Dealing with sub-meatal urethral stricture: meatoplasty and dilation (related: fossa navicularis strictures)

Note: my surgery was for Rigid Cystoscopy and Optical Urethrotomy (direct visual internal urethrotomy – DVIU).

EVEN IF MY SURGEON HAD DONE A DVIU DURING RADICAL PROSTATECTOMY, THIS ISSUE WOULD HAVE REMAINED A LIFELONG ISSUE

When urethral strictures are identified at the time of catheter placement for another surgical procedure, assessment of the need for catheterization should be made. [Source: Male Urethral Stricture: American Urological Association Guideline] 

Urethral strictures may be dilated in this setting [when a stricture is suspected during surgery]to allow catheter insertion, and dilation over a guidewire is recommended to prevent false passage formation or rectal injury. Alternatively, DVIU may be performed, particularly if the stricture is too dense to be adequately dilated. SP cystotomy may also be performed to provide urinary drainage at the time of surgery if these initial maneuvers are unsuccessful, or when subsequent definitive treatment for urethral stricture is planned in the near future. [Source: Male Urethral Stricture: American Urological Association Guideline]

[Sanjeev: My surgeon felt something blocking the catheter during the prep for the prostatectomy. He did not do dilation or DVIU at that stage but moved on with the prostatectomy. I understand that using a large cathether is essential for such a surgery. In my case the goal of fixing the bigger issue – cancer – led to a secondary injury that is going to remain with me lifelong. EVEN IF HE HAD CONDUCTED A DVIU AT THAT STAGE, THE SITUATION I NOW HAVE WOULD HAVE BEEN UNCHANGED. Therefore, there was NO WAY to avoid what I’ve now got.]

URETHROTOMY IS GUARANTEED TO FAIL

After 1 urethrotomy Pansadoro and Emiliozzi found a 5-year stricture-free survival rate of 6%, which closely matched our 5-year stricture-free survival rate of 7%. Treatment eventually failed in all 7% of the patients by 79 months. [Source] – i.e. 100 PER CENT RECURRENCE WITHIN FIVE YEARS, WITH MOST RECURRING WITHIN 3-6 MONTHS.

The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. [Source]

RECOMMENDATION: NO MORE THAN ONE URETHROTOMY

“During the last 30 years urethroplasty has improved in efficacy and safety, while urethrotomy is increasingly considered neither cost-efficient nor effective in the long term. Urethroplasty is reported to have lifetime success rates ranging from 75% to 100%. Repeat and unsuccessful urethrotomies impose costs to the patients in the form of lost wages, unnecessary health care expenditures, decreased quality of life and unnecessary anesthesia. The fact that urethrotomy has a low success rate is a strong argument for opting for the more effective urethroplasty instead of a less effective urethrotomy.” [Source]

NOTE: THIS ISSUE IS NOT STENOSIS!

It is hard to get information on this issue from the internet. First thing to note is that it is quite different to meatal stenosis, which is a narrowing of the opening (this is how it looks). “Meatal stenosis is a common complication of circumcision.” Curing stenosis is relatively easy and is done through a surgical procedure called meatotomy during which the meatus is crushed with a straight mosquito hemostat and then divided with fine-tipped scissors. (here is a video of how it is done]

WHAT A MEATAL (or fossa navicularis) STRICTURE LOOKS LIKE?

What it looks like – picture.

Causes

It appears this issue was very common with prostatectomies in the past (Some Common Complications After Prostatectomy, J. Cosbie Ross and L. F. Tinckler, The British Medical Journal, Vol. 2, No. 5153 (Oct. 10, 1959). The issue still occurs in around 2 per cent of the patients.

Male Urethral Stricture: American Urological Association Guideline (2017)

Male Urethral Stricture: American Urological Association Guideline (full guideline needs online journal access) says that uncomplicated urethral stricture confined to the meatus or fossa navicularis should be treated with simple dilation or meatotomy, with or without guidewire placement.

However, urethroplasty is needed for to patients with recurrent meatal or fossa navi­cularis strictures. Meatal and fossa navicularis strictures refractory (i.e. stubborn to) to endoscopic procedures are unlikely to respond to further endoscopic treatments (e.g. Urethrotomy).

Patients who opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment, such as ure­throplasty should be advised that success of a sub­sequent reconstructive procedure may be lower when following a plan of repeated endoscopic surgery and/ or intermittent self-dilation. Similar to other types of stricture, exact delineation of length and etiology is important for guiding treatment.

Dilation is a bad idea. In my case, when the stricture recurs, I should undergo urethroplasty (or whatever the term is called).

TREATMENT OPTION 1: DILATION [not recommended]

Pictures of Dilation of the Urethral Meatal Stricture

INTERMITTENT SELF MEATAL DILATATION – AN INFORMATION LEAFLET, January 2017

What are the Treatments for Meatal Stricture / Meatal Stenosis? [Sanjeev: these are quite different things]

• Intermittent self meatal dilatation – In some men it is possible that the narrowing of your urethra may re-occur. To reduce this risk you may be taught how to perform intermittent self meatal dilatation. [Sanjeev: it appears it will recur in almost all cases, and instead, aggravate things.]

What is Meatal Dilatation? Meatal Dilatation is a procedure which involves you passing a short catheter into the end of your urethra. The catheter is passed beyond the narrow section and this helps to keep the urethra open.

What Are The Alternatives?

