Dr.

Vasant Shet
Prof & HOD
Department of Urology
VIMS, Bellary.

STRICTURE URETHRA
Male urethra is a tubular structure which carries urine from the bladder to the exterior. It also
serves as a channel for semen during ejaculation.
ANATOMY: (Fig. 1, 2, 3, 4)
Urethra is broadly divided into two portions: 1: Anterior urethra 2: Posterior urethra.
The Anterior urethra extends from external urinary meatus to urogenital diaphragm including
external meatus, fossa navicularis, penile or pendulous urethra and bulbar urethra.
The posterior urethra extends from urogenital diaphragm to bladder neck and includes
membranous urethra (urogenital diaphragm to veru montanum) and prostatic urethra.
Urethra lies within the corpus spongiosum. Bulbar urethra begins at the root of the penis and
ends at the urogenital diaphragm. The penile urethra has a more central position within the
corpus spongiosum in contrast to bulbar urethra which is more dorsally placed.
Blood supply to the skin of the penis is by superficial external pudendal arteries and deep
external pudendal artery. Ventral skin is supplied by posterior scrotal artery, a superficial
branch of deep internal pudendal artery.
Blood supply to the deep structures of penis including urethra is derived from the common
penile artery which is a continuation of internal pudendal artery. Corpus spongiosum has got
a dual blood supply: a proximal blood supply from bulbar and urethral arteries and a
retrograde blood supply by way of the dorsal arteries as they arborize in the glans penis.
Penis is drained by three venous systems: superficial, intermediate and deep. Superficial
veins contained in the dartos fascia on the dorsolateral aspect of the penis unite at its base to
form a single dorsal superficial vein. Intermediate system contains deep dorsal and
circumflex veins, lying within and beneath Buck's fascia. The deep drainage system consists
of crural and cavernosal veins.
Lymphatic drainage is to deep inguinal lymph nodes of the femoral triangle. Part of the
drainage is to the presymphyseal lymph node and by the way of these to the lateral lymph
nodes of the external iliac group.
Nerve supply is derived from pudendal and cavernosal nerves. Pudendal nerves supply
somatic motor and sensory innervation to the penis. Cavernosal nerves are a combination of
parasympathetic and visceral afferent fibres and constitute the autonomic nerves of the penis
which supply innervation to erectile tissue.
Urethral stricture refers to anterior urethral narrowing; urethral stricture is scarring of urethral
epithelium which commonly extends into the underlying corpus spongiosum, a column of
erectile tissue that surrounds the urethra.
The stricture (scar) is composed of collagen and fibroblasts; when scar starts healing, it
contracts in all directions thus shortening the urethral length and importantly narrowing the
diameter of the urethra. For a while, this narrowing may be asymptomatic. When the lumen is
reduced beyond certain diameter, it will produce significant voiding symptoms.

Posterior urethral stricture disease is better called as distraction injury and the term 'stricture'
is limited to scar disease of only anterior urethra.
AETIOLOGY:
Any insult that injures the urethral epithelium or underlying corpus spongiosum to the point
that healing results in a scar can cause an anterior urethral stricture.
1. Trauma (most common cause)
i) Usually following blunt injury to perineum (straddle injury)
ii) Instrumentation
iii) Catheter induced
2. Inflammatory stricture
i) Following gonorrheal infection: less common
ii) Nonspecific urethritis (infection by chlamydia and ureaplasma urealyticum)
iii) Lichen sclerosis - Balanitis Xerotica Obliterrans usually begins with inflammation of
glans and inevitably causes meatal stenosis - progression of stricture eventually to extensive
involvement of anterior urethra is supposed to be due to high pressure voiding
3. Congenital stricture - very rare. It results from inadequate fusion of the anterior and
posterior urethra is of short length and not associated with trauma or inflammation.
SYMPTOMATOLOGY:
Obstructive symptoms: As the urethral lumen gradually narrows, obstructive voiding
symptoms worsen. These include
1. Weak urinary stream
2. Straining to urinate
3. A spread out stream
4. Hesitancy
5. Sensation of incomplete voiding
6. Post void dribbling
7. Painful urination
8. Urinary retention
Symptoms due to infections:
Stricture can present with features of infection usually as prostatitis or as epididymitis.

