Urethral Replacement

Urethral replacement surgery

The urethral replacement surgery is a reconstructive surgery that is done to substitute a damaged or severely scarred part of the urethra. This is often done when the urethral stricture is long, recurrent or when it is not amenable to simple excision and primary anastomosis (EPA). It is among the most progressive surgeries in urethral reconstruction.

Indications of Urethral Replacement

It is recommended when:

• Long urethral stricture (more than 2 cm or more than 3 cm based on its location)
• Lichen sclerosus-associated strictures.
• Pan-urethral stricture
• Postoperative urethrotomy/dilation/urethroplasty failure.
• Extreme trauma with loss of urethral tissue.
• Repairs of hypospadias fail.
• Gonadal fistula or fallopian tubes.

Urethral Replacement Techniques

Surgeons selected one of the following depending on the stricture length, location (bulbar, penile, membranous) and cause:

Buccal Mucosal Graft (BMG) Urethroplasty

• The most prevalent and the most accepted gold standard
• They are grafted onto the urethra by using tissue that is taken off the inside of the cheek of the mouth.

Approaches:

• Dorsal onlay BMG
• Ventral onlay BMG
• Lateral onlay
• Two-stage BMG urethroplasty (in very complicated cases)

Penile Skin Flap (Local Skin Flap) Urethroplasty

• It is a strip of skin of the penis (foreskin/penile shaft) with no hair.
• Indicated in penile strictures that are long or in cases where BMG is not sufficient.

Two-Stage Urethral Replacement (The Method of Johanson)

Used for:

• Lichen sclerosus
• Previously failed repairs
• Severe scarring
• Stage 1: Opened diseased urethra and graft on it.
• Stage 2 (above 6-9 months): Urethra is tubularised.

Preputial Skin Graft

• Foreskin skin is grafted on the skin.
• Common in pediatric cases.

Full-thickness Skin Graft or Thigh Skin Graft

• Applied in the case of unavailability of oral and penile grafts.

Urethral Replacement (Advanced) Tissue-engineered

• Includes lab-grown grafts.
• In its early stages and not popular.

Urethral replacement procedure

Urethral replacement or substitution urethroplasty is a reconstructive surgery in which a section of the urethra that has become damaged is replaced with a graft or flap. Buccal mucosa (inner cheek) is the most widely used tissue.

Pre-Operative Preparation

Prior to the surgery, the patient is subjected to:

Required Tests:

• Retrograde urethrogram (RUG)
• Voiding cystourethrogram (VCUG/MCUG).
• Uroflowmetry
• Urine culture
• Blood tests
• Sometimes cystoscopy

Pre-surgery instructions:

• Stop anticoagulants (doctor prescribed)
• Fast 6–8 hours before surgery
• Treat UTI if present
• Recommended oral hygienic in case of cheek graft.

Anaesthesia & Positioning

• The most common is general anaesthesia.
• Patient is put in the lithotomy position (raised legs).

Exposure of the Urethra

• Depending on stricture location, a small incision is made on the perineum (between the scrotum and anus) or penile.
• The identification and opening of the urethra are made on the diseased part.

Assessment of the Stricture

The surgeon evaluates:

• Stricture length
• Tissue around it Quality.
• One stage repair or two stage repair.
• In case of a very long stricture or lichen sclerosus stricture, a two-step operation can be scheduled.

Harvesting the Graft

In case of buccal mucosa graft:

Harvesting Buccal Graft

• Cheek is stretched
• A section of mucosa of the inner cheek is removed.
• Salivary tubes are retained.
• The region is sutureed or allowed to heal.
• When other tissues are availed (penile skin, preputial, thigh skin), the same steps are carried out in their areas of source.

Graft Placement / Urethral Replacement

Two major techniques exist:

Onlay Urethral Replacement (Most common)

• Applied in case of opening the urethra and leaving it unremived.

Steps:

• Malady urethra is longitudinally opened.
• The graft is attached on the dorsal, ventral or lateral side.
• The edges of the grafts are sewed to the urethral mucosa.
• Blood supply is offered by the surrounding tissues.
• This dilates the urethra without IAC removing the whole segment.

