Complications of Urethral Stricture Disease

Observation is always a management option, and the potential complications of observation must be discussed when patients are counseled and giving informed consent. Patients often present with obstructive voiding symptoms, and it would be a mistake for a patient to conclude that having to live with obstructive voiding symptoms would be the only potential drawback of observation.

Distal obstruction is associated with high-pressure voiding. The bladder compensates by thickening with the development of trabeculation, and the urethra proximal to the obstruction can become distended ( Fig. 51.1 ). High-pressure voiding through the prostatic urethra can be associated with extravasation of urine in retrograde fashion into the prostatic ducts. In a physiologically normal patient, extravasation of contrast material into the prostatic ducts is not seen during retrograde urethrography, but this finding is not uncommon in patients with strictures. Retrograde flow of urine through these ducts can lead to complications such as recurrent prostatitis or epididymitis. Eventually, diverticular formation and/or bladder decompensation can develop with an increased capacity and residual or urinary retention. Secondary reflux with or without associated recurrent pyelonephritis can also occur. Ultimately, although it is not common, acute or chronic renal failure can develop as a complication of untreated stricture disease.

Markedly dilated posterior urethra proximal to a narrow-caliber bulbar stricture seen on voiding cystourethrography.

In patients with lichen sclerosis (LS), also known as balanitis xerotica obliterans (BXO), a disease of the penile skin, glans penis, and urethra ( Fig. 51.2 ), stricture progression is common. The obstruction is generally initially within the distal urethra. Often, extravasation into the periurethral glands of Littre is seen during urethral imaging studies in patients with LS ( Fig. 51.3 ), and it is thought that the extravasation of urine into the periurethral glands may be associated with proximal stricture progression. It is not at all unusual for patients with LS who are conservatively managed to undergo their first retrograde urethrogram and be diagnosed with a >20-cm panurethral stricture ( Fig. 51.4 ). Patients who are clinically diagnosed with LS on physical examination and who have stricture disease limited to the distal urethra are best managed with open staged urethral reconstruction or extended meatotomy. In summary, the complications of treatment with observation include, but are not limited to, prostatitis, bladder decompensation, urinary retention, secondary vesicoureteral reflux, pyelonephritis, renal deterioration, and stricture progression in addition to obstructive symptoms.

Lichen sclerosis can manifest with whitish skin color changes and meatal stenosis (A) or with a more severe deformity including a total loss of the coronal sulcus and loss of penile length and girth (B).

Retrograde urethrography with extravasation into the periurethral glands of Littre.

(A) Appearance of the penis and (B) retrograde urethrography of the same patient with lichen sclerosis.

Complications of Diagnostic Procedures

Diagnostic testing procedures for known or suspected urethral strictures include urethral calibration with bougie à boule, urethroscopy, retrograde urethrography (RUG), and voiding cystourethrography (VCUG). Bougie calibration, properly performed to assess the caliber of the urethral meatus and fossa navicularis, does not dilate the urethra and therefore is generally not associated with complications. When urethroscopy is performed, the most common complication is urethral trauma. This trauma is intentional when scope dilation is performed in an effort to visualize the stricture in its entirety and enter the bladder. This situation represents treatment with dilation before the extent of the stricture is first assessed and the patient is informed of all treatment options. Should the patient be a candidate for open repair, the operation must be delayed for several months following scope or other dilation because open reconstruction is best performed when the stricture is mature and stable.

Urethral contrast imaging is necessary to assess the length and exact location of the stricture because urethroscopy usually identifies only the distal aspect of the disease. Complications of urethral imaging include urinary tract infection with or without sepsis and extravasation. Urine studies should be performed prior to imaging to ensure the urine is sterile, or allow time for treatment if bacteriuria is present. Improperly performed studies can be associated with a higher complication rate. At our institution, diagnostic testing is performed with flat plate imaging, and this includes both RUG and VCUG. The patient is placed in the oblique position. After a scout film is obtained, gauze is wrapped around the coronal sulcus and the penis is placed on stretch. A 60-mL syringe connected to a cone-shaped adaptor is placed into the urethral meatus to form a seal, and RUG is performed during the injection of contrast material. The bladder is then slowly filled in a retrograde fashion similarly until the patient has the urge to void. VCUG is performed while the patient is voiding.

Extravasation into the corpus spongiosum or venous system is rare when contrast material is instilled gently. However, this complication can occur ( Fig. 51.5 ). Sepsis is a concern with extravasation, and when extravasation occurs, prophylactic antibiotics are given. When imaging is performed with alternative techniques at radiology imaging centers, we have observed a high complication rate related to poor technique.

Extravasation into the corpus spongiosum and venous system during retrograde urethrography injection.

