Case of the Month
Management of Complex Urethral Stricture NYU Case of the Month, February 2017 Lee Zhao, MD, MS Department of Urology, NYU Langone Medical Center, New York, NY
[Rev Urol. 2017;19(1):52-55 doi: 10.3909/riu0752]
®
© 2017 MedReviews , LLC
A
57-year-old man presents with a urethral stricture following a GreenLight (American Medical Systems, Minnetonka, MN) laser photoselective vaporization of the prostate that was refractory to three direct vision internal urethrotomies (DVIUs). He is frustrated with performing “urethral calibration” with a catheter twice daily to prevent restenosis and self-refers to NYU Langone Department of Urology.
™
Evaluation at NYU
Uroflowmetry is shown in Figure 1. The patient’s maximum flow rate is 10 mL/s. His postvoid residual urine volume is 50 mL. A cystoscope cannot be inserted past the fossa navicularis because of narrowing of the urethra. The retrograde urethrogram is shown in Figure 2.
Management
A urethroplasty of both the penile and the bulbar urethra is performed as an outpatient procedure, using a buccal mucosa graft (Figures 3 to 7). A Foley catheter is removed on postoperative day 14. A voiding cystourethrogram confirms urethral patency. 52 • Vol. 19 No. 1 • 2017 • Reviews in Urology
Comment
Technique Urethral stricture in men accounts for approximately 0.9% of clinical visits in the Medicare population. The incidence in nonindustrialized countries is thought to be greater.1 The true incidence of multifocal strictures is unknown.2 One study of nearly 300 patients reported that multifocal urethral stricture diseases accounted for 13% of urethral strictures.3 A multifocal stricture is defined as a stricture involving more than one segment of the urethra, such as the penile and the bulbar urethra.4 Historically, the most common cause of multifocal strictures was lichen sclerosus and gonococcal urethritis, although iatrogenic trauma remains an important cause in the developed world.5 The treatment of these long urethral strictures continues to be a challenge.6 Urethral stricture following transurethral procedures can occur anywhere within the urethra.7 Iatrogenic causes of urethral stricture are thought to represent 35% of all urethral strictures,8 with ischemia contributing to urethral stricture formation and propagation.9
25 mL/s flow rate
Management of Complex Urethral Stricture
0
10
Voiding time Flow time Time to max flow Max flow rate Average flow rate Voiding volume
20
t100 tQ tQmax Qmax Qave Vcomp
30
40
50
60
70
80
79 s 78 s 3 s 9.3 mL/s 6.6 mL/s 518 mL
Figure 1. Uroflowmetry showing a “plateau” pattern consistent with a urethral stricture.
The surgical technique of urethroplasty produces success rates of 75% to 99%, depending on the site of the stricture. 3 The surgical management of urethral stricture varies based on the etiology, location, and length of the stricture. Treatment options include a single versus a staged approach, and the use of fasciocutaneous skin flaps or augmentation of the urethra with a buccal mucosa graft.
Figure 2. Retrograde urethrogram identifying urethral stricture disease throughout the penile and bulbar urethra.
Additionally, urethral strictures greater than 7 cm often require a combination of techniques (flap and graft).6 At NYU Langone Medical Center, we prefer to use a single midline perineal incision to access the entire urethra and a buccal mucosa graft for a dorsal onlay urethroplasty. Surgical Procedure We use a perineal incision similar to the repair of an isolated bulbar urethral stricture. Next, the penis is invaginated into the perineal incision, which exposes the entire penile and bulbar urethra. The urethra is rotated to the patient’s right and then released from the underlying corpora along the entire length of the stricture. Multiple interrupted holding sutures help rotate the urethra (Figure 3). A 26 Fr bougie dilator defines the distal aspect of the urethral stricture and the urethral plate is incised at its lateral edge. Next, the urethrotomy is extended proximally for the entire length of the stricture. The length
of the urethral stricture defines the amount of buccal mucosa graft needed for the repair (Figure 4). Buccal mucosa graft harvest is performed in the following fashion: the parotid duct, or Stensen duct, is identified at the level of
Figure 3. Urethra exposed and rotated. Note the bougie dilator at the 12 o’clock position, identifying the distal healthy urethra. Note also the left corpora cavernosa of the penis (which is under the bougie dilator), demonstrating our ability to evaluate and treat these long urethral strictures.
