Urethral Resection Anastomosis

Urethral resection anastomosis procedure

The following is a good, systematic description of the process of Urethral Resection and Anastomosis (URA) surgery, which is usually used to treat short-segment urethral strictures with the exception of one through the bulbar urethra.

Pre-operative Evaluation

• Uroflowmetry - to determine urine flow.
• Retrograde urethrogram (RUG) -in order to estimate the stricture length.
• Voiding cystourethrogram (VCUG) - to assess proximal urethra and bladder.
• Urine culture - cure infection preoperative.
• Blood analysis, anaesthesia clearance.
• Success rate counselling and recovery counselling.

Urethral Resection and Anastomosis Surgery: Stepwise

Anaesthesia & Positioning

• General/spinal anaesthesia.
• Lithotomy position of patient.
• Shaved and cleansed perineal region.

Perineal Incision

• Midline perineal incision is done.
• The muscle of the bulb is separated.
• Bulbar urethra is exposed

Mobilisation of Urethra

• The strictured segment is recognized.
• Mobilization of urethra is done cautiously without causing blood loss.

Excision of Stricture

• The thin layer is completely peeled off.
• Terminals of urethra freshened.
• Length measured to take note of whether the defect is tension-free to anastomosis.

End-to-End Anastomosis

• Fine absorbable sutures should be used.
• The two healthy urethral ends are hooked in a circular fashion.
• Through the repair, a Foley catheter (14-16 Fr) is inserted.
• Suturation is made over the catheter to be in place.

Closure

• Bleeding controlled
• Muscles and skin closed
• Perineal dressing applied

Duration of Surgery

• Typically 2–3 hours
• Usually 1–2 days hospital stay

Success Rate

• 90–95% long-term success
• Reduced re-occurrence than dilation or urethrotomy.

Post-operative Care

• Catheter kept for 2–3 weeks
• Medications including antibiotics and pain killers.
• Do not lift heavy, have sex, or strain in 4- 6 weeks.
• Post-catheter uroflowmetry.
• VCUG can be carried out prior to catheter removal to ensure the healing.

Recovery Timeline

• Go back to regular functioning: 1-2 weeks.
• Complete recovery of anastomosis: 6-8 weeks.
• The sexual activity can be resumed in 6 weeks.
• Recommended follow-up 1-2 months.

Urethral resection anastomosis surgery

• Anastomosis and Urethral Resection (URA) is a cure that is used as a definitive treatment of short urethral strictures that is less than 2 cm.
• In the operation, the diseased (narrowed) urethral portion is removed and the two healthy portions reconnected to normalize the urine flow.
• It has the best long-term success rate of treatments of urethral stricture.

Indications

URA is recommended for:

• Short bulbar urethral strictures (most frequent).
• Strictures (e.g., straddle injury) Traumatic strictures.
• Repeat strictures following unsuccessful dilation or internal urethrotomy.
• Almost total obstruction by urine.
• Tension free reconnection is possible only in healthy surrounding tissues.

Advantages of URA

• Short strictures (Gold-standard).
• Best cure rates of urethral reconstructions.
• Eschews similar repetitive procedures such as dilation or urethrotomy.
• Durable, long-term results

Urethral resection anastomosis for urethral stricture

• Urethral Resection and Anastomosis involves trying to repair the constricted (strictured) part of the urethra by completely excising it and re-joining the two healthy ends of the urethra to get the normal flow of urine.
• It is believed to be the golden standard therapy of short bulbar urethral strictures (typically <2 cm).

Why Is This Surgery Done? 

Physicians prescribe the procedure as a response to:

• Short bulbar strictures
• Traumatic strictures (e.g., straddle injury)
• Frequent stricture following dilation or urethrotomy.
• Obstructed or constricted urethral lumen.
• Conservative or endoscopic treatment failure.
• It is associated with the largest long-term cure rate of any urethral stricture surgeries.

Urethral resection anastomosis technique

The Urethral Resection and Anastomosis Technique. (Also referred to as Excision and Primary Anastomosis EPA urethroplasty) will be described in detail and step-by-step below. This is the common method of repairing short bulbar stricture of urethra.

Urethral Resection and Anastomosis Technique

Patient Preparation

• General or spinal anaesthesia: General or spinal.
• Posture Lithotomy position.
• Preparation: Prepared by shaving, cleaning and covering the perineum.
• Antibiotics prophylaxis.

Perineal Incision & Exposure

• A midline incision of the perineum is done between the scrotum and anus.
• Subcutaneous and skin are divided.
• Bulbar urethra exposes the bulbars of the intestines, which is located and pulled back or cut through by the bulbospongiosus muscle.
• Special concern is given to maintain bulbar arteries and perineal vessels.

