Urethroplasty is applicable to all strictures of bulbar and penile portions and is the treatment of choice if simple measures fail.
Anatomical remarks:
The male urethra can be divided into different portions.
a)The posterior urethra:
It includes the a)Membranous urethra
b)Prostatic urethra
b)The anterior urethra
It includes
1) Navicularis
2) Penile urethra
3) Bulbar urethra
Causes of stricture:
a) Congenital
b) Traumatic –Bulbar urethra
c) Inflammatory –Post gonorrhea
Post urethral chancre
Tuberculous
d) Instrumental -Indwelling catheter
Endoscope
e) Post operative -Prostatectomy
Amputation of the penis
Preoperative Management
Investigation
a) Blood routine
b) Urine routine
c) RBS
d) BUN
e) Creatinine
f) Serum electrolytes
g) USG-KUB
h) Ascending urethrogram
i) Cytoscopy
2) Bowel preparation should be done
3) Anaesthetist order should be followed
PROCEDURE
1) TYPES OF URETHRPLASTY:
a) End-End Urethroplasty
b) Substitution Urethroplasty
c) Augmented Urethroplasty
d) Staged Urethroplasty
a) End-End Urethroplasty:
It is performed when excision of the diseased part is necessary resection of the short segment of strictured part of urethra
is done & re anastamosis of the clear edge is done.
b) Substitution Urethroplasty:
It is performed when the excision of the diseased part is necessary & while the stricture is more than 2cm
* It requires graft substitution for the diseased part
* Resection of the long segment of urethra & substitution with the graft is done .
c)Augmented Urethroplasty:
It is performed for the long strictures especially penile strictures which requires the incision of the
diseased part
*the strictured part of urethra incised & augmented with the graft especially with the free graft
d)staged urethroplasty:
in this procedure it is performed at two stages as the strictured urethra is laid open at the initial stage &
reanastamosis is performed at the later stage
GRAFTS:
Grafts are the flaps take from the different part of the ones own body to substitute the diseased part of the urethra.
a) free graft:
these are the grafts free from hair as *buccal mucosa
*bladder mucosa
*prepucal mucosa
b) pedicle graft :
these are the grafts with blood vessls as*scrotal skin
*penile skin
*perineal skin
PROCEDURE
A) anaesthesia:*epidural
*spinal
b)antibiotic:
inj gentamycin
inj cefataxim
c)position:*exaggerated lithotomy
d)incision:inverted u & lambda incision
BULBAR URETHROPLASTY
a) the patient is positioned on exaggerated lithotomy position & a midline perineoscrotal incision is made
b) the bulbo-cavernous muscle are separated in the midline & in patients with the proximal bulbar urethral stricture the central tendo of the perineum
is dissected
c) the bulbar urethra is then free from the bulbo- cavernous muscle & it is dissected from the corpora cavernosa .
d) the urethra is completely mobilized from the corpora cavernosa & rotated at 180 degrees & incisee along the dorsal surface.
e) The stricture is opened along its whole length.
f) The graft is harvested from the mouth (or) prepuse
g) Then the fenestrated ovoid preputial skin or buccal mucosa graft is spread fixed and quilted to the overlying tunica albuguina of the corporal
bodies.
h) The right mucosal margin of the opened urethra is sutured to the right side of the patch graft then the urethra is rotated to its oroginal position
i) Then the left urethral margin is sutured to the left side of the patch graft & the corporal bodies
j) The patch graft is entireky covered with the urethral plate.
k) The bulbo cavernosal muscle are approximated over the grafted area.
l) A small suction drain is placed & AN INDWELLING 16FR SILICONE FOLEY catheter is left in place.
m) Suprapubic catheterization is not necessary.
End-End urethroplasty:
a) midline perineo scrotal incision is made.
b) The subcutaneous fat & collies fascia is dissected & the bulbo cavernous muscle is ligated.
c) Then separate or dissect the spongism and urethra above and below the strictures.
d) Then cut and remove the strictured area
e) Mobilize the proximal and distal urethra spatulate and anastamose using 4-0 vicryl suture material.
f) A small suction drain is place and silastic 16fr silicon foley catheter is left in placed
g) SPC should be done
Post operative management:
1. the drain is removed on trhe 1st post operative day and the patient is discharged
2. the catheter is removed after 3 weeks
3. voiding cystourethrography is obtained
4. uroflowmetry and urine culture is repeated every 4 months durind the 1st year and yearly thereafter.
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