Editing Penis and Urethra Surgery (section)

=== Management ===

==== Options (4): ====
# '''<span style="color:#ff0000">Dilation</span>'''
# '''<span style="color:#ff0000">Direct Visual Internal Urethrotomy</span>'''
# '''<span style="color:#ff0000">Urethral stent</span>'''
# '''<span style="color:#ff0000">Urethroplasty</span>'''

===== Dilation =====
* '''<span style="color:#ff0000">Goal of this treatment, a concept that is frequently forgotten, is to stretch the scar without producing more scarring.</span>'''
** If bleeding occurs during dilation, the stricture has been torn rather than stretched, possibly further injuring the involved area.
** '''The practice of blind passage of filiforms and blind dilation without knowledge of the anatomy of the urethral stricture is condemned.'''
* Dilation can be curative and has short-term and mid-term efficacy rates equal to internal urethrotomy based on retrospective analysis, though there has been no RCT comparing the two.

===== Direct Visual Internal Urethrotomy (DVIU) =====
* '''<span style="color:#ff0000">Involves incision through the scar to healthy tissue to allow the scar to expand and the lumen to heal enlarged.''' 

====== Technique ======

*'''<span style="color:#ff0000">Usually, a single incision is made at the 12 o’clock position.'''
** '''However, the 12 o'clock position might be questioned based on the location of the urethra within the corpus spongiosum.'''
*** Although the anterior aspect of the corpus spongiosum is thicker, a deep incision in the more distal aspects of the anterior urethra will certainly enter the corpora cavernosa, and these incisions have been associated with the creation of erectile dysfunction.
*Normal saline should be used as the irrigant
*To date, the results of laser urethrotomy are mixed.

====== Adverse events ======
# '''<span style="color:#ff0000">Recurrence of stricture (most common complication).</span>'''
#* Studies have shown that the failure rate of long-term catheterization after internal urethrotomy is similar to that seen with 3-7 days of catheterization
# <span style="color:#ff0000">'''Bleeding (almost always associated with erections immediately after the procedure)'''</span>
# <span style="color:#ff0000">'''Extravasation of irrigation fluid into the perispongiosal tissues'''</span>
# <span style="color:#ff0000">'''Erectile dysfunction'''</span>
# <span style="color:#ff0000">'''Decreased success rate of reconstruction'''</span>
#* Many studies have shown that the success of reconstruction is diminished by multiple prior urethral dilations and internal urethrotomy
===== Urethral stent =====
* '''Contraindications to the use of the UroLume:'''
** '''Prior substitution urethral reconstruction, particularly where skin has been incorporated into the urethra'''
*** Contact of the stent with the skin is associated with a virulent hypertrophic reaction.
**Poor candidates for the UroLume includes patients with strictures associated with deep spongiofibrosis.
*** Patients who fall into this category have had urethral distraction injuries and straddle injuries associated with deep fibrosis.
* '''Technique'''
**'''Must be placed only in the bulbar urethra'''
*** When placed beyond the area of the scrotal urethra, placement has been associated with pain on sitting and intercourse.
*** Some patients (particularly young patients) complain of perineal pain, often with vigorous activity, even after implantation of the stent in the deep bulbous urethra.
*** Longer bulbous strictures require two stents that are overlapped. These stents can migrate away from each other, leaving a gap between them where recurrence of stricture is inevitable. When this occurs, the stricture recurrence is excised, and a third stent is placed to span the gap.
**UroLume has been taken off the market and is currently not available for implantation.
* Adverse Events
**Permanently implantable stents, such as UroLume are associated with unique complications.
**However, there are still many patients who will present with UroLume stents, and many will need treatment.

===== Open reconstruction: excision and reanastamosis =====

====== Technique ======

*The best results are achieved when the following technical points are observed:
** The area of fibrosis is totally excised
** Urethral anastomosis is widely spatulated, creating a large ovoid anastomosis
** Anastomosis is tension free
* '''<span style="color:#ff0000">Position: lithotomy'''
*'''Steps to gain urethral length:'''
*# '''Vigorous mobilization of the corpus spongiosum'''
*# '''Development of the intracrural space and detachment of the bulbospongiosus from the perineal body'''
* '''When the length of stricture precludes total excision of fibrosis with primary anastomosis, tissue transfer in the form of graft or flap is required.'''
** '''Tubularized grafts and skin islands should be avoided, if possible.'''
*** Onlay procedures (graft or flap) are associated with a higher success rate than tubularized grafts or tubularized skin islands.
** '''Excision with primary anastamosis should be avoided in patients with a history of hypospadias repair due to expected altered or absent retrograde blood supply to the urethra through the normal arborization in the glans'''
* It is imperative to evaluate the urethra completely proximal and distal to the stricture with endoscopy and bougienage during surgery to ensure that all the involved urethra is included in the reconstruction.

====== Adverse Events ======
* '''<span style="color:#ff0000">Intraoperative</span>'''
*'''<span style="color:#ff0000">Post-operative</span>'''
**'''<span style="color:#ff0000">Late post-operative</span>'''
***'''<span style="color:#ff0000">Sexual dysfunction</span>'''
***# '''<span style="color:#ff0000">Permanent ejaculatory dysfunction</span>'''
***#* '''May occur in as high as 20% of men following urethroplasty.'''
***#* Complaints are usually related to pooling of semen within the urethra and/or loss of force with ejaculation. The etiology is poorly defined but is presumed to be due to either tortuosity of the neourethra and/or dysfunction of the bulbocavernosal muscle.
***# '''<span style="color:#ff0000">Temporary erectile dysfunction</span>'''
***#* Found in up to 20% of individuals undergoing an anterior urethroplasty.
***#** This incidence is similar between all types of anterior urethroplasties, e.g., excision and primary anastomosis, vascularized or graft urethroplasties.
***#** The erectile dysfunction symptoms classically resolve 6 six months with < 3-4% of patients reporting a permanent alteration in their erectile capabilities.
***#*** Overall, the rate of erectile dysfunction after urethroplasty was ≈equal to the rate after circumcision.
***#** Longer-segment reconstructions were associated with a higher risk of postoperative erectile dysfunction, although the patient’s erectile function improved over time in many cases.
***# '''<span style="color:#ff0000">New onset of penile curvature</span>'''
***#* May occur usually following an overaggressive attempt at excision and primary anastomosis performed in the distal bulbar region.
***# '''<span style="color:#ff0000">Loss of libido and anorgasmia</span>'''
***#* Very rare and are predominately due to a psychological component.