Urethroplasty

What urethroplasty is

Urethroplasty is open surgical reconstruction of the urethra. Rather than stretching or cutting scar tissue and accepting that it will re-form, the diseased segment is removed or widened permanently, and the channel is rebuilt.

It is the only treatment for urethral stricture designed to be definitive. That is why it is recommended for men who have had recurrent strictures, longer strictures, or disease that dilatation and urethrotomy will not resolve.

The main techniques

There is no single urethroplasty. The right operation depends on where the stricture is, how long it is, what caused it and what has been done before:

• Excision and primary anastomosis — the scarred segment is cut out completely and the healthy ends joined. Highly durable, and suited to short bulbar strictures.
• Non-transecting techniques — the urethra is opened and repaired without dividing it completely, preserving the blood supply that runs through it. Used to reduce the risk of affecting erectile function and to protect against later problems.
• Graft augmentation urethroplasty — the narrowed segment is opened along its length and a patch of tissue is let in to widen it. The graft can be placed on the top (dorsal) or underside (ventral) of the urethra depending on the anatomy.
• Penile urethroplasty — for strictures in the penile portion, performed in one or two stages.
• One-stage pan-urethroplasty by the Kulkarni approach — for long strictures involving most of the urethra, performed through a single perineal incision.
• Meatoplasty, including staged and Malone techniques, where the external opening is the site of disease.
• Two-stage reconstruction — graft is laid down at the first operation and tubularised into a new urethra several months later. Used where scarring is severe or the tissue is unhealthy, and it gives a more reliable result than forcing a single-stage repair.
• Perineal urethrostomy — creating a permanent opening behind the scrotum, a valid and sometimes preferable option in selected men.

Graft tissue

The workhorse graft is buccal mucosa, taken from the inside of the cheek. It suits the urethra well because it is adapted to a wet environment, it takes reliably, it carries no hair, and the donor site heals within a couple of weeks with minimal long-term effect. Where more tissue is needed, lingual mucosa from under the tongue or preputial skin from the foreskin can be used.

Assessment before surgery

Planning depends on precise mapping. This means flow rate measurement and bladder scan, flexible cystoscopy, and a urethrogram showing the exact site and length of the narrowing. Urine is cultured and any infection treated. Where you have had multiple previous procedures, obtaining previous operation notes is valuable. Smoking cessation before surgery meaningfully improves graft healing.

The operation and recovery

Urethroplasty is performed under general anaesthetic. The incision is usually in the perineum for bulbar disease, or on the penis for penile disease. Most men stay one to two nights.

You will go home with a catheter, typically for two to three weeks depending on the repair. Before it is removed, a contrast X-ray is performed to confirm the reconstruction has healed and is watertight. If it has not, the catheter stays in a little longer — which is common and not a cause for alarm.

Most men return to desk work within two to three weeks, and avoid heavy lifting, cycling and strenuous exercise for around six weeks. Where buccal graft has been used, you will have a sore mouth for one to two weeks and will be advised on soft diet and mouth care. Follow-up includes flow rate measurement at intervals, because a falling flow rate is the earliest sign of recurrence.

Risks

Risks include bleeding, infection, wound problems, urinary leak, recurrence of the stricture, changes in ejaculation such as post-void dribbling or reduced force, penile shortening or curvature with certain techniques, altered sensation, and erectile dysfunction, which is uncommon and usually temporary. Donor site problems in the mouth are usually minor and short-lived. Every one of these is discussed against the specific operation you are having.

My practice

I set up and lead the Southeast London Urethral Reconstruction Team at Guy's Hospital, established in 2012, and specialise in all types of urethral surgery. With my consultant colleague Raj Nair, a leading expert in robotic surgery, we also offer buccal graft reconstruction of bladder neck strictures, ureteric strictures and PUJ strictures, with the largest experience of this type of robotic reconstruction in the UK — see robotic reconstruction.