Mobilization of Urethra

• At the stricture point the bulbar urethra is cut circumferentially.
• Adequate mobilization must be done to facilitate tension-free anastomosis yet excess mobilization is discouraged in order to maintain the blood supply.
• Strictured segment is easily recognized with the help of catheter or bougie.

Stricture Excision

• The urethra is cut both above and below the stricture.
• The diseased fibrotic part would be totally removed.
• The two extremes are examined to make sure that the mucosa is healthy.
• Edges are also trimmed to clean up the edges in order to enhance healing.

Urethral Ends spatulation

• The urethra is spatulated on both extremes (slightly opened).
• Typically either dorsal or lateral.
• This enlarges the anastomosis and minimizes chances of restenosis.

Tension-Free End-to-End Anastomosis

• A 14-16 Fr Foley catheter is inserted through the upper urethra to the bladder.
• The anastomosis is done above the catheter.
• Fine absorbable monofilament sutures (usually 4-0 or 5-0) are applied in an interrupted and circumferential manner.

Typically:

• The first sutures to be placed are the sutures at the posterior walls.
• Correct placement is ensured by catheter.
• Sutures which are put in front of the wall laid at the back of the wall are given.
• Guarantees complete mucosa-to-mucosa contact.

Re-approximation & Closure

• Hemostasis achieved.
• To cover the repair, the bulbospongiosus muscle can be re-approximated.
• There are closed layers of subcutaneous tissue and skin.
• Perineal dressing applied.

Postoperative Protocol

• Catheter duration: 2–3 weeks.
• VCUG at discharge to ensure healing.
• Activity information no straining, cycling, heavy lifting, or sexual activity 4 6 weeks.
• Follow-up: uroflowmetry 3, 6 and 12 months.

Technical Pearls (Key Surgical Principles)

Limited mobilization that was adequate

• Enough to bring about tension-free closure.
• Push back on dissection of urethra to maintain blood supply to urethra.

Full resection of fibrosis

• Excision should also involve the thickness of the fibrotic plate and scarred spongiosum.

Wide spatulation

• Prevents narrowing
• Ensures a wide lumen

Accuracy of mucosa to mucosa alignment

• Important to success in the long term.
• Minimizes recurrence

Minimal urethral tension

• The most significant predictor of recurrence is tension.
• In case there is tension, extra mobilization or perineal separation methods could be applied.

Factors Affecting Urethral resection anastomosis surgery cost India

Here are the key factors that affect its cost in India:

Complexity and Location of Strictures

• Longer sections or those with more than one site or scarred spongiosum need larger surgeries - adding to the time, resource and possible graft/flap demands of the surgeon.
• A simple short bulbar stricture (suited to normal excision + anastomosis) will be cheaper than a complicated recurrent or an injury based stricture of the pelvis.
• Certain websites clearly indicate that condition/complexity of the patient is a key consideration. 

Procedure used in Surgical Operation

• Basic excision and primary anastomosis (EPA) involves fewer steps and graft harvesting than graft-onlay, flap repairs, or pelvic fracture -urethral distraction repairs.
• Grafts (such as buccal mucosa) or flap repair or staged repair are costly. (Source refers to type of surgery as cost factor. 
• Raised cost may represent technology used (microsurgical instruments, intraoperative imaging).

Infrastructure Tier/Hospital Tier

• The cost of private multispecialty hospitals in metro cities is higher compared to non-metro, or smaller hospitals.
• Cost is also dependent on room category (general ward and private suite).

City/Region

• Big urban centres (Delhi, Mumbai, Bengaluru) are also likely to be costlier than smaller urban centres due to overheads.
• The sources indicate urban differences. 

Pre-operational and Post-operational Services

• Diagnostic imaging (RUG, VCUG, cystoscopy), tests, and preop clearance are added to costs.
• After care: number of days in hospital, intensive care (where applicable), follow-up visits, catheterization.
• In the event of complications, there will be cost increment. (This is clearly mentioned in cost breakdowns). 

Specialty and Experience of the surgeon

• A high-volume reconstructive urologist surgeon can also cost more (though can also decrease risk and/or recurrence).
• The less repeat surgeries required the more cost effective in the long run.

Room Category, Consumables, and Miscellaneous

• Single, special bed/amenities and private room are more expensive.
• Consumables: sutures, catheter, graft materials, special disposables.
• Other services: physiotherapy, dietician, additional nursing.

