Surgical management of urethral stricture in the male

Urethral dilatation has long been the standard treatment for patients with urethral stricture. However, in many patients such dilatations may be difficult, painful, or have to be done at frequent intervals. The alternative techniques of direct vision urethrotomy or urethroplasty have been considered in 101 patients over a twelve-year period. Skin inlay urethroplasty in this series showed a significant level of complications and an absolute failure rate of 15 per cent. A prospective study of 39 patients undergoing urethrotomy using the Sachse optical urethrotome has shown that 82 per cent of patients are symptom-free and 13 per cent symptomatically improved at a follow-up ranging from sixteen months to three and one-half years (mean twenty-five months). We believe that urethrotomy using the Sachse optical urethrotome should now be the initial treatment of choice in the management of urethral stricture. Urethral dilatations or urethroplasty should be reserved for those patients who have persisting stricture despite such urethrotomy.     

Artifactual urethral stricture in male child.

Artifactual urethral obstruction at the suspensory ligament of the penis may be produced if the penis is left in its normally dependent position during a urethrogram. We present 2 such cases to re-emphasize this phenomenon so that caution is taken in interpreting distal bulbous urethral strictures.     

Long-term results of the treatment of male urethral stricture

The authors present 56 patients treated for urethral stricture between 1976 and 1983. Patients without recurrence of the stricture were followed for more than 5 years, the mean follow-up was 8 years +/- 2.1 (standard-deviation) (5 to 12 years). Thirty-eight patients (67.9%) had a recurrent stricture. Patient age ranged from 29 to 86 years (mean age 61 +/- 12.8 years). The best results were obtained with a one-stage anastomotic procedure and urethroplasty with foreskin graft. Patient age and topography of the stricture are not prognostic factors. Traumatic and infectious strictures have a better prognosis than other forms (the difference is statistically significant: chi-square = 3.9; P inferior to 0.05).     

The ultrastructure of human male urethral stricture.

Biopsy material was examined from 20 urethral strictures at the time of urethroplasty, using ultramicroscopic methods not hitherto applied to the study of the pathogenesis of stricture. Abundant smooth muscle and elastic tissue was found in the post-inflammatory strictures. The scar tissue from post-traumatic strictures merely showed dense collagen. An anatomical basis for the well known difference between the fibrous and the resilent stricture is demonstrated, and the role of smooth muscle in the development and behaviour of strictures is discussed.     

尿道成形术在男性尿道狭窄中的应用及疗效

尿道成形术是当前治疗大多数男性尿道狭窄的最佳方案。组织替代技术在过去数十年中快速发展并为进行尿道成形术后实现良好的远期疗效提供了极大可能。尿道成形术需要的辅助手段如可明确狭窄的部位、长度以及狭窄严重程度的尿道造影和移植物组织质量的严格评估对手术的成功至关重要。本文就不同解剖位置的尿道狭窄可用的尿道成形术及疗效进行综述。     

Canadian Urological Association guideline on male urethral stricture

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient’s quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.     

重复尿道内切开术治疗尿道狭窄的疗效观察

目的　探讨尿道内切开术治疗尿道狭窄的可重复性。　方法　收集经尿道内切开术治疗的尿道狭窄及闭锁患者共 2 96例 ,分析重复实施尿道内切开术的价值。　结果　 2 96例中手术成功 2 6 1例 (88.2 % ) ,其中 1次手术成功者 2 17例 ;行 2次内切开术者 79例 ,32例成功 ,行 3次内切开术者 4 7例 ,12例成功。 35例 (11.8% )手术失败 ,其中 2 6例改行镍钛记忆合金螺旋支架置入治疗 ,9例行开放手术。病程 >1年者重复尿道内切开术成功率低。　结论　尿道内切开术治疗尿道狭窄应争取首次成功 ,重复手术价值有限 ,病程 >1年者不宜行重复尿道内切开术。     

腔镜下钬激光内切开加定期尿道扩张治疗男性尿道狭窄及闭锁

目的探讨腔镜下钬激光内切开治疗男性尿道狭窄及闭锁的效果及安全性。方法我院2007年4月～2009年11月收治男性尿道狭窄或闭锁病人17例,狭窄段长0.5～3.0cm,平均1.4cm,采用腔镜下钬激光狭窄段内切开治疗。术后留置尿管2～4周。拔除尿管后根据随访排尿状况定期作尿道扩张。结果 17例病例均取得手术成功,手术时间30～90min,平均40min,术后排尿显著改善,最大尿流率(Qmax)由术前平均6.5(2.8～11.5)ml/s提高到术后20.4(16.6～25.3)ml/s,无尿失禁、阳痿、尿瘘并发症。术后随访3～18个月,均排尿良好,无再狭窄发生,B超检查剩余尿<20ml。结论腔镜下钬激光内切开加定期尿道扩张治疗男性尿道狭窄及闭锁安全有效,近期治疗效果良好,手术创伤小,并发症少,值得推广应用。     

The morbidity of urethral stricture disease among male Medicare beneficiaries

Background

To date, the morbidity of urethral stricture disease among American men has not been analyzed using national datasets. We sought to analyze the morbidity of urethral stricture disease by measuring the rates of urinary tract infections and urinary incontinence among men with a diagnosis of urethral stricture.

