Urethroplasty - Procedure and Its Complications

Introduction:

The urethra is a small tube that carries urine from the urinary bladder (the sac that stores urine) to the outside body. In men, the urethra carries urine from the bladder to the outside of the body through the penis. It also carries sperm through the penis. In certain conditions, the urethra might have blockages restricting normal urine flow. Due to this, the urine can backflow to the kidneys. This can lead to infection and damage to the kidneys. Urethroplasty is the surgery performed on the urethra to treat the blockage or stricture.

Who Needs Urethroplasty?

Urethroplasty is the procedure to remove the scar tissue that forms within the urethra, thus repairing it. The physician connects the two ends of the urethra after removing the scar tissue.

Urethroplasty is done in case of:

• Urethral Stricture - Some part of the urethra becomes narrow, thus blocking the flow of urine across it. These strictures are more common in men than in women.

• Epispadias or Hypospadias - These are congenital conditions (present since birth) affecting the urethra. The blockages are common in the urethras that have been rebuilt previously.

• Gender Affirmation Surgery - This is the surgery undergone by an individual to change their sexual characteristics. These surgeries could give rise to a stricture in the urethra that needs to be removed.

How Is Urethroplasty Carried Out?

Before the Procedure -

An X-ray known as retrograde urethrogram or cystoscopy confirms the location of the blockage in the urethra. Both these diagnostic techniques are minimally invasive procedures. Before beginning the procedure, the physician advises about the food and water intake and any medications one takes. A suprapubic catheter- a tube inserted through a hole in the abdomen and then directly into the urinary bladder, is placed before the surgery to empty the bladder. This is recommended if one requires self-catheterization to keep the blockage open. Such catheters are placed directly into the bladder from the area just above the pubic bone. The surgery is performed under general anesthesia.

During the Procedure -

The surgeon makes an incision into the muscle to reach the urethra. This cut is either on the underside of the penis in the scrotum or between the scrotum and the anus-perineum. The stricture's position is identified, either removed or the place is rebuilt, depending upon its length and position. If the blockage is longer or positioned in the urethra of the penis, the physician will take a skin graft from either the mouth, genital or rectal tissue to build the incised tissue from the urethra. The incision is closed with the help of sutures, and a small draining tube is placed for a couple of days. The catheter allows the urethra to heal while passing out urine. The incised muscle and skin are then sutured and closed after the completion of the procedure.

After the Procedure -

Time is required for general anesthesia's effect to wither completely. One night stay in the hospital is preferred. The individual is discharged with a urinary catheter, painkillers, and certain medications to prevent bladder spasms. In men, medications are given to avoid erections. If a skin graft from the mouth has been used to reconstruct the urethra, then a special mouthwash is prescribed to keep the area clean.

Follow-up is usually after two or three weeks. A radiology procedure might be performed to check the surgical area for repair. The bladder will be filled with a contrast media or dye, the catheter is removed, and X-rays are taken while one is urinating. This gives a clear picture of the urethra. The medical team will then review the images and advise accordingly.

What Are the Different Types of Urethroplasty?

1. Excision and Primary Anastomosis (EPA) Urethroplasty - In this Procedure, a small part of the urethra is removed, and the cut ends are sutured back together.

2. Graft Urethroplasty - In this Procedure, a piece of tissue from the extra-genital skin or the inner lining of the mouth (buccal graft) is removed and used as a patch to increase the size of the urethra.

3. Penile Flap Urethroplasty - A patch or flap of the skin of the penis is removed and used as a patch to treat urethral stricture.

4. Staged Urethroplasty - This technique is used when the stricture requires many fixable procedures. Each procedure is termed a stage.

• Stage 1 - A cut is made on the underside of the penis, and an opening is made just before the stricture. This allows urine to flow freely. The stricture is opened beyond the cut, and the scar tissue is removed. A graft of skin taken from either inside the mouth or cheek is used to replace the position of scar tissue. The catheter (tube) and dressing are removed after two weeks.

• Stage 2 - This Procedure is usually performed after three months of the stage 1 procedure. The graft is formed like a tube with an opening near the tip of the penis, allowing normal urination. A small tube or catheter is usually left inside the penis for proper healing. This tube is removed after a few weeks of surgery.

What Are the Complications of Urethroplasty Surgery?

Surgical procedures come with their share of risks and complications.

• Possible complications with anesthesia.

• Risks of developing infections post-surgery.

• Leakage or blockage of catheters.

• Urine infection.

• Nerve injuries to legs, feet, elbows, or fingers due to the surgical positioning of the body.

• Pain in the perineum or scrotum due to damage to the nerves.

• Leakage of urine or semen from the penis and collection in the surgical area.

• Erectile Dysfunction - Difficulty in getting and keeping an erection. This is a temporary complication that might resolve on its own.

• Nerve damage.

• Urethroplasty might not work over a long period, and additional procedures like internal cutting procedures to completely remove the scar tissue might be needed. Hence, follow-up visits should not be postponed.

Conclusion:

Urethroplasty is a surgical procedure that is carried out to repair the urethra. The surgery is needed to remove the presence of scarring in the urethra, which causes difficulty in urination. The recovery rate differs for individuals, but it usually takes around six weeks to complete recovery. The outlook for the surgery is good if one abides by the advice of their physician.