• Meatal dilatation – If your urethra is not too narrow, it can be dilated or stretched in theatre under local anaesthetic or a general anaesthetic (when you are put completely to sleep) using catheters (soft, hollow plastic tubes) which are graduated in size.
• Meatotomy – A small operation to stretch or cut through the narrow tissue in your urethra may be necessary. This is called a ‘meatotomy’. Occasionally an additional procedure called circumcision (removal of the foreskin) may be necessary if repeated infections and inflammation (balanitis) at the tip of the penis has resulted in a tight foreskin. [Sanjeev: this is – as described – ONLY meant for a stenosis; not applicable in my case]

What are the risks of Meatal Dilatation?

• Pain. At first it may be a little painful or uncomfortable to pass the catheter, especially if you have had recent surgery. This, however, should improve with time and most men are able to tolerate the procedure with little discomfort.
• Bleeding. You may see a little blood on the end of the catheter after performing the procedure or experience a little bleeding from the urethra. This is nothing to worry about and should soon stop. If the bleeding becomes heavy and prolonged then contact your healthcare professional. [Sanjeev: actually bleeding is a BAD thing during dilation, as it will simply aggravate scarring]
• Infection. It is important to wash your hands and penis before performing meatal dilatation so that no bugs are passed up into the bladder. However, if you experience pain or burning when passing urine, notice that your urine is cloudy or smelly or, especially, if you start to feel unwell (i.e. high temperature, abdominal pain or flu like symptoms), contact your GP or healthcare professional immediately as you may have a urine infection.
• Recurrent Stricture If you notice a reduction in your flow of urine or if it becomes difficult to pass the catheter into the urethra, it may be because the narrowing has re-occurred. If this happens seek advice from you healthcare professional. [Sanjeev: This is STUPID. The advice should be provided upfront, including discussion of all risks]

General Advice

• For how long and how often should I perform Meatal Dilatation? As everyone is different, a personalised regime will be agreed between yourself and your healthcare professional as to how often and for how long you should perform the procedure.

Dilatation catheters
These are usually sterile hydrophilic coated single use catheters with NO drainage eyes. They are used for keeping the urethra patent in patients with strictures or who have had surgery to the urethra. Dilatation catheters will not drain the bladder. Shorter length meatal dilators are available for men who need only to dilate the meatus to avoid meatal stenosis, or to dilate a sub-meatal stricture. If the stricture is higher in the urethra then a full length dilatation catheter (40cm) will be needed. [Source: Trust Guideline for the Management of Teaching Clean Intermittent Self-catheterisation (CISC)]

DILATION IS NOT A GREAT IDEA

Treatment approach to pre-TURP urethral strictures:

– Meatal/sub-meatal stricuture: Do a formal meatotomy instead of excess dilation

Source: Common Urologic Problems: Benign Prostatic Hyperplasia By Sujata Patwardhan

NOT RECOMMENDED

“For urethral strictures in the penile urethra to the bulbar urethra, dilation is not recommended.” [Source]

CAN DILATION WORK IN SOME CASES? – UNLIKELY

It is said in the Male Urethral Stricture: American Urological Association Guideline that stricture recurrence is significantly lower among patients performing self-catheterization. Data suggests that performing self-catheterization for greater than four months after DVIU reduced recurrence rates compared to performing self-catheterization for less than three months. [Sanjeev: I find this hard to believe – given the study which showed that RECURRENCE IS GUARANTEED WITH DVIU – see this study].

TREATMENT OPTION 2: MEATOPLASTY/ URETHROPLASTY – fixes 90 per cent of the time

URETHROPLASTY CAN FAIL IF YOUR SURGEON IS NOT EXTRAORDINARLY COMPETENT

” the success of open urethroplasty is very dependent on the surgical technique and the expertise of the surgeon. When urethral surgery is not properly performed, early recurrence of the stricture is a very common complication. … Although stricture recurrence is always a possibility, even when the surgery is performed by a qualified experienced specialist, recurrences more commonly occur when surgery is performed by urologists not exclusively specialized in male urethral and penile reconstructive surgery. When the surgery is not properly performed, failure is an expected outcome.” [Source]

NOTES

Note that this is different from the ear meatoplasty! And note that is is not meatotomy, although some doctors use the terms interchangeably.

ONE-STAGE MEATOPLASTY IS POTENTIALLY AN OPTION IN MY CASE

SUB-MEATAL STRICTURE SOMETIMES REQUIRES TWO STAGE SURGERY

“For the most complex strictures of the anterior urethra, including the urethral meatus, a staged surgical approach is adopted, removing the stricture then placing a graft in the open space. This is allowed to heal open to the air for a period of 6-12 months, before it is “re-tubularized” into a urethra. This is usually reserved for individuals with strictures in the pendulous urethra, very scarred strictures, repeated failures, and very long strictures.” [Source]

A TEN PERCENT RECURRENCE RATE EXISTS EVEN FOR URETHROPLASTY

“Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate.” [Source]

The surgical technique of Meatoplasty is generally suggested in patients with meatal urethral strictures. There are three basic types of Meatoplasty [Source] This is perhaps the best description.

• Meatoplasty using skin flap. Using this technique, the urethral meatus is augmented using a penile skin flap (figure 1).

• Meatoplasty with oral mucosal graft. Using this technique, the urethral meatus is augmented by a transplant of an oral graft (figure 2).

• Meatoplasty with skin graft. Using this technique, the urethral meatus  is augmented by a transplant of a skin graft.

Jordan Flap Meatoplasty – a lot of details here.

DETAILS – IN A PAPER: Meatoplasty using double buccal mucosal graft technique – Apul Goel, Anuj Goel, Diwakar Dalela, Satya N. Sankhwar, International Urology and Nephrology, December 2009, Volume 41, Issue 4, pp 885–887

Glanular/meatal stricture can be seen as an isolated problem or as part of more extensive urethral stricture disease. Various treatment options are available, including penile flap and buccal mucosa, for the treatment of stricture at this location