Sténose de l'urètre

The treatment of urethral stricture

Treatment of urethral stricture improves human comfort by allowing him to urinate with ease, and it protects the urinary tract threatened with deterioration because of the impact of the obstruction.
However, one of the main difficulties of this treatment is the frequency with which these strictures recur.
The indications and the choice of surgical treatment depends on:

  • The characteristics of the stenosis: seat length and tight or not shrinking,
  • The number of interventions before, the techniques used in these opportunities and possible complications, including infections that could be enameled their suites,
  • Patient age & general state of comorbid conditions, 
  • Its antecedents such as radiation therapy in the pelvic area.

Endoscopic interventions in the light of the channel urethra oppose open surgical techniques.
Note: The terminology regarding urethral anatomy is defined in the article on this subject.
The urethral stricture is defined as a reduction more or less extended of the urethra caliber.
The goal of surgery is to restore normal caliber of canal zone .
These surgical procedures may be conducted by the inside lumen of the channel (endoscopic surgery) or by conventional open surgically by performing Urethroplasty.

1. Endourethral Interventions and actions

These techniques are less vulnerable compared to classic open surgery, but they usually provide a less durable result.

Endoscopic internal urethrotomy

It is performed using an endoscopic urethrotome the surgeon inserts while the patient is under anesthesia, in the urethra through the meatus. It then move the device under visual control until the stenosis which prevents further progression of the endoscope.

The operator keeps the path of the channel by placing in the residual stenosis perthuis end of the wire guide wire that pushes up the bladder. He then cuts the stenosis which is split on the roof or wheel spokes up to restore a normal caliber channel.

This section is usually performed using a cold knife. Using a laser is optional and does not bring better results especially in terms of reducing the risk of recurrence.

The procedure is simple, excellent tolerability and short hospital but the stricture recurrence in 68-94% of cases according to the different series in the literature, usually in the first year after surgery.

 

– Urethral dilatation

metal dilators

metal dilators

The operation is designed to progressively expand the constricted area by means of rigid probes – metal or gum – of increasing diameters which are introduced therein, to restore the normal size of the urethral lumen.
This intervention is exclusively palliative because it inevitably leads to recidivism since it leaves in place the lesions responsible for urethral stenosis.
It is simple, fast and practice outpatient and under local anesthesia.
As against the gesture is painful, painful. Each session expansion even performed in the best conditions, carries a risk of bleeding, superinfection of aspiration: frequent complications of the art and to the advancement of the stenosis.
The frequency with which it is to be repeated is empirical (daily? Weekly? Monthly? …).
The repetition of expansion jeopardizes the chances of success of subsequent urethroplasty if it is necessary to consider it.
The prospect of having to repeat these expansions throughout life is often painfully experienced by the patient.

 

– Ureteral stent:

Endoprothèse urétrale

This technique involves inserting endoscopically, temporarily or permanently, and having restored the normal caliber of the canal by urethrotomy, stent.

This is usually a metallic spiral intended to shape the channel to maintain the output from the gauge urethrotomy.

The procedure is simple, fast and is done under anesthesia.

By against failures or complications are common and must be urethroplasty him always preferred.

Avoid final stents which are embedded in fibrosis shrinking and whose removal is difficult and painful for failure and open response needed.

When temporary stents, how long they should be left in place is arbitrary and ill-defined.

These stents can generate perineal pain, and be at the origin of recurrent narrowing, especially at both ends of the stent.

Their indications are few definitive (urethroplasties failure?).

 

2. open surgical technique: urethroplasty

It is indicated after failure of one or maximum two uretrotomies, and before starting the cycle of expansion.

3 types of interventions are suggested as appropriate:

  • The suture resection,
  • Urethroplasty with the patch at a time,
  • Urethroplasty with the patch in two stages.

 

– Resection suture

 

Uretroplastie résection – suture

 

It is indicated in cases of short stenosis of less than one to more than two centimeters. It is in fact little used in sclerotherapy-inflammatory strictures and especially indicated in the original traumatic strictures.

