What is Urethra?
The urethra (urinary channel) is a channel that varies between 15-20 centimeters depending on the size of penis and that discharges urine from the bladder via penis. The urethra consists of two sections, which are the rear and the front. The rear urethra has length of 4-5 cm. It is examined in 2 sections. The channel that traverses the prostate is called the prostatic urethra. The first sphincter, which is one of urine retaining mechanisms (urine retainer mechanism), is located right under the bladder and right under the prostate. It operates involuntarily, meaning that it automatically closes and retains urine. The second 1-1.5 cm section, which is called the membranous urethra, is under the prostate. It is the most narrow section with zero elasticity. It is surrounded by the urine retainer mechanism, which we call the second sphincter. It allows voluntary urine retention. As the Membranous Urethra is deeply located inside the pelvic base (perineum), it is difficult to reach during surgery. It closely neighbors the blood vessels and nerves that provide penile erection. Surgeries on rear urethra strictures are difficult as both 2-bolt mechanisms are located in the rear urethra and it is difficult to access the rear urethra. Surgical failure may result in continuous urinary incontinence. The front urethra consists of 3 sections. The bulbar urethra is the widest section of the urethra. It has a length of 2-3 cm. It is wrapped by a spongy layer called Corpus Sponciozum, which is rich in thick blood vessels. The penile urethra has a length of 10-12 cm. This part is seen and felt under the penis. The 1cm section inside the penis head (glans), which is called Fossa Navicularis, opens to the urination hole that is called mea.
Symptoms of Urethral Stricture
Adjacent pictures show the stricture levels occurring in the urinary channel. Frequent, painful, difficult and thin urination are the most important findings of urethral stricture. There is painful fullness sensation at the bladder section, as urine cannot be discharged completely. Dripping occurs after urine is discharged. Blood may be seen in urine and semen. There can be curvature in the penis. Pain may occur during sexual intercourse.
At its most advanced level, stricture completely blocks the urinary channel. Urine cannot exit the penis. Urine accumulates in the bladder. The bladder swells (Complete Retention). A tube is inserted from the lower abdomen region and urine is discharged (cystostomy). It is an emergency situation. In case of strictures that slowly develop over a long time, urine rebounds to the bladder and from there, to the kidneys through a channel called ureter that drains urine from the kidneys to the bladder. Kidney infection occurs when urine rebounds to the kidneys. When both two kidneys malfunction, patients may apply to a physician with chronic kidney failure.
What are the Disorders that Manifest Symptoms Similar to Urethra Stricture?
We can see complaints similar to urethra stricture during simple prostate enlargements and cancers. Correct diagnosis is made through simple screening methods. These concretize whether stricture owes to urethra or prostate.
Sudden spasms and cramps of the bladder muscle, which we call overactive bladder or painful bladder, may also manifest similar symptoms. The most common cause of bladder pains is the infection of the bladder. Patients may return to normal by drug treatment. These shouldn’t be confused with urethra stricture.
Causes of Urethral Stricture
The most common cause in developed countries is the damaging of urinary channel during the closed surgeries of the prostate (trans urethral resection - TURP). Furthermore, forcibly applying catheters into the urinary channel bear an important place (45%). In developing countries such as ours, traumatic strictures that owe to traffic accidents are at the forefront. In serious accidents where the pelvis fractures, bone parts rupture the rear urethra, which represents 10% of the cases. Operation on such ruptures represents the most challenging urethroplasty surgery and demands utmost experience.
There are also other causes. Bulbar urethra strictures appear in falls that resemble horse-riding. Strictures in the front urethra may also be caused by inflammatory sexually-transmitted diseases, unsuccessful hypospadias surgeries, and other idiopathies such as liken Sclerosis that effect the interior of the urinary channel and the penis head.
Diagnosing Urethral Stricture
The purpose of diagnosis is to determine the location, length, depth (and number) of stricture(s). These determine the surgery method. The most important test is retrograde and anterograde uretrography. Retrograde film is taken while contrast (dyed) material is administered from tip of penis inside the urethra. The entire urethra becomes visible due to contrast (dyed) material and strictures can be diagnosed.
