Urethroplasty in Iran
Full Urethroplasty package in Iran performed by the best Iranian Urologists
GOALS
- To eliminate stenosis and maintain normal urine flow
URETHROPLASTY IN IRAN: ALL YOU NEED TO KNOW
The urethra is defined as a part of the males and females urinary system responsible for passing urine outside the body. In males, it is also important for the ejaculation process. Following subepithelial inflammation and hemorrhage caused by swelling, trauma, and infection, a scar tissue (fibrosis) may form which makes the thin tube narrower or even cause to block it. Therefore, urine flow is hindered. In addition, the scar tissue affects corpus spongiosum in males which causes trouble in the erection. This condition is known as urethral stricture and could be painful. Urethral stricture is more common in men because their urethra is longer and more susceptible to injuries.
The “gold standard” treatments for urethral stricture are urethroplasty, primary anastomosis, and excision. This procedure is effective and efficient since it is cost-effectiveness, high success rates in the long term and low morbidity.
What are the causes of urethroplasty?
As a matter of fact, various causes can lead to scar tissue formation in the urethra including:
• Previous injury and trauma to urethra due to falling onto the perineum and scrotum
• Former medical procedures such as catheter insertion, prostate surgery, kidney stone removal surgery, hypospadias surgery
• Infectious disease such as different types of sexually transmitted diseases
• Lichen sclerosis and other inflammatory diseases which may affect on the inside and outside part of the penis, Reiter's syndrome
• Prostate enlargement, inflammation, and infection
• Malformation of the urethra due to congenital conditions in children (rare)
• Urethral meatus irritation related to diaper
• Treating prostate cancer by the placement of radiation seeds into the prostate called brachytherapy
How can preparations for urethroplasty accomplish?
Prior to urethroplasty, some considerations should be observed including:
• The scar tissue should not be contracting and unstable. Therefore, you should not undergo dilating or cutting procedures for three months before the scheduled date for your surgery. If urinary retention occurs in this period, a suprapubic tube is placed through the skin to drain the urine directly from the bladder.
• Your doctor should be informed about the medications you are taking, herbal supplements you are consuming and your special diets. Your surgeon will recommend you to stop taking blood thinners such as warfarin a week before surgery.
• You will be instructed to refrain from eating and drinking 8 hours prior to surgery except for the required medications with a sip of water.
• You will undergo some tests and examinations to determine the exact location of the scar tissue including:
• Physical examination
• Uroflow test
• Urodynamic test
• Cystoscopy and urethroscopy
• Ultrasound
• Retrograde (against the flow) urethrogram (a contrast dye is injected from the tip of the penis without using catheters and needles. The flow of the dye is seen by X-ray and the number, severity, position, and length of the strictures are determined)
• Antegrade (with the flow) urethrogram (the contrast dye is injected in the bladder and fills the bladder and urethra until it reaches the stricture)
What are the common risks of urethroplasty?
Urethroplasty may carry some complications and risks like any other interventional surgery. They may include: early and late complications.
Early complications may be:
• Scrotal swelling and bruising
• Infection at the surgery site
• Urinary urgency
• Scrotal ecchymosis
• Rectal injury
• Urosepsis
Late complications:
• The feeling of wound tightness
• Scrotal numbness
• Urine spraying
• Chordee
• Fistula
• Anastomotic leak
• Erectile dysfunction (transiently after the surgery, in pelvic fracture urethral injury it may be due to the injury itself, not the reconstruction surgery)
• Recurrence of the condition due to poor graft take and poor primary anastomosis technique
What to expect from urethroplasty operation?
There are three types of treatments for urethral stricture:
- Dilation: in this treatment stretching is gradually done on the stricture to enlarge it. The scar can return quickly.
- Urethrotomy: The scar is cutting through using a scope and camera to guide a knife or laser and inserting a catheter to hold the gap open until it heals. this method is useful for small or new scars.
- Open surgery: In this procedure, the stricture is surgically removed and the tissue is reconnected and reconstructed. If grafts are used for reconstruction it is called urethroplasty, is long-lasting and has the lowest rates od recurrence.
This operation is done under general anesthesia and has two types: anastomotic urethroplasty and substitution urethroplasty.
Anastomotic urethroplasty
In anastomotic urethroplasty, an incision is made over the stricture area between scrotum and rectum. Then the stricture is removed and then the two ends of the cut are sutured together. After the surgery, a urethral catheter is placed for 2 to 4 weeks. In the follow-up session, the bladder is filled with contrast dye using the catheter.in next step it is removed accordingly through voiding, the area is evaluated. This method is commonly used for short strictures especially in the bulbar urethra with a 95% success rate.
