If the patient has urinary retention or a high amount of residual urine, the patient should be treated with a suprapubic bladder fistula. An existing urinary tract infection is treated appropriately. Endouroscopic therapeutic procedures:
- Bougienage (dilatation of the stricture) – has only a temporary effect (recurrence of the stricture after 4-6 weeks).
- Urethrotomia interna (internal urethrotomy; urethral slit) – high recurrence rate of up to 60%; more suitable for short-stretch stricture in the bulbar portion (between the sphincter and the beginning of the mobile penis) of the urethra (urethral bulbar stricture).
Open surgical therapy procedures (reconstructive surgery):
- Resection of the stricture and end-to-end anastomosis (two urethral segments will be sutured back together at their opened ends, creating a continuous course); good results for short-stretch (< 2.5 cm) strictures of the bulbar urethra (approximately 90%).
- Urethroplasty (urethroplasty) with free graft (graft e.g. foreskin or oral mucosa) – for longer-stretched bulbar and penile strictures.
- The success rate after primary urethroplasty is very high (79-95%).
- If a repeat procedure was required because of recurrence, most patients had a bulbar stricture (71, 4%), according to one study. When urethroplasty was repeated with buccal mucosa of the contralateral side of the cheek, the following success rate, defined as the proportion of patients without urethral stricture, was 82% (follow-up: 45.6 months). Thus, primary therapy did not represent a risk factor for re-intervention.
- Perineal urethrostomy (Boutonnierère) – in exceptional situations with completely destroyed urethra (eg, after urethral stenting); palliative procedure in which the urethra (urethra) is sewn below the scrotum (scrotum)Note: micturition (urination) via naturalis becomes impossible by this procedure, as well as normal ejaculation.
- Bulboprostatic anastomosis of the urethra.
Possible complications of open surgical therapy:
- Ejaculatory disorders (25%)
- Penile deviations, ventral (5-20%).
- Sensory disturbances of the glans penis/sickle (15%); in end-to-end anastomosis.
- Skin necrosis (15%); in flap (flap) urethroplasty.
- Fistula formation (5%); in flap urethroplasty.
Other notes
- Analysis of 128 men who underwent internal urethrotomy (see above) for anterior urethral stricture (anterior urethral narrowing) showed a success rate of 51.6%. The median follow-up time was 16 months. On average, it took six months for the urethra (urethral narrowing) to recur.After recurrence (recurrence of disease):
- The creation of a suprapubic urinary diversion (urinary diversion by bladder catheter inserted above the pubic bone through the abdominal wall into the urinary bladder to drain urine bypassing the urethra) before surgical correction of a high-grade anterior stricture changed the surgical plan in 47% of cases:
- Most often from augmentation to excision of the stricture, but also vice versa.
- In 8% of cases, the localization changed, from bulbar only to bulbar and penile
The authors also found that despite optimal urethral imaging with suprapubic cystostomy (artificial bladder outlet), the stricture length was underestimated by an average of 0.8 cm in men with highly obstructed urethra.
- If the timing for urethroplasty is delayed for years in urethral stricture, increased complications may occur during reconstruction. For each year of delay until reconstruction, men underwent an average of 0.9 (± 2.4) endoscopic procedures. These treatments appear to prolong strictures and increase the complexity of repair.
