Impassable strictures

A stricture which you cannot bougie is a difficult problem. A short traumatic one can be be excised, and the ends of the patient's urethra anastomosed end to end. If however it is the result of inflammation, it is likely to be longer, and to need a formal urethroplasty in at least two stages, in which a new urethra is made with scrotal skin. This is a lengthy and difficult procedure, which many patients will not submit to. Unless a stricture is very short, a urethroplasty is work for an expert urologist, so refer all patients with impassable strictures if you can.

If you cannot refer a patient, you may be able to:

(1) Assist bouginage by putting a finger into his bladder through a cystostomy.

(2) Leave him with a permanent opening between his bladder and the outside (a suprapubic drain or cystostomy). His drain will need to be changed every few weeks (23.7).

(3) Leave him with a permanent artificial opening between his urethra and the outside by doing the first stage only of a Blandy's posterior urethroplasty. This will leave him with a permanent urethrostomy orifice in his perineum, through which he will pass urine ''like a woman'. It will not effect his potency, but he may not like his semen coming out of ''the wrong place'. The first stage is not easy, but is much easier than the second, for which you may be able to refer him. Even the first stage may do him much good, and is much better than a permanent suprapubic drain, which may be the only alternative. It is not easy to get a good channel which will not restenose, and bleeding can be a nuisance. This is one of the operations for a ''careful caring operator' (1.8). You can do it for an impassable stricture anywhere in the urethra, even as high as the verumontanum.

(4) Do a simple urethroplasty if a stricture is short enough. Unfortunately, few strictures are short enough, and relief is likely be temporary only, especially in Africa, because African patients have a particular tendency to make scar tissue.

(5) Do an external urethrotomy with closure, if his stricture is fairly short, and is anterior enough in his membranous urethra for there to be some normal urethra above it. Fortunately, although gonococcal strictures may be long, there is almost always some normal urethra above them. Strictures without normal urethra above them are likely to be the less common traumatic ones of the posterior urethra (see below under ''Difficulties'). An external urethrotomy is: (a) not nearly as good as an expert internal urethrotomy or a urethroplasty, (b) not an easy operation, so try to avoid doing one if you can.

To do an external urethrotomy you will need to find both ends of the stricture, cut down on it, pass a plastic (not rubber) tube through it, and let his urethra heal round this. He will need dilating for life, but he will at least be able to pass his urine through his penis.

You can easily find the distal end of a stricture, by passing a sound down his urethra. Finding its proximal end is more difficult. There are two ways of doing this: (a) You can open the dilated part of his urethra and pass a bougie forwards. If you do this, you cannot go astray in a false passage, and you can find the lumen of the stricture more easily. (b) You can open his bladder and pass a curved C-shaped sound forwards through a cystostomy incision into his urethra.

Stom J H, ''Management of urethral strictures in a rural hospital in Ghana', Tropical Doctor 1982;12:32[nd]34.

IMPASSABLE STRICTURES BOUGINAGE [s7]ASSISTED BY A FINGER IN THE BLADDER This may avoid external urethrotomy, so try it first. Do an open suprapubic cystotomy, and introduce a large urethral sound through the patient's external meatus. With a finger in his bladder, guide the tip of the sound through the stricture. Fix a plastic catheter to the tip of the sound, remove the sound, and draw the catheter into his urethra in a retrograde manner from above.

Fig. 23-12 PERINEAL URETHROSTOMY. This is the first stage of Blandy's urethroplasty. A, the outline of the flap. B, the flap allowed to fall down. C, reflect the patient's bulbospongiosus from his bulbar urethra. D, open his urethra on to a bougie just distal to his stricture. E, oversew his corpus spongiosum to control bleeding. F, inspect his urethra with a nasal speculum, and continue to incise it, until you emerge into healthy mucosa, and can see his verumontanum (his ''veru'). This is normally a cystoscopic landmark, and is a posterior midline swelling in his urethral mucosa. It is just proximal to his external sphincter and his ejaculatory ducts open onto it. G, use a modified atraumatic needle to insert sutures at the edge of his divided urethra. H, how to bend the needle. I, lead 5 sutures through the apex of the flap. J, the top 5 sutures tied, bringing the flap into his opened-out urethra. K, his scrotal skin approximated to his urethra all round.

1, the scrotal flap. 2, his ischial tuberosities. 3, the flap reflected. 4, his bulbospongiosus. 5, his urethra. 6, his bulbospongiosus being incised. 7, the bougie. 8, the sutured edge of his corpus spongiosum. 9, his ''veru'. From Blandy J, ''Operative Urology', Figs. 14.43 et seq. Blackwell Scientific Publications, with kind permission.

PERINEAL URETHROSTOMY, [s7]the first stage only of Blandy's posterior urethroplasty. INDICATIONS. Impassable strictures. You can do a urethrostomy, suitably modified, anywhere in the urethra, even if the stricture reaches as high as the verumontanum.

ANAESTHESIA. General anaesthesia; an erection will increase bleeding.