On the other hand, anterograde is making the urinary channel visible during urination after filling the patient’s bladder with contrast (dyed) material. The location and length of stricture are therefore concretized. The patient may be required to take different positions while taking the film so that a better diagnosis is made about the stricture.
Both examinations should be made simultaneously. We personally perform uretrography or are present while it is being performed so that the desired view of the stricture can be obtained.
Uretrocystoscopy is another important diagnosis method. Entry is made from the tip of the penis with a telescopic tool. Inside of the urinary channel is observed and recorded with the help of camera. There may be a the need for the method called uroflowmetry, which measures the urine flow speed and the urine amount remaining in the bladder, for an MR screening of the pelvis and for urine culture. The purpose of all these examinations is to determine the location, depth and number(s) of strictures. The physician should possess this information prior to surgery.
Treatment of Urethral Stricture
There is no drug treatment for urethra stricture. Treatment for urethra strictures is examined under two titles, which are open and closed treatment. Closed treatment provides a temporary healing of the disorder. Apart from small strictures, closed method has a limited place in treatment. Closed methods should be applied maximum 2 times. Dilatation and closed method represents a method of entering the urinary channel with metal catheters in case of urethra strictures. The procedure called urethrotomy, which is applied herein and which is personally seeing the stricture and incising it with a knife, only provides a temporary healing. Although the patient is free of symptoms for a while, these reoccur after a few months.
On the other hand, open surgery completely eliminates the disorder. Urethroplasty surgeries are conclusive solutions (removing the stricture by surgery). But these surgeries are difficult and sophisticated. Our patients that have undergone more than 60 surgeries have been completed treated by urethroplasty surgery.
Closed Surgery for Urethra Surgery
Especially strictures located in the front urethra and the membranous urethra section of the rear urethra are widened by dilatation or closed endoscopic methods. These methods works for short strictures that are not deepened. But in long and deepened strictures, the patients returns after 1-2 months with worsened complaints. The established rule is that if no healing can be obtained maximum two times with the endoscopic method (closed method), then the patient should be referred to an experienced center for open operation. Different from incising with knife under endoscopy, passage is made through the stricture zone using a catheter and the stricture is widened by tearing it. A partial healing can be obtained. For medium-sized strictures, the patient can be taught to apply dilatation personally and continue his life. But this is an undesirable and inconvenient process.
The prostate and the seminal vesicles are removed as a whole during prostate cancer surgeries. 4-5cm of the urinary channel stays open for after the organ is removed. This gap is rejoined to the bladder outlet and the integrity of the urinary channel is ensured. But stricture may occur at this joint over time. It is easy to treat such strictures that occur at the bladder neck and the beginning of the urinary channel. Most of the time, it can be successfully corrected with closed method through incision with a knife. Unfortunately, strictures that occur with a 4-5% rate after prostate cancer surgeries represent full strictures that entirely block the passage of urine. Urethroplasty (open surgery) is need for eliminating the stricture.
Why Can’t Cutting the Stricture by Dilation and Closed Method Provide Permanent Healing?
In our body, only the liver, the skin and the mucosae renew themselves with original tissue when they are injured. When all other organs and tissues are injured, healing occur by scar tissue, meaning a type of filling material by the body. This scar tissue constricts the urinary channel. It creates difficulties during urination. The urinary channel widens when the scar tissue is incised by closed and dilatation method. But the body recreates the filling material after a time and stricture reoccurs. Patient’s urinary channel becomes more constricted than before. No healing occurs unless the scar tissue in the patient’s urinary channel is removed entirely by urethroplasty surgery and replaced with healthy tissue.
Do urethral stents have a place in treatment?
Stents, which are placed at the constricted locations during the strictures of coronary blood vessels, open the stricture and the blood easily flows through these stents. But urethral stents, which are amongst temporary methods, have not been as efficient in urethra strictures as they did in coronary blood vessel strictures. Furthermore, application of stents highly renders future urethroplasty surgeries more difficult. Urethral stents have no place in the treatment of urethra strictures.
