Director of the Center
Prof. Ofer Shenfeld

Shaare Zedek Reconstructive and Functional Urology Center

The Shaare Zedek Reconstructive and Functional Urology Center is highly skilled in the diagnosis and treatment of urinary tract structural and functional disorders. As can be seen below, reconstructive and functional urology are two branches of this discipline that are often very closely if not inextricably linked.

What is reconstructive urology?

Reconstructive urology is a sub-discipline of urology dealing with the treatment and restoration of urinary tract organs subject to a defect or structural injury caused by trauma, illness, surgery or congenital malformation. When such structural impairments adversely affect functioning, we advise considering reconstructive surgery. Reconstructive surgery in the urinary tract often requires the transfer of healthy tissue to repair the damaged area. The reconstructive approach is essentially a surgical one; it is based on procedures to repair the damaged area and thus to restore healthy functioning as far as possible. Reconstructive surgery requires a variety of surgical skills, including general urological surgery, 
plastic surgery and general surgery. Sometimes reconstructive surgery may even require a joint effort by several experts from different fields. Urological disorders treatable with reconstructive surgery include: ureteral strictures (narrowing of the tubes connecting the kidneys and the urinary bladder) or damage, urinary bladder injury, urethral disorders or diseases (both male and female urethral stricutres and urinary fistulas, female urethral diverticula and cysts), injuries or structural defects in the male genitals (pubic scoliosis or impotence), and urinary incontinence due to damage to the sphincter system.


 

What is functional urology?

Functional urology is a sub-discipline of urology dealing with a wide range of diseases and conditions that cause lower urinary tract disorders (urinary bladder, sphincter and urethra), as well as impairing sexual function. Examples of urinary dysfunction include difficulty in urination and urinary incontinence problems (loss of bladder control and involuntary urination). Sexual dysfunction (in men) may include a lack of sexual desire, erectile dysfunction, penile structural disorders adversely affecting sexual intercourse, ejaculation and orgasm disorders.


Lower urinary tract dysfunction may result from disorders or structural impairments such as an enlarged prostate, urethral stricture, urinary bladder injuries or other illnesses arising from such neurological injuries and diseases that adversely affect the functioning of the urinary bladder control mechanisms.

Urethral stricture

 
What is the urethra?  The urethra is a thin tube whose main function in both men and women is to pass urine out of the body. In addition, in males the urethra also plays an imporant role in delivering semen. Sometimes a scar or swelling of the urethral wall due to an injury or infection may block or slow down the urine flow in this tube, creating a condition called urethral stricture.


What happens under normal conditions? 
The bladder empties out of the body through the urethra. The female urethra is much shorter than the male organ. In men, urine must travel a much longer distance from the bladder through the urethra, including the penile urethra.
Because the male urethra is longer, it is more prone to injury than the female equivalent, thus urethral strictures are much more common amongst men than women.


In men, the first part of the urethra, called the posterior urethra, is 5-7 centimeters long. The posterior urethra includes :
The bladder neck (the opening through which the bladder empties).
The prostatic urethra (the part of the urethra surrounded by the prostate.
The membranous urethra (the part of the urethra surrounded by the sphincter muscle that helps prevent urinary incontinence).
The constrictions that occur in these parts of the urethra are called posterior urethra strictures.
 
 
In men, the first part of the urethra, called the posterior urethra, is 5-7 centimeters long. The posterior urethra includes:

  • The bladder neck (the opening through which the bladder empties).

  • The prostatic urethra (the section of the urethra surrounded by the prostate).

  • The membranous urethra (the section of the urethra surrounded by the sphincter muscle that helps prevent urinary incontinence).

  • The constrictions occurring in these sections of the urethra are called posterior urethra strictures.

 
In men, the remaining urethra, called the anterior urethra, is about 20 cm long. The anterior urethra includes:

  • The bulbar urethra (continuation of the urethra passing behind and inside the scrotum).

  • The penile urethra (inside and along the lower part of the penis).

  • The urethral meatus (the opening at the tip of the penis).

  • The constrictions occurring in these sections of the urethra are called anterior urethra strictures.

 
In women the urethra passes behind the front wall of the vaginal cavity.
 
