38-year male presented to us with complaints of recurrent urinary tract infections with narrow stream of urine for 1 year. He had undergone staged hypospadias repair in his hometown at 15 years of age. He was undergoing treatment at a hospital in his city where they attempted catheterization, but they were unable to negotiate even the smallest catheter of 6Fr size. He presented to us for a permanent solution for all his problems.
On examination in the OPD at Hypospadias Foundation, the meatus was glanular, with mild chordee. Urine stream was very poor and preoperative uroflowmetry showed max urine flow rate of 1ml/sec and average urine flow of 1.1ml/sec, this uroflometry is suggestive of severe obstruction in the urinary passage most probably urethral stricture.
Pic 1: Preoperative uroflometry
We planned a staged oral mucosa graft urethroplasty.
Stage 1 Oral Mucosa graft urethroplasty:
Cystoscopy was done as a part of the initial assessment in the operative theatre. Cystoscopy was done by a 4fr scope which showed strictured narrow anterior urethra with white patches in the posterior urethra suggestive of chronic obstructive changes and pus flakes in the bladder.
Redo Hypospadias Surgery was started by taking a stay stitch over the glans using 4-0 prolene. Urethra was laid open till normal urethral mucosa was identified. Unhealthy fibrotic urethra was removed completely. Urethral bed was prepared for placement of oral mucosa graft. Proximal stump of urethra was mobilized and fixed using 6-0 PDS to the tunica albuginea. Glans wings were raised widely.
Oral mucosa graft of size 7x3cm was harvested from the left cheek. Graft was defatted slightly and quilted in place using 5-0 vicryl. Pressure dressing was applied, and the catheter was fixed. Dressing and catheter were removed after 7 days.
Graft uptake was 100% with no loss. After 21 days, local steroid massages were started and continued till 5 months. Over these 5 months, the graft became as soft as oral mucosa and felt like lip texture.
Stage 2 Oral Mucosa graft Urethroplasty:
Graft was soft and supple at 6 months after graft placement. Surrounding skin was also healthy. We planned to do the second stage OMG urethroplasty. At stage 2, graft edges were marked. Local anaesthesia lignocaine with adrenaline was infiltrated at the marked site. U shaped incision made and deepened till the corpora. Urethroplasty was done with 5-0 Vicryl in 2 layers over a 14Fr silicone catheter. Local dartos flaps were used for second layer coverage. Skin was closed in 2 layers and dressing was done. Suprapubic cystostomy was done using 14 Fr malecot’s catheter. Dressing inspection was done on post operative day 4 and every 4th day thereafter. During every dressing change betadine wash was given and re dressing done. Hyperbaric oxygen therapy was given for 5 sessions starting from post operative day 2. Per urethral catheter was removed on post operative day 14 and suprapubic catheter was removed on post operative day 21. Patient was passing urine in good stream without pain or leak after catheter removal.
Pic 1: Preoperative assessment and arrow showing stricture in the anterior urethra.
Pic 2: Identification of normal urethral mucosa proximally and calibre of proximal urethra checked using urethral dilator
Pic 3: Urethral bed prepared for placement of oral mucosa graft, 7cm oral graft required
Pic 4: Graft harvested from the left cheek and sutured over the urethral bed using 5-0 PDS
Pic 5: 100% graft uptake and graft noted to be soft 8 months after stage 1, marking at the margin of the graft
Pic 6: Incision given at the margin of the graft and stay sutures placed to align the urethra
Pic 7: Graft tubularized over a 14Fr silicone catheter to complete the urethroplasty
Pic 8: Dartos flap harvested from the right side and sutured over the urethroplasty. Skin closed using 6-0 vicryl rapide
Pic 9: Post opertaive uroflowmetry showing significant improvement in maximum and average flow rate
Urethral stricture can occur as a complication following hypospadias repair surgery. It occurs when the new urethra becomes narrow. The overall incidence of urethral stricture is between 10% and 20% but this incidence varies as per the surgeon experience and type of hypospadias surgery. The common causes for stricture formation are development of scar tissue formation in the urethra, development of BXO or poor surgical technique.
The symptoms of urethral stricture are difficulty in urinating, poor urine stream, feeling of incomplete emptying of the bladder, straining while urination, pain while passing urine or urinary tract infections due to urine stasis.
Diagnosis of Urethral Stricture post hypospadias surgery
- Physical examination: A doctor will examine the penis and urethra. In cases of urethral stricture, the urethra may appear cord like on palpation.
- Retrograde Urethrogram: This imaging test can help determine the location and extent of the stricture. A contrast agent is injected through the urinary opening and x rays are taken. The site of stricture will appear narrow on Xray.
- Cystourethroscopy: This procedure involves inserting a thin tube with a light and camera into the urethra to visualize the exact site of stricture. Treatment of Urethral Stricture
The treatment for urethral stricture depends on the severity and location of the stricture. In cases of urethral stricture post hypospadias surgery, the only treatment option is surgery. Urethral dilatation can provide only temporary relief in these cases and should not be the treatment of choice. In cases of short segment stricture, single stage oral mucosa graft inlay urethroplasty is the preferred surgical option. For a long segment stricture, the entire stricture segment needs to be replaced, and it is usually a staged repair.
If you are experiencing symptoms of urethral stricture after a hypospadias repair, it is important to see an experienced hypospadias surgeon because the treatment options for this is different from urethral strictures not related to hypospadias. Early diagnosis and treatment can help prevent complications and improve your quality of life.
About Hypospadias Foundation
Hypospadias Foundation is a centre specialized for treatment of children and adults with hypospadias. Our expertise in hypospadias makes us one of the best centres for hypospadias repair surgery and treatment in the world. At hypospadias foundation, we perform more than 250 hypospadias surgeries every year and more than 20% of these are adults with hypospadias. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra.
Dr A K Singal is an expert and one of the best hypospadias surgeons in India with experience in pediatric and adult hypospadias. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.
Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.