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Current Concepts

Current concepts in the management of stricture of the urethra

The treatment of urethral strictures is divided into three categories.

First

Management consists of VIU, Dilation, CIC and Diversion.

VIU (Visual Internal Urethrotomy-to incise the stricture with an endoscope) is advocated for short bulbar strictures only once. The results are bad in penile urethral strictures. And it is not advocated for traumatic strictures.

Dilation (Dilatation-expansion of the urethra with metal or plastic dilators) rarely cures a stricture, and is advised in unfit patients, those who refuse surgery, and after multiple failed urethroplasties.

CIC (CSIC-Clean self intermittent catheterization) There is a trend to ask patients to perform CIC after VIU indicating poor success rate of VIU. This method of treatment is not favored by most urethroplasty surgeons in the world.

Diversion (Bypassing normal passage) like perineal urethrostomy, Mitrofanoff procedure is reserved for multiple failed and compex urethroplasties, in older men.

Second

Cure is possible in most patients for traumatic urethral strictures by excision of the stricture and anastomotic urethroplasty. It is applicable to bulbar urethral trauma and fractured pelvis and ruptured posterior urethra.There is a debate going on about whether to transect or not to transect the bulbar urethra for non traumatic urethral strictures. And the mood is swinging in favor of non transection.

Third

To create stable urethra of normal caliber. We cannot excise long segments of urethral strictures without chordee. For long strictures and those of non traumatic in origin augmentation urethroplasty (patch) with oral mucosa graft is the treatment of choice.

 

Guido Barbagli revolutionized the treatment of long segment urethral strictures by his dorsal onlay graft technique.

We (Kulkarni and Barbagli) described a new technique of one side dissection, dorsal onlay BMG urethroplasty for bulbar, penile and full length urethroplasty. We preserve the neurovascular tissue on one side of the urethra. This new technique is an example of minimal invasive technique of urethroplasty.

Today with only two urethroplasty techniques namely anastomosis and one side dissection we can perform surgery in more than 90% of the patients of stricture of the urethra. Complex cases need variety of procedures fit to be performed in centers of excellence and devoted to the treatment of stricture urethra.

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