Preparing for anterior urethral stricture disease treatment

Lower urinary tract symptoms: These are most commonly slow urine flow, urine dribbling, and urinary retention, which is the inability to empty the bladder. Symptoms can also include urinary urgency and frequency (having to urinate often and on short notice) and pain or burning with urination. 

Urinary tract infection (UTI): UTIs are more common in men who cannot fully empty their bladder. Urinary tract infections can cause painful urination, cloudy or smelly urine, and sometimes fevers and body chills. In severe cases, the infection can involve the kidneys and requires hospitalization and antibiotics given through an intravenous (IV) catheter. 

Bladder dysfunction: The bladder muscle can thicken if the stricture is not treated in time. The thickening of the bladder muscle can lead to an increase in urine symptoms and, eventually, the weakening of the bladder wall, an increase in bladder size, and, ultimately, the inability to empty the bladder. 

Kidney dysfunction: This can occur if the urine backs up into the kidney or if the pressure in the bladder is too high. 

Most men with urethral stricture disease (50-60%) do not know why they have the condition. In other men, the stricture is caused by infection or sexually transmitted disease (10%), trauma to the urethra (20%), or a congenital or pediatric condition (10-20%).

In most cases, treatment is elected by the patient when urinary symptoms are severe. The most common symptoms that lead to treatment are recurrent UTIs and urinary retention. Sometimes treatment is required because of urinary retention or kidney damage.

Retrograde urethrogram (RUG): Retrograde urethrogram is an X-ray of the urethra. X-ray dye (also called contrast) is injected into the urethra before the X-ray is taken. The X-ray images show the location, length, and severity of the stricture and can help you and your surgeon pick the correct treatment option. 

Uroflowmetry: Uroflowmetry measures the flow of urine — how quickly you are able to empty your bladder, how much urine comes out, and how long it takes. You will be asked to arrive at your appointment with a full bladder so that you can urinate into a device that measures the flow in milliliters (mL) per second. 

Post-void residual: An ultrasound device is placed on your lower abdomen to measure how much urine remains in your bladder after you urinate.

There are no medical treatments for anterior urethral stricture disease. In some cases when the urethral stricture disease occurs with lichen sclerosus (a rare skin disease that causes itchy, painful patches of white, wrinkled-looking skin in the genital area), your urologist may offer a topical steroid (usually clobetasol) to help with some of the itching and irritation common on the tip of the penis.

Minimally invasive treatments for urethral stricture disease are endoscopic procedures, which means the surgeon uses a device called a cystoscope that has a thin tube with a light and a tiny video camera on the end.

Minimally invasive treatments are intended to open the urethra to improve urination. However, none will remove the scar tissue. The most common minimally invasive treatments are urethral balloon dilation and direct visual internal urethrotomy. In both procedures, additional medication can be injected into the urethral stricture to decrease the risk of the stricture coming back.

These procedures can be performed in the clinic while you are awake, with medication to numb the urethra. They can also be performed in the operating room while you are under general anesthesia.

The location and type of anesthesia will depend on your comfort and on the length and location of the stricture. Both procedures begin with the placement of a wire through the stricture. 

Urethral balloon dilation: A small catheter with a balloon port is advanced over the wire. The balloon is then inflated and the stricture is dilated. A catheter is then placed over the wire and remains in place for 48 to 72 hours. In some men, we use a newer balloon that is coated with a medication that can decrease scar reformation. This balloon is called Optilume®. 

Direct visual internal urethrotomy (DVIU): An instrument with a small blade is introduced into the urethra. The blade cuts open the strictured (narrowed) area. A catheter is then placed over the wire and remains in place for 48 to 72 hours.

Two business days before your procedure, you will be contacted by UI Health Care with information about when and where to arrive for your operation.

On the day of the procedure, you will meet with the anesthesiologist and the urology team, and a final plan for surgery will be agreed upon.

During the procedure you will be in lithotomy position. The surgery will be performed with a cystoscope. There will be no incisions in the skin.

The procedure will generally last 30 to 60 minutes. In most cases, the patient is able to go home on the day of surgery. If there are concerns about bleeding or pain, an overnight admission can be arranged.

Complications immediately following an endoscopic procedure can include: 

Hematuria (blood in the urine): Dilating or cutting a stricture can lead to blood coming from the tissue under the stricture. In nearly all cases, this bleeding is managed with the urethral catheter and no further intervention is required. Most of the blood will be seen around the catheter and may appear to be crusted. In rare cases (less than 1%), a second procedure is needed to stop the bleeding. 

Pain: Most of the pain that occurs after endoscopic urethral stricture procedures comes from having the urethral catheter in place. Your urology team can provide medication (oxybutynin/Ditropan) at the time of discharge to help with this pain. 

Nerve injury: In some cases (less than 5%), the patient may wake up from anesthesia with numbness or tingling in the extremities. This is related to the positioning of the legs and arms and to the anesthesia. In nearly all cases (99%), this numbness and tingling goes way within 24 to 48 hours. 

Infection: We minimize the risk of infection by operating on men who do not have active infection and by providing antibiotics at the time of the procedure.

