Uretheral Stricture

WHAT IS THE URETHRA?

The urethra is the tube which drains the urine from the urinary bladder to outside the body via the penis in males and via the urethral opening in females. The length of the male urethra is 15-20cm. And the female urethra is shorter by about 4-5cm in length.

WHAT IS STRICTURE URETHRA?

Stricture urethra is narrowing of the urethra resulting in obstruction to the outflow of the urine. The reason for development of such a stricture in males can be infection, balanitis xerotica of the penile opening, trauma, or as a consequence of medical intervention. In the female the stricture is usually due to age induced deficiency of estrogen resulting in narrowing of the urethral opening.

WHAT ARE THE SYMPTOMS OF STRICTURE URETHRA?

The patients usually present with poor urinary flow and frequency of urination. They may have a prior history of sexually acquired infection, medical intervention or trauma.

HOW IS IT DIAGNOSED BY URO-SURGEONS?

Initial ultra-sonography may demonstrate an increase in the residual urine volume after the patient has passed urine. The uroflowmetry test usually demonstrates poor urine flow. To confirm the diagnosis the uro-surgeon usually performs a flexible cystoscopic evaluation along with an X-ray study – the ascending urethro-gram. This evaluation allows complete assessment of the length and the severity of the stricture.

Surgical Management

MANAGEMENT OF SHORT SEGMENT URETHRAL STRICTURES? OPTICAL INTERNAL URETHROTOMY

Short segment strictures shorter than 2cm in length with no prior history of complication or medical intervention are best managed by endo-surgical incision of the stricture and then subsequent catheter placement for 3 weeks. After this procedure the patient is trained to perform self dilatation at home with soft Foleys catheter. The patient needs to remain on follow-up with a trained uro-surgeon for periodic evaluation and if need be for day care dilatation in the clinic.

MANAGEMENT OF LONG SEGMENT URETHRAL STRICTURES? BUCCAL MUCOSAL GRAFT URETHROPLASTY

Longer segment or complicated strictures are best managed by substituting the affected urethra with a segment of the buccal mucosa. The buccal mucosa is the inner lining of the cheek of the patient. A 5 cm segment is harvested painlessly from the inner cheek of the patient under local anesthesia. This is then grafted on affected strictured segment of the urethra to augment the diameter of the stricture. If the stricture is longer, two grafts or even three grafts may be utilised. The procedure is performed via an incision placed below the scrotum of the patient. The patient is usually discharged with catheter after four days stay in hospital. He remains on catheter for a period of three to 4 weeks, and then the catheter is permanently removed. The patient is subsequently trained for self dilatation with Foleys catheter at home. Since the strictured segment has been augmented with fresh mucosa the stricture stabilizes gradually over the next few years. Most patients are then free of the dilatation after that period of time, however they are required to remain under periodic follow-up with the clinic of the treating uro-surgeon.

The Ureter

What is the Ureter?

The ureter is the narrow tube which carries the urine from each kidney to the urinary bladder for storage and then discharge from the body. This is a very narrow tube each carrying the urine from one kidney. The ureter is narrowest in the portion where it enters the urinary bladder and the other portion which is tapered is the pelviureter junction or the junction between the kidney and the ureter.

Why does ureteral stricture form?

Ureteral strictures are usually the result of trauma caused by prior stone passage , infection like tuberculosis, or due to prior accidental damage due to medical intervention. The stricture may vary with the intensity of the narrowing and the length of the obstruction. And in severe cases may cause significant kidney damage.

How is it managed?

In cases of minor stricture of the ureter which are short length and not very dense in nature, these are best managed by ureteroscopy and dilatation and then placement of a stent, which can then be subsequently removed after three months and the patient can be followed up in a outdoor basis.

However in case the stricture is dense and long segment then the management has to include a replacement of the ureter using a flap created from the urinary bladder. This flap is called the boari flap. Since the bladder is highly vascular and has good muscular strength therefore this flap is very reliable in the replacement of a damaged ureter.