Often RUGs are performed with catheter insertion into the urethra and inflation of a balloon within the urethra and subsequent contrast injection through the catheter. We measured the caliber of the balloons of 12 to 16Fr catheters after inflation with 1–3 mL of water. With only 2 mL of inflation, the caliber of the balloon was >50Fr ( Fig. 51.6 ), and even 1 mL creates a 39Fr caliber balloon. The caliber of the penile urethra is approximately 30Fr, except for the glans and fossa navicularis, which are generally <25Fr in caliber, and this painful RUG technique often dilates and traumatizes normal urethra. Forceful attempts to insert a catheter through a stricture will both compromise the diagnostic value of the study and damage the urethra ( Fig. 51.7 ).

Foley catheter after balloon inflation with 2 mL of water. The caliber is >50Fr (1.7 cm diameter).

Outside retrograde urethrography obtained during a forceful attempt to advance the catheter for the injection procedure. The prostatic urethra and bladder neck cannot be assessed.

In addition, errors in technique are associated with an incorrect diagnosis of the length and location of the strictures, and this misdiagnosis can compromise subsequent treatment. For example, if the films are taken when the patient is not in the oblique position, the length of the stricture can be significantly underestimated ( Fig. 51.8 ). Furthermore, if the penis is not on stretch, the length of the stricture will likely be underestimated.

A, Contrast imaging with the patient in the supine position suggests a 2-cm obliteration. B, Repeat study with the same patient appropriately placed in the oblique position confirms that the obliteration is actually 8 cm in length.

When RUG is performed, the normal posterior urethra is coapted and narrowing in this area is a normal finding. Any disease of the posterior urethra cannot be diagnosed or excluded from the injection film. During voiding, however, the bladder neck and posterior urethra are normally widely patent and are often hydrodistended, as shown in Fig. 51.1 . Wide patency of the posterior urethra confirms the absence of bladder neck and membranous urethral stenosis. Patients with anterior strictures in the absence of pelvic fracture trauma or prior prostate surgical or radiation therapy rarely have disease proximal to departure of the bulbar urethra. However, patients with bulbar strictures can also have membranous strictures, particularly when there has been prior endoscopic treatment. When VCUG is not performed, one possible consequence of incomplete imaging is an error in diagnosis that can compromise treatment outcomes.

Complications of Urethral Dilation

Urethral dilation is commonly used to manage urethral strictures. Dilation techniques include the use of metal sounds, filiforms and followers, catheters, and high-pressure balloons. Ideally, dilation should be performed in the absence of urinary tract infection or colonization. Intraoperative complications include the creation of a false passage, bleeding, urethral perforation, rectal injury, and failure to achieve the intended increase in urethral caliber. Balloon dilation with direct visualization was designed to minimize the risk of these severe complications. Early postoperative complications include sepsis and urinary retention.

Urethral perforation, generally associated with significant bleeding, can be managed with gentle attempts at insertion of an indwelling catheter. The use of a flexible cystoscope to insert a flexible guidewire may facilitate the placement of a Council-tipped catheter. Suprapubic tube placement is a very reasonable option when a catheter cannot be placed without further trauma.

The most frequent long-term complication of urethral dilation is stricture recurrence, and recurrent strictures after multiple dilations may be longer and denser. Ideally, dilation is meant to only stretch the scar tissue, but in reality it tears open the strictured area, as evidenced by even minor urethral bleeding after the procedure. This tear then heals with more scar tissue, which can be more extensive than prior to treatment. Dilation represents a potentially curative treatment, although only for very discreet strictures with minimal associated spongiofibrosis. Urethral squamous cell cancer is rare. However, chronic irritation from frequent dilations and self-catheterization is associated with an increased risk of developing this malignant disease. In patients with a history of chronic irritation who develop a fistula to the scrotum, priapism, or a very unusual appearance of the urethral mucosa seen on urethroscopy or contrast imaging, squamous cancer should be suspected.

Complications of Internal Urethrotomy

The Otis urethrotome was routinely used to incise urethral strictures blindly before the development of endoscopic equipment that permitted direct vision internal urethrotomy (DVIU) with the use of a cold knife or a laser fiber. Incision of the scar into the corpus spongiosum increases the caliber of the urethra, and generally a catheter is subsequently placed. As with dilation, immediate complications can include bleeding, which is generally managed with catheterization and is usually self-limited, and damage to the urethra, which prevents subsequent catheter placement. Suprapubic tube placement is then indicated. Extravasation of blood or irrigation fluid into the scrotum or penis can occur and generally resolves with conservative management. However, extravasation into the periurethral tissues can significantly complicate dissection and mobilization of the urethra if subsequent open repair is required. Early complications include urinary tract infection and sepsis.

