Surgery is an important event for anyone. The success of the operation does not only require the doctor’s excellent medical skills, but also depends to a large extent on the patient’s close cooperation. This is especially true for patients with urethral strictures. If we compare the human body to a car, the disease we suffer from is equivalent to a malfunction somewhere in the car, and the surgery is the process of removing the malfunction, while the correct pre-operative examination and preparation is equivalent to the analysis of the use of the car, which facilitates the correct maintenance of the car.
1.Pre-operative examination
The preoperative examination is to understand the site, number, degree, length of urethral stricture, scar tissue around the stricture and whether there are any comorbidities.
General examination: detailed medical history, history of previous surgery and reasons for surgical failure, urethral palpation, urine culture + drug sensitivity test, and if necessary, feasible urethral probe examination.
Special examinations: imaging including cystourethrography (required), CT 3D reconstruction and urethral magnetic resonance imaging, ultrasound imaging, flexible cystoscopy or urethroscopy if necessary, and urodynamic examination to evaluate the degree of urethral stricture and postoperative outcome.
2. Preoperative preparation.
Urethral stricture is usually treated with urinary obstruction and difficult urination in the acute stage by first rerouting the urinary flow (commonly suprapubic cystostomy), and surgery is performed after the urinary tract has been vacant for 3-4 months to wait for the inflammation and edema to subside. Preoperative examination (cystourethrography, etc.) clarifies the situation of urethral stricture and the choice of surgical approach, urinary routine and midstream urine culture, and the use of sensitive antibiotics ensure that there is no bacterial infection in the urinary tract at the site to be operated. Pre-operative full assessment of the surgical pathway, especially the perineum, lower abdomen and scrotum for any abnormalities.
3. Active treatment of urethral and periurethral infections
Urethral stricture causes rough and uneven urethral mucosa and poor urination, which creates good conditions for urethral infection. High-pressure urination can cause bacteria in the urethral cavity to enter the periurethral tissues and cause periurethral infections. Urethral and periurethral infections are the most important cause of surgical failure. Therefore, special attention should be paid to its pre-surgical treatment. In addition to the active and rational use of antibacterial drugs, suprapubic cystostomy should be performed first, and surgical treatment of urethral stricture should be performed after the infection has been adequately controlled, if any of the following conditions are present.
(i) The presence of acute or subacute periurethritis or pyelonephritis.
②purulent and blood-like discharge from the urethra with significant pressure pain and difficulty in urination.
③ recurrent episodes of acute pyelonephritis, acute prostatitis, orchitis or epididymitis.
④complicated bladder stones, diverticula, infection.
(⑤) Complicated urethrorectal fistula or urethral skin fistula.
⑥Posterior pubic bone infection, residual abscess, and osteomyelitis of the pubic bone.
The purpose of suprapubic cystostomy is to stop the urine above the stricture from passing through the infected urethra, and to allow the urine to drain freely so that the local inflammation gradually dissipates, which usually takes 3 months. During the cystostomy, care of the suprapubic cystostomy should be enhanced.
4. Duration of surgery for urethral stricture.
Bulbous urethral stricture: 3 months after the injury and no urethral dilatation operation within the last 1 month.
Membranous urethral stricture: 6 months after injury, no urethral dilatation operation within the last 1 month
Urethral dilatation bleeding, re-injury of the urethral mucosa, and local scarring aggravated by repeated urethral dilatation bleeding. For patients with dilatation bleeding, it is recommended to leave a urinary catheter in place for 2 weeks. In addition, forced dilation tends to form a false tract. Therefore, for patients with urethral stricture to be operated, it is recommended that no urethral dilatation operation should be performed within the last 1 month, while the time since the last operation or injury should be at least 3-6 months, and the timing of the operation should be chosen according to the local conditions.