This flap is raised from the bladder and then made into a tube and attached to that segment of ureter which is unaffected by the stricture disease process.

This is a very reliable and strong flap which has a very high success in salvage of difficult ureteral damage.

UTI (Uninary Track Infection)

What is the Ureter?

The ureter is the narrow tube which carries the urine from each kidney to the urinary bladder for storage and then discharge from the body. This is a very narrow tube each carrying the urine from one kidney. The ureter is narrowest in the portion where it enters the urinary bladder and the other portion which is tapered is the pelviureter junction or the junction between the kidney and the ureter.

Why does ureteral stricture form?

Ureteral strictures are usually the result of trauma caused by prior stone passage , infection like tuberculosis, or due to prior accidental damage due to medical intervention. The stricture may vary with the intensity of the narrowing and the length of the obstruction. And in severe cases may cause significant kidney damage.

How is it managed?

In cases of minor stricture of the ureter which are short length and not very dense in nature, these are best managed by ureteroscopy and dilatation and then placement of a stent, which can then be subsequently removed after three months and the patient can be followed up in a outdoor basis.

However in case the stricture is dense and long segment then the management has to include a replacement of the ureter using a flap created from the urinary bladder. This flap is called the boari flap. Since the bladder is highly vascular and has good muscular strength therefore this flap is very reliable in the replacement of a damaged ureter.

This flap is raised from the bladder and then made into a tube and attached to that segment of ureter which is unaffected by the stricture disease process.

This is a very reliable and strong flap which has a very high success in salvage of difficult ureteral damage.

UTI (Uninary Track Infection)

WHAT IS URINARY TRACT INFECTION?

The urine inside the bladder is sterile and does not contain any micro-organism. Whenever bacteria are able to access the urine within the bladder then infection of the urinary system occurs.

WHAT ARE THE SYMPTOMS OF UTI?

The patient usually complains of low fever and pain in the lower abdomen with a feeling of fullness of the urinary bladder. The patient also needs to pass urine very frequently, however she feels that the evacuation has been incomplete.

WHY DOES URINARY INFECTION OCCUR MORE IN FEMALES?

Since the urethra, the tube which carries the urine from the urinary bladder to the outside of the body is very short in females therefore the bacteria which colonises the vagina can easily access the urinary bladder, therefore females are more prone to infection when compared to males. The commonest organism which causes infection is a bacteria which is called E. Coli. This is a normal inhabitant of the bowel in every human being. However in some females, this bacteria can adhere to the inner lining of the vagina. Whenever the vagina is disturbed, as in, after sexual intercourse and also during periods, this bacteria can travels up the short female urethra and infect the urine within the urinary bladder.

HOW IS THE PATIENT EVALUATED FOR THIS PROBLEM?

The usual evaluation protocol for these patients includes a routine urine evaluation along with a urine culture. The patient is also advised to be evaluated by an ultra-sonography and uroflowmetry. The random blood sugar and serum creatinine levels are also checked.

WHAT IS THE MANAGEMENT OF UNCOMPLICATED URINARY INFECTIONS?

In uncomplicated cases there is no retention of urine, the patient discharges urine at very good speed and has normal sugar levels in the serum. These patient respond very well to urinary antiseptics like nitrofurantoin, which is administered as a single night time dose only. Once the patient has recovered then the prevention of recurrence becomes the focus area.

HOW TO PREVENT FREQUENT URINARY INFECTION IN FEMALES?

Urinary infection can be prevented by drinking plenty of water and passing urine frequently. Urinary infection is never caused by usage of public urinals, it is always internally acquired. Therefore prolonged retention of urine, which may be habitual in some individuals is never recommended. Drinking cranberry juice can reduce the incidence of urinary infection in many females. Therefore regular intake is recommended among those individuals who are prone to develop urinary infections. Since the E.Coli colonises the vagina therefore after intercourse, in sexually active females, it is recommended to pass urine immediately and also clean the inside of the vagina with plain water. This habit goes a long way in reducing the chance of urinary infection. However even after all these precautions, infection may still breakthrough which is then managed by self administration of urinary antiseptics like nitrofurantoin, whenever the patient feels the symptoms.