Its principle is based on the surgical resection of the open stenosis, followed by the restoration of the continuity of the urethra by a delicate suture making a finished-end anastomosis.

This suture must be done without any traction on paid ureteral walls of all attachment to several centimeters. Urethral sacrifice must not exceed three or four centimeters.

This technique can lead to sexual problems, including premature ejaculation or in connection with the shortening of the penis, and a lower sensitivity of the glans penis.

 

 

– The urethroplasty with a patch in time

The urethroplasty is a surgical procedure that aims to repair a defect in a part of the wall of the urethra by providing a plugin from “patch” this defect.

The urethroplasties techniques are numerous.

 

Uréthroplastie avec patch en un temps

Possible patches are made of:

  • Free skin (foreskin), used since the 50s or even bladder mucosa,
  • Pedicle of skin,
  • Oral mucosa especially now because it gives the best success rate

In the future, tissue obtained from cell cultures will be likely to be used.

Maximum pan urethroplasty in a time with oral mucosal flap according KULKARNY is indicated in rare cases of stenosis very extended all the anterior urethra, penile and bulbar.

The management of urethral strictures requires knowledge of various techniques in order to adapt the treatment to the characteristics of the lesion and the various constraints (history, seat of the stenosis). The oral mucosa urethroplasty flap transplant allows a repair at a time with satisfactory results preferentially at the bulbar urethra.

Applicable in all circumstances, except in very rare exceptions, the free flap urethroplasty oral mucosa is an excellent way of treating urethral strictures which can reconstruct a normal caliber urethra and ensure a high success rate, with 96 % of satisfied patients

In all cases, prolonged monitoring is necessary to detect a recurrence.

– The urethroplasty with patch in two times

Described for the first time by BENGT JOHANSON en 1953, it allows, with a long delay between the two operating times, to handle complex situations of extensive stenosis, infected, possibly associated with fistulas.

This is a method for reconstructing the urethra based initially by any of flattening the narrowed segment of the channel until healthy tissue, followed by the reconstruction of the urethra after a period of about 6 months.

uréthroplastie avec patch en deux temps

The results of this technique are interesting: 95% good results TURNER-WARWICK.

Since JOHANSON, many technical variants have been described, some using a tissue intake by oral mucosa flap.

The disadvantages inherent in this technique are stenosis holes, sexual repercussions and especially the patient’s psychological discomfort.

 

 

Some bibliographical elements

In English

http://urology.wustl.edu/en/Patient-Care/Urethral-Stricture-Disease/Urethral-Stricture-Evaluation

http://www.uptodate.com/contents/treatment-of-urethral-stricture-disease-in-men

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382007000400002

https://www.med.umich.edu/1libr/urology/umurethral_stricture.htm

http://www.urethralcenter.it/English_version/pagine/terapia.html

http://www.urethralcenter.it/English_version/pagine/uretrotomia.html

In French

http://www.dematice.org/ressources/DCEM2/urologie/D2_uro_008/co/Module_RU_7.html

http://www.uroinfo.ca/brochures_kidney_fr/renalColic_fr.html

http://urofrance.org/nc/lurologie-grandpublic/fiches-patient/resultats-de-la-recherche/html/resection-anastomose-dune-stenose-de-luretre.html

https://www.researchgate.net/publication/266420898_Le_traitement_des_stenoses_de_l%27uretere_par_catheters_de_dilatation_a_haute_pression

http://www.keneya.net/fmpos/theses/2008/med/pdf/08M18.pdf

http://urofrance.org/nc/lurologie-grandpublic/fiches-patient/resultats-de-la-recherche/html/uretrotomie-interne-par-endoscopie.html

http://urofrance.org/science-et-recherche/base-bibliographique/article/html/endoprotheses-uretrales-de-fabian-urospiraltm-coloplast-indications-et-technique-de-pose.html

http://www.lemoniteurdespharmacies.fr/revues/le-moniteur-hospitalier/article/n-205/les-endoprotheses-uretrales.html