Open Surgery for Urethra Stricture (Urethroplasty)
Urethroplasty; Conclusive treatment in urethra stricture is possible by completely removing the stricture and replacing it with intact tissue, which operation with call urethroplasty. As long as the reconstructive (restructuring) surgeon has a usable urethra (urinary tract) tissue, he can restructure the urethra and therefore makes urination through normal means possible.
Reconstructive (restructuring) urethroplasty is amongst the most difficult surgeries in urology. For this reason, urethroplasty surgery should always be performed by a reconstructive (restructuring) urologist. Urethroplasty is the operation to remove the scar tissue, which causes stricture in the urinary channel), and to repair the urinary channel (urethra). The patient can comfortably urinate after a successful surgery. Even in experienced centers such as ours, patients with a history of unsuccessful operations can reach success after undergoing several surgeries. That is because during the surgery that follows an unsuccessfully one, bad tissues associated with the previous unsuccessful surgery are removed and intact tissues extracted from different parts of the body are transferred thereto. After the tissues coalesce, integrity of the urinary channel is provided with the 2nd and 3rd surgeries. The first urethroplasty surgery should always be performed in experienced centers. That is because patients who can achieve success with a single operation performed by experienced surgeons, can only heal after several surgeries after an unsuccessful one. The general rule in medicine is that “the first surgery is the most successful one”.
A reconstructive urologist engaging in urethra surgery should know and have applied all tissue transfer techniques. No surgery on complex cases is similar to other ones. The surgeon should know all tissue transfer techniques. Different surgical techniques are applied according to the particularity of the stricture.
Types of Urethroplasty Surgery
Surgical techniques vary depending on the zone where urinary tract stricture is present. Beginning from strictures in the bladder neck, we will explain surgical techniques for rear urethra ruptures, membranous urethra injuries, bulbar urethra traumas, penile urethra strictures and mea strictures.
Surgery for Strictures in the Bladder Outlet
Strictures in the bladder outlet due to simple surgeries for prostate enlargement
Such stricture owe to the use of laser prostatectomy or electrocautery prostate resection (TURP) that are performed due to prostate enlargement. These occur rarely following open benign prostate surgeries. When using closed method, entry is made from the urinary channel and the stricture in the bladder neck is cut. Closed method should be applied maximum 2 times. It is stated that chemotherapy drug injections into the stricture zone of these patients softens the scar tissue. But apart from simple strictures, this drug isn’t efficient. If the closed method has been tried 2 times and failed, then the stricture zone is entirely removed until the intact issues are reached by an open operation performed from the bladder, and the bladder neck is repaired again.
Strictures occurring as a complication of prostate cancer surgery;
Prostate is located below the bladder and the rear urethra (urination channel) passes through it. During radical prostatectomy surgeries that are performed for prostate cancer, the prostate and the seminal vesicles are removed together with the urinary channel inside the prostate. This provides a 3-4 cm gap. The urinary channel is rejoined with the bladder neck (outlet). Norma urination is provided. The reoccurrence rate of strictures at the juncture point is stated to be around 10-30%. Such strictures occurring in the bladder neck aren’t deep in most of the cases. They can be successfully corrected by incision using closed method.
But with a ratio of 4-5%, the strictures completely block the urinary channel as a serious complication of the prostate cancer surgery. Patients can never urinate. This leads the most difficult surgeries in urology. The name of this surgery is Perineal R-DO Ureterovesical Anastomose.
The main principle for the surgery is to free the tissues, opening the necessary shortcuts, gaining distance by such shortcuts and joining two edges of the urinary channel for repairing the urinary channel.
