Urethroplasty is a reconstructive surgery to repair the urethra, the tube that carries urine from the bladder out of the body. This surgical intervention addresses issues that obstruct or damage this passageway, aiming to restore normal urinary function by rebuilding the affected segment. It is a specialized procedure performed by urologists to provide a lasting solution for urethral problems and their associated health complications.
Indications for Urethroplasty
The most common reason for a urethroplasty is to treat urethral stricture disease. A urethral stricture is a narrowing of the urethra caused by the formation of scar tissue, or spongiofibrosis, which restricts the normal flow of urine. Symptoms often include a weak urinary stream, difficulty starting urination, a feeling of incomplete bladder emptying, and recurrent urinary tract infections.
Injuries and trauma are frequent culprits behind urethral strictures. A pelvic fracture or a “straddle injury,” such as falling onto a bicycle frame, can damage the urethra and lead to scarring. Strictures can also be iatrogenic, meaning they result from a previous medical procedure, including long-term catheter use, prostate surgery, or endoscopic treatments.
Infections also play a role in forming urethral strictures. Sexually transmitted infections (STIs) like gonorrhea or chlamydia can cause inflammation (urethritis) that heals with scar tissue, leading to a narrowing. In some instances, inflammatory skin conditions such as Lichen Sclerosus can affect the genital area and cause extensive scarring that extends into the urethra. Less commonly, some individuals are born with a congenital narrowing of the urethra.
Common Urethroplasty Techniques
Surgeons use several techniques for repairing urethral strictures, and the choice depends on the length, location, and severity of the narrowing. One method is Excision and Primary Anastomosis (EPA). This procedure is for shorter strictures, usually less than 2 centimeters, in the bulbar urethra, the section of the urethra just below the prostate. During an EPA, the surgeon removes the scarred segment and then stitches the two healthy ends of the urethra back together.
For longer or more complex strictures, surgeons often use a graft to widen the narrowed urethral channel in a substitution urethroplasty. The graft material is harvested from the patient’s own body, with buccal mucosa—the tissue lining the inside of the cheek—being the most widely used source. Buccal mucosa is favored because it is a moist, resilient tissue with a robust blood supply that promotes healing, and can be harvested with minimal long-term impact on the mouth. The graft is used as a patch to increase the diameter of the urethra, allowing for unobstructed urine flow.
Another approach for particularly long or complex repairs is a flap urethroplasty. Unlike a graft, which is tissue detached from its original blood supply, a flap consists of tissue moved to the repair site while still attached to its native blood vessels. This flap is often created from nearby penile or scrotal skin. By keeping the blood supply intact, the flap brings its own nourishment to the area, which is beneficial where surrounding tissue is heavily scarred or has poor circulation. This technique is often reserved for challenging cases where other methods may be less suitable.
The Patient Journey Through Surgery and Recovery
The process of undergoing a urethroplasty begins with pre-operative assessments. Patients meet with their urologist for consultations and undergo diagnostic imaging to map out the stricture. A retrograde urethrogram, an X-ray procedure using contrast dye to visualize the urethra, is commonly used to determine the exact location and length of the narrowing. This evaluation allows the surgical team to plan the most appropriate reconstructive technique.
Urethroplasty is performed under general anesthesia and can last for several hours, depending on the complexity of the repair. The surgeon makes an incision in the perineum (the area between the scrotum and anus), the scrotum, or on the underside of the penis to access the urethra. Following the procedure, patients stay in the hospital for one to two nights for monitoring. A urinary catheter is placed through the newly repaired urethra to drain urine, acting as a stent to allow the surgical repair to heal undisturbed.
Recovery continues at home after hospital discharge, with the catheter remaining in place for two to four weeks. During this period, patients are advised to avoid strenuous activities, heavy lifting, and sexual activity to prevent stress on the surgical site. About two to three weeks after surgery, the patient returns for a voiding cystourethrogram (VCUG). In this test, contrast dye is used to fill the bladder, and X-rays are taken while the patient urinates to confirm the repair is healed and free of leaks before the catheter is removed.
Long-Term Outcomes and Follow-Up Care
Urethroplasty is a highly successful procedure, with reported success rates often exceeding 85-95%, particularly for techniques like EPA for short strictures. Success is defined as the ability to urinate freely without the need for further procedures. These high success rates make it a definitive treatment for urethral strictures, offering a durable solution compared to less invasive options like urethral dilation, which have much higher rates of recurrence.
While the outcomes are positive, some potential long-term effects can occur. The primary risk is the recurrence of the stricture, although this is less common than with other treatments. Some patients may experience post-void dribbling, which is the leakage of a small amount of urine after urination is complete. Changes in the force of ejaculation are also possible, and more rarely, complications can include nerve injury or temporary erectile dysfunction.
Consistent long-term follow-up with a urologist is an important part of post-surgical care. These appointments allow the surgeon to monitor the success of the repair and watch for any signs of potential issues, such as a recurrent narrowing. This ongoing monitoring helps to maintain the long-term success of the urethroplasty and preserve the patient’s quality of life.