Meatal & Fossa Navicularis Strictures

Management:

Dilation

Meatotomy

Urethroplasty

For recurrent strictures

Penile Urethral Strictures

Management:

Penile strictures are rarely cured by dilatation or urethrotomy.

Urethroplasty is needed for all strictures of the penile urethra.

Stricturotomy and Patch

Stricturotomy and patch is preferable to excision and a tube‐graft flap.

Grafts (like buccal mucosa) and flaps are equally good.

Grafts are easier to use. Occasionally, when the local conditions are not favorable for a graft, a flap must be used. Like when there is extensive scarring from previous surgery or radiotherapy.

Genital skin flaps should be avoided in Lichen sclerosis.

Circumferential Repair

Is needed if urethral segment needs to be excised due to irretrievably scarred urethra after previous surgeries, or irretrievably fibrotic in lichen sclerosis.

When a circumferential repair is needed, a two stage reconstruction is more reliable than a one stage technique.

In such circumstances a graft is interposed as a flat plate. The flat plate is then rolled in to form a tube and closed in layers at a second stage three to six months later.

Bulbar Urethral Stricture < 2 cm

Management:

Urethral Dilation

Direct Visual Internal Urethrotomy (DVIU)

Urethral catheter maybe removed within 72 hours

Self-catheterization maybe advised.

Anastomotic Urethroplasty

Bulbar Urethral Stricture ≥2cm

Management:

Anastomotic Urethroplasty

Excision with primary anastomosis is the gold standard.

Previously, excision with primary anastomosis was limited to strictures shorter than 1.5 to 2 cm.

However, in some cases, strictures up to 3 to 5 cm can be totally excised, and a primary anastomosis can be performed.

Stricturotomy and Patch

If a bulbar stricture is too long for anastomotic urethroplasty.

We will usually use a buccal mucosal graft as a patch.

Pelvic Fracture Urethral Injury (PFUI)

Delayed anastomotic urethroplasty after major injuries stabilize should be done.

Bladder Neck Contracture

Etiology:

Surgical treatment of benign prostatic enlargement.

Management:

Dilation

First-line treatment.

Up to 90% may recur within the first two years.

Bladder Neck Incision

Hot-knife, cold-knife, or laser techniques.

Self-catheterization maybe advised after procedure.

Transurethral Resection

Permanent Suprapubic Catheters

Open Reconstruction

For recalcitrant stenosis.

Y-V plasty techniques.

Bladder neck ablation with injection of cytotoxic agents like mitomycin C can be associated with significant complications, including extravasation or bladder neck necrosis.

Vesicourethral Anastomotic Stenosis

Etiology: Post radical prostatectomy anastomotic stricture.

Management:

Dilation

Incision

Fistulation to the pubic symphysis is a rare but serious complication after endoscopic procedures in patients with history of radiation therapy.

Patient will have severe pelvic pain. MRI should be done.

Urinary diversion is required.

Resection

Intermittent Catheterization

Open Reconstruction

Require placement of an artificial urinary sphincter.

Post Instrumentation Urethral Stricture

Etiology: Instrumentation as in transurethral resection of prostate.

Most common site: membranous urethra

Management:

Urethral Dilatation: It is the treatment of choice.

Radiation-Induced Urethral Stenosis

Most common Location:

Proximal bulbar urethra to prostatic apex.

Management:

Endoscopic Techniques

Usually refractory to them.

Urethroplasty

If endoscopic treatments fails.

Urinary Diversion

If there is extensive prostate necrosis, cavitation, prostatosymphyseal fistula, osteomyelitis, or a small functional bladder capacity.