For penile urethra and long strictures, the tension is too high in bringing the ends together that may lead to failure and potentially chordee and penile shortening. In these cases, substitution urethroplasty is recommended.
What is the use of substitution urethroplasty?
In this approach, the stricture area is cut and replaced with tissue transferred from another area. The surgery is done by an experienced and professional surgeon. based on the origin of the tissue and the difficulty of the procedure 3 types of substitution may be utilized:
• Free graft: in this method, the tissue is transferred from another part of the body such as skin from the penis shaft or buccal mucosa from inside the mouth (cheek). The mouth heals quickly in less than 7 days and the pain is minimal. The graft relies on the host tissue for blood supply. After the surgery, you may stay in the hospital for a short time and use a urethral catheter for 2 to 3 weeks.
• Penile skin Flap: in this procedure performed by a surgeon with plastic surgery experience, the skin is attached to the body and is rotated to replace the stricture area. This tissue doesn’t need the damaged host site's blood supply for its survival. This method is used in severe and long strictures with 80 to 85% success rate. The success rate decreases when the flaps are rolled. Therefore, the flaps are used for patching, not a total replacement. Scrotum skin flaps are avoided due to high complication rates and poor success rates. After surgery, you may stay in the hospital for a short time and use a urethral catheter for 2 to 3 weeks.
• Staged: this method is used when the urethra and local skin are severely damaged. In these cases, the procedure has two stages. In stage one, the underside the urethra is opened until the whole length of the stricture is at sight. Then a graft is attached to the incised urethra and left to mature and heal for 3 months to one year. The surgeon makes a new opening under the stricture to make urinating possible during this period. Several months later the second stage is performed to return urethra to its normal condition by forming the graft into a soft and flexible tube. After the surgery, a soft catheter is placed in the penis for 10 to 21 days.
Urethroplasty FAQs
1. Does urethroplasty cause scar formation on the penis?
The surgeries are often performed through the distance between the rectum and scrotum that is a hidden area. In the surgeries that are performed on the penile area using the penile flap, a cut is made on the penis. However, with a professional surgeon and post-surgery care, scar tissue formation is minimal.
2. Is the procedure painful?
After the surgery, you may feel some pain and discomfort which is manageable by taking medications. The pain level is higher in the first 12 hours after the surgery and gradually subsides in a few days. The catheter may cause some sudden pain in the lower abdomen and pubic area which are “bladder spasms” and are managed by taking Ditropan or Detrol.
3. How is the recovery process?
the patients often recover quickly. However, it may take weeks for swelling to disappear. Tight underwear and scrotal support can help limit swelling. You should use ice packs in the first 24 hours to accelerate the healing process. It is recommended to clean the catheter daily with soap and water and put antibiotic ointment at the penis opening. You can begin showering after 2 to 3 days. Bathing is not recommended in the first week after surgery.
Limit your activities until the wounds are healed which takes about 2 weeks. Refrain from heavy lifting and long walks. It is suggested to take 3 to 4 weeks off work especially if your job demands physical activities.
4. How long is the surgery?
The surgery can take 2 to 5 hours to complete but normally it takes about 3 hours.
5. Does urethroplasty have any effects on my sexual activity?
Generally, patients don’t have trouble in this area. The patients can start their sexual activities after the swelling and catheter are removed. In rare cases, psychogenic factors and damages to the cavernous nerve, perineal nerve, and bulbar artery may cause erectile dysfunction. In older men, the surgery decreases erectile dysfunction. Overall, if the surgery is performed by an experienced and up to date surgeon, the risk of damage to nerves is very low.
6. What happens if I get erections while the catheter is in?
Generally, the erection will not cause any damage to the tissues or compromise the outcome of the surgery. In addition, most of the patients lose their erection as soon as they feel pain. However, if your erections are painful and wake you up from sleep, your doctor will prescribe medications to suppress the erections.
7. Will the strictures come back after surgery?
The urethroplasty success rate is over 95%. However. If the stricture returns, it is thin and like a web. These scars can be obstructive but can be managed by the urethrotomy technique. These scars respond well to internal cutting and aren’t similar to initial strictures that are very damaged.
Some scars may be very dense to respond to dilation or urethrotomy. In this case, the patient may need a second surgery.
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Urethroplasty in Iran