Vol. 19 No. 1 • 2017 • Reviews in Urology • 53
Management of Complex Urethral Stricture continued
Figure 8. Voiding cystourethrogram performed at the time of catheter removal, showing patent penile and bulbar urethra.
Figure 4. The entire 9-cm diseased urethra is opened.
the second molar in order to avoid injuring it. The graft must be kept thin to avoid damage to the buccinator muscle. To reduce postoperative pain, we suture a patch of acellular dermal matrix to cover the area of the buccal mucosa harvest site (Figure 5). The buccal mucosa graft is transferred to the dorsal surface of the urethra; the buccal mucosa is then tacked to the corpora posteriorly
Figure 5. Surgical image showing the acellular dermal matrix stitched into place over the site of the buccal mucosa harvest.
Figure 6. Two pieces of buccal mucosa are required for this repair. Note that the inferior graft has already been tacked down and that the superior graft is beginning to be tacked into place.
with sutures (Figure 6). The buccal mucosa graft is approximated first on the left side and then on the right, using a fine running suture. A 16 Fr Foley catheter is placed prior to wound closure (Figure 7). Follow-Up The catheter is removed on postoperative day 14. A voiding
Figure 7. The left side of the urethra is sewn first, and then the right side is brought across and sutured into place. Note the clear Foley catheter in the center.
54 • Vol. 19 No. 1 • 2017 • Reviews in Urology
cystourethrogram is performed at this time to assess patency (Figure 8).
Conclusions
Urethral stricture disease is undertreated both nationally and internationally. A review of the practice patterns of American urologists found that, although urologists treat between 6 and 20 urethral strictures annually, the majority of these urologists do not perform urethroplasty.10 The success rate is low for the endoscopic management—either DVIU or dilation— for initial treatment, and lower with repeat endoscopic procedures.11 In contrast to the dismal long-term outcomes of endoscopic procedures, urethroplasty has a durable success rate of 80% to 90%,12 and can typically be performed on an outpatient basis. The American Urological Association guidelines on urethral strictures9 recommend that patients undergo urethroplasty for long strictures or after failure of one endoscopic treatment for shorter strictures. The guidelines also recommend that if urethroplasty is not offered at the center where the patient is treated, the patient should be referred to a center with expertise in the procedure.
Management of Complex Urethral Stricture References 1.
2.
3. 4.
Miller DC, Saigal CS, Litwin MS. The demographic burden of urologic diseases in America. Urol Clin North Am. 2009;36:11-27. Anger JT, Buckley JC, Santucci RA, et al; Urologic Diseases in America Project. Trends in stricture management among male Medicare beneficiaries: underuse of urethroplasty? Urology. 2011;77:481-485. Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol. 2007;177:1667-1674. Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of panurethral stricture. Urol Clin North Am. 2017;44:67-75.
5.
6.
7.
8. 9.
Palminteri E, Brandes SB, Djordjevic M. Urethral reconstruction in lichen sclerosus. Curr Opin Urol. 2012;22:478-483. Martins FE, Kulkarni SB, Joshi P, et al. Management of long-segment and panurethral stricture disease. Adv Urol. 2015;2015:853914. Lumen N, Hoebeke P, Willemsen P, et al. Etiology of urethral stricture disease in the 21st century. J Urol. 2009;182:983-987. Zhao LC. Management of urethral strictures. Urol Clin North Am. 2017;44:xv. Wessells H, Angermeier KW, Elliott S, et al. Male urethral stricture: American Urological Association Guideline. J Urol. 2017;197:182-190.
10.
11.
12.
Bullock TL, Brandes SB. Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States. J Urol. 2007;177:685-690. Greenwell TJ, Castle C, Andrich DE, et al. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor costeffective. J Urol. 2004;172:275-277. Eltahawy EA, Virasoro R, Schlossberg SM, et al. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007;177:1803-1806.