PREPARATION. Put him into the cystoscopy position to allow access to his suprapubic region. Shave his perineum, and prepare his skin with care.

METHOD. Make an inverted ''U'-shaped scrotal flap with rather a flat apex to end just in front of his ischial tuberosities (A, Fig. 23-12). The key to the operation is access, so the flap must go far back. Cut through his skin and dartos, tying and coagulating vessels as you go, and allow the flap to hang down.

CAUTION ! (1) Allow a generous lining of fat on the flap. (2) Try not to disturb the vessels in its base. (3) Don't use diathermy on the flap, or you may coagulate them.

Pass a 24 Ch bougie down to the face of the stricture, and ask your assistant to hold it in the midline. Feel for it, and dissect down to it, until you see his bulbospongious muscle (B). Dissect the muscle from the bulb and reflect it on either side (C). Cut down on to the bougie (D), and immediately insert a 4/0 continuous catgut suture on either side, to close his spongy tissue and prevent bleeding. Incise until you reach healthy tissue; in a bulbar stricture you may have to cut to within a few millimetres of his ''veru', and you have completely divided the stricture. Cut 1 cm at a time, and control bleeding by continuing your haemostatic stitch down each side of his split corpus spongiosum (E).

CAUTION ! Be sure to carry the incision past his stricture. The only way to be sure about this is to pass your finger past the stricture, to make sure there are no strands of fibrous tissue remaining.

Inspect his stricture and his ''veru' with a nasal speculum (F). Divide all fibrous bands until you see his ''veru'.

Partly straighten a 3/0 chromic catgut atraumatic needle (H). Hold it in a needle-holder, so that it almost points straight ahead, and pass it under the edge of his urethra, until it emerges into the lumen (G). Grasp it with a long needle holder or haemostat and advance it up towards his bladder, until the catgut emerges; then withdraw it backwards. Pass it through the apex of the flap and hold it in a haemostat. Pass 5 sutures like this. Clip each haemostat to the drapes, so that they cannot be muddled up (I). Push the flap towards his bladder. Tie one throw on each knot until it is tight. Reinsert the speculum, and check that the edge of the flap is neatly up against the defect in his urethra, before completing the series of knots. If not, readjust and replace the suture which was at fault. When you are sure the flap is in the right position, put several more throws on each knot, and cut their free ends. Withdraw the speculum and complete the work of sewing in the flap, trimming away surplus skin where necessary (J). Use fine monofilament to bring the edges of his scrotum to the edges of his urethra (K). Leave the catheter in.

POSTOPERATIVELY, give him frequent salt baths (22.1), remove the catheter at 5 days, and the sutures, after premedication, at 14 days. Make sure that there are no cross- adhesions between the suture lines. If a bridge has formed, part it, and ask him to keep the passage open by inserting his finger daily in the bath. If possible, refer him for the second stage at 3 months.

DIFFICULTIES with a Blandy's posterior urethroplasty. Curiously, incontinence is uncommon.

If the TIP OF THE SCROTAL FLAP of a posterior urethroplasty necroses, take it down, trim it and resuture it; there is usually plenty of skin.

If a HAEMATOMA forms, take him back to the theatre, take down the wound, evacuate it, and secure haemostasis. Fig. 23-13 A SIMPLE URETHROPLASTY. A, pass a straight metal sound up to the distal face of the stricture, and a curved one down to its proximal face through the cystostomy wound. B, cut down on the stricture. C, if it is short, sew it up transversely. Kindly contributed by JH Stom.

A SIMPLE URETHROPLASTY INDICATIONS. A stricture [lt]2 cm long.

CONTRAINDICATIONS. A stricture more than [mt]2 cm. One contributor considers even a shorter one is contraindicated, if there is intense fibrosis in an African patient.

METHOD. Do an open suprapubic cystostomy (23.7). Pass a straight metal sound through his external urinary meatus, up to the distal face of the stricture, as above. Open his skin, subcutaneous tissue, bulbocavernosus muscle, and corpus spongiosum at the tip of the sound, over the area of the stricture. A 2.5 cm incision is usually enough.

Pass a curved metal sound through the cystostomy wound, into his urethra, and down to the proximal face of the stricture. Incise his urethra longitudinally between the two sounds.

If the stricture is long, you will have to do an external urethrotomy, as below.

If the stricture is short, sew it up transversely, using 2/0 chromic catgut on a cutting needle, or better ''Vicryl'. Slight traction on the sutures will not jeopardize the end result. Insert a small-bore catheter, and leave it in place for 14 days.

Close the wound in layers. If much pus discharges from the external ostium of his urethra, remove the catheter on the 7th day.

Fig. 23-14 EXTERNAL URETHROTOMY. A, different kinds of strictures as seen on a urethrogram. B, pass Powell's sound in the urethra to find the distal end of the stricture. C, place stay sutures. D, open the bulb of his urethra, by cutting between the stay sutures. E, pass a straight bougie into his bladder. F, pass a bougie forwards to find the proximal end of the stricture. G, pass the tube into his bladder. H, pass the tube down his distal penile urethra by first fixing it to the end of the sound. I, J, and K, if you are not using a self-retaining catheter, anchor the tube ]]like this. After Davey, ''Companion to Surgery in Africa', (1st edn), p. 334. Churchill Livingstone, with kind permission.