Methods

We analyzed Medicare claims data for 1992, 1995, 1998, and 2001 to estimate the rate of dual diagnoses of urethral stricture with urinary tract infection and with urinary incontinence occurring in the same year among a 5% sample of beneficiaries. Male Medicare beneficiaries receiving co-incident ICD-9 codes indicating diagnoses of urethral stricture and either urinary tract infection or urinary incontinence within the same year were counted.

Results

The percentage of male patients with a diagnosis of urethral stricture who also were diagnosed with a urinary tract infection was 42% in 2001, an increase from 35% in 1992. Eleven percent of male Medicare beneficiaries with urethral stricture disease in 2001 were diagnosed with urinary incontinence in the same year. This represents an increase from 8% in 1992.

Conclusions

Among male Medicare beneficiaries diagnosed with urethral stricture disease in 2001, 42% were also diagnosed with a urinary tract infection, and 11% with incontinence. Although the overall incidence of stricture disease decreased over this time period, these rates of dual diagnoses increased from 1992 to 2001. Our findings shed light into the health burden of stricture disease on American men. In order to decrease the morbidity of stricture disease, early definitive management of strictures is warranted.     

腔内尿道会师法治疗复杂性男性尿道狭窄

目的总结腔内尿道会师法治疗复杂性尿道狭窄的经验。方法16例男性复杂性尿道狭窄患者,术前行耻骨上膀胱造瘘术,硬膜外麻醉下经尿道外口置入尿道内切开镜,经耻骨上膀胱造瘘口置入一软性膀胱镜经膀胱颈口顺行进入尿道。经内切开镜或软性膀胱镜插入一细输尿管导管,经正道通过狭窄段尿道。沿此导管用内切开刀切开狭窄段尿道,沿正道进入膀胱,再用Otis刀彻底切开狭窄段。结果16例患者均成功地顺利完成了腔内尿道会师手术,拔除尿管后排尿通畅。平均手术时间122min。平均最大尿流率18mL/s。随访15月,F20尿道扩张器可以顺利通过。结论利用内切开镜和软性膀胱镜腔内尿道会师治疗复杂性尿道狭窄,方法简单易行,疗效确切可靠,成功率高。     

Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome

PURPOSE: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success. MATERIALS AND METHODS: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications. RESULTS: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee. CONCLUSIONS: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.     

男性外伤性尿道狭窄治疗效果的多因素分析

目的 探讨影响外伤性尿道狭窄治疗效果的相关因素。方法 对64例外伤性尿道狭窄的初次治疗效果进行回顾性多因素分析，用卡方、卡方分割及生存分析的统计方法分析其疗效。结果 在狭窄复发的因素中，狭窄长度分组（0—2cm；24cm）的P值〈0．05，围手术期尿路感染的P值〈0．05，狭窄期初次治疗方式（尿扩，尿道内切开，尿道吻合）的P值〈0．05。结论 ①尿道内切开治疗外伤性尿道狭窄，其疗效与狭窄长度有关，狭窄长度〈2cm复发率低，〉2cm复发率高；②尿道吻合治疗外伤性尿道狭窄，其疗效与狭窄长度、狭窄部位、既往手术史无关，与手术本身有关。即术中彻底切除狭窄疤痕及坏死组织、吻合无张力则复发率低，反之则高。     

前尿道替代膜部尿道治疗男性后尿道狭窄52例报告

目的：探讨长段后尿道狭窄手术治疗方法。方法：同顾性总结前尿道替代膜部尿道端端吻合治疗狭窄段〉2cm的后尿道狭窄患者52例。结果：一次手术成功49例,成功率94．2％,3例术后尿线细,排尿不畅经内窥镜切除0．3～0．5cm瘢痕后排尿通畅。随访5～20年,全部排尿通畅,最大尿流率20～25ml／s,平均22ml／s。结论：切除狭窄段瘢痕前尿道替代膜部尿道端一端吻合治疗后尿道狭窄成功率高,远期效果好。术中彻底切除瘢痕,满意的无张力外翻端一端吻合及术后预防感染是手术成功的关键。