Urethral reconstruction in rare diseases and conditions (males)

Urethral reconstructive surgery (urethroplasty) is a surgical procedure of open repair of urethral strictures and congenital urethral malformations.

What is Urethral Stricture?
A urethral stricture is a narrowing of the urethra which can lead to reducing flow or blockage of urine. The stricture results from inflammation, infection or injury, and is much more common in men than in women. The scarring can occur anywhere between the bladder and the tip of the penis. In addition to uncomfortable urinary symptoms such as painful voiding, slow urine stream and more frequent urination, a urethral stricture can lead to complications that include urinary tract infections, urinary retention and kidney damage.

Causes of Urethral Stricture
Many underlying conditions can lead to the development of urethral strictures including irradiation therapy,  previous lower urinary tract surgery and instrumentation, pelvic trauma, lichen sclerosus and severe congenital malformations of the male urethra.

  • Postirradiation strictures: a stenosis of the urethra might occur after irradiation therapy of organs that are close (like rectum or prostate). Normally, irradiation is performed for cancer treatment. In a review of over 16,000 patients with irradiation for prostate cancer, strictures occurred in 1.5% after EBRT (external irradiation), 1.9% post Brachytherapy (internal radiation with carriers), and 4.9% post combination therapy. As the tissue is damaged and healing is restricted these strictures are more difficult to treat and surgical interventions have fewer success rates.
  • Strictures after treatment of prostate disease: The incidence of urethral stricture after transurethral resection of the prostate (TURP), which is considered as the gold standard surgery for the treatment of benign hyperplasia of the prostate (BPH), varies between 2.2% and 9.8%. The extent of stenosis may depend on the technique used, reflecting the surgeon’s skills. The stricture may include the bladder neck or different parts of the urethra, in rare cases causing complete obliteration of the urethra. Urethral stricture after laser prostatectomy is less frequently reported than TURP, which is about 3,2%. Stricture of the bladder neck at the level of the anastomosis after radical prostatectomy (RP) for localized prostate cancer is higher in open RP than in robot-assisted radical prostatectomy ( RARP) (7.5% vs. 2.1%, respectively).
  • Panurethral strictures: stenosis involves the full length of the urethra from meatus (external opening) until most proximal bulbar urethra. The main causes of panurethral strictures are previous prolonged catheterization, endoscopic urethral instrumentation and lichen sclerosus. Due to a shortage of tissue to cover long segments of narrowing these strictures are most difficult for the reconstruction and are more likely to be associated with complications.
  • Lichen sclerosus (balanitis xerotica obliterans-BXO) is a chronic inflammatory disease of uncertain aetiology, primarily involving the genital skin and urethra in men. The sclerotic white plaques are localized to the foreskin and glans, especially around the meatus. In cases of urethral involvement, the stricture typically starts at the meatus and progressively moves proximally within the urethra.
  • Amyloidosis: Primary localized amyloidosis of the urethra is a rare condition with clinical features resembling those of urethral cancer. Urethral amyloidosis demonstrates a benign but progressive clinical course and always leads to a urethral stricture. In such cases, further treatment is required. Urethroplasty has been used in a limited number of urethral amyloidosis cases, with beneficial short‑term outcomes.
  • Secondary strictures after urethroplasty: despite urethroplasty remains the gold standard for the management of urethral strictures, the overall recurrence rate for all reconstructive procedures is over 15%. Patients with failed urethroplasty have less healthy tissue to use for reconstruction and denser, more extensive scarring, and need more complex repair with lower success rates.
  • Posterior posttraumatic strictures: stricture in the posterior urethra (from the bladder neck to the sphincter), most commonly results from an injury associated with a pelvic fracture, such as from an automobile or industrial accident.
  • Congenital urethral malformations: proximal hypospadias is a severe form of hypospadias where the urethral opening is located at the scrotum or the perineum with a downward curvature of the penis.

Urethral reconstructive surgery ( urethroplasty)

Urethroplasty is the repair of an injury or defect within the walls of the urethra. The choice of treatment depends largely on the severity of the stricture. There are 2 general types of urethroplasty procedures: primary anastomotic repairs and substitution repairs. Primary anastomosis involves excision of the stricture with reconnection of the healthy urethra in a broader configuration. Substitution urethroplasty consists of surgical removal of the stricture and subsequent reconstruction of the area with flaps or grafts, typically using buccal mucosa (inner cheek lining) graft. More complex flaps and staged repairs are done in failed or especially complex cases. The success rates for substitution urethroplasty are generally higher than 80 percent.