URINARY INFECTION IN FEMALES ABOVE THE AGE OF 50 YEARS?

At this age with the decline in levels of female reproductive hormones there is a possibility of development of stricture urethra, which can result in urinary infection and retention of urine. Therefore after the age of 50 whenever there is poor urinary flow the uro-surgeon generally advises a uroflowmetry to rule out urinary obstruction. If present then the urethra is dilated to allow easy discharge of the urine.

Hematuria

Blood in the urine, Hematuria?

What is hematuria?

Hematuria is red colloured urine due to blood mixed in the urine.This has to be diffrentiated from other causes of dark coloured urine. This is a very important and not to be neglected. Immediate consultation with a uro-surgeon is essential.

What are the reasons for dark colored urine other than bleed in the urine?

Urine may become darker in colour due to intake of food like beetroot. Drugs such as nitrofurantoin can change the colour of urine to brownish colour which the patient may confuse with bleeding. Patients with high bilirubin level in the blood can also have high coloured urine.

Severe dehydration allows the urine to be concentrated which also can result in very dark coloured urine which can be confused with blood in the urine.

Mensurating women may accidentally confuse the blood of the mensuration, when mixed with urine, this may appear as hematuria.

Where has the blood come from?

Once these other conditions have been ruled out, it is now important to assess the source of the bleed.If the blood is coming from the kidneys the patient may complain of pain in the side or flank which is radiated to the lower abdomen. Generally these patients complain that the entire urine was red color. These patients may pass long and narrow clots,
which the patient may compare with worms.

When the blood is originating from the urinary bladder the patient also presents with bleed in the entire urine, however if clots are passed these clots are generally rounded and larger in dimensions. These patients may have urinary sysptoms like burning and difficulty in passing urine along with the bleed in the urine.

In male patients if the bleed has occured from the prostate it often apperas as staining of the underclothes, while the urine remains clear. Patients very often say that they discovered blood spot in their clothes and did not know when the blood came out. This kind of bleed is typical of bleed from the prostate or the urethra.

Among sexually active women bleed can often occur with severe burning in the urine, also accompanied by a sense of incomplete evacuation of the urine. This is generally a sudden occurence and typically indicative of the presence of urinary infection.

What are the initial diagnostic tools to assess the source of the bleed?

All such patients are to be immediately evaluated with standard diagnostic tools.

The tests include

What is the role of flexible cystoscopy in these cases?

Flexible cystoscopy is a very important diagnostic tool in these cases. Since it allows the uro-surgeon direct visualization of the urinary tract prostate, the bladder and the ureter orifices within the bladder. This procedure is preferably performed as soon as possible so that the site of the bleed can be located while the bleeding is present and active.

Pelvi-ureter junction obstruction management

What is PUJ obstruction?

The kidney drains via the renal pelvis into the ureter which then carries the urine to the urinary bladder. The junction between the kidney and the ureter is a narrow area, which in some individuals can be exceptionally narrow which can result in backpressure towards the kidney. This in the long term can result in damage to the renal function. This is a congenital condition since the kidney and the ureter are formed in the mother’s uterus. However in our country since routine ultrasound evaluation is not often done therefore some patients do present much later in their life.

How does it present?

The commonest presentation is that of pain in the flank region of the patient which can then migrate towards the lower abdomen to the urinary passage. This presentation although the commonest is not the only presentation. Since the prevalence of ultrasound evaluation is increasing therefore the chance of detection of this disease before the symptoms starts is now quite frequent.

What tests are needed to ascertain the plan of treatment?