COMMON DIFFERENTIAL DIAGNOSIS:

1. Bladder Outlet Obstruction from BPH or Carcinoma prostate
2. Bladder neck contracture after TURP or simple or radical prostatectomy
3. Urethral malignancy
4. Urethral Diverticulum

PATIENT EVALUATION:
When a patient presents with acute retention, supra pubic trocar catheterization may be
needed initially and stricture may be evaluated later. In all other cases, treatment is initiated
only after total evaluation of stricture disease.
For devising an appropriate treatment plan, it is important to determine the location, length,
depth, caliber, density of the stricture (spongiofibrosis) and functional significance for which
following investigations are useful.
1. RADIOGRAPHY :( Fig 5, 6, 7, 8, 9). The length and location of the stricture can be
determined with radiography using retrograde urethrography (RGU) and voiding
cystourethrography (VCUG). Dynamic radiographic study (imaging during retrograde
injection of contrast material while patient is voiding) is more informative and desirable.
2. ULTRASONOGRAPHY (Fig 10, 11, 12) is particularly useful for evaluation of bulbar
urethral stricture. It is useful in measuring the length of stricture and degree of scarring i.e.
spongiofibrosis.
Advantage using sonography is that true stricture length can be determined before the
operation and graft and flap mobilization can be performed first with the patient on his back,
thus limiting positioning complications. Using ultrasonograhy, post void residue can be
estimated.
3. MRI: (Fig 13) Magnetic Resonance Imaging for routine evaluation of stricture urethra is
not beneficial, but invaluable in the diagnosis of urethral tumors.
4. ENDOSCOPY: It is usually conducted after the contrast study. Flexible cystoscope has
simplified the procedure. Pediatric cystoscope has proved extremely valuable to examine the
urethra proximal o the area of stricture without the requirement for dilatation of the stricture.
It is imperative to completely evaluate the urethra, proximal and distal to the stricture with
endoscopy and bougienage during surgery to ensure that all the involved urethra is included
in reconstruction.
5. UROFLOWMETRY / PEAK FLOW URINE STUDY usually gives a diminished flow
rate.
6. Urine analysis and urine culture are routinely done.
COMPLICATIONS OF STRICTURE URETHRA
1.
Retention of urine
2.
Urinary tract infection including chronic prostatitis and epididymo-orchitis
3.
Periurethral abscess
4.
Urethro cutaneous fistula
5.
Urethral diverticulum
6.
Bladder stone
7.
Bleeding

8.
9.

Urethral cancer
Renal failure.

TREATMENT
The final goal of stricture management is permanent cure, not just temporary relief from
symptoms. Treatment options should be discussed with the patient with emphasis on
anticipated outcome with regard to care.
Following treatment options are available in stricture management.
1.
Urethral dilatation
2.
Internal urethrotomy:
i)
visual
ii)
blind
3.
Urethral Stents
4.
Excision of stricture segment and primary anastomosis ( end to end anastomosis)
5.
Free grafts
i)
skin
ii)
buccal mucosa
iii)
bladder mucosa
iv)
rectal mucosa
6.
Island flaps
i)
penile skin
ii)
prepuce (foreskin)
iii)
scrotal flap
7.
Staged open surgical procedures

1. Urethral Dilatation

It is the oldest and simplest treatment of urethral stricture disease. This procedure is reserved
for patients who are not candidates for more aggressive surgical intervention. It may be
curative only for rare cases of epithelial stricture without spongiofibrosis. The aim is to
stretch the scar without producing scarring. If bleeding occurs during dilatation, it indicates
that stricture has been torn which is likely to produce more scarring; hence to be avoided.
Urethral balloon dilatation is quite safe. Long term success is poor and recurrence rate is
high. Once the repeat dilatation is discontinued, the stricture will recur.
2. Internal Urethrotomy
This is a procedure that opens the stricture by incising it transurethrally. It involves incision
through the scar to healthy tissue to allow the scar to expand and the lumen to heal enlarged.
The goal of internal urethrotomy is to have epithelial regrowth before scar recurs in the same
area. If epithelialization progresses completely before wound contraction significantly
narrows the lumen, the internal urethrotomy may be a success. If wound contraction