EXTERNAL URETHROTOMY INDICATIONS. An impassable stricture.

EQUIPMENT. Make a solution containing lignocaine 2% 20 ml, hyaluronidase (''Hyalase') 1 ml, adrenalin 1/1000 1 ml, and 0.9% saline 80 ml. Even if you operate under general anaesthesia, use this fluid; it is essential for controlling bleeding. If you don't use it, alarming bleeding will obscure the anatomy. Apart from the hyaluronidase, which is not strictly necessary, it is the ''jungle juice' recommended in Primary Anaesthesia (A 5.4). A straight Powell's sound. About 45 cm of 7 mm tube; ideally, silastic, or, less satisfactorily some other plastic. Don't use red rubber[md]it is too irritant. The tube should not be too big[md]about 18, or at the most 20 Ch, so that there is enough space between it and the urethra for secretions to drain. Some surgeons cut small side holes to promote drainage. Alternatively, use a self retaining catheter, and don't sew it in place.

ANAESTHESIA. Use general or local anaesthesia, with the patient well premedicated with pethidine or morphine.

METHOD. Put him into the lithotomy position and pass a Powell's sound, until it meets the anterior end of the stricture (B, in Fig. 23-14).

Start to infiltrate his perineum 3 cm in front of his anus and carry the infiltration well forwards, past the tip of the Powell's sound.

Start to incise 2.5 cm in front of the place where you can feel the tip of the sound, back to a point 5 cm in front of his anus. Cut his deep fascia. Use blunt dissection with scissors in the midline to display the muscles round the bulb of his penis.

The thick spongy tissue of the bulbus spongiosum through which the urethra passes easily slips away from your scalpel, which may stray from the midline. So, before you cut it, anchor it with deep stay sutures, and use them to pull the bulb of his penis forwards on to the knife, which can now cut boldly, exactly in the midline through the median raphe of his bulbospongiosus muscle (C).

As you open his urethra, urine will spurt out (D). If it does not, assist it with a hand on his abdomen. To make sure you have found the lumen, pass a straight bougie into his bladder (E). Withdraw it, and push it gently forwards from the urethral opening, to find and pass through the stricture from behind (F). Divide the stricture by cutting down on this bougie, until there is a clear passage into his urethra anteriorly.

Take the 45 cm lenth of 7 mm tube, pass one end back into his bladder, and the other end forwards out through his external meatus (G). The easiest way to do this is to thread it on to the end of the Powell's sound (H).

This tube must remain in his urethra for 3 weeks. So fix it with a Colt's needle through all the layers of his perineum, and let the needle take a bite of the tube on the way (I, J, and K).

Close his muscle and fascia loosely with interrupted catgut, and his skin with monofilament. Finally, anchor the stitch that you passed through the tube, and prevent it cutting into his skin, by passing it through a short length of plastic tube (K).

Apply a pad and a firm T-bandage for 24 hours to prevent a haematoma forming. Raise his scrotum with strips of broad strapping, and fix it to his thighs to to minimize the swelling that may follow.

Give him a sulphonamide for 7 to 10 days, and make sure that he has a daily fluid intake of at least 3 litres.

At 10 to 14 days, remove all sutures except the one which anchors the tube. Get him up with the tube spigotted for 2 or 3 hours at a time. If he is able to reattend easily, you can now discharge him.

At 3 weeks, cut the anchoring stitch and remove the polythene tube. Pass a large (22 Ch) bougie, and ask him to return for regular dilatation.

CAUTION ! Make sure that he understands that he is not cured, and that he must continue to attend for regular dilatations for the rest of his life.

DIFFICULTIES [s7]WITH EXTERNAL URETHROTOMY If there is a STEADY OOZE from the cut surfaces of his cavernous tissue, after he has returned to the ward from a urethrotomy, you may need to take him back to the theatre, reopen his wound and search for the bleeding point. Pack it with dry or haemostatic gauze.

If his STRICTURE IS SO HIGH in his urethra that you can find no normal urethra above it (rare), it is probably a TRAUMATIC STRICTURE. If you cannot refer him, he will have to live with a permanent suprapubic cystostomy (23.7).

Fig. 23-15 STONES IN THE URINARY TRACT. A, a stone jammed in a calyx causing hydrocalyx. B, the parenchyma over the dilated calyx has atrophied. C, a staghorn calculus has formed, and there are several stones elsewhere in the kidney. D, a stone has impacted at the pelviureteric junction. E, the calyces have dilated. F, the stone has been removed, but not before the patient's kidney has been severely damaged by obstruction and infection. G, a stone in the ureter causing loin pain, segmental referred pain, haematuria, and frequency. H, a bladder stone with squamous metaplasia ending in carcinoma (rare in Africa). I, a stone in the urethra. After Blandy J, ''Operative Urology'. Blackwell Scientific Publications, with kind permission.