The cure rate after a minimally invasive endoscopic procedure for urethral stricture disease is around 50%. The rate is higher in patients who have:

• Short strictures (less than 1 cm)
• No previous endoscopic procedures (dilations or incisions) of the stricture
• Proximal bulbar stricture location (closer to the sphincter and prostate) rather than a stricture located in the penile urethra
• Addition of steroid or other medications after the stretching or incision of the stricture

The gold standard treatment for urethral stricture disease is an anterior urethroplasty. In this procedure, the strictured (narrowed) portion of the urethra is either excised (removed) or incised (opened up) surgically.

Excising the stricture can be done using two techniques: transecting (cutting the spongy tissue in half) and nontransecting (preserving the spongy tissue). The decision is usually made intraoperatively (during the operation), after the surgeon evaluates the health of the tissue.

When the stricture is incised, the opened urethra is usually augmented (added to) with tissue from the mouth called buccal mucosa.

Two business days before your procedure, you will be contacted by UI Health Care with information about when and where to arrive for your operation.

On the day of the surgery, you will meet with the anesthesiologist and the urology team, and a final plan for surgery will be agreed upon and the consent form will be signed.

During the procedure you will be in high lithotomy position. A perineal incision will be made for a bulbar stricture. For penile urethral strictures, a penile incision will often be made.

The typical procedure lasts two to three hours. In most cases, the patient is able to go home on the day of surgery. If there are concerns about bleeding or pain, an overnight admission can be arranged. Patients requiring buccal mucosa harvest for their repair are more commonly admitted overnight. 

Complications immediately following anterior urethroplasty can include: 

Bleeding: The procedure does not end until all bleeding has been managed, but delayed bleeds can occur. Delayed bleeds can lead to bruising of the area around the incision and, sometimes, blood coming out around, or in, the catheter. In most cases this bleeding will stop on its own. 

Pain: Most pain following urethroplasty procedures comes from having the urethral catheter in place. Your urology team can provide medications (oxybutynin/Ditropan) at the time of discharge to help with this pain. The pain of the incision is usually minimal but can be controlled with hot/cold compresses. 

Nerve injury: In some cases (less than 5%), the patient may wake up from anesthesia with numbness or tingling in the extremities. This is related to the positioning of the legs and arms and to the anesthesia. In nearly all cases (99%), this numbness and tingling goes way within 24 to 48 hours. 

Infection: We minimize the risk of infection by operating on men who do not have active infection and by providing antibiotics at the time of the procedure. However, in some men (2-3%) an infection of the surgical incisions, or in the urinary tract, can occur. Infections usually result in pain or redness around the incision, or cloudy or smelly urine in the catheter.

Catheter 

An indwelling catheter will be left in place for two to three weeks. When the catheter is removed, a retrograde urethrogram (RUG) will be performed to make sure the urethra has healed appropriately. The catheter can be attached to an overnight bag or a leg bag. You will be provided with both before your discharge. 

Wound care 

The skin incision is closed with absorbable sutures that will be visible on the skin.

Your surgical team will discharge you with a topical antibiotic (bacitracin) that should be applied to the incisions twice daily for one week.

The sutures will start to fall out in about two weeks, although it’s possible they will stay in place for up to one month. After 10 days, you can begin to use a washcloth in the shower or bath to help loosen the sutures. That will speed up the removal process. 

Activity 

Walking is encouraged immediately after surgery. You may resume all normal activities as tolerated after your urethroplasty, with these exceptions:

• No bike riding or other activity that puts pressure directly on the incision for one month.
• No heavy lifting (greater than a gallon milk jug) for two weeks. After two weeks, heavy lifting and more strenuous physical activities can be performed as tolerated. 
• No swimming in a pool or hot tub for one month. 

Pain control

You will be discharged with three days of narcotic pain medication. Take these only if you need them. Alternatives to narcotics include:

• Ibuprofen
• Tylenol
• Hot/cold compresses 

Antibiotics

Before the surgical incision is made, you will receive antibiotics. You will also receive a prescription for an antibiotic that you should start taking the night before you are scheduled to have your catheter removed. Starting the antibiotics before manipulation of the catheter can decrease the risk of urinary tract infection. 

Clinic visits 

First postoperative visit: At your first visit, a retrograde urethrogram will be performed to ensure adequate healing of your urethra has occurred. Antibiotics are to be started the night before this visit. 

Second postoperative visit: If the catheter was removed at the first postoperative visit, the second visit will be scheduled three months after surgery. At this visit, a cystoscopy will be performed. A cystoscope is placed into the urethra so that the doctor can see if the repaired urethra is healing appropriately. 

Third postoperative visit: The final postoperative visit will take place one year after surgery. At this visit, a uroflowmetry test will be performed. If you are urinating well and the uroflowmetry study shows an adequate urine flow, no further testing will be required. If there is concern about the urethra narrowing again, a cystoscopy may be performed. 

Future visits
If the urethroplasty is successful at one year, very few people have recurrence of their stricture later. However, if you notice a slowing of your urinary stream or a recurrence of urinary symptoms similar to symptoms you had before your urethroplasty, please call to set up an appointment.