The most common complication is stricture recurrence. Along the circumference of the urethra epithelium is present, except where the urethra was incised. As healing occurs, the outcome is favorable when epithelialization results and leads to a stable increase in the caliber of the urethra. However, more commonly, wound contracture dominates, and the stricture recurs.

The actual recurrence rate after DVIU is not clearly defined in the literature because the multiple reports published on the subject do not include long-term objective follow-up. However, it is known and clearly established that long-term cure with urethrotomy is a reasonable expectation only for strictures that are not recurrent, are <1–1.5 cm long, and have minimal associated spongiofibrosis. The recurrence rate with repeated urethrotomies is extremely high, and the standard of care for the initial management of longer strictures or of strictures that recur after incision is open reconstruction. Investigators have reported that in patients who require open reconstruction after multiple failed DVIUs, the success rate is lower than when open surgical procedures are performed for initial management.

Both DVIU and dilation have been reported to increase the risk of recurrence after urethroplasty, perhaps by worsening the degree of spongiofibrosis or lengthening of the stricture. We have not found prior dilation or DVIU to compromise urethroplasty outcomes in our own experience, but we have observed strictures lengthen after endoscopic treatment, which may then require tissue transfer reconstruction when the original stricture would have been amenable to an excision and primary anastomosis.

Other complications of DVIU include erectile dysfunction that may be veno-occlusive because a deep dorsal urethral incision can extend into the corpus cavernosum and create a vascular shunt. This complication was reported to be successfully treated with open urethral mobilization and fat pad interposition. The overall rate of erectile dysfunction was 5.3% in one meta-analysis. High-flow priapism following DVIU has also been reported and can be successfully treated with embolization. Multiple incisions other than at the 12-o’clock position may reduce the incidence of this complication. Incontinence is generally not a complication of urethrotomy unless incisions involve the membranous urethra when the bladder neck is already compromised (e.g., after radical prostatectomy) or when the bladder neck is incised in patients whose membranous urethra is not fully intact.

Complications of Endoscopic Treatment of Posterior Urethral Injuries

In men who suffer pelvic fracture trauma and associated membranous posterior urethral disruption, immediate treatment options include a gentle attempt at catheter placement when a partial tear is diagnosed on RUG and suprapubic tube placement with delayed reconstruction. Immediate open urethral reconstruction is not indicated except when the injury is at the level of the bladder neck.

Early primary realignment is a procedure that can be performed immediately in a stable patient or within the first week after the injury when the patient is stabilized. The technique involves endoscopic antegrade and retrograde urethral instrumentation in an effort to place a urethral catheter. As the pelvic hematoma is reabsorbed and healing occurs, the hope is that the catheter will guide the urethra back together in proper alignment, and the patient can then avoid the need for subsequent urethral reconstruction. If a stricture develops after catheter removal, the goals are for the realignment to reduce the length of the stricture or any misalignment and thus to facilitate subsequent repair. The success rate of primary realignment is not clearly established, although this technique is reported to be of possible benefit. At this time, it is considered very reasonable to manage posterior urethral disruptions acutely with primary realignment or suprapubic tube placement and delayed reconstruction.

The most common complication of primary realignment is the development of a urethral stricture or total obliteration of the urethra after urethral catheter removal. One significant drawback of primary realignment is that recurrent strictures are then often managed with DVIUs and self-catheterization in an effort to avoid open reconstruction, subjecting the patient to multiple procedures and significantly delaying the time to resolution of stenosis. When a recurrent stricture develops subsequent to urethral catheter removal, delayed open posterior urethral reconstruction is the standard of care and is generally performed approximately 3 months after urethral catheter removal.

In the past an endoscopic alternative to delayed open reconstruction for obliterative distraction defects was a “cut-to-the-light” procedure. This technique involved simultaneous antegrade and retrograde cystoscopy with “core through” incisions into the obliteration toward the light of the other scope until continuity was established. The failure rate was very high, and this technique fell out of favor and is not recommended.

Complications of Urethral Stents

The UroLume stent (American Medical Systems, Minnetonka, MN) was taken off the market as of January 2013 and is no longer manufactured, but patients who have had these placed may still suffer from future complications. Complications that have occurred with high frequency include pain, infection, incontinence, and recurrent strictures within the stent or proximal or distal to the stent. Development of a panurethral stricture can also occur in patients with hypospadias. Recurrent strictures that develop after stent placement can be successfully managed with open stent removal using excision and primary anastomosis for relatively short proximal strictures or with tissue transfer reconstruction for longer strictures. Individualized open reconstruction can generally be performed in one stage and has a high long-term success rate.

