1. Actively treat urethral and peripheral infections;
2. Restore the urination function of urethra and restore the anatomical continuity and integrity of urethra;
3. Avoid new complications during treatment;
4. Patients with chronic renal insufficiency underwent cystostomy;
5. If there is a urorectal colostomy, colostomy should be performed first;
Non-surgical treatment
Non-surgical treatment mainly depends on urethral dilatation, even after surgical treatment, it should be dilated regularly to prevent restenosis. Urethral dilatation should not be performed when there is acute inflammation of urethra, but under good anesthesia and strict aseptic conditions. Expand and avoid violence. If necessary, guide it in the rectum with your fingers to prevent it from penetrating into the false passage or even the rectum. The expansion must be gradually increased from small probe to large probe, and don't be impatient. Excessive dilatation can easily lead to tearing of urethral canal wall, which in turn will form scar and aggravate stenosis. It is more suitable for men to expand to F24. After each urethral dilatation, the urethra is congested and edematous. It takes about 2 ~ 3 days to subside, and it is not advisable to continue to expand within 4 days. The second interval generally starts from 1 week and gradually extends.
Transurethral perfusion can prevent the recurrence of urethral stricture. Play soft extension effect. Physical therapy methods such as audio frequency and iodine ion penetration can accelerate scar softening and consolidate the effect of expansion.
Surgical therapy
(1) Treatment of posterior urethral stricture: It is appropriate to treat urethral stricture 3 ~ 6 months after urethral injury. According to the degree of injury, the following surgical methods can be selected:
1) urethrotomy (optional): cut the scar at the stricture with a urethral scalpel (cold knife) or laser, and leave a catheter after enlarging the urethral diameter. Suitable for short and narrow sections
2) Urethral anastomosis (recommended): Perineal incision is adopted to remove stricture and scar, and two urethra are anastomosed end to end, which is suitable for stricture.
3) Urethral traction (optional): It is suitable for patients who cannot perform urethral anastomosis. After the urethral stricture is removed, the distal urethra is free, so that it can be moderately pulled through the proximal stricture with a traction wire and fixed or fixed to the abdominal wall through the bladder. The disadvantage is that erection will cause penis shortening and penis bending down.
4) Urethral replacement plasty (optional): long urethral stricture or atresia. Free transplantation of pedicled skin flap to repair urethral defect.
ⅰ. Pedicled skin flap: skin commonly used in penis and perineum. Skin flap needs good blood supply, and hair, stones and diverticulum are its complications. The incidence of long-term urethral restenosis is still high.
ⅱ. Free transplantation: All kinds of autologous mucosa, skin and tissue engineering materials (acellular matrix) are suitable for urethroplasty and reconstruction of long stenosis.
(2) Treatment of anterior urethral stricture: It is more appropriate to treat urethral stricture after injury after 3 months.
Short segment anterior urethral stricture involving superficial urethral cavernous body (
For urethral stricture with bulbar root less than 2cm, scar resection and anastomosis is a suitable treatment (recommended), and the success rate of this treatment can reach 95%. However, simple end-to-end anastomosis is not recommended for penis urethral stricture and bulbous urethral stricture (-2 cm), because it will cause the patient's erection to bend downward and be painful. For this kind of patients, it is recommended to replace urethroplasty with transferred skin flap or free transplantation (recommended). Urethral stents are not recommended for patients with traumatic urethral stricture [88].
Patients with urethral stricture who failed in non-surgical treatment can choose appropriate surgical treatment. There are many surgical treatments, and how to choose depends on the experience of doctors, the degree of stenosis of patients and medical conditions.
1. Incision of external urethral orifice is suitable for cases of external urethral orifice stenosis. It is more common in patients with balanitis prepuce, partial penile amputation or hypospadias repair. It can be cut longitudinally on the ventral side of the external urethral orifice to form mild hypospadias, and the cut urethral mucosa on both sides is sutured with the skin of the penis head to stop bleeding.
2. Internal urethrotomy If the length of urethral stricture is very short, even membranous stricture, the stricture ring can be cut with a special refrigeration knife under the direct vision of urethroscope. Incision can be performed under the guidance of inserting a thin ureteral catheter. If necessary, excess scar tissue can be removed by electrosurgery. If the narrow posterior urethra is completely occluded, but the length is not long, you can cut the bladder, guide it with your fingers, and drill it through with a resectoscope or urethral probe. An electrosurgical mirror is then placed to remove the scar and form a channel. Then indwelling catheter for a long time (more than 20 days), waiting for healing. It is also suggested to leave several thin silicone tubes in the urethra for 3 months after operation, so that urine can be discharged from the gap of silicone tubes when the patient urinates, and at the same time, it plays a role in water expansion and achieves good results. If multiple long urethral strictures can be put into Otis incision, an internal incision should be made. The depth of the incision can be controlled.
3. In the case that the internal incision cannot be made after urethrotomy, a suitable incision should be selected, the strictured urethra and its surrounding scar tissue should be removed under good exposure, and the bleeding should be stopped strictly, and the two broken ends of the urethra should be everted without tension with absorbable suture. The wound should be completely drained, and the catheter should be retained for about 2 ~ 3 weeks after operation. Silicone tube with less irritation must be selected for indwelling catheter, suprapubic incision can be selected for posterior urethral stricture, and part of pubic symphysis can be removed if necessary to achieve good exposure. The bulbar urethra can choose perineal arc or straight incision. During the operation, the damage to the surrounding normal tissues should be minimized to avoid more scars and impotence after the operation. In order to reduce the tension of anastomosis, the distal urethra can be dissociated, even directly to the coronary sulcus. However, proximal urethra should not be too long. It is difficult to anastomose after resection of posterior urethral stricture. A long straight needle can be used to anastomose the abdominal perineum wound, or the distal urethral stump can be fixed on the catheter with catgut, dragged into the bladder and closed at both ends, and the catheter can be fixed as a bracket to achieve the purpose of closure.
4. Narrow urethrotomy is suitable for penile urethral stricture or long urethral stricture that is difficult to repair in one stage. Incision or excision of narrow urethra and other distal and proximal urethrotomy to form hypospadias. After 3 months, hypospadias was repaired. One-stage resection and anastomosis for penile urethral stricture often leads to urethral skin fistula. The posterior urethral stricture that is difficult to repair can also be cut through perineum, and the skin flap of perineum or scrotum can be dragged into the ditch and sutured to the bladder neck to form perineal hypospadias, which can be repaired in the second stage later.
5. The urethra with urethroplasty defect can use its own bladder mucosa and pedicled bladder flap. Pedicled skin flap and/or medium-thick skin graft are used for plastic repair.
6. Urethral bypass generally requires bladder fistula to drain urine at the same time, so that the operation can be successful. Patients with failed surgery can maintain cystostomy and undergo reoperation or permanent treatment.
Urethral stricture surgery is a difficult operation. Before the operation, we must make full preparations, the surgical plan must be designed accurately, and the volume must be expanded regularly to achieve good results. Recurrent stricture, urinary fistula, impotence and urinary incontinence are common complications. [ 1-5]
Polizel's therapy
After simple internal incision, indwelling catheter was 65438 0 ~ 2 weeks. After other operations, indwelling catheter is usually 3~4 weeks. According to the urination situation, the time of cystostomy is decided. Encourage patients to drink plenty of water and use antibiotics appropriately.