What is Urethral Stenosis?
Urethra is the urinary canal between the tip of the penis and the bladder that allows urine to be carried out of the body. Urinary tract stenosis (urethral stenosis) is a mechanical disease that prevents urine from being discharged easily from the bladder, and ultimately causes urine to accumulate in the bladder and the bladder cannot be emptied completely.
Urethral stenosis affects approximately 0.5-1% of men and is a result of damage to the urinary tract cells (urethra epithelium) due to some reasons, resulting in fibrosis (Scar) of the epithelium or the structure that forms the urinary tract body (corpus spongiosum). ) is a disease that results in Stenosis occurs due to injury or damage to the urethra and surrounding tissue. For example, if there is a stretching in skin injuries and a thickening (scar tissue) in the injured area, similarly, a scar tissue is formed in urethra injuries. When this stretching and thickening blocks the thin space of the urethra, urine cannot pass through the urethra, it is difficult to pass depending on the extent of stenosis, and therefore it is in the bladder. It accumulates and is not emptied completely.
Traumas, some medical practices such as radiotherapy for prostate cancer, some surgical operations performed in this area, and some infections such as gonorrhea can cause urethral stenosis. The causes of urethral stenosis vary depending on the age of the patient and the location of the stenosis. While anterior urethral strictures occur mostly as a result of inflammation (40%), medical intervention (iatrogenic-40%) or trauma, posterior urethral strictures occur iatrogenicly after pelvic fracture (pelvic fracture) or as a result of surgical intervention. Sometimes no cause can be found (15-20%). Stenosis may have a length ranging from a few millimeters to a few centimeters between the bladder and the tip of the penis.
Symptoms and Diagnosis
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Clinical history
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Symptom scoring (Patient Reported Outcome Measure)
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Physical examination
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Uroflowmetry and Ultrasonography, amount of residual urine
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Urethrography
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Urethro-cystoscopy (in some cases)
Patients with urethral stenosis usually present with lower urinary tract symptoms and findings. Have difficulty urinating Patients apply with complaints such as difficulty in urine flow, a feeling of not fully emptying the bladder, dribbling after urination, and frequent trips to the toilet. Sometimes patients may present with recurrent urinary tract infection, prostatitis, epididymitis-orchitis or bladder stones. It should be kept in mind that in cases of complete stenosis or obstruction, sudden inability to urinate (retention) may occur.
For urethral stenosis, a detailed history should be taken regarding the cause before treatment. It is important to evaluate urinary hole pathologies during physical examination and to feel the scar tissues in the anterior urethra manually (palpation) in cases called lichen sclerosis. In patients with urethral stenosis, the maximum urine flow rate and urination pattern should be evaluated with a voiding test (uroflowmetry). Ultrasound may be required to evaluate bladder pathologies and measure the amount of residual urine. Retrograde urethrography (RUG) may be performed to evaluate the exact location and length of urethral stricture. Retrograde urethrography is the gold standard, especially for the diagnosis of anteriorurethral strictures. However, since RUG is insufficient in posterior urethral stenosis and bladder neck pathologies, a combination of voiding cystouretrography (MSU) and RUG should be performed in these cases.
In cases where the diagnosis cannot be made, urethrocystoscopy may be required to clarify the stricture. Flexible cystourethroscopy performed simultaneously through external urethral meatus or cystostomy can be an important diagnostic tool in measuring the location and length of the stricture. Once the location and length of the stenosis are clarified, the type and time of intervention are planned.
Treatment
Treatment in urethral stenosis depends on the cause (etiology) and location (anterior, posterior). It may vary depending on the number of stenosis, the length of the stenosis, the density-severity of the stenosis (degree of spongiofibrosis), previous treatment attempts and the age of the patient. While relatively short simple strictures are treated endoscopically, long-complex strictures are treated with one or two-stage open surgery (urethroplasty).
