Urethroplasty indications

For the treatment of urethral strictures, urethroplasty is currently regarded by many authors as the best option. The number of endoscopic treatments (optical internal urethrotomy and Otis urethrotomy) has declined in recent years because of the poor outcomes of treating challenging strictures. Below are some of the conditions where urethroplasty is recommended: 

• Fistula: Urethral fistulas, which occur in 7% to 15% of cases, are the most frequent significant complications requiring a second surgery. The fistula is excised and closed using a local vascularized flap where possible.
• Urethral strictures associated with chronic inflammation: Recurrent urethral strictures are best treated with urethroplasty, which has been suggested to be more successful than direct vision internal urethrotomy (DVIU).
• Urethral trauma: Initial care of individuals with pelvic fracture urethral injury may involve primary realignment or placement of a suprapubic tube with a plan for a definitive urethroplasty later.
• Complicated hypospadias: Anatomical congenital abnormality of the male external genitalia is known as hypospadias. The urethral opening is positioned abnormally because of abnormal development of the urethral fold and the penis' ventral foreskin. The innovative Duckett method is a feasible and suitable choice for patients with proximal hypospadias.
• Failed prior repair: Urethroplasty is used when optical urethrotomy and urethral dilatation are ineffective. The mainstay of surgical treatment has always been endoscopic management, either by urethral dilatation or optical urethrotomy; nevertheless, high recurrence and low long-term success rates have led to the development of new procedure, urethroplasty.
• Long-length Strictures: When basic procedures are ineffective in managing a urethral stricture due to its length or density, urethroplasty is recommended.

Urethral stones, abscesses, urethral diverticula, and false passage are some of the other indications of urethroplasty.

Urethroplasty contraindications

Urethroplasty surgery is unsafe in some conditions; Therefore, it is not recommended. Below are some of the situations where urethroplasty is not recommended:

• Purulent urethritis: The inflammation of the urethra, along with purulent discharge, is known as purulent urethritis.
• Periurethral abscesses: Like other genitourinary pathologies, periurethral abscesses can present with fever, dysuria, pyuria, and acute urine retention along with pain (scrotal, penile, pelvic, perineal, or suprapubic).
• Blood clotting disorders: Sometimes, blood clotting disorders are referred to as thrombophilias or coagulation disorders. These disorders involve issues with the body's capacity to regulate blood clotting.
• Urinary tract infections: A urinary tract infection (UTI), is an infection of the urinary tract. Several locations throughout the urinary system may become infected with the illness, including the bladder, kidneys, ureters, and urethra.
• Penile urethral strictures: Even in cases of mild penile urethral strictures, end-to-end urethroplasty is not recommended because excision and primary anastomosis (EPA) in this area might cause chordee and penile shortening.
  

The gold standard for treating urethral strictures is urethroplasty. Below are some of the advantages of urethroplasty surgery: 

• Long-term success rates: The most effective treatment option for urethral strictures is urethroplasty, which has success rates that can range from 80% to 90%, depending on the complexity of the repairs that need to be made.
• Cost-effective: Urethroplasty is a cost-effective therapeutic option, whether utilized as the main treatment or as a follow-up after a failed dilation and direct visualization internal urethrotomy (DVIU).
• Long lasting: Urethroplasty lasts longer than other procedures like endoscopic urethrotomy.
• Low recurrence rate: Urethroplasty has a lower recurrence rate than endoscopic urethrotomy.
• Failed urethrotomy: Urethroplasty is used when optical urethrotomy and urethral dilatation are ineffective or when the urethral stricture is too long.
  

Urethroplasty procedure steps

The urology team follows the below steps for performing urethroplasty surgery:

• If instructed by the surgeon, patients need to have completed blood tests, X-rays of the urethra, and electrocardiograms (EKGs) before surgery.
• Before surgery, patients might be required to visit at the preoperative clinic. Patients might require a uroflow test or cystoscopy to assess the urinary tract. 
• Before surgery, patients must stop using blood thinners; the exact time duration changes depending on the blood thinner type. Ensure patients are informed of the number of days they need to avoid blood thinners before surgery.
• Individuals who use anticoagulants and NSAIDs (nonsteroidal anti-inflammatory medicines) might need to take a separate blood thinner or follow particular guidelines. To ensure it is safe for them to stop taking these medications during surgery, patients should speak with the physician who wrote the prescriptions. Continue taking them until the physician confirms.
• Patients should speak with the doctor immediately if they begin taking any new drugs before the procedure to see whether they can continue taking them up to and including the day of the procedure.
• Never allow someone to try inserting a scope or Foley catheter or dilate or stretch the urethra. This could make the surgery more difficult. Before surgery, patients will require the insertion of a suprapubic catheter to collect urine. The catheter, which inserts into the bladder via the abdomen, can drain urine into a collection bag. When the urethroplasty is performed, it will be removed. 
• Patients are asked not to eat or drink for 6 hours before surgery.
  