significantly narrows the lumen before completion of epithelialization, the stricture has
recurred.
A single incision at 12 O clock position is made following which a catheter is inserted which
is removed after 3 to 5 days. Urethrotomy is potentially curative for short strictures (less than
1 cms) that are not having significant spongiofibrosis.
After each successive urethrotomy, there is a period of fleeting good urinary flow followed
by a worsened degree of spongiofibrosis and lingering stricture. Short term success rate is 70
80 % (6 months). By 5 years the recurrence rate approaches 80%.
Complications of internal urethrotomy are
1. recurrence of stricture
2. bleeding usually associated with erections immediately after the procedure.
3. extravasations of irrigation fluid into perispongiosal tissue
4. sepsis
5. urinary incontinence
6. erectile dysfunction
7. glans numbness.

URETHRAL STENTS: (Fig 14, 15, 16)

Both removable stents and permanently implantable stents are available. Stents are inserted
after internal urethrotomy or dilatation. Removable stents are left in place from 6 months to 1
year and prevent epithelialization from incorporating the stents into urethral wall. Memokath
(made of Nitinol) is currently available.
Urolume (made of an alloy) is currently available permanent stent. Once in place, it gets
incorporated into the wall of the urethra and corpus spongiosum. It is ideal for short stricture
of bulbar urethra with minimal spongiofibrosis. Overall success rate is less than 30% over 10
years.
Permanent stents are contraindicated in patients with prior substitution urethroplasty
especially when skin has been used as its insertion is associated with virulent hypertrophic
reaction. Patients with distraction injuries and straddle injuries with deep spongiofibrosis are
also not suitable candidates. These stents are preferably used in older patients of more than 50
years and in patients who are unfit for lengthy operation procedures.
Complications of permanent urethral stents:
1. perineal discomfort seen in 86% of patients
2. dribbling of urine: 14%
3. painful erections: 44%
4. mucous hyperplasia: 44%
5. recurring stricture: 29%
6. incontinence : 14%

Percentage of recurrence increases with length of the stricture: varies from 40 to 80% over 12
months.

LASERS:
Lasers used for the treatment of urethral stricture are carbon dioxide, argon, KTP, Nd YAG,
Holmium YAG and Excimer laser. Carbon dioxide laser is ideal, but it requires gas
cystoscopy which comes with the risk of carbon dioxide embolus. Till this date, the results of
laser treatment of urethral stricture are modest.
EXCISION OF STRICTURE AND END TO END URETHRAL ANASTOMOSIS: (Fig 17,
18, 19, 20, 21, 22)
Complete stricture segment is excised and primary anastomosis of normal urethral end is
done after spatulation. It should be meticulously observed that the area of fibrosis is totally
excised; urethral anastomosis is widely spatulated and is tension free. Ideal procedure for
stricture 1 2 cms length and in some cases up to 5 cms long stricture can be excised and
urethra re-anastomosed by vigorous mobilization of corpus spongiosum. Closer the stricture
to membranous urethra, longer the stricture which can be excised. Single layer anastomosis is
one which is preferred with a success rate of 95%. Chordee is important sequelae when
extensive mobilization is done.
SUBSTITUTION URETHROPLASTY:
It is done using a graft. A graft is a tissue transfer that is dependent on the host blood supply
for survival. This process is called graft take and occurs in two stages: Imbibition and
Inosculation.
1. Imbibition is nutrition absorption from the host bed in the first 48 hours.
2. The second phase is Inosculation which takes place from 48 to 96 hours after grafting.
Inosculation is graft vascularization by blood vessels and lymph joining from the host
bed to the graft.
The tissue used is one of the following
1. full thickness skin graft
2. bladder epithelial graft
3. rectal mucosal graft
4. buccal mucosal graft.
Vascularity of rectal mucosa is based on vascularity of underlying muscles. Hence, when
rectal mucosa is used, it may not get adequate vascularity. So it is not a favored graft in
urethral reconstruction.
Buccal Mucosal Graft Urethroplasty: (Fig 23 to 30)
This is a versatile technique of urethroplasty. Barbagli technique is very popular. After
dissection of urethra with corpus spongiosum adequately, Urethrotomy is done through the
stricture in the dorsal wall till we get normal urethra on either side. In the area of
urethrotomy, a graft is applied and fixed in the midline to corpora cavernosa. The edges of
stricture are then sutured to the edges of the graft. The results are excellent.