Generally the patient will be advised to undergo an IVP evaluation. This tells the surgeon of anatomy of the obstruction and helps in planning the surgical reconstruction of the ureter. Another test the diuretic DTPA scan may help in the decision making in cases with borderline obstruction to take a decision regarding observation versus surgical intervention.

How is the condition treated?

When the obstruction is significant resulting in pain and decrease in renal function the obstruction must be relieved, those cases presenting with recurrent urinary infection also need to be treated. Patients who develop stone disease due to the obstruction also must be treated.

The gold standard treatment is the Anderson hynes dismembered pyeloplasty. This is performed by a surgical approach, which is most often performed by laparoscopy by me. This surgery entails removing the obstructing segment and then creating a wide and dependant anastomosis for the urine to drain from the kidney into the ureter.

Laparoscopy means performing this entire complex procedure by three small access ports each port being less than 1cm in length. Therefore the patient has a much smother post operative recovery from this surgery .

Do I need to be cut open or can this kidney be saved by keyhole surgery?

Generally in national kidney and prostate clinic these complex procedures are completely performed using micro invasive laparoscopic technique and generally open surgery is not needed. However the chance of open surgery is one in fifty cases. Dr Avishek Mukherjee is an expert laparoscopic surgeon and has not needed to convert to open surgery in laparoscopic pyeloplasty in the last 10 years of his experience.

What is the success of this surgery in saving the kidney?

If the patient reaches the surgeon with a functioning kidney then the chance of renal salvage is very high more than 97 percent cases, can be salvaged. These kidneys in the absence of intervention would not have survived.

What is the recovery time needed in this surgery?

Generally the patient is discharged on the day four after the surgery, and the patient can resume normal activity after two weeks from the surgery. They are needed to return for a day care stent removal after three months and the routine IVP test is performed in the sixth month after the surgery.

Why is laparoscopy and minimal access surgery preferred to open surgery?

With increase in my expertise in minimal access ureteral surgery I have routinely performed numerous ureteral salvage using pure laparoscopic approach with very high kidney salvage rate.

This entire surgery is performed using small laparoscopic incisions. Each incision is smaller than 1 cm. These access ports generally number 3-4 ,such incisions are needed to accomplish this complex ureteral reconstruction.

The patient generally has little pain and recovers much better than with open surgery. The patient is usually discharged on day five after the surgery and then stent is removed after three months. The patient is advised to review with an IVP test after six months for the final confirmation that the kidney is saved and the ureter is functioning well.

Hypospadias Dieases

Hypospadias is a congenital condition wherein the urethra, the tube which carries the urine via the penis to outside the body, is partially formed. As a result of this condition the urine discharges from an opening on the lower surface of the penis which is located proximal to the tip of the penis.

This condition is visible at birth and should be treated before the age of four. However in India we have often found patients with neglected cases wherein the patient presents to us as an adult with Hypospadias.

This condition is nowadays treatable with a very good success rate, by using newer reconstructive approach to surgery. There is no medical management for this condition.

The treatment relies on

• A) creation of a urethral tube up to the tip of the glans penis.
• B) correction of the downward bend of the penis when erection occurs.
• C) removal of the hooded appearance of the foreskin, therefore giving a better cosmetic and functional penis.

Using the Snodgrass technique and its modifications we have over the past years given excellent results in treatment of this condition.

What is CHYLURIA?

Chyluria is the passage of milk like urine which is almost white in colour or may be slightly pink in colour if mixed with blood. Sometimes the patient may have a large amount of fat and clotted blood in the bladder, which then clots and cause infection or obstruction to the flow of the urine. This condition is caused by the disease parasite which causes filaria. These parasites then cause inflammation of lymphatic channels which drain the intestine. When a person consumes a meal with fat in it, the absorbed fat is transported by the lymphatics into the blood stream. In Chyluria the lymphatic channels are blocked by the parasite, therefore they leak into the urinary collecting system. When the person passes fat mixed with water in the urine the colour becomes white, like milk.