During Urethroplasty surgery

• During the surgery, patients will be fully asleep due to the use of complete general anesthesia. The anesthetist may also use an epidural anesthetic, which reduces pain after surgery in certain patients. Before the surgery, patients will often be given an injection of antibiotics after having checked any drug allergies.
• Either on the penis or in the skin between the scrotum and the anus (the perineum), an incision is made over the stricture. Either the scar is removed the urethra is rejoined over a catheter, or the incision is enlarged, and a portion of the buccal mucosa is placed over a catheter.
• It is possible to insert a drain and put a second catheter through the lower abdomen into the bladder. Absorbable sutures are used to close the wound. When the cheek lining is used for surgery, the wound heals fast and occasionally doesn't need to be sutured.
• Depending on the complexity of the repair, the procedure might take two to four hours to complete.
  

• Patients are usually not required to remain overnight for the surgery because it is performed as an outpatient procedure. However, if concerns arise after surgery, patients can stay that night in the hospital.
• A foley catheter (urinary catheter through the penis) is positioned.
• The catheter will be removed at the clinic two to three weeks after surgery.
• After surgery, patients might be prescribed antibiotics that they must take strictly as prescribed.
• Patients can resume self-care after going home with a shower. They can use soap and water to wash the incision gently, then let it dry. At the end of the penis, where the catheter is placed for comfort, a small amount of ointment may be applied. 
• Patients may experience pain in the mouth if a buccal (cheek) graft has been done. Patients should avoid picking away the white or yellow film that may form over that area; it is normal. A tiny gauze pad can be soaked in magic mouthwash and applied to the cheek multiple times daily by patients. This will decrease the discomfort.
• Patients need to wear any mouth appliances, partials, or dentures they have during the healing phase to avoid scar development, preventing a proper fit later on. However, after the mouth heals, adjustments may still be required.
• For at least 24 hours after the procedure, patients should avoid operating any motorized equipment or driving a motor vehicle, especially if they are taking narcotic (opioid) painkillers.
• For at least 24 hours following the procedure, patients are permitted to avoid signing legal papers, making complicated judgments, or engaging in tasks that could endanger others, such as cooking or caring for small children, without supervision.
• After the treatment, patients are advised not to consume alcohol for at least 24 hours.
• Patients can manage to start eating gradually. After starting with small sips of liquids, they can add solid food as tolerated. They can drink liquids if they don't feel like consuming solid food. During this time, nausea and vomiting are common and not considered harmful unless extreme or continued after the first day.
• After surgery, patients can get back to their regular physical activities, such as driving, climbing stairs, and walking. Patients need to refrain from strenuous and aerobic exercise for six weeks. Patients need to wait for the urologist's consent before involving in any straddle-position activities (such as riding a bicycle, motorcycle, snowmobile, etc.).
• After surgery, people can start involve in sexual activity six weeks later.
  

Urethroplasty complications

The location of the stricture, the surgical method, the type of substitution tissue, the stricture's length, the surgeon's skill level, and patient selection all directly impact urethroplasty complications. From minor and temporary to severe and complicated, complications may occur. Below are the complications of urethroplasty: 

• Recurrent stricture: Repeated urethral strictures, a common but sometimes overlooked urological disorder defined by urethral narrowing, can cause urinary symptoms and consequences.
• Erectile dysfunction: The inability to develop and sustain a penile erection that is needed for satisfactory sexual performance is a hallmark of erectile dysfunction (ED), previously known as impotence.
• Post-void dribbling: Post-micturition dribbling is another term for post-void dribbling. The unintentional leak of urine that occurs right after urinating is known as post-micturition dribbling (PMD).
• Urethral fistula: A urethral fistula is a straight urethral outpouching that ends at the skin's surface or another viscous cavity (bladder or intestine). It may be caused by incomplete urethral repair following trauma, tissue damage from inflammation, surgery, or radiation.
• Urinary urgency: The International Continence Society (ICS) defines urinary urgency as the experience of an intense, urgent need to urinate that isn't easy to postpone.
• Scrotal swelling: An unusual enlargement of the scrotum is known as scrotal swelling. The sac that surrounds the testicles is known as the scrotum.
• Urinary tract infections: An infection related to the urinary tract is called as a urinary tract infection, or UTI. Several locations throughout the urinary system may get infected with the illness, including the bladder, kidneys, ureters, and urethra.

Skin sloughing, scrotal ecchymosis, ejaculatory dysfunction, urethral sacculation, issues with glans sensation, abscess development, scrotal numbness, urine spraying, and feeling of wound tightness are some of the other complications of urethroplasty surgery.

Although most patients recover from urethroplasty surgery quite quickly, the surgical site swelling may take weeks to reduce. Until the catheter is removed, it is generally advised to restrict activities to basic needs. In the first week following surgery, patients will likely experience a decrease in pain.

Questions that the patients can ask the healthcare team about urethroplasty surgery?

Endoscopic urethrotomy vs Urethroplasty

Urethrotomy is the initial treatment for urethral stricture. About half of the strictures comes back after four years. Open urethroplasty or repeat urethrotomy are options for further treatment. Below are some of the parameters that differentiate endoscopic urethrotomy and urethroplasty.