Length of stay and Complications in hospitals

• Longer stay = more cost.
• In case of complications (bleeding, infection, leak) there is a chance of increased cost.

Recovery after urethral resection anastomosis

The following is a sensible and thorough manual of the Recovery After urethral Resection and Anastomosis (Excision and Primary Anastomosis -EPA) to the urethral stricture. This will guide you on what to anticipate during the time of surgery, weeks, months and so on.

Post Urethral Resection and Anastomosis

Short-term Post-Operative (Day 1-3)

• A urethral catheter (typically 14-16 Fr) will be in place.
• Perineal pain/discomfort of mild to moderate type is typical.

You may feel:

• The incision is surrounded by swelling.
• Minor bleeding on the end of the penis.
• Soreness while sitting
• Antibiotics and painkillers are administered.
• Majority of patients begin walking on Day 1.
• Hospital stay: 1–2 days.

First Week After Surgery

• The catheter can be taken home.

Expect:

• Minor pain in the area of the incision.
• Occasional bladder spasms
• Wipe the perineal area with a dry towel.

Avoid:

• Sitting on hard surfaces
• Squatting
• Cycling
• Heavy work
• You are free to do light activities, short walks.

Catheter Duration

• Catheter remains for 2–3 weeks.

Before removal:

• To examine healing, a VCUG (voiding cystourethrogram) can be performed.
• In case there is healing, good, then catheter is removed.
• Following Catheter Removal (3-6 Weeks)

You may notice:

• Minor burning during urination (1-2 days)
• Briefly increased frequency.
• Flow also shows quick improvements among the majority of patients.

Restrictions:

• No sexual activity
• No cycling or heavy exercise
• No weight lifting
• Keep on taking lots of water.

Return to Work

• Desk job: 1–2 weeks
• Light physical work: 3–4 weeks
• Physical heavy labor: 6 weeks or above.

Activity Restrictions

To protect the anastomosis:

Avoid for 6 weeks:

• Sexual intercourse
• Masturbation
• Cycling / motorbiking
• Lifting heavy weights
• Squats / jumping / running
• Straining(preventing constipation is significant)

Avoid for 8–12 weeks:

• Gym workouts
• Contact sports

Follow-Up Schedule

• You are likely to have an appointment with your doctor:
• Uroflowmetry at 1–3 months
• Flow test every 6 months, 12 months and annually.
• Cases that have recurrence symptoms require urethroscopy.

Expected Long-Term Healing

• Internal healing: 6–8 weeks
• Strength returns gradually
• A stabilizing of anastomosis takes place within 3 months.
• Urine flow outcomes at 3-6 months.

Conclusion

Urethral resection and anastomosis (excision and primary anastomosis) is a very effective and reliable surgical intervention to short-segment urethral strictures particularly in the bulbar urethra. This procedure is highly effective by providing excellent long-term outcomes and a success rate of 90-95 by fully resected diseased segment and placing a tension-free mucosa-to-mucosa connection. With the correct postoperative care, treatment of catheters, and limitation of activities, recovery is usually painless. Under the influence of the appropriate surgical experience and early intervention, patients feel significant urethral catheterization, a decrease in complications and an extended period of relief of the symptoms caused by stricture. Follow-up will also be conducted to achieve ideal healing and prompt detection of any relapse.

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FAQ

1. Would I be having a catheter after the operation?

• Yes. A urinary catheter is held between 2-3 weeks to enable embarkation of the urethra.

2. Do you feel pain when the catheter is taken out?

• The vast majority of the patients experience some mild pain or burning during several seconds, but it is bearable and short.

3. When would I be able to start normal functioning again?

• Light work: 1–2 weeks
• Physical work: 4–6 weeks
• Sexual activity: after 6 weeks

4. Am I going to feel pain after surgery?

• The first week is characterized by mild to moderate perineal pain that can be ameliorated slowly with medication.

5. Would my urine flow improve after some time?

• Majority of patients report increased flow right after the removal of the catheter.

6. Can the stricture come back?

• Recurrence occurs with 5-10 percent incidence mostly during the first year. Follow-ups frequently will assist in its early detection.

7. Am I able to sit normally following surgery?

• Sitting is allowed, not on hard surfaces or excessive sitting during the first 2-3 weeks.

8. Is sexual function affected?

• The erectile functioning is not lost in general. A low percentage can undergo temporary changes that normally improve.

9. What is the best way to take care of the incision site?

• Always keep it dry and clean, never pressurize it and adhere to the hygiene guidelines given to you by your doctor.

10 .Do I need follow-up tests?

• Yes. Uroflowmetry is typically performed at 1-3 months, 6 months later and annually thereafter.