Please advise surgical treatment of stricture of bulbar urethra (post traumatic-pelvic injury and post catheterization)
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Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial strictures (no involvement of corpus spongiosum). Internal urethrotomy Internal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision allows for release of scar tissue. Success depends on the epithelialization process finishing before wound contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the 12 o'clock position, either with a ?cold? knife or urethrotome or a ?hot? knife that uses electrocautery to cut through the scar tissue. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction. Complications include recurrence of stricture, which is the most common complication, bleeding, or extravasation of irrigation fluid into perispongial tissues, thus increasing the fibrotic response. The curative success rate is reported as 20%-35%, with no increase in the success rate with a second internal urethrotomy procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen. However, strictures typically return once the patient stops.[8] Permanent urethral stents Permanent urethral stents are placed endoscopically. Stents are designed to be incorporated into the wall of the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated in patients with dense strictures and in patients with prior substitution urethral reconstruction because it elicits a hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo lengthy open urethral reconstruction procedures
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