Why does it happen?

Chyluria is a manifestation of filaria. This disease is caused by the bite of Culex mosquito resulting in infection by the parasite which causes filaria. This parasite can infect the lymphatic channels which drain the intestine. Once these channels are blocked they can aberrantly drain into the urinary collection system. This drainage of the fat containing Chyle into the urine results in the milky urine called Chyluria.

What is the best management for this condition?

This condition is best managed by a surgery called Chemofulguration. In this procedure the surgeon cannulates both the ureters. This is performed under anesthesia, Therefore the patient has no pain. Then the surgeon injects a sclerosant agent into the kidney. These chemicals result in fibrosis of the lymphatic channels which drain into the kidney. Therefore the condition is cured by this surgery.

Does the Chyluria recur?

Rarely in one in twenty cases the patient, may have a recurrence of the Chyluria. This can be treated by re-instillation of the sclerosant into the kidney thereby destroying the residual draining lymphatics.

What is the role of coconut oil in the management of Chyluria?

During the first month after the instillation of the sclerosant agent into the kidney, I advise my patients to take less oil and fat in the food, and if possible to replace the cooking medium with coconut oil. Since coconut oil is made of medium chain trigycerides therefore they are directly absorbed into the blood stream.This therefore does not increase the chance of Chyluria during the immediate post operative period of the patient.

BLADDER AND URETER INJURY AFTER GYNECOLOGICAL SURGERY.

Gynecological surgery like removal of uterus is a very safe procedure. However in complicated cases there may be severe adhesions between the bladder and the vagina and uterus. In these cases there remains a possibility of injury to the bladder and the ureter in approx. 1% of cases.

These cases can be successfully repaired today with minimal invasive approach thereforeallowing the patient to recover to lead a normal life.

WHAT IS A VESICO VAGINAL FISTULA?

The term fistula means an abnormal communication between two structures. Therefore in this context it means a hole connecting the bladder (which contains urine) to the vagina. Therefore the bladder starts leaking the urine into the vagina.

WHAT ARE THE SYMPTOMS OF A FISTULA BETWEEN THE BLADDER AND THE VAGINA?

These patients generally present one to three weeks after the surgery with urine discharge via the vagina. Since the patient is able to hold urine via the normal passage which is the urethra, but the vagina normally does not hold the urine, therefore when the patient starts leaking urine from the bladder to the vagina she becomes incontinent. This is unaware incontinence wherein the patient dribbles urine all the time without any urge to pass urine and without any stress over the abdomen.

HOW ARE THESE PATIENTS EVALUATED?

These patients are evaluated by a dye study called Cystogram wherein the dye is instilled into the urinary bladder and then radiological pictures are taken to demonstrate the hole connecting the bladder to the vagina- that is the fistula. She also undergoes an IVP test to rule out any ureteral injury. Very often I evaluate these patients by a Flexibe Cystoscope to check the location of the fistula directly by visualization.

WHICH PATIENTS CAN BE MANAGED CONSERVATIVELY?

For small and recent fistula, a reasonable approach is to keep the patient on a catheter for a few weeks. This is usually performed after the fistula site has been fulgurated to destroy the mucosal lining which can prevent healing of the tract. The patient however must be counselled that this method is successful only in very small and recent fistula. Therefore if this approach fails then more definitive treatment has very high success rate.

WHAT ARE THE POSSIBLE METHODS OF REPAIR OF THE VAGINAL FISTULA?

The fistula can be approached via two methods either Transvaginally in case of low fistula or via the abdomen in case of large or high fistula. Also if the ureter orifice is very close to the fistula site then the abdominal approach is better since in these cases the ureter is reimplanted along with the repair of the fistula.

WHICH PATIENTS CAN BE MANAGED BY VAGINAL APPROACH?

Patients who have low down and small fistula can be managed by this approach. This approach avoids an abdominal incision and therefore the patient has lesser pain and bleed and recovers faster.