Lateral onlay has got the advantage that urethra is cut through where it is relatively thin with
less bleeding and better exposure.
Ventral onlay technique can be used in bulbar urethral strictures where it is invested by bulk
of ischiocavernosus muscle. Ventral onlay requires that the corpus spongiosum is relatively
normal and spongioplasty is possible.
Full thickness skin graft:
Skin is usually taken from posterior auricular area and is used for urethral reconstruction as
they have a high take rate and shrink only about 15 20 %.
Split thickness skin graft is not suitable for single stage procedures as they can shrink as
much as 50%. Penile skin is to be avoided when penile skin is not abundant and in Lichen
Sclerosis Balanitis Xerotica Obliterrans.
FLAPS: (Fig 31 to 37)
A flap is a tissue transfer where donor blood supply is left intact. The success of flap is
described as survival and has got better success than grafts.
There are basically two types of island flaps
1. Penile and fore skin island flaps
2. Non hair bearing scrotal skin island flaps
Penile island flaps are the mainstay of anterior urethral reconstruction. Penile skin flaps rely
on rich blood supply within the tunica dartos.
Transverse, longitudinal or circumferential island flaps may be used. A skin island flap is
elevated on the penile dartos fascia which serves as the vascular supply. A lateral
urethrotomy is made along the length of the stricture extending to normal urethra on either
side. The skin island flap is then transposed to the incised stricture area and sutured to the
edges of the urethrotomy incision.
Island pedicle skin flaps give a success rate of 85 90%. But when tubularized island flap
procedure is used, success rate falls to 50%. Hence tubularized grafts or flaps have to be
avoided. When tubularization of flaps cannot be avoided because of the length of anterior
urethra to be reconstructed, a flap can be used distally and graft onlay may be used
proximally or a combination of a graft spread fixed to re-establish the urethral plate with flap
onlay may be used.
Scrotal Skin Island Flaps:
They are used when penile skin is not available. When scrotal skin island flap is to be used,
non hair bearing area has to be selected; often found in the midline and posterior scrotum.
When scrotum is hairy and non hair bearing area is not available, epilated scrotal ski can be
used. Intervals between epilations should be 6 8 weeks and urethral reconstruction
accomplished 10 12 weeks after the last epilation.
The scrotal skin is inferior to penile skin because it is more difficult to work with, tends to
shrink and it has got unilateral blood supply.

COMBINED PROCEDURES:
1. AUGMENTED ANASTOMOSIS:
When the length of the stricture precludes excision and end to end anastomosis, the
technique of augmented anastomosis with graft onlay is useful. The narrowest part of the
stricture is excised and the urethral ends are spatulated on the dorsum. Two layer floor
strips (ventral) anastomosis is performed and the graft is spread fixed to corpora
cavernosa. Edges of the urethra are then sutured to the graft. Thus, reconstruction is
tension free with good results.
For augmented anastomosis, island flaps from penile or scrotal skin based on dartos fascia
can also be used. Where tubed reconstruction is required, a graft is spread fixed to reestablish the urethral plate with flap onlay may be used. When long segments of anterior
urethra require reconstruction, a flap may be used distally and augmented by graft onlay
proximally.

STAGE PROCEDURES: (Fig 38 44)

Two stage procedures are undertaken usually for complicated anterior urethral strictures
or recurrent strictures.
In the first stage, a medium thickness skin graft or a buccal mucosal graft or a Wolff graft
(post auricular skin graft) is placed over dartos fascia. Direct placement on to the tunica
albugenia or corpora is to be avoided as tubularization during second stage becomes
difficult.
Second stage is usually undertaken about 9 12 months after the first stage.

Complications of urethroplasty:
1.
2.
3.
4.
5.
6.
7.

urinary tract infections

wound infection
wound dehiscence
urethro cutaneous fistula
recurrent stricture
impotence.
chordee.