Complete replacement (Tubularized Graft Replacement).

• Applied in case of a long segment that is missing or badly damaged.

Steps:

• A long graft is cut into the shape of an oval.
• It is enwrapped to a catheter forming a tube.
• The tube leads to the healthy ends of the urethra.
• This is complete replacement, and is applicable to very complicated strictures.

Catheter Placement

• A Foley catheter is placed and maintained between 2 and 3 weeks.
• In other instances a suprapubic catheter (SPC) can be retained.

Closure

• Suturing of muscles and tissues back is done.
• The skin is sewed with absorbable stitches.

Post-Operative Care

Hospital Stay:

• 2–4 days

Recovery Guidelines

• Catheter remains for 2–3 weeks
• Urethrogram of pericatheter is performed prior to removal.
• Heavy lifting should be avoided in 4-6 weeks.
• Avoid intercourse for 6–8 weeks
• Mouth healing (when cheek graft) requires 7-10 days.

Medications

• Antibiotics
• Pain relief
• Mouthwash: anti-inflammatory (BMG patients only)

Follow-Up Tests

• Uroflowmetry
• RUG/VCUG
• Sometimes cystoscopy
• Conducted at 3, 6 and 12 months postoperative.

Success Rate

• Depending on the cause, length and skill of the surgery, most urethral replacement surgeries have a success rate of 85-95%.

Buccal mucosal graft urethral replacement

• Buccal mucokal graft urethral replacement is a reconstructive surgery in which a surgeon replaces a scar or constriction of the urethra with tissue removed off the inner cheek lining (buccal mucosa).
• It is believed to be the standard of long or complicated urethral strictures.

BMG is chosen due to the fact that cheek mucosa is:

• Hairless
• Weaknesses: Resistant to wet conditions.
• Highly elastic
• Has excellent blood supply
• Heals quickly
• Low complication rate

BMG Urethral Replacement indications

This process is advisable in cases where:

• Stricture is long (>2–3 cm)
• Repeat of strictures following dilation or urethrotomy.
• Penile, bulbar or pan-urethral strictures.
• Lichen sclerosus cases (typically the cases with the repair in stages)
• Traumatic or infectious stricture.
• Redo urethroplasty (also known as failed hypospadias repair).

BMG Urethral Replacement

Dorsal onlay BMG (Most Preferred)

• Graft is put over urethra on the upper (dorsal) side.

Ventral Onlay BMG

• Graft is applied in the lower part (ventral side).

Lateral Onlay BMG

• Graft over urethra side.

Two-Stage BMG Urethroplasty

• In the case of severe scarring, lichen sclerosus, or penile strictures.
• Stage 1: Opening of urethra and grafting
• Stage 2: urethra is tubularised after 6-9 months.

Factors Affecting Urethral replacement surgery cost India

The following are some of the critical aspects, which influence the price of urethral replacement/urethroplasty surgery in India:

Stricture/ Procedure Type Complexity

• Elongated strictures, pan-urethral involvement, repeated failures necessitate more radical surgery (e.g., grafts/flap, two-stage repair) → more expensive.
• Easy short strictures that are corrected through primary anastomosis are cheaper.
• According to sources, complexity is greater in cost. 

Graft/Flap Use and Donor Site

• The graft (buccal mucosa) or skin flap will increase the cost due to the addition of donor site preparation, increased operation time, and increasing the number of consumables used.
• A graft-less repair is comparatively less complex.

Expertise in Surgeon and Hospital Infrastructure

• Reconstructive urologists who are highly qualified charge higher.
• Advanced infrastructure of a hospital which is either corporate or private is more expensive than the small centres. 

Hospital Location & Category

• Big cities such as Delhi, Mumbai, Bangalore have a higher cost than the small cities. 
• The multi-specialty hospitals that are privately owned incur higher costs than government or smaller hospitals.

