Anterior urethral stricture surgery

Anterior urethral stenosis is caused by infection of the urinary system or urinary stones. Therefore, everyone should be clear about the cause of anterior urethral stenosis and then treat it according to the cause of the disease. Generally, in cases of anterior urethral stenosis, an internal urethrotomy is required to remove obstructing waste in the urethra or to enlarge the anterior urethral opening to keep the urethra open.

Surgery

(1) Treatment of posterior urethral stenosis: The treatment of posterior urethral stenosis after urethral injury should be continued for 3 to 6 months. The following surgical methods may be used depending on the extent of the injury:

1) Internal urethrotomy (optional): Use a urethral scalpel (cold knife) or laser to cut the scar at the narrow area, expand the inner diameter of the urethra, and then place a catheter. It is suitable for patients with shorter stenosis segment (<1cm) and mild scar. If the second internal incision is not effective, other treatment methods should be used.

2) Urethral anastomosis (recommended): Make a perineal incision, remove the stricture and scar, and anastomose the two ends of the urethra. It is suitable for membranous urethral strictures with a stricture segment of less than 2 cm. Posterior urethral strictures with longer stricture segments can be treated with urethral anastomosis by separating the corpus cavernosum septum, resecting the lower edge of the pubic bone, or resecting part of the pubic bone. During the operation, the scar should be removed as much as possible and the two ends of the urethra should be sutured without tension. Suprapubic cystostomy is very useful for draining urine and finding the proximal urethra during surgery.

3) Urethral dragging (optional): It is suitable for patients who cannot undergo urethral anastomosis. After the stricture of the urethra is removed, the distal urethra is freed and dragged appropriately over the proximal stricture segment and fixed to the abdominal wall or fixed to the bladder with a traction line. The disadvantage is that it can cause penis shortening and curvature of the penis during erection.

4) Urethral replacement surgery (optional): for urethral stenosis or atresia in longer sections. The urethral defect was repaired with pedicled flap and free graft.

Ⅰ. Pedicle flap: commonly used is the penis and perineum skin. The flap needs a good blood supply; hair, stones, and diverticulum formation are complications. The long-term incidence of urethral restenosis is still high.

Ⅱ. Free grafts: Various autologous mucosa, skin, and tissue engineering materials (decellularized matrix) are suitable for long-segment urethral reconstruction.

(2) Treatment of anterior urethral stenosis: The most appropriate time to treat stenosis after urethral injury is 3 months after the injury. Short-segment anterior urethral strictures (<1 cm) involving the corpus cavernosum, especially those located in the bulbar region, can be treated with endoscopic transurethral incision or urethral dilation (recommended).

For patients with dense anterior urethral strictures involving the corpus spongiosum or those who are refractory to endoscopic transurethral incision or urethral dilation, open urethroplasty is required (recommended). Because the effectiveness of repeated use of these two treatments for patients who do not respond to endoscopic transurethral incision or urethral dilation is very low and the medical economic benefits are very poor, repeated incision may also cause patients to eventually need more complex urethroplasty. For urethral strictures less than 2 cm in the bulb, scar excision and anastomosis is a more suitable treatment method (recommended), with a success rate of up to 95%. However, for penile urethra and long bulbar urethra strictures (>2cm), simple end-to-end anastomosis is not recommended because it can cause erectile dysfunction and pain. For such patients, alternative urethroplasty using a transfer flap or free graft is recommended (recommended). Urethral stenting is not recommended for patients with traumatic urethral strictures[88](not recommended).