STRICTURE OF POSTERIOR URETHRA (URETHRAL DISTRACTION

INJURIES)
It usually follows blunt injury to the pelvis like road traffic accidents and industrial
injuries. 10% of pelvic fractures are associated with urethral distraction injuries. The
spongiofibrosis which ensues totally obliterates the urethra. It is usually the membranous
urethra which is involved, especially at the junction with bulbar urethra.
Urethral stricture develops in all patients with complete urethral disruption; but an
aligning catheter can make the ensuing stricture more easily manageable. Thus cases
where urethra is partially disrupted, aligning catheter may prevent development of
stricture.
In majority of patients, diverting suprapubic catheter is introduced immediately after the
injury. After 4 to 6 months, the pelvic hematoma is reabsorbed and the urethra and
prostate come closer, thus reducing the gap. Eventual stricture length is usually less than
2 cms which can be bridged easily by single stage urethroplasty. The stricture involves
varying degree of spongiofibrosis of bulbar and membranous urethra and the remaining
segment of the gap is rather a scar tissue in the intervening space between dislodged
prostate and pelvic diaphragm.
Evaluation:
Before the treatment is undertaken, the depth, length and location of the stricture have to
be assessed. In assessing the length of the stricture, Dynamic fluoroscopic imaging with
simultaneous voiding and retrograde cystourethrography is the standard modality used.
If the bladder neck does not open and proximal urethra cannot be assessed, Bougiogram
with Retrograde urtethrogram will help in assessing the length of the stricture. Even
advancing a Flexible cystoscope in the prostatic urethra till it reaches the stenosed end
and simultaneous retrograde urethrogram will also give the exact length of the stenosed
urethra. (Fig 45)
When fluroscopic images are confusing, MRI is very helpful in assessing the distraction
defect and aids in surgical planning.
Before embarking on surgical correction, following points have to be confirmed.
1. no persistent pelvic infection or pelvic abscess
2. A competent bladder neck (since the external sphincter in relation with membranous
urethra is damaged, a competent bladder neck is essential to assure continence after
reconstruction).
3. no urethral instrumentation in the last 3 months
4. Normal anterior urethra.
In majority of cases the distraction defect is short (less than 2 cms). Eventhough a
competent bladder neck is desirable, quite often it is difficult to assess the competence of
bladder neck before surgery. Hence the patient has to be forewarned and if the patient
experiences less than adequate continence, he should be managed according to the
problem.

First endoscopy is performed through the meatus and again through the suprapubic tract
1. Perineal approach is usually chosen ( Fig 46, 47)
2. Exaggerated lithotomy position is the preferred one
3. It provides the optimal exposure of the membranous urethra and prostatic apex.
4. Either a vertical midline or lambda shaped incision is used in the anterior perineal
triangle (anterior to transverse perinei muscle). Ischiocavernosus muscle fusion is
divided and the muscle is dissected from corpus spongiosum and bulbospongiosum.
The corpus spongiosum is detached from triangular ligament and corpora cavernosa.
Bulbospongiosum is detached from the perineal body.
Triangular ligament is divided; intracrural space is developed down to pubis. If dorsal vein is
encountered it is ligated and divided. Bougie or Haygrove staff is introduced suprapubically
till normal urethra is obtained. Another bougie is introduced through the external urethral
meatus to know the distal end of the stricture. The area of scar is totally excised. If
anastomosis is likely to be under tension, corpus spongiosum is released from corpora
cavernosa distally.
Development of intracrural space, inferior pubectomy and re-routing of corpus spongiosum
are additional procedures necessary to allow reconstruction without attendant chordee.
Proximal urethrotomy is spatulated so that it allows 32 F bougie. 10 anastomotic sutures are
placed and tagged to identify their position in proximail urethra. Proximal portion of anterior
urethra is spatulated till 32 F and anastomotic sutures are placed in their respective locations.
Anastomosis is closed after introducing steneting catheter.
Corpus spongiosum is reattached to corpora cavernosa and bulbospongiosum isreattached to
perineal body. Wound is closed in layers after drain is fixed.
Urethral catheter is left in place for 21to 28 days and trial voiding is undertaken after removal
of the urethral catheter and filling the bladder with contrast. If voiding trial is normal, patient
is allowed to void through the urethra for 5 to 7 days and suprapubic catheter is removed.
Patients are evaluated at 6 and 12 months with endoscope. The curative rate is around 90%
and the failure is usually due to ischemic spongiofibrosis.
The complications of excision and end to end anastomosis are
1. Restricture usually due to spongiofibrosis consequent to ischemia
2. Impotence mainly because of injury to deep penile artery occurring at the time of
trauma. Impotence is sometimes due to neural injury.
Transpubic approach (Waterhouses procedure) (Fig 48) which is combined abdominal and
perineal approach is rarely required in posterior urethral distraction injuries. But for the
Vesico urethral distraction following radical prostatectomy, this is the procedure of choice.
In cases of bladder neck urethral distraction injuries usually following radical
prostatectomy; when the distraction is short length, bladder neck incision at 3 O clock and 9
O clock position and repeated after 3 to 6 weeks gives good result, but incontinence is a
complication. In cases of stricture involving external sphincter area, only dilatation is the
preferred method as urethrotomy leads to incontinence. When the patient is fit, combined
abdomino perineal exposure with excision of the stenosed bladder neck segment and vesico
urethral anastomosis with enveloping the anastomotic area with omentum is the procedure of
choice.