Pre-operative Investigations & Diagnostics

• Such tests as retrograde urethrogram, MCU, cystoscopy, uroflowmetry should be performed. Additional work-up is also more expensive. 

Length of Hospital Stay & Post-operative care

• Increased stay (particularly due to complications) and increased resources after the operation increase expense.
• Contributions include donor site (cheek) care, catheter management, follow up visits.

Room / Accommodation Type and Consumables

• Room selection (general ward or private deluxe) will not be the same.
• Special consumables (grafts, flap instruments) are also expensive.

Problems or Supplementary Procedures

• In case of complications or in case of some extra operative procedure (e.g., flap revision, redo urethroplasty), the cost increases. 

Patient Factors / Comorbidities

• The comorbidity conditions, prior surgeries, infection or scarring are risk/time and cost increasing factors.
• The complexity may be affected by age and overall health of patient.

Best hospital for urethral replacement India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Urethral replacement surgery recovery time

The recovery is dependent on the kind of urethral reconstruction, length of stricture, graft/flap applied and health of patients. The following is the common schedule that is undertaken.

Hospital Stay

• 2–4 days
• Monitoring urine flow
• Pain control
• Mouth care (in case of buccal mucosa graft)
• Initial wound observation

Catheter Duration

• 2–3 weeks
• A Foley catheter remains to help the urethra to heal.
• There are also patients with a suprapubic catheter (SPC).
• A pericatheter urethrogram (X-ray dye test) is performed before a catheter is removed to ensure that it heals.

Pain & Mobility Recovery

• 2–4 days: Walking allowed
• 1–2 weeks: Pain greatly reduces
• Cheek graft healing: 7-10 days (in patients of BMG)

Daily Activity Recovery

• 4–6 weeks

Avoid:

• Heavy lifting
• Strenuous exercise
• Cycling or bike riding
• Long sitting sessions
• Pressure on perineal area
• The majority of patients are able to resume their work at the desk in 2-3 weeks, comfortably.

Sexual Activity

• 6–8 weeks
• Until your urologist confirms full healing of the urethra, sexual intercourse is to be avoided.

Full Urethral Healing

• 8–12 weeks
• The healing of internal wounds is longer compared to external wounds.
• Flow stabilizes gradually.

Extended Recovery Following ATC

Up to 1-2 months

Follow-ups include:

• Uroflowmetry
• RUG/MCU if needed
• Physical exam
• Symptom assessment
• The majority of patients are fully healed in 2-3 months and they are chronicled to follow-up to ensure that urethra is healthy.

Conclusion

The urethral replacement surgery is an advanced and effective method of reconstructing the urethra of patients with long, complex and recurrent urethral strictures, which are not curative under simple procedures. Buccal mucosal graft (BMG) urethroplasty, skin flaps, and two-stage repairs are the techniques that offer long term and long-term outcomes with success rates of 85-95. Most patients can resume normal urinary function and quality of life with proper follow-up although recovery process will entail a short hospitalization, 2-3 weeks of catheterization and several weeks of healing. The total price will vary depending on the severity of stricture, surgical procedure, hospital facility and the experience of the surgeon. Urethral replacement surgery has an overwhelming success rate, few long-term side effects, and an improved urinary stream in most patients because modern reconstructive urologic modalities and skilled surgeons have provided a superior solution.

Urethral replacement surgery India GetWellGo

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FAQ

Is the surgery painful?

• The pain is mild to moderate and is treated using drugs.
• The discomfort of cheeks (under the condition of BMG use) takes several days.

How long is the catheter kept?

• Typically 2–3 weeks.
• Before it is removed a dye test (urethrogram) is performed.

Will the procedure of removing tissue off my cheek impact on speaking or eating?

• Only temporarily
• A majority of the patients resume normal speech and feeding in 1 week.

Does stricture relapse following urethral replacement?

• Repetition is not common but possible.
• The majority of occasions are during the initial 6-12 months.

Is this surgery associated with fertility or erections?

• Generally no
• Erectile impotency is infrequent and normally elastic in case it happens.