Operation to treat urethral stricture
A urethral stricture is a narrowing of the calibre of the urethra. The stricture is made up of scar tissue. This commonly occurs in the bulbar urethra. It can occur after catheterisation, prostate or bladder surgery, or trauma. Some men have a congenital stricture, which develops early in life.
A urethroplasty is a definitive operation to treat urethral stricture.
As an initial treatment, many men will have an Optical Urethrotomy, a minor internal procedure using a camera to incise or cut the scar tissue that causes a stricture. However, a urethrotomy, while a minor procedure, does not cure or remove scar tissue. If a urethral stricture comes back after an optical urethrotomy, we often discuss a urethroplasty.
Bulbar Urethroplasty procedure
Urethral strictures commonly occur in the bulbar urethra. This is the dependent part of the urethra downstream from the prostate. Strictures occur here due to a lack of blood supply. A urethroplasty is performed via an incision in the perineum, (the skin between the testicles and anus). Before surgery, a urethrogram will take place. This is an x-ray using dye to define the length of the stricture, its position, and whether there are any other issues in the urethra. The urethrogram helps us to plan surgery, although the final decision as to what type of surgery we will perform is made during the operation.
If at all possible, we try and perform an anastomotic urethroplasty. This involves cutting out the scar tissue and joining the urethra back up. This is a simpler procedure, but there are limitations. If there is a long segment of scar tissue, we cannot perform the anastomotic urethroplasty as this will shorten and/or bend the penis. This is obviously unsatisfactory. An anastomotic urethroplasty commonly takes 60-90 minutes with an overnight stay in the hospital for 1-2 nights. A catheter will be in place for 3 weeks. We perform another urethrogram, to ensure there is no leak at the site of the joint and if no leak, the catheter can be removed.
Urethroplasty using a graft (buccal mucosa, or cheek)
If the urethral stricture is long, we need to use a graft rather than cutting out the scar tissue. The best graft to use is the inside of your cheek. While this sounds painful, men recover rapidly from this. It feels like to have a big mouth ulcer, but you will soon be back to eating toast. A very small proportion of men have ongoing issues with the graft site, but this is rare.
A urethroplasty using a graft is a longer operation, commonly taking 2.5 hours. You may be in the hospital for 2-3 nights. Again, we need to do a urethrogram 3 weeks postoperatively to make sure that there is no leak. There is a higher chance of leak after this type of urethroplasty, and it may be that the catheter stays in longer than 3 weeks.
Urethroplasty is delicate surgery, whether we use a graft or not. It is very important to look after the area and stay away from bikes (including motorbikes) wooden chairs, horses, ride-on mowers, etc. Sitting directly on your perineum puts pressure on the operation site and may compromise the blood supply. This would lead to more scar tissue. A ring cushion is a very important investment! You should avoid heavy lifting and heavy exertion for 4 weeks postoperatively.
Risks of urethroplasty
An anastomotic urethroplasty has a lower complication rate and a higher success rate. With either operation, you will notice bruising and swelling around your perineum and scrotum. The risks after any urethroplasty are incontinence or leakage. This is rare, but if the stricture is close to the sphincter (the muscle that keeps you dry) this risk increases. There is also a risk of erectile dysfunction, but this risk is low. Some men have numbness or sensitivity around the incision, but this usually settles down with time. There is always a risk that you need further surgery. All these risks are higher using when we have to use a graft. Specific to graft surgery, some men notice some leakage after they pass urine.