TWO STAGE RECONSTRUCTION OF POSTERIOR URETHRAL DEFECT:

Successful one stage urethral reconstruction can be achieved by direct end to end
anastomosis from a perineal approach alone or can be combined with Transpubic
exposure or tissue substitution technique. The proven success of one stage repairs and
emerging popularity of early realignment procedures and endoscopic management
technique have resulted in diminished prominence of two stage procedure for these
urethral defects.
Nevertheless, two stage reconstruction options present some particular advantages in
specific situations and should remain in the armamentarium of urological surgeon for
treating posterior urethral injuries.
Indications for two stage procedures for reconstruction of posterior urethral distraction
defects are,
1. Inability to achieve adequate urethral length.
This usually occurs as a result of fibrosis from previous surgery as in the case of failed
prior urethroplasty or when the prostate is fixed high in the pelvis or where prostatic fossa
is partially obliterated because of fibrosis and when other substitution techniques are not
feasible.
Anterior urethra may have strictures from prior inflammatory disease. The anterior
urethra may suffer from vascular compromise resulting from prior mobilization or from
vascular injury from blunt trauma.
Local infection and inflammation- In case of chronic infection in deep pelvis and
perineum in the face of active tissue infection and frank purulence, where free graft, flap
and anastomotic techniques are doomed to fail; staged procedures may be preferable.
Osteomyelitis due to persistent infection in retropubic region from urinary extravasation,
management requires debridement and antibiotics. In this situation, staged procedure is
the one likely to succeed. In the setting of multiple urethral cutaneous fistula recent fecal
contamination and active tissue infection, staged procedure may be ideal.
Technique:
The principle of the technique is marsupialization of the opened proximal
prostatomembranous urethral to healthy skin mobilized from the scrotum or perineum
with a resultant perineal urethrostomy as a first stage followed by closure of the perineal
urethral opening through tubularization of the transposed and local skin, urethral tissues
as a second stage.
The major step in first stage urethroplasty in two stage reconstruction is the use of
posteriorly based perineal flaps, posteriorly based scrotal flaps or invaginated scrotal wall
transposed to perineum.
Johanson described use of invaginated scrotal wall to transpose healthy scrotal skin deep
into perineum essentially as an anteriorly based scrotal tunnel.
In Turner Warwicks procedure (Fig 49), a wide posteriorly placed scrotal inlay is used
for reconstruction of posterior urethral defect.

Second stage reconstruction involves tubularization and closure of the marsupialized

urethra including an appropriate amount of transposed perineoscrotal skin or adjacent
local tissue to create an adequate caliber neourethra.
Outcome and Complications:
1. Increased duration of hospitalization
2. Multiple anaesthesia procedures
3. Stomal stenosis occurs in 30% requiring re-adjustment procedures
4. About 80 90 % success rate is observed with 2.5 procedures per patient.
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