Vol. 19 No. 1 • 2017 • Reviews in Urology • 55
Management of Complex Urethral Stricture NYU Case of the Month, February 2017 Lee Zhao, MD, MS Department of Urology, NYU Langone Medical Center, New York, NY
[Rev Urol. 2017;19(1):52-55 doi: 10.3909/riu0752]
®
© 2017 MedReviews , LLC
A
57-year-old man presents with a urethral stricture following a GreenLight (American Medical Systems, Minnetonka, MN) laser photoselective vaporization of the prostate that was refractory to three direct vision internal urethrotomies (DVIUs). He is frustrated with performing “urethral calibration” with a catheter twice daily to prevent restenosis and self-refers to NYU Langone Department of Urology.
™
Evaluation at NYU
Uroflowmetry is shown in Figure 1. The patient’s maximum flow rate is 10 mL/s. His postvoid residual urine volume is 50 mL. A cystoscope cannot be inserted past the fossa navicularis because of narrowing of the urethra. The retrograde urethrogram is shown in Figure 2.
Management
A urethroplasty of both the penile and the bulbar urethra is performed as an outpatient procedure, using a buccal mucosa graft (Figures 3 to 7). A Foley catheter is removed on postoperative day 14. A voiding cystourethrogram confirms urethral patency. 52 • Vol. 19 No. 1 • 2017 • Reviews in Urology
Comment
Technique Urethral stricture in men accounts for approximately 0.9% of clinical visits in the Medicare population. The incidence in nonindustrialized countries is thought to be greater.1 The true incidence of multifocal strictures is unknown.2 One study of nearly 300 patients reported that multifocal urethral stricture diseases accounted for 13% of urethral strictures.3 A multifocal stricture is defined as a stricture involving more than one segment of the urethra, such as the penile and the bulbar urethra.4 Historically, the most common cause of multifocal strictures was lichen sclerosus and gonococcal urethritis, although iatrogenic trauma remains an important cause in the developed world.5 The treatment of these long urethral strictures continues to be a challenge.6 Urethral stricture following transurethral procedures can occur anywhere within the urethra.7 Iatrogenic causes of urethral stricture are thought to represent 35% of all urethral strictures,8 with ischemia contributing to urethral stricture formation and propagation.9
25 mL/s flow rate
Management of Complex Urethral Stricture
0
10
Voiding time Flow time Time to max flow Max flow rate Average flow rate Voiding volume
20
t100 tQ tQmax Qmax Qave Vcomp
30
40
50
60
70
80
79 s 78 s 3 s 9.3 mL/s 6.6 mL/s 518 mL
Figure 1. Uroflowmetry showing a “plateau” pattern consistent with a urethral stricture.
The surgical technique of urethroplasty produces success rates of 75% to 99%, depending on the site of the stricture. 3 The surgical management of urethral stricture varies based on the etiology, location, and length of the stricture. Treatment options include a single versus a staged approach, and the use of fasciocutaneous skin flaps or augmentation of the urethra with a buccal mucosa graft.
Figure 2. Retrograde urethrogram identifying urethral stricture disease throughout the penile and bulbar urethra.
Additionally, urethral strictures greater than 7 cm often require a combination of techniques (flap and graft).6 At NYU Langone Medical Center, we prefer to use a single midline perineal incision to access the entire urethra and a buccal mucosa graft for a dorsal onlay urethroplasty. Surgical Procedure We use a perineal incision similar to the repair of an isolated bulbar urethral stricture. Next, the penis is invaginated into the perineal incision, which exposes the entire penile and bulbar urethra. The urethra is rotated to the patient’s right and then released from the underlying corpora along the entire length of the stricture. Multiple interrupted holding sutures help rotate the urethra (Figure 3). A 26 Fr bougie dilator defines the distal aspect of the urethral stricture and the urethral plate is incised at its lateral edge. Next, the urethrotomy is extended proximally for the entire length of the stricture. The length
of the urethral stricture defines the amount of buccal mucosa graft needed for the repair (Figure 4). Buccal mucosa graft harvest is performed in the following fashion: the parotid duct, or Stensen duct, is identified at the level of
Figure 3. Urethra exposed and rotated. Note the bougie dilator at the 12 o’clock position, identifying the distal healthy urethra. Note also the left corpora cavernosa of the penis (which is under the bougie dilator), demonstrating our ability to evaluate and treat these long urethral strictures.