We rejoin the urinary channel with the bladder neck by an operation we perform from the perineum. A 5-6 cm reverse Y incision is made in the perineum between the anus and the scrotum. The principle for the surgery is to obtain distance for repairing the urinary channel. The front urethra is freed. The integrity of the bulbar urethra with the central tendon in the perineum isn’t distorted. 2 adjacent bars, which are called corpus cavernosum and which enable penile erection, are separated from each other. The pubis bone section of the hipbone is revealed. A 4X5 cm portion is removed from the bone. This allows reaching the stricture zone and provides the distance required to anastomose the urinary channel to the bladder. All scar tissues are cleaned until the intact tissues.
A separate incision is made on the lower abdomen, and even on the bladder region. As the prostate was removed during the previous surgery, the bladder has adhered to the rear surface of the pubis bone. This adhesion is removed. The front surface of the bladder is freed entirely. This allows obtaining a distance also from the bladder zone.
When the bladder is freed from above, the urinary channel is freed for 5-6 cm, the penile bars are separated from each other and a bone part is removed, the urinary channel is easily anastomosed again to the bladder neck by a shortcut. This surgery is similar to connecting a meandrous path to the main road via viaducts and tunnels. Opening viaducts and tunnels is an arduous and time-consuming task. You can find visuals and videos from our own surgeries.
Can complications occur after stricture surgeries at bladder outlets?
Yes. Patients may suffer urinary incontinence even if the surgery was successful. This does not solely owe to the surgical technique. It owes to its structure. That is because the involuntary automatic sphincter (bolt) is removed during prostate surgeries together with the prostate. Urine control is only provided by the second urine retainer sphincter (bolt). But there may be damages also in the second sphincter. Also during surgeries where we obtain distance for the urethra and re-anastomose it, the second sphincter (bolt) can be damaged. Although the patients can urinate normally after a successful operation, they may suffer continuous urinary incontinence if the second sphincter is also damaged. But there is a solution for urinary incontinence in cases where the second sphincter is damaged. Urinary control can be achieved in these patients after installing artificial sphincter (bolt) to these patients 3 months after surgery.
Surgery for the Rupture of Rear Urethra;
It owes to accidents inside and outside vehicles in generally in developing countries. It is rare in Japan as the rate of accidents is low. Fractures in bones result in partial or complete rupture or tearing in the rear urethra. Urine cannot be discharged through normal means. One should never attempt inserting catheter through the penis. As the urethra is partially torn, it can get ruptured completely due to unnecessary use of catheter. Such patients apply to emergency units. The most logical approach will be applying catheter to the patient from the lower-abdomen bladder zone (cystostomy).
Operations performed within 1-10 days after the accident are called early repairs. With the method performed for correcting full urethra ruptures in the early period, which is called early urethral endoscopic realignment (anastomosing the ruptured ends by closed method), the ruptured ends are found by using 2 separate endoscopic imaging devices that are sent through cystostomy and the penis. Integrity is provided by installing a catheter. Same operation can also be performed openly. The open early urethral realignment can be applied similarly by making an incision from the lower abdomen. But this early method, whether open or closed, has a very low success rate. That is because ruptured ends can be approximated but no full reunion can be achieved by suturing. It is also harmful because it negatively affects the success of late period perineal urethroplasty.
Late Perineal Urethroplasty Surgery;
Late perineal urethroplasty surgery should be applied as the aforementioned method has a limited success and many complications. The basic principle of late perineal urethroplasty is having the patient to discharge his urine by cystostomy catheter for 3 months, during which period the body repairs the damage in the pelvic bone (hipbone cavity) associated with urethra rupture. The patient achieves full rehabilitation with a surgery performed 3 months later by experienced surgeons. With our surgical technique, we can perform this surgery within 3-6 weeks in appropriate cases.
