What is it?
An operation to correct a urethral stricture, which is a tight narrowing of the urethra (water passage). This may be due to scarring from prior vaginal surgery, trauma, longterm catheter, radiotherapy, or no cause may be identified. A urethroplasty may be required if other less invasive treatments such as urethral dilatation, urethrotomy or catheters have failed. A urethroplasty can also be used to reconstruct a severely damaged or short urethra.
What are the symptoms of a urethral stricture?
Symptoms of obstructed voiding, such as a weak slow dribbling flow of urine, or incomplete emptying of the bladder, or a frequent and urgent need to pass urine. They can be a source of recurrent urine infections or cause pain when passing urine.
What tests might be required?
A urine test for infection, a cystoscopy, and fluoroscopic urodynamic studies or a voiding urethrogram (an x-ray while passing urine). An MRI scan may be required to exclude other causes of your symptoms.
What does a urethroplasty involve?
The procedure is performed through a vaginal incision. It involves cutting the scarred tissue, and bringing in healthy tissue, so that after healing the channel will be wider.
How we do this depends on the location, length and severity of the stricture.
If the stricture is limited to the opening of the urethra, then a flap of healthy vaginal skin can be made and sutured in to the scarred tissue. If the stricture is longer and extends up the urethra towards the bladder then a vaginal flap may not reach far enough. An alternative tissue which can be used in this case may come from the lining of the mouth, called a ‘buccal graft’. A piece of this tissue can be taken from the inside lining of the cheek, and sutured into the urethra. This tissue is very useful as it is used to being wet and dry, the mouth heals very well, and there is plenty of tissue available.
If there is also stress incontinence sometimes a procedure is performed at the same time to correct this. Sometimes tissue from within the labia is used to support and protect the urethra. This is called a ‘Martius labial fat pad graft’.
A catheter is left in the urethra, and sometimes a suprapubic catheter (through the abdominal skin) is also needed. A vaginal pack helps to reduce bleeding. You may have a small drain to remove excess blood.
Will it work and for how long?
Most women (85%) are relieved of their presenting symptoms and around 15% can recur.
How long does the operation take?
Around two to three hours, depending on the complexity of the surgery and whether any other procedures are required.
What is the usual post-operative course?
The vaginal pack is removed the following day. Any wound drain is removed after 1-2 days. The catheters remain in for 1-3 weeks to allow the repair of the urethra to heal. Most patients can manage to empty the catheter bag themselves and can go home 1-2 days after surgery. When ready for the catheter to be removed patients may be readmitted or seen in the continence clinic. A contrast X-ray is performed to ensure the urethra has healed and if so the suprapubic catheter is also removed once you are passing urine well.
Other instructions for when you go home.
It takes about 1-2 weeks to return to normal activity. It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 2-4 weeks. You will usually need to wait 6 weeks form surgery before you can have sexual intercourse or use tampons or pessaries. This recommendation can vary on how complex the surgery was and you will need to check with your surgeon. Following discharge paracetamol and antiinflammatories are usually all that is required for pain relief. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day).
If a buccal graft has been required this is usually the most uncomfortable part. To reduce swelling try to rest propped up on pillows rather than flat. You can eat and drink anything you like; you may prefer cool fluids. Mouth washes of salty water or a mouthwash containing chlorhexidine may be soothing. Expect the area to look yellow and have a particular smell, which on first impressions may appear infected, however true infections of the mouth wound are rare. Your surgeon will check this area regularly.
What are the risks and complications?
- Recurrence: There is a risk of failure to correct the stricture or that the scarring process progresses, in which case the stricture can recur and require further treatment, such as catheters, dilatation, or further surgery. Overall risk of recurrence is about 15%.
- Incontinence: There is a 20-30% risk of developing urinary incontinence, as the stricture may have involved the urethral sphincter. You may need to wear pads after the surgery. This may even require another subsequent surgical procedure to correct.
- Fistula: Failure of the urethra to heal can result in a communication between the urethra and vagina (a fistula), causing urinary leakage from the vagina and requiring further surgery.
- Bleeding: The risk of bleeding is small and the risk of requiring a blood transfusion is very small
- Infection: There is a small risk of urine infection or infection in the wound.
- Damage to surrounding structures like the bladder and ureter is a small risk, which could require further surgery to repair.
- Irritative bladder symptoms or urgency may persist, needing medication to control.
- Chronic pain, or difficulty with intercourse is a small risk
- If a Martius labial fat pad is performed, uncommon problems reported following this include pain with intercourse, intermittent discomfort at the wound, numbness, or altered appearance of the labia.
- If a buccal graft is used the donor site (mouth) can be painful, swollen, bleed, or rarely become infected. As above, expect the area to look yellow and have a particular smell, however true infections of the mouth wound are rare. Eating and drinking may be difficult initially. In the long term there may be problems with increased or decreased sensitivity or numbness of the cheek or lip, reduced saliva production, or difficulty opening the mouth widely.
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
There are also general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses associated with surgery. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke). There is a small risk of death; less than 5 in 10,000.
You will be given a follow up appointment.
If you experience any of the following problems after discharge you should contact your surgeon’s rooms or seek other medical attention;
- Severe pain not controlled with pain killers
- Wound problems – infection or breakdown
- Inability to pass urine or a catheter if required
- Or any other significant trouble.
If at any stage in the future your symptoms return you should arrange a review visit.
Version: V2, July 2013