WHAT IS LAPAROSCOPIC REPAIR OF THE VAGINAL FISTULA?

When the fistula is higher up on the bladder or the bladder is small in capacity and needs to be augmented or the ureter need to be reimplanted then an abdominal approach is preferred. Today laparoscopic approach provides equal success rate to open surgery while avoiding the need for a larger incision and therefore the patient can recover better and faster.

WHAT IS THE SUCCESS RATE OF THESE REPAIRS?

Most of the these fistulas can be repaired by either of these approaches and the success rate is very high nearing 95-97 %. The patient can return to full normal life within a few months after this procedure.

WHAT IS TISSUE INTERPOSITION?

Since the bladder and the vagina are weakened due to the prior surgery and then the development of the fistula further weakens the walls. As a result the walls of these structures may not have enough strength to allow a successful repair in some cases. Therefore in these cases interposition of good strong tissue with good blood supply prevents a recurrence of the fistula. The most commonly used tissue is the fat within the labia majora in a vaginal approach and the free floating omental fat apron in an abdominal approach.

HOW ARE THESE PATIENTS MANAGED IN THE POST OPERATIVE PERIOD?

These patients usually complain of bladder pain and spasms therefore a liberal use of bladder calming drugs like flavoxate are used to relieve the pain and spasms. The patients usually regain full urinary holding capacity within a few months of the surgery.

WHAT ARE URETERO VAGINAL FISTULA?

Like the bladder, the ureter may also be injured in some cases of gynecological surgery. These are usually very complicated gynecological surgeries as in cases of Endometriosis. In these cases which are generally less than one in hundred gynecological surgeries the ureter may be injured. These patients also may present with leakage of urine via the vagina after one to three weeks after the surgery.

HOW DO THEY PRESENT ?

These patients may present with leakage of urine all the time. Also the leakage may persist even if the patient is catheterized. They may also present with pain in the flank region of the kidney.

WHAT IS THE MANAGEMENT OF THESE CASES?

In these cases also surgery is the best option. If the fistula is small and recent then a trial of stent placed ureteroscopically may be attempted. But in most cases the best option is to perform a laparoscopic repair of the ureter wherein the damaged and weakened ureter is removed and the healthy ureter is then reimplanted into the bladder. This is a reliable surgery wherein a large majority of cases are cured in the first attempt. Very often we fashion a tube from the urinary bladder, this tube is called the Boari flap. This tube is then attached to a healthy ureter therefore allowing a wide and healthy passage for the ureter to drain into the bladder.

Cancer Cervix and Ureteral Stricture Disease.

Cancer cervix is one of the commonest cancers affecting women. Cervix is the lowermost part of the uterus which projects into the vaginal vault. Once it is affected by the cancer the management most often involves radiation of the cervix with or without chemotherapy. Since the ureters, the tubes which convey the urine from the kidney to the bladder, are located very close to the lowermost part of the uterus therefore these are very often affected by the cancer or by the radiation of the cancer. Once the ureter is damaged, then the kidney is unable to drain the urine and starts swelling and is then damaged by the back pressure.

If the obstruction is mild then the uro-surgeon is able to manage the obstruction by placement of a stent which drains the urine into the bladder which is then removed after the obstruction resolves.

However in most cases a more permanent treatment is needed in these cases the uro-surgeon replaces the damaged ureter by creating a neo ureter. This is best created by using the urinary bladder.

The procedure is usually performed nowadays by laparoscopy, however in some places open surgery is also used. The procedure involves replacement of the damaged ureter. Since the urinary bladder is a very sturdy organ, therefore if a part of it is used to fashion a tube and then this tube is attached to the undamaged part of the ureter, then the obstruction is bypassed.This procedure is called laparoscopic boari flap reconstruction and it can save the affected renal unit.

since it is performed by laparoscopy therefore the patient has very good recovery.