Complications of Open Surgical Procedures

Open surgical procedures for urethral reconstruction include excision and primary anastomosis and tissue transfer reconstruction with skin flaps or grafts. The remainder of this chapter is a discussion of complications associated with patient positioning, excisional repair for posterior and anterior bulbar strictures, graft harvest, and tissue transfer reconstruction.

Patient Positioning

Distal strictures involving the urethral meatus, fossa navicularis, and penile urethra are often repaired with the patient in the supine position. If care is taken to prevent pressure points, positioning complications generally do not occur. In contrast, more proximal strictures are repaired by a perineal approach that requires placement of the patient in the lithotomy position, often an exaggerated lithotomy position ( Fig. 51.9 ). This position is associated with many complications including neuropraxia (peroneal nerve in particular) that is often temporary but can be permanent, back pain, compartment syndrome, and rhabdomyolysis.

Exaggerated lithotomy position.

Proper positioning can reduce the incidence of these serious complications. A modified Skytron table (developed by Gerald Jordan, MD) provides pelvic tilt, and modified stirrups allow additional extension of the lower extremities to prevent extreme hip or knee flexion with associated nerve stretch. Proper adjustment of the boots of the stirrups prevents pressure on the calves and reduces the risk of compartment syndrome, a condition that when diagnosed is generally managed with emergency fasciotomies. Investigators have shown that the time spent in the lithotomy position is related to the risk of the development of compartment syndrome, neuropraxia, and rhabdomyolysis. Therefore, when possible, any portion of the surgical procedure (e.g., buccal graft harvesting when indicated) that can be done without the patient being in the exaggerated lithotomy position should be done with the patient supine. This can be facilitated by obtaining proper imaging preoperatively, which allows the surgeon to accurately determine how much buccal graft is needed, if any, prior to positioning in lithotomy. When neuropraxia develops, it is usually a temporary sensory impairment along the lower leg and the dorsum of the foot in particular. One report of 185 patients found 12 patients with neuropraxia, which was by far the most common positioning-related complication, but only one of these was severe. Normal sensation usually returns without treatment in 2 to 3 days. However, more significant and long-term disability can occur along with motor deficits, including but not limited to impaired dorsiflexion of the foot.

Rhabdomyolysis is a potentially serious complication of prolonged lithotomy positioning with associated painful muscle damage. The serum creatine kinase level is markedly elevated, and myoglobin may be detected in the dark brown urine. Acute renal failure with oliguria and elevation of the serum creatinine may occur. Aggressive treatment is indicated to prevent renal damage, and appropriate management includes hydration and urine alkalization. Temporary dialysis is required in severe cases. In addition, deep vein thrombosis and pulmonary embolism have been reported as possible complications of high lithotomy positioning, although a large population-based study of 126,891 patients undergoing urologic surgery actually found that the lithotomy position conferred a lower risk of these complications than did the supine position.

Excision and Primary Anastomosis for Posterior Disruptions

The most common complication of posterior urethral reconstruction with excision and primary anastomosis is recurrence of the stricture or obliteration. Technical success is defined as durable wide patency of the entire urethra without the need for any subsequent or other intervention. At referral centers for urethral surgery, the success rate of posterior urethral reconstruction (including both initial treatment and revision) is 90–98%. Factors that increase the probability of a technically successful outcome include the administration of culture-specific antibiotics perioperatively, complete scar excision so the proximal and distal segments of the urethra are widely spatulated to >30Fr with healthy mucosa circumferentially, and a tension-free repair.

Maneuvers that promote a tension-free repair include midline separation of the corporal bodies along the triangular ligament and, when indicated, infrapubectomy. In rare cases, corporal rerouting has been reported to reduce tension. Investigators have stressed in the literature that posterior reconstructions and urethral reconstructions in general are best performed by urologists with expertise and specialization in urethral stricture surgery because a poor outcome increases the complexity and difficulty of subsequent surgical treatment.

Long recurrent total obliterations that develop as early complications of failed surgical procedures ( Fig. 51.10 ) are likely caused by inadequate proximal exposure and scar excision. Fortunately, these patients can usually undergo corrective treatment with a very high success rate with repeat excisional repair. The finding that revision surgery was highly successful with the same operation that previously failed before referral suggests that the experience of the surgeon may be significantly related to the success of the operation. Discrete nonobliterative anastomotic recurrences can be successfully managed with urethrotomy. In contrast to the low success rate of DVIU for the initial treatment of strictures, this technique has a high success rate when it is used to treat anastomotic strictures, presumably because these discrete recurrent strictures are not associated with any significant spongiofibrosis.

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