For patients that have stayed in cystostomy for 3 months, we make a 4-5 cm reverse Y incision in birth position. There are 4 blood vessel pairs that reach to the penis from the depths of the perineum. As it is known, the penis erects with blood build up. These blood vessels feed the spongy tissue that enable erection, the penis skin, the penis head and the urethra. There are connections between these blood vessels that have routes from the bottom and top the penis. They feed each other with these connections. Standard surgeries disrupt the integrity of these blood vessels. The urethra is fully incised, freed and the ends are joined. In our technique however, we join the ends without disrupting blood vessel integrity in the majority of cases. Normally, the urethra is freed both from the bottom and top of the perineum. But we only free the urethra from the top and join the urethral ends. The blood vessels that feed the penis are not damaged, as we do not free the bottom side. This is a more difficult surgical method that requires higher levels of experience. This is called surgery protecting the bulbar and urethral blood vessels (non-transecting anastomose).
Surgery for Strictures in the Rear Urethra;
We have mentioned membranous (rear urethra) urethral ruptures, we will now strictures in the Membranous Urethra (rear urethra). Surgical techniques are similar.
Strictures in the membranous urethra are frequently seen after closed and open operations performed for prostate enlargement and prostate cancer. There are 2 pcs urine retainer mechanisms in human body, one voluntary and the other involuntary, which we call sphincters. The urine retention mechanism at the bladder outlet is completely removed during prostate surgeries. This is required by the surgical procedure. Urine control is only provided by the voluntary urine retainer bold that surrounds the membranous urethra. Similarly in traditional surgeries performed for strictures therein (Transecting Anastomotic Bulbar-Membranous Urethroplasty), the bulbar urethra is incised and re-sutured to the membranous (rear) urethra. But when the bulbar urethra is incised, the last urine retainer bold suffers damage. Even this surgery provides the integrity of the urinary channel, the patient suffers continuous urinary incontinence as the patient’s last urine retainer mechanism is also removed. By a urine retainer artificial bold that is installed 3 months after the urine integrity is obtained, which we call artificial sphincter, the patients can be re-enabled to retain their urine. But the technique we apply does not disrupt the integrity of the urine retainer mechanism and the bulbar urethra. The patient therefore leaves the operation with minimum damages. But these patients should nevertheless be explained about a possible requirement for artificial bolt.
Our Technique (Non-Transecting Anastomotic Bulbar-Membranous Urethroplasty) makes a reverse Y incision from the perineum, frees the bulbar urethra completely from the front & the back without incising the bulbar urethra and the blood vessels of bulbar urethra. The operation subsequently continues into the depths of the urinary channel. We encounter 2 bars that enable penile erection. These 2 bars are separated from each other at the middle line. This allows obtaining distance for the next phase. We encounter the pubis bone after these bars are separated. A 2x3 width of bone is removed if sufficient distance could not be obtained. Later a metal catheter is inserted from above, meaning the bladder. It is pushed into the urinary channel from the bladder outlet, felt from the perineum and the stricture is identified. After the stricture is identified, it is incised longitudinally and sutured transversely using the Heineke-Mikulicz technique (picture). The operation is concluded by widening the stricture. This operation protects the sphincter (urine retainer mechanism) and the blood vessels feeding the urethra. The patient therefore suffers minimum damages in terms of penile erection and urine retention complications.
Surgery for Strictures in the Front Urethra;
The front urethra is composed of the bulbar section (the first segment of the front urethra in the perineum), the penile section (the section easily felt from the bottom of the penis) and the navicular section (the section within the penis head).
Strictures in the bulbar urethra owes falls similar to horse-riding. The bulbar urethra is the most rear and widest section of the urethra. The bulbar urethra is surrounded by a strong spongy blood vessel tissue. Strictures are easily repaired by grafts taken from the mouth mucosa. Such strictures may be accompanied by membranous urethra strictures in the rear urethra. The bulbar urethra zone is accessed by an incision made on the perineum. The spongy layer that surrounds the bulbar urethra is incised longitudinally. The stricture is accessed. Similarly, the constricted bulbar urethra is also incised longitudinally. The graft taken from the mouth mucosa is sutured to this gap. It is closed by covering it with spongy layer again. This allows feeding the grafted stricture zone with a strong spongy tissue. The integrity of the urinary channel is therefore provided. You can find the visuals of urethroplasty surgery at the bottom of our article.
