Distal urethroplasty

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your Urologist or Nurse Specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse.

What does the procedure involve?

Open repair of the urethra for a stricture at the tip of the penis.

What are the alternatives to this procedure?

Observation, optical urethrotomy (cutting of the stricture under direct vision), repeated stretching using metal/plastic dilators.

What should I expect before the procedure?

You will usually be admitted on the day of your surgery and you will receive an appointment for pre-assessment, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your Urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• a high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The water pipe (urethra) can become scarred at any point along its length. At the distal end of the urethra, a common cause is a condition called balanitis xerotica obliterans (BXO), which is a particularly aggressive type of scarring with inflammation. When the urethra is affected by this condition, urethroplasty usually needs to be performed in at least two stages.

The first stage involves opening the urethra from the tip of the penis down to the normal urethra, with a cut on the under surface of the penis. The scarred portion is then cut away and the graft, usually taken from the cheek lining (buccal mucosa) is laid in place and fixed with stitches, so that the graft looks like a quilt.

The graft can also be taken from the under surface of the tongue. The skin on the under surface of the penis is then stitched back to maintain the opening along the length of the previously scarred urethra. A catheter is inserted into the penis and this remains in place for approximately two to three weeks.

The second stage of the repair cannot take place until at least three months after the first operation. It is essential that the graft picks up a good blood supply and, once this has occurred, it can be rolled into a tube, restoring the urethra to its normal calibre. On occasions a further graft needs to be taken from the cheek at the second stage, to ensure an adequate calibre for the urethra. After the second or subsequent stages, a catheter is usually inserted for a two to three week period.

If a graft is taken from the cheek lining, this area usually heals quickly and does not require any stitches. A small dressing (pack) is usually inserted into the mouth overnight to prevent bruising or swelling.

What happens immediately after the procedure?

If a graft has been taken from the cheek lining, a pack will be removed from your mouth on the same day or the following day. Antiseptic and anaesthetic mouthwash will be used regularly and wide opening of the mouth is encouraged.

You are allowed to eat and drink straight after the operation but it may be a few days before you are fully comfortable with doing that.

You will be given an injection under the skin of a drug (dalteparin) that, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins.

The average hospital stay is 24 to 48 hours.

Are there any side effects?

Most procedures have a potential for side‑effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Discomfort in the mouth and restricted jaw opening if a graft has been taken from the cheek lining
• Swelling and bruising of the wound site
• Recurrent stricture formation requiring further surgery or other treatment

Occasional (between one in 10 and one in 50)

• Failure of the procedure requiring further surgery
• Wound infection requiring antibiotics
• Failure of the urethra to join completely, resulting in urinary leakage (a fistula)
• Loss of or altered erections as a result of injury or surgery to the urethra
• Need to carry out self-catheterisation to keep the urethra open
• Dribbling post operatively due to ‘bagginess’ of the graft
• Shortening of the penis
• Spraying of urine
• Numbness from the corner of the mouth from the graft harvest

Rare (less than one in 50)

• Painful intercourse with reduced ejaculation

Hospital-acquired infection (overall risk for Addenbrooke’s)

• Colonisation with MRSA (0.01%, two in 15,500)
• Clostridium difficile bowel infection (0.02%; three in 15,500)
• MRSA bloodstream infection (0.00%; 0 in 15,000)

(These rates may be greater in high risk patients eg with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

There may be some discomfort from the catheters and antibiotics are usually needed for a period after surgery, and often until the catheter is removed.

Physical activity will generally be restricted for two to three weeks.

Jaw movements may be restricted if a graft has been taken from the cheek lining, wide opening of the mouth is encouraged.

What else should I look out for?

Any increasing pain, wound discharge or swelling should be reported to your GP immediately.

Are there any other important points?

The catheter is removed in a first-stage procedure after two to three weeks. The urine will, inevitably, spray out at this stage and you will probably need to sit down to pass urine.

For subsequent procedures, the catheter is usually removed after three weeks. An x‑ray (peri-catheter urethrogram) of the water pipe maybe taken before the catheter is removed.

After catheter removal, you will be followed up in the outpatient clinic after 12 weeks with a flow test on arrival; it is important, therefore, to arrive for this appointment with a full bladder.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy & dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team may need to remove hair to allow them to see or reach your skin. If the healthcare team consider it is important to remove the hair, they will do this by using an electric hair clipper, with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself, or use a razor for hair removal, as this can increase the risk of infection to the site of the operation. If you have any questions, please ask the healthcare team who will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008);

Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at Addenbrooke’s Hospital?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….