous tissue.
B) URETHROPLASTY IN TWO TIMES
The repair of the urethra occurs through two interventions separated by a variable time interval, which depends on the evolution of the stenosis urethral pathology (usually greater than 10 months).
- Urethroplasty 1st time: consists of the opening of the urethral canal (surgical urethrotomy) and in the urine deviation by the formation of a new urinary tract at the perineum (perineal urethrostomy) or along the ventral surface of the penis (penile urethrostomy). In cases characterized by severely damaged urethral tissue and suspicious dysplastic lesions, this intervention allows the affected urethral tract to be cleansed (by partial ureterectomy) and diverting the urine while waiting for tissues to heal and subsequently reconstruct the continuity of the urethral light.
- Urethroplasty 2nd time: consists of the surgical closure of the aforementioned urinary deviation (perineal or penile urethrostomy) resulting in the reconstruction of the continuity of the urethral light. Therefore, the patient will eventually return to urinate from the original urinary meatus.
In the interval between the 1st and 2nd time of a two-times urethroplasty, urethral revision surgeries may be required due to the progression of basal urethral stenosis. These revisions may be considered actual urethroplasty procedures from a surgical point of view.
All surgical procedures on the urethra include the possibility of performing histologic examination of the urethra sample in order to identify pathologies requiring further therapies or careful control over time.
The patient shall know that surgery can cause iodinated penile curvatures that could alter erectile function.
Duration of the procedure:
The duration of the surgery varies depending on the surgical technique chosen by the operator and the length and location of the urethral tract affected by the lesion. Typically, 1st time urethroplasty takes between 1 and 2 hours, 2nd time urethroplasty takes 1.5 hours. A single-time urethroplasty takes between 2 and 3 hours for the front urethra stenosis and between 3 and 5 hours for the back urethral stenosis.
Type and length of stay:
In the front urethral stenoses the surgery can be performed both in general and local-regional anesthesia. Sometimes during surgery, a wound drainage tube is left to be removed after a few days.
A bladder catheter is applied during surgery. In the postoperative period, the patient will have to remain in bed for a few days: 1 day after end-terminal anastomosis, 2-3 days after 1st time urethroplasty, 3 days after urethroplasty with the use of grafts (to allow the transplanted tissues to grow), 2-3 days after back urethral stenosis urethroplasty.
Later, caution in the movements should be exercised for about 15 days to minimize possible trauma on the perineum, genitals and urethra: in this perspective it will be useful to use tight slip and keep the penis high, overturned on the abdomen.
The length of hospital stay and the keeping of the catheter depends on the type of urethroplasty.
In all cases, the variation in the catheter keeping time will depend on the complexity of urethral reconstruction, which will vary from case to case.
Results:
A. SYMPTOMATOLOGY
After the removal of the catheter, the improvement in the symptoms consists in an increase in the urinary flow force, the disappearance of the feeling of obstruction in the bladder emptying and during ejaculation, reduction of the post-urination residue, progressive reduction and disappearance of repeated urinary infections. However, it should be noted that in long-drawn stenoses, the recovery of original contractile bladder capacity will be gradual and slow.
B. OBJECTIVE RESULTS
Single-time urethroplasty has a 70% to 98% success rate: 98% in end-terminal anastomosis.
In fact, the result depends on the evolution of the stenosis of the urethral pathology: the fibro-sclerotic process at the scar may reactivate, and the extra-urethral tissues involved in the urethroplasty are also experiencing a progressive deterioration over time.
The percentages of successful urethrotomy (30%), which consists of endoscopic stenosis, are considerably lower than those of urethroplasty (higher than 85%): open surgical repair is therefore the treatment of choice for urethral stenosis.
Advantages:
- Better and lasting results in the treatment of urethral stenosis.
- Only possible treatment in the case of long and complex urethral stenosis, or fistula or ureterocele.
- Complete histological examination.
- Total costs not expensive.
Complications:
- Postoperative haemorrhage: The need for blood transfusion is very rare in the repair of frontal stenoses, but rare in the repair of back urethral stenosis.
- Urinary and epididymal infections: gradually resolving after catheter removal.
- Compartmental syndrome (due to prolonged intraoperation lithotomy position): very rare. The use of special thighs and the attention of the surgeon in positioning the patient almost completely eliminated this complication.
- Urinary incontinence: It may occur after frontal urethroplasty in patients who have undergone prostate and urethral stenosis involving the residual distal urinary sphincter. This possibility is reduced by certain technical forethoughts during the intervention. Rear urethral stenosis repair may be more commonly the cause of a urinary sphincter apparatus lesion already damaged by pelvic trauma.
- Postoperative erectile dysfunction: it is very rare but documented in surgical repairs of the proximal bulbous urethral tract, near the distal urinary sphincter where surgical maneuvers could potentially damage the erection nerves. The integrity of the latter is more frequently at risk in repairing the back urethral stenosis.
- Perineal pains in the site of the wound: they diminish and disappear after a while.
- Hematoma and edema of the genitals or perineum: it is not so rare but it is gradually reabsorbed.
- Dehiscence of the wound: healing by second intention.
- Penile scar, penile curvature, glans rotation: sometimes a subsequent corrective surgical procedure may be required.
- Fistula urethra: in most cases it resolves with an extension of catheter keeping periord after surgery.
- Urethrocele (diverticular urethra bag in urethral repair): may need a surgical repair if it is due to post-urination dripping and repeated urethritis.
- Temporary paresthesia of the lip or cheek from where the sample came from.
- Recurrence of urethral stenosis: see what was said above about the percentages of successful urethroplasty. Surgical correction may be necessary.
Attentions after discharge of the patient:
Urinary antiseptic therapy until the third day following the removal of the catheter.
In the 45 days following the discharge, a morigerized period of life is recommended: reduce physical stress, avoid sexual activity. The introduction of oral fluids should be normal.
During the 12 months following the surgery, any possible traumatic action on the genito-perineal region should be avoided: avoid cycling, motorcycle, tractor, horse riding; Avoid prolonged sitting position, 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 deal with home-related complications:
In case of blood leak between urethral meatus and catheter, lay in bed with a compression ice bag on the perineum and penis: if the bleeding persists and tends to increase, consult the urologist.
In the event of leakage of purulent secretions between urethral meatus and catheter, help shedding the pus squeezing with the fingers on the urethral canal from the perineum on the scrotum and the penis in the direction of the meatus. In case of painful erections, wipe the penis with cold water or put the icing on the penis.
In the event of a malfunction (obstruction) of the bladder catheter, perform prolonged washing with physiological liquid using a 60 cm wide beak syringe.
In the event of accidental emission of the catheter before the established time, try to let reposition with “extreme delicacy”, and without forcing the obstacle, a soft Foley 14 ch. bladder catheter: in case of failure of this maneuver, let place an overpubic cystostomy .
In the case of acute urinary retention after the catheter removal, try to let reposition with “extreme delicacy” a soft or rigid Foley 8-10 ch bladder catheter (if this maneuver fails let place overpubic cystostomy) and contact the urologist who has performed the surgery.