Urethral dilation: It can be performed with metal dilators, balloon dilation or nelaton catheters. This treatment method is used in short segment stenoses (<1 cm). It can provide temporary relief to the patient by opening the chancre scar. It is generally applied to patients with additional diseases (high comorbidities), who cannot tolerate any further intervention, and who have a limited life expectancy. However, it can rarely provide complete treatment (curative) in short stenosis without severe scar tissue (spongio-fibrosis). Urethral dilations; It can be tried in the treatment of bulbar urethra stenosis, stenosis in the external hole and close to the external hole (Meatal-fossa navicularis), and stenosis in the urinary valve region (Sphincteric stenosis).
Internal Urethrotomy (IU): Urethrotomy. interna 17-20 F It is the process of cutting short urethral stricture with a cold knife at the 12 o'clock position with a urethroscope. This method has been widely used for about fifty years. In the treatment of urethral stricture, various lasers (Argon, carbon dioxide, excimer, diode, KTP and Nd) are used in addition to the cold knife. :YAG lasers) are used. In general, it is reported that the success of laser urethrotomy is the same as that of cold knife. Urethrotomy Post-internal scarred epithelial tissue is left for secondary wound healing and with epithelialization, a new urinary tract (urethral lumen) and its continuity are formed. If normal healing (epithelialization) occurs before scar tissue (contraction), the procedure will be successful; otherwise, if wound contraction occurs faster, stenosis recurrence is almost inevitable.
Complications: The most common main complication of urethrotomy interna surgery is the recurrence of stricture. Other complications (0.5-5%) generally include bleeding, hematoma, and epididymo-orchitis. In some rare cases, deep incisions may cause a fistula between the penile corpus cavernosum and the urinary tract (corpus spongiosum), leading to erectile dysfunction.
Urethroplasty: Urethroplasty urethra. It is the most effective method for the complete treatment of stenosis and is considered the gold standard. In this method, the stenosis area is removed and then urethral reconstruction is performed either by end-to-end anastomosis or by using a flap/graft.
1-Removal of Stenosis and end-to-end anastomosis (Excision and primary anastomosis): The aim of this treatment method is to completely remove the scar tissue (fibrotic tissue). After insertion, the urethra is anastomosed end to end in a proper manner (spatulated and not stretched). In cases of stenosis longer than 2cm (in cases where augmentation urethroplasty is not possible), the two corpus cavernosum tissues are carefully separated to reduce end-to-end anastomotic tension. With this method, approximately 5 cm of stenosis can be anastomosed end to end, but if tension still occurs, a part of the pelvic bone can be cut (inferior pubectomy). In addition, end-to-end joining (anastomosis), especially in cases of anterior urethral stenosis above 2 cm, may result in shortening of penis length and curvature. Therefore, it is necessary to use augmentation urethroplasty techniques in long segment stenoses.
2-Augmentation Urethroplasty: This treatment method is generally preferred in cases that are longer than 2 cm and where end-to-end anastomosis urethroplasty is not suitable. This method is done in one or two stages. Recurrence of stricture in augmentation urethroplasty has been reported at a rate of 14-15%. Penile skin, scrotal skin, oral mucosa, bladder mucosa, and colonic mucosa can be used for grafting. Among these, it is the most frequently preferred material due to the ease of obtaining oral mucosa, the absence of scalp, low complications and high success rate. Oral mucosa can be obtained from the cheeks, lips or tongue. Reported complications related to oral mucosa graft use and harvesting include intraoperative bleeding, postoperative pain, infection, swelling, and salivary gland duct injury. Some patients may experience temporary difficulty in opening the mouth. Island flap/graft (Onlay grafts) are used front, side and back.
3-Two-stage urethroplasty: It is applied in the penile urethra and especially in cases with unsuccessful hypospadias surgery or lichen sclerosus. After the first stage, severe stenosis (contraction) due to graft scar may occur in 10-39% of cases. Therefore, it is necessary to wait 3 to 6 months for the second stage.
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