Urethroplasty

Overview

Difficulty urinating may result from scar tissue that narrows the urethra, and in such cases, surgery might be necessary to fix the issue. This surgery, called urethroplasty, involves repairing or replacing the urethra, the tube that transports urine from the bladder to the outside of the body. In men, the urethra also serves as the pathway for semen to leave the body.

Reasons for undergoing the procedure

Urethroplasty is performed to repair or replace the urethra when scar tissue has developed within it. During the procedure, your surgeon will remove the scar tissue and then reconnect the two ends of the urethra. Alternatively, they may use tissue from another part of your body to reconstruct the obstructed section of the urethra.

Urethroplasty may be necessary if:

• A urethral stricture is present, meaning a section of your urethra has narrowed, blocking the flow of urine. Men are much more likely to experience urinary strictures than women.
• You were born with epispadias or hypospadias, conditions that affect the urethra and were corrected in childhood. Urethral blockages are more likely to occur in urethras that have been surgically reconstructed.
• You have undergone gender affirmation surgery.

The following bodily tissues are most frequently utilized to repair a urethra:

• The part of your mouth that extends from the back of your lips to the lining of your cheek is known as the buccal mucosa. 
• Your genitals. Your surgeon might use skin from your penis if you have one. Your surgeon may use skin from your labia or vagina during gender affirmation surgery.
• Your rectum, using a technique carried out through your anus during surgery while you are unconscious.

Risks

Every surgical procedure carries potential risks, including issues related to anesthesia and the possibility of infection. You might experience complications such as blockages or leaks with the catheter, which may necessitate a visit to the doctor for adjustments. Infections at the incision site or in the urine are also possible, typically occurring during or shortly after catheter placement.

The main risk of urethroplasty is that the results may not be permanent, and you might need additional treatments, such as a procedure to remove scar tissue. It is important to attend all follow-up appointments to monitor for any issues and ensure the best outcome.

Other uncommon dangers include of: 

• Damage to fingers, elbows, feet or legs from nerve injuries sustained while undergoing surgery.
• Pain in the scrotum or perineum as a result of nerve damage. 
• Leakage or oozing of urine or semen from your penis if it accumulates in the surgical area.
• Problems with erection. If this does arise, it usually goes away in less than 18 months.

Nerve injury cases may improve with time.

Before the procedure

To assess the length and location of the blockage, your doctor may use an X-ray known as a retrograde urethrogram or perform a cystoscopy. Both procedures are quick and involve minimal discomfort, usually conducted in the doctor’s office. Prior to your surgery, your doctor will give you instructions on dietary restrictions and how to manage any medications you are taking.

Your doctor may recommend inserting a suprapubic catheter before your surgery. This catheter helps to empty your bladder and allows your urethra to rest, making any scar tissue more visible and easier to address before the procedure. This approach is generally suggested if you need to use self-catheterization to keep the blockage open. The catheter is placed directly into your bladder through a small incision above the pubic bone.

On the day of the surgery, you will need to remove any jewelry and change into a hospital gown. You will then be taken to the operating room, where you will receive general anesthesia to ensure you are fully asleep throughout the procedure.

During the procedure

To access your urethra, your surgeon will make an incision in the surrounding muscle tissue. This incision is typically made on the underside of your penis, in your scrotum, or more commonly, between your scrotum and anus (the perineum). The stricture is then either removed or reconstructed, depending on its length and location.

For longer blockages or those in the penile urethra, the surgeon may use tissue from your mouth, genital area, or rectum to replace the removed section of the urethra. After the procedure, the incision is closed, and a small drain may be placed for a day or so. A catheter will be inserted to allow the urethra to heal while still enabling urine to be expelled. The incision site will be closed with stitches that dissolve on their own, so there’s no need for removal.

After the procedure

Following the procedure, you will spend some time in the recovery room to awaken from the anesthesia. If you’re undergoing urethroplasty as an outpatient, you’ll need someone to drive you home. Most patients either return home the same day or stay in the hospital for one night. You will be discharged with a urinary catheter, pain medication, antibiotics, and possibly medication to prevent bladder spasms. If tissue from your mouth was used in the reconstruction, you may receive a special mouthwash to keep the area clean. Additionally, you might be given medication to prevent erections.

About two to three weeks after your surgery, you’ll have a follow-up appointment with your doctor. At this visit, you may undergo a radiology procedure to assess the repair area if it hasn’t been done previously. During this procedure, the radiologist will fill your bladder with contrast material, remove the catheter, and take X-rays while you urinate. Your clinical team will review these images with you afterward.

Outcome

While your catheter is in place, you should avoid driving and sitting for long periods. Refrain from squatting or spreading your legs widely, such as when taking high steps. Normal walking and climbing stairs are generally fine. You should wait six weeks after surgery before resuming sexual activity or masturbation.

Your oral cavity will heal quickly, with new tissue typically covering the area where tissue was removed within about three weeks.

Plan to take time off from work or school while your catheter is in place. For less complex surgeries, this may be around two weeks, and for more complex procedures, it could extend to three weeks.