What are the causes of urethral strictures?  Men are more prone to contract urethral disease or suffer injury due to the length of their urethra. For this reason, strictures are more common amongst men; they are in fact rare in women and infants.
 
Stricture (narrowing of the urethral cavity) can occur in any section of the urethra from the bladder to the tip of the penis. Such a stricture limits or delays the urine flow outwards and sometimes to the point of stopping or blocking it altogether. Some common causes of stricture are:

  • Trauma or injury to the urethra.

  • Infection such as a sexually transmitted disease or any other inflammatory cause.

  • Damage caused by surgery or other mechanical operation through the urethra, including the insertion of a catheter.

  • Conditions that cause swelling or edema in the urethra tissue.

 
Examples of situations that lead to the development of anterior urethra strictures in men are injury due to falling or trauma to the scrotum or perineum, prostate surgery, procedures for crushing or removing stones in the urinary tract, catheterization or other urinary tract surgery. In most cases, however, strictures cannot be attributed to a specific trauma or condition.
 
Posterior urethra injuries are unique injuries usually caused by severe trauma with fractures in the pelvic bones. In such cases, the posterior urethra is damaged or even dislocated, where it is adjacent and connected to the broken pelvic bones.
 
Other causes of posterior urethra obstruction are benign or malignant enlargement of the prostate. Although these conditions are common they are not considered "urethral strictures."
 
What are the signs of urethral strictures?  Urethral strictures can lead to a weakening of the urinary stream and sometimes even to total obstruction of urinary flow. A patient with such a stricture may experience difficulty or pain in urination, a split or splashing stream, a weak flow or even dribbling. Infections or urinary bleeding, swelling of the penis and difficulty controlling urine can sometimes develop.
 
Over time, damage might occur to the urinary bladder and kidneys due to the effort and pressure required to empty the system because of the stricture and the urine trapped in the urinary bladder.
 
How are urethral strictures diagnosed?  Apart from the typical patient story and findings from physical examination, the doctor may use various tests to diagnose urethral strictures:

  • The urinary flow test (uroflowmetry) is performed by urinating into a computerized device that records an accurate chart of urinary flow speed throughout urination.

  • An ultrasound can rule out other causes of urinary incontinence, as well as assess whether there is urine left in the bladder after urinating due to a blocked bladder exit.

  • Cystourethroscopy (also referred to as cystoscopy) is performed by a thin optical fiber inserted through the urethral opening. It allows visual examination of the urethral cavity and changes in the urethral wall.

  • X-ray imagery of the urethra (urethrography or cystourethrography) is performed by the infusion of contrast material through the urethra meatus (opening) to the urinary bladder in parallel to X-ray imaging, followed by further X-rays being taken after the bladder fills and then afterwards during urination. This test allows us to evaluate the location and length of the urethral stricture and also assess the degree of disturbance it causes to urinary flow.

 
How to treat urethral strictures?  There are two main approaches to treating urethral strictures. One approach is more "conservative" and includes expansion of the urethra and endoscopic cutting of the urethral stricture. The expansion is designed to stretch and even tear the scar tissue in the urethral wall to create a wider passage for the urine passing through the urethra. We can perform expansion by using various devices such as catheters of a gradually increasing size or by a small balloon inflated within the urethral stricture and thereby expand this area of the urethra. We perform endoscopic cutting, using a special cystoscope that enables us to view the immediate area of the urethral stricture, and with the help of a blade or energy source such as a laser for cutting tissue. These methods are designed to cut through the urethral stricture and thus to create a broader passage for the urine flow through the urethra. On occasions, following expansion or cutting, the physician may decide to leave a catheter in the urethra for a while. Despite the difference between these conservative methods, there is no difference in their chances of success. Their chances of providing a long-term solution to the problem of urethral strictures range from 30-50%. On most occasions, the stricture will return. Any urethral stricture treated by conservative methods as mentioned above and which then reappears at a later date, will always reoccur if a further expansion is carried out.
 
The second approach to urethral stricture treatment is to perform either urethral reparative or reconstructive surgery (also called urethroplasty). These surgical procedures involve an effort to repair the affected urethra by various methods: either to remove the damaged urethral section and then to attach the healthy urethral segments, or to repair the damaged urethra by using a patch of healthy tissue grafted from another location.