(1)
Pediatric Surgery, Al Azher University, Cairo, Egypt
Abstract
Urethral stricture defined as congenital only if it is not an inflammatory, it is a short-length and it is not associated with history of or potential for urethral trauma, or instrumentation. It is not considered a rare disease, and we must note the existence of such anomaly, especially in boys suffering from recurrent urinary tract infections, dysuria, disturbed voiding, drug- resistant diurnal enuresis, pollakisuria or hematuria in pediatric urological practice. Stricture also disturbs spontaneous healing of vesicoureteral reflux. Usually findings above the stenotic segment include a bladder wall thickening, hydronephrosis, and renal dysplasia. VCUG demonstrates the stenotic segment and the associated alterations.
Keywords
Urethral strictureCobb’s CollarMoormann’s ringAnterior Urethral ValveDefinition
Urethral stricture defined as congenital only if it is not an inflammatory, it is a short-length and it is not associated with history of or potential for urethral trauma, or instrumentation.
It is not considered a rare disease, and we must note the existence of such anomaly, especially in boys suffering from recurrent urinary tract infections, dysuria, disturbed voiding, drug- resistant diurnal enuresis, pollakisuria or hematuria in pediatric urological practice. Stricture also disturbs spontaneous healing of vesicoureteral reflux. Usually findings above the stenotic segment include a bladder wall thickening, hydronephrosis, and renal dysplasia. VCUG demonstrates the stenotic segment and the associated alterations.
Congenital urethral stricture should be differentiated from other different causes of congenital urethral obstruction, which may be caused by different pathologies discussed before like; urethral polyp, cyst and diverticulum.
Sonourethrography (Urethral Ultrasound) is best used adjunctively to guide treatment planning in patients with known bulbous urethral strictures and has been reported to be more accurate than retrograde urethrography for estimating the length of urethral strictures (Fig. 33.1).
Fig. 33.1
Sonourethrography diagnosing accurately the stricture(a), in comparison to the calibre of the rest normal urethra (b) (Case courtesy of Dr Maciej Mazgaj, Radiopaedia.org, rID: 24047)
In paediatric cases, it worth using ultrasound instead of radiological and CT imaging to reduce dose of x-rays exposure at the young age, although this may be a challenging test due to lack of cooperation. MR imaging is considered to be the best ancillary imaging modality for assessing urethral, adjacent anatomy and associated other anomalies.
The most effective treatment of this lesion is optic internal urethrotomy under direct vision. Early endoscopic intervention is safe and feasible and its short-term clinical outcomes are favorable. Long-term clinical outcomes, however, remain to be investigated [1].
Urethrotomy and dilation are acceptable for short bulbar urethral strictures or as salvage after failed urethroplasty with stenotic annular rings. Repeat urethrotomy is futile and potentially harmful. Anterior urethral strictures of the bulb can be successfully managed by anastomotic urethroplasty if short and substitution urethroplasty (buccal grafts) if long.
33.1 Historical Background
Urethral stricture disease in children has been cited as long ago as ancient Greek. Historically, the treatment consisted of urethral dilation with sounds. Hamilton Russell described the first surgical procedure for repair of a urethral stricture in 1914 [2]. But urethral stricture in adult is a well-known entity long time ago in the history, and urethral dilation was described by the Egyptians in 3000–2000 BC; they used different types of sounds to dilate urethral strictures.
Congenital Urethral stricture classified herein to:
33.2 Cobb’s Collar
The Cobb’s collar or Moormann’s ring is a congenital narrowing of the bulbar urethra with variable clinical presentation and obstruction grade, it is largely unrecognized but has considerable relevance urologically as the site of congenital or postinstrumental strictures [3].
It is important to distinguish other congenital urethral obstruction and Cobb’s collar from type-III PUV, as in some cases the posterior urethral membrane may prolapse until the bulbar urethra, making these two conditions similar; however, the fold is attached to the verumontanum in all cases of posterior urethral valve. This congenital stricture also differs from acquired types of stricture in that there is a distinct lack of periurethral fibrosis or any abnormal tissue surrounding the urethra (Fig. 33.2). At the same time the posttrumatic stricture is unlikely to be smooth and circular, mostly it is longitudinal and with irregularity (Fig. 33.3).
Fig. 33.2
Cobb’s collar: a ring is observed by urethroscopy at bulbar urethra level. External sphincter is observed proximally to the ring, without any fibrosis
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