There is a variety of different types of treatment for urethral strictures, depending on the location of the narrowing of the urethra. During a diagnostic evaluation, a stricture should be closely examined in order to accurately determine which treatment option will be best for that specific patient. Many urology centers skip this crucial step, and as a result, patients do not get the best possible urethral stricture treatment.
If a stricture is located near the opening of the urethra at the tip of the penis, a meatotomy may be the most effective treatment technique. In cases of complex long recurrent strictures involving a long segment of the urethra, a perineal urethrostomy may be the best treatment technique, especially when the goal is the most simple solution to urethral blockage.
A meatotomy is an excellent option for treatment of short strictures of the opening of the urethra at the tip of the penis (the urethral meatus). It is absolutely essential to fully understand the extent of the stricture before performing a meatotomy, as the procedure is not necessarily a good option for longer strictures if the goal is to avoid having the urethral opening on the undersurface of the penis. To determine if the urethral stricture is at the very tip of the penis, the location of the stricture must first be evaluated with a Bougie calibration. After a Bougie calibration, a retrograde urethrogram (RUG) will be performed in order to accurately determine the extent of the disease. Our approach is to use custom instrumentation developed by Dr. Gelman. If any of these evaluative steps are skipped, it may be best to seek out a different urology center in order to receive the best possible treatment. The following is a RUG of a patient with stricture disease limited to the meatus itself.
RUG of meatal stenosis
After a thorough evaluation that confirms that the stricture is short and near the opening of the urethra, it will likely be determined that a meatotomy is the best treatment option. A meatotomy is a simple outpatient procedure that consists of an incision of the urethral opening followed by the placement of sutures at the edges of the incision.
In certain situations, an extended meatotomy may be considered. If the patient also has Lichen Sclerosus with a urethral stricture that extends into the fossa navicularis (the area of the urethra near the tip of the penis), an extended meatotomy is a reasonable option. While this procedure will extend the opening of the urethra slightly towards the undersurface of the penis, it will effectively relieve the obstruction and a more complex open reconstruction would not necessarily yield an improved cosmetic or functional result.
A perineal urethrostomy may be the best treatment option for patients who have extensive strictures of the urethra, and the strictures have recurred following previous treatment. It is a simple procedure to relieve the obstruction and is particularly appealing to older patients with multiple medical problems who desire relatively simple and definitive treatment.
A perineal urethrostomy creates a small opening under the scrotum that connects the skin to the urethra. This opening means that during urination, the urine exits from the urethrostomy and therefore does not have to travel through the narrow urethral stricture to reach the tip of the penis. The unconventional nature of the procedure means that it is not very popular with all patients, as they do not want to sit while urinating or have semen exit from under the scrotum during ejaculation. However, others already sit to urinate and just want the easiest definitive treatment.
It is essential to have an expert perform a perineal urethrostomy because if the procedure is not performed properly, there is an increased change the surgery can be complicated by narrowing at the newly created opening. Narrowing at the opening under the scrotum, known as stenosis of the urethrostomy, can be very challenging to repair. It is also important for the patient to be evaluated with a RUG and VCUG prior to undergoing perineal urethrostomy. Strictures that extend deep into the urethra may not be well suited to the procedure, as the skin flap cannot easily be advanced deep into the pelvis where the urethra is normal. In rare cases, a buccal mucosa graft can be used to augment the proximal urethra just so the skin could reach the urethra without tension.