Penile urethra stricture may occur during open heart surgeries when a catheter is inserted into the bladder through the penis. When the heart is connected to the heart & lung machine, there may be blood shortage in the urethra (urinary channel). This may lead to full-length stricture in the front urethra. In addition, full-length stricture may occur in the penis head and the entire urinary channel due a disorder we call Liken Sclerosis Atrophicus. Another cause may be the installation of traumatic urine catheter. Stricture is more regional in this case.
The penis skin is peeled of over the circumcision line and the front urethra is revealed. First, the urethra is incised at full-length and the interior of the channel is reached. Same full-length incision is also made on the upper surface from inside of the urinary channel. The graft taken from the mouth mucosa is laid on this long gap. The urethra on the bottom side, which is incised at full-length, is rejoined. This method presents minimal trauma for the patient. The patient wears catheter for approximately two months and is entirely relieved from stricture. Our archive includes visuals on this subject.
Situations that require two-phase surgery in penile urethroplasty;
In some situations, we may require a full-length construction of urethra as there is no urethra tissue left. This type of surgery consists of 2 phases. At the advanced stages of urethra strictures, the spongy tissue that fully surrounds the urinary channels is entirely constricted. Inflammation has jumped to this tissue and it shrinks the full-length of the urinary channel. No urine may pass through it. There are cases where the penis bends up to 90 degrees. The patient can neither urinate nor make sexual intercourse. In such case, the entire scar tissue should be removed together with the 10-15cm urinary channel. The urethra will be reconstructed in full-length. During the first phase, grafts taken from the mouth’s interior, both cheeks and the lips are laid on the bottom side of the penis that is completed purged from bad tissues. We wait for 3 months. During the second phase, the mouth mucosa previously laid is constructed as urinary channel in a tube-shaped form. Supportive transfers are made from the peripheral tissues that are located over the new urinary channel.
Surgery for Penis Head (Fossa Navicular) Strictures
Strictures in the urinary channel inside the penis head are called Fossa Navicular strictures. Again, it is seen at the beginning of the disorder called Liken Sclerosis that constricts the urinary channel. The front urethra is constricted at full-length during advanced stages of the disease. Strictures may also occur in the outlet hole of the urinary channel that we call mea, which owes to unnecessary catheter applications. After the stricture zone is removed, it is repaired by a graft taken from the mouth mucosa. The penis head is incised at full-length from the bottom side during a standard surgery. Graft taken from the mouth mucosa is laid. The penis head is approximated again by a second surgery performed after 3 months.
We generally perform this surgery in a single phase. We remove the stricture by passing the stemmed grafts (flaps), which we obtained from the proximate penis skin, under the glans (penis head) bridge. Same operation can also be performed by using independent graft instead of stemmed graft (flap). The most ideal graft here is the mouth mucosa. After the stricture zone is removed, 1-2 cm of mouth mucosa is placed inside the urinary channel in a circular format. Adjacent visuals are from archive. These studies of ours have been published in international journals.
Situations that don’t allow urethroplasty
There are two reasons for the inability to perform urethroplasty. First is a technical reason. There is no urethra tissue left or the bladder neck is completely damaged. Second reason is the incapacity of the patient to undergo surgery due to his old age although it is technically possible. Below methods can offer solutions to such cases.
It is applied to patients that have completely blocked urinary channels or those with very bad general conditions that don’t allow surgery. A hole is opened in the perineum of the patient from the intact urinary tract (perineal urethrostomy). The patient urinates from the perineum.
It is applied for patients that offer no means of repair even they are healthy. Patients that have undergone many unsuccessful surgeries have no intact urethra tissue left and the surgeon may not reconstruct the urinary channel as no tissue is left. The solution is to construct a bridge between the bladder and the skin by a 5-6 cm channel that is created from the bowels. By using a catheter, the patient personally discharges his urine 4-5 times a day from a small hole opened on the skin. No urine bag is placed outside as the technique operates with a check-valve mechanism. No hygienic problems occur. These cases are extremely rare.