Urethral Stricture Disease

Educational Objectives

The goal of this lecture is to improve the management of urethral stricture. After hearing and assimilating this program, the clinician will be better able to:

1. Select diagnostic tests for urethral stricture.

2. Use appropriate techniques for perineal urethrostomy and insertion of a suprapubic tube.

3. Explain the key steps in urethroplasty.

Summary

Summary of lessons learned: speaker no longer performs preoperative voiding cystourethrography (VCUG) or retrograde urethrography (RUG); not all strictures require surgical repair; perineal urethrostomy advantageous; urinary diversion using suprapubic (SP) tube for 3 mo required for all patients; strictures and fistulas induced by irradiation — refractory to repair; manifestations of global disease of pelvis; repair not advantageous because abnormalities of bowel function and disease of bladder remain (eg, small capacity, frequency, urgency, dysuria, nocturia, incontinence, hemorrhagic cystitis, retention of clots); incidence of multiple procedures high; operations not successful because repair of diseased tissue not possible; malnutrition that contributes to disease of tissue not treated; removal of diseased tissue often only solution (eg, cystectomy, pelvic exenteration)

Diagnostic tests: undergoing multiple procedures (eg, catheterizations, dilations) leads to fear of physicians

Voiding cystourethrography: difficult to perform if patient fearful; does not supply good data; images can be misinterpreted; not useful for detection of strictures abutting sphincter, at meatus, or in fossa (eg, hypospadias); does not gauge spongiofibrosis or density of vascularity

Retrograde urethrography: conical departure of bulbar urethra normal finding; however, normal conical departure also occurs in presence of stricture; smooth constriction of membranous urethra normal finding; therefore, strictures abutting sphincter can be missed

Cystoscopy in office setting: recommended test; more comfortable for patient; eliminates need for unnatural voiding; provides detailed anatomy of stricture; assesses presence of spongiofibrosis and adequacy of blood supply; good blood supply necessary for successful operation; if blood supply adequate, excision of stricture and spatulated end-to-end anastomosis may be sufficient; stricture with inadequate blood supply requires augmented procedure (end-to-end anastomosis with buccal graft); purpose of cystoscopy to confirm presence of stricture; proximal urethra may be examined using flexible cystoscopy by way of SP tube; proximal urethra exposed to high pressure, subject to hydrodistention, and may have poor blood supply (surgical results poor, even for short strictures)

Management of strictures: repairing every stricture not necessary — abnormal urethra not necessarily indication for urethroplasty; patients with urethral diameter 16F to 18F (and ability to pass cystoscope) usually have normal flow rates, empty bladder completely, and do not have urinary tract infections; urethroplasty not required in these patients; managing vs curing strictures — managing strictures acceptable, but document that option of cure discussed with patient; according to survey, ≤33% of US urologists continue to perform dilation and direct vision internal urethrotomy (DVIU) even after multiple failed attempts

Perineal urethrostomy: contraindications — stricture that serves as mechanism of continence (repair may result in incontinence); incontinence from penis (can be managed by condom catheter, penile clamp, or insertion of artificial sphincter or sling); management of incontinence in patient who has had perineal urethrostomy difficult; patients with neurogenic bladder (self-catheterization not possible after perineal urethrostomy); hirsutism of perineum (associated with complications of perineal urethrostomy); technique — do not divide urethra; urethra mobilized and brought to skin (analogous to creation of loop colostomy); divided longitudinally and sewn to skin; never transected (dividing urethra transects blood supply and does not allow drainage of distal obstructed urethra); procedure coded as “urethroplasty, first stage, for fistula, diverticulum, or stricture” (not “perineal urethrostomy” [procedure performed after penectomy])

Insertion of SP tube: necessary procedure; position SP tube high on abdominal wall (near umbilicus) in patients with obesity and in dome of bladder (least sensitive area); allows urethra to rest and results in resolution of inflammation and hydrodistention; character of urethra changes after period of rest; decreases operative blood loss and enables antegrade and retrograde access to stricture; do not tunnel SP tube, especially in patients with posterior distraction injury (insertion of urethral sound and elevation of pelvic floor required to locate proximal urethral stump); SP tube remains in place for 3 mo; plugging of SP tube and intermittent drainage allow bladder to function normally, avoid need for urinary drainage bag, and prevent pain associated with movement of catheter in trigone (most sensitive portion of bladder); insert SP tube above patient’s belt line; use Malecot rather than Foley catheter to prevent tip from falling into prostatic urethra and causing irritation; secure catheter using ethylene terephthalate (Ethibond) sutures (soft; skin reaction minimal)

Positioning patient: exaggerated lithotomy position using stirrups (Guardian style) preferred; use fixed perineal retractor (Jordan Bookwalter) and beanbag to support and stabilize pelvis; provide adequate padding for feet; position legs symmetrically; administer adequate intravenous fluid to maintain urine output at 100 mL/hr; perform repair using deep anesthesia and muscle paralysis; patient’s anatomy guides positioning; exaggerated lithotomy position brings perineum parallel to floor

Management: overview — perform office cystoscopy to confirm presence of stricture; insert SP tube in operating room; 2 wk later, patient returns to office and receives plug; schedule patient for urethroplasty (“urethroplasty, possible buccal graft, possible skin graft” on consent form); operation — when patient on stretcher, administer anesthesia, dry shave genital area, clean surgical field with alcohol, and perform cystoscopy through SP tube to determine distal level of stricture; insert wire antegrade, and pass it through meatus; pass 5F catheter over wire to achieve complete access to stricture; catheter serves to identify stricture, measure its length, and locate fistulas; patient then transported to operating table and positioned; fixed perineal retractor allows excellent exposure of deep perineum; DVIU — often useful; rate of success of first DVIU ≈30%, second DVIU ≈15%, and third DVIU 0%; cut through all scar tissue (down to healthy bleeding urethra), not just enough to enable passage of cystoscope; second DVIU may be appropriate if cut traverses all of scar tissue; repair of fistulas — appropriate for patients with posterior distraction injury, diverticular disease, and trauma; repair of fistulas induced by irradiation difficult (tissue not healthy); dilation — whether results equivalent to DVIU not determined; do not dilate to point of bleeding (indicates tear, which does not heal well); DVIU (continued) — characterized by controlled cut (heals better)

Readings

Erickson B, et al: Understanding the relationship between chronic systemic disease and lichen sclerosus urethral strictures. J Urol 2016 Feb;195(2):363-368; Ferguson GG et al: Minimally invasive methods for bulbar urethral strictures: a survey of members of the American Urological Association. Urology 2011 Sep;78(3):701-6; Figler BD et al: High regional variation in urethroplasty in the United States. J Urol 2015 Jan;193(1):179-83; Lacy JM et al: Trends in the management of male urethral stricture disease in the veteran population. Urology 2014 Dec;84(6):1506-9; Osterberg EC et al: Cost-effective strategies for the management and treatment of urethral stricture disease.Urol Clin North Am 2017 Feb;44(1):11-17.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Carney was recorded at the Georgia Urological Association 2016 Annual Fall Meeting, held September 8-11, 2016, on Sea Island, GA, and presented by the Georgia Urological Association. For information about the Georgia Urological Association 2017 Annual Fall Meeting, please visit wjweis.association-service.org/securesite/gua/meetings. The Audio Digest Foundation thanks the speakers and the Georgia Urological Association for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR400701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.