Vol. 19 No. 1 • 2017 • Reviews in Urology • 53
Management of Complex Urethral Stricture continued
Figure 8. Voiding cystourethrogram performed at the time of catheter removal, showing patent penile and bulbar urethra.
Figure 4. The entire 9-cm diseased urethra is opened.
the second molar in order to avoid injuring it. The graft must be kept thin to avoid damage to the buccinator muscle. To reduce postoperative pain, we suture a patch of acellular dermal matrix to cover the area of the buccal mucosa harvest site (Figure 5). The buccal mucosa graft is transferred to the dorsal surface of the urethra; the buccal mucosa is then tacked to the corpora posteriorly
Figure 5. Surgical image showing the acellular dermal matrix stitched into place over the site of the buccal mucosa harvest.
Figure 6. Two pieces of buccal mucosa are required for this repair. Note that the inferior graft has already been tacked down and that the superior graft is beginning to be tacked into place.
with sutures (Figure 6). The buccal mucosa graft is approximated first on the left side and then on the right, using a fine running suture. A 16 Fr Foley catheter is placed prior to wound closure (Figure 7). Follow-Up The catheter is removed on postoperative day 14. A voiding
Figure 7. The left side of the urethra is sewn first, and then the right side is brought across and sutured into place. Note the clear Foley catheter in the center.
54 • Vol. 19 No. 1 • 2017 • Reviews in Urology
cystourethrogram is performed at this time to assess patency (Figure 8).
Conclusions
Urethral stricture disease is undertreated both nationally and internationally. A review of the practice patterns of American urologists found that, although urologists treat between 6 and 20 urethral strictures annually, the majority of these urologists do not perform urethroplasty.10 The success rate is low for the endoscopic management—either DVIU or dilation— for initial treatment, and lower with repeat endoscopic procedures.11 In contrast to the dismal long-term outcomes of endoscopic procedures, urethroplasty has a durable success rate of 80% to 90%,12 and can typically be performed on an outpatient basis. The American Urological Association guidelines on urethral strictures9 recommend that patients undergo urethroplasty for long strictures or after failure of one endoscopic treatment for shorter strictures. The guidelines also recommend that if urethroplasty is not offered at the center where the patient is treated, the patient should be referred to a center with expertise in the procedure.
Management of Complex Urethral Stricture References 1.
2.
3. 4.
Miller DC, Saigal CS, Litwin MS. The demographic burden of urologic diseases in America. Urol Clin North Am. 2009;36:11-27. Anger JT, Buckley JC, Santucci RA, et al; Urologic Diseases in America Project. Trends in stricture management among male Medicare beneficiaries: underuse of urethroplasty? Urology. 2011;77:481-485. Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol. 2007;177:1667-1674. Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of panurethral stricture. Urol Clin North Am. 2017;44:67-75.
5.
6.
7.
8. 9.
Palminteri E, Brandes SB, Djordjevic M. Urethral reconstruction in lichen sclerosus. Curr Opin Urol. 2012;22:478-483. Martins FE, Kulkarni SB, Joshi P, et al. Management of long-segment and panurethral stricture disease. Adv Urol. 2015;2015:853914. Lumen N, Hoebeke P, Willemsen P, et al. Etiology of urethral stricture disease in the 21st century. J Urol. 2009;182:983-987. Zhao LC. Management of urethral strictures. Urol Clin North Am. 2017;44:xv. Wessells H, Angermeier KW, Elliott S, et al. Male urethral stricture: American Urological Association Guideline. J Urol. 2017;197:182-190.
10.
11.
12.
Bullock TL, Brandes SB. Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States. J Urol. 2007;177:685-690. Greenwell TJ, Castle C, Andrich DE, et al. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor costeffective. J Urol. 2004;172:275-277. Eltahawy EA, Virasoro R, Schlossberg SM, et al. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007;177:1803-1806.
Vol. 19 No. 1 • 2017 • Reviews in Urology • 55
