今日の臨床サポート

尿道狭窄

著者: 丹司望1) 放射線第一病院 泌尿器科

著者: 三浦徳宣2) 愛媛大学 泌尿器科

監修: 中川昌之 公益財団法人 慈愛会 今村総合病院 泌尿器科顧問

著者校正/監修レビュー済:2021/11/02
参考ガイドライン:
  1. American Urological Association(AUA):Male urethral stricture: American Urological Association guideline(2016)
  1. Société Internationale d’Urologie(SIU):Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up(2017)
  1. European Association of Urology(EAU):EAU Guidelines on Urological Trauma 2021
  1. European Association of Urology(EAU):EAU Guidelines on Urethral Strictures 2021
患者向け説明資料

概要・推奨   

  1. 臨床評価:問診、ウロフローメトリー(推奨度2)
  1. 画像評価;逆行性尿道造影/膀胱造影(推奨度1)、軟性膀胱鏡(推奨度1)、超音波(推奨度3)、CT/MRI(推奨度3)
  1. 治療:
  1. 閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
丹司望 : 特に申告事項無し[2021年]
三浦徳宣 : 特に申告事項無し[2021年]
監修:中川昌之 : 研究費・助成金など(武田薬品工業株式会社)[2021年]

改訂のポイント:
  1. AUAガイドライン2017 SIUガイドライン2010 EAUガイドライン2020に従い、尿道損傷の治療について改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 尿道狭窄症とは、けがや炎症、尿道カテーテルや経尿道的手術などによって、尿道粘膜が傷つき、修復される過程で尿道粘膜や尿道周囲の尿道海綿体に瘢痕化が起こり、尿道内腔が狭くなる疾患である。
  1. 主症状は排尿困難である。重症化すると自力での排尿ができなくなり、適切に治療しないと尿路感染症や腎機能障害を合併する可能性がある。
  1. 頻度は地域により異なるが、報告では全人口の0.6%とそれほど多くはない[2]
  1. 尿道狭窄症は尿道のあらゆる部位で起こり得るが、球部尿道の狭窄が大半を占めており、振子部尿道、外尿道口、膜様部尿道の狭窄と続く。
  1. 治療は、狭窄の長さや、初発か再発かによって異なる。狭窄の長さが1.5cm未満であれば、内尿道切開術による再発率は 27%であり、第1選択とされる。一方、1.5cm以上の狭窄がある場合は、内尿道切開術の再発率が80%以上であり、尿道形成術が勧められる。また、1.5cm未満でも再発を繰り返す症例では、尿道形成術が勧められる。
 
内尿道切開術

内尿道切開術の内視鏡写真 cold knifeで12時方向を切開する。

出典

img1:  著者提供
 
 
 
  1. 尿道外傷(2020EAUガイドライン)アルゴリズム(推奨度1(参考文献:[1]
    二輪車の交通事故などでみられる骨盤骨折では、後部尿道損傷が合併する。その合併頻度は、男性で4~19%、女性で0~6%と報告されている。
問診・診察のポイント  
  1. 尿道狭窄の原因として淋菌性尿道炎や騎乗型損傷、骨盤外傷、経尿道的手術の既往や尿道カテーテルの使用歴が挙げられるので、そのような既往がないか確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: R Gómez, P Marchetti, O A Castillo
雑誌名: Actas Urol Esp. 2011 Mar;35(3):159-66. doi: 10.1016/j.acuro.2010.09.008. Epub 2011 Feb 19.
Abstract/Text INTRODUCTION: the management of anterior urethral stricture is controversial. A review article was written, which updates the current situation of the surgical treatment of anterior urethral stricture.
MATERIALS AND METHODS: the experience of the Hospital del Trabajador in Santiago de Chile regarding its different surgical approaches, as well as scientific literature on the topic, were reviewed.
RESULTS: traditionally, anterior urethral stricture has been treated using minimally invasive techniques (dilatation and internal urethrotomy), which are unable to cure more than 30-35% of patients. On the other hand, urethral reconstruction surgery (urethroplasty) is more complex and requires training, however it can cure a wide majority of patients in a single surgical procedure. Due to a lack of experience and training in reconstructive surgery, non-invasive methods are overused and abused, to the detriment of the patients' quality of life. There is substantial evidence that internal urethrotomy is an excellent method for treating stricture of up to 1cm in length, however its efficacy decreases drastically above 1.5cm. Notwithstanding, urethroplasty is directly indicated for larger strictures, especially if prior urethrotomy failed.
CONCLUSION: this procedure must be managed selectively, applying the appropriate treatment aimed at curing and not only palliating the disease. Urologists must be better trained in urethroplasty and/or centres of excellence must be established to be able to offer the best treatment in each case.

Copyright © 2010 AEU. Published by Elsevier Espana. All rights reserved.
PMID 21339014  Actas Urol Esp. 2011 Mar;35(3):159-66. doi: 10.1016/j.a・・・
著者: Travis L Bullock, Steven B Brandes
雑誌名: J Urol. 2007 Feb;177(2):685-90. doi: 10.1016/j.juro.2006.09.052.
Abstract/Text PURPOSE: We determined the methods and patterns of the evaluation of and treatment for adult anterior urethral stricture disease by practicing urologists in the United States.
MATERIALS AND METHODS: A nationwide survey of practicing members of the American Urological Association was performed by a mailed questionnaire. A total of 1,262 urologists were randomly selected from all 50 states, of whom 431 (34%) completed the questionnaire.
RESULTS: Most urologists (63%) treat 6 to 20 urethral strictures yearly. The most common procedures used by those surveyed for urethral strictures were dilation (92.8%), optical internal urethrotomy (85.6%) and endourethral stent (23.4%). Minimally invasive procedures are used more frequently that any open urethroplasty technique. Furthermore, most urologists (57.8%) do not perform urethroplasty surgery. When used, the most common urethroplasty surgeries performed were end-to-end anastomotic urethroplasty, perineal urethrostomy and ventral skin graft urethroplasty. Few urologists (4.2%) performed buccal mucosa grafts. For a long bulbar urethral stricture or short bulbar urethral stricture refractory to internal urethrotomy 20% to 29% of respondents would refer to another urologist, while 31% to 33% would continue to manage the stricture by minimally invasive means despite predictable failure. Of the urologists 74% believed that the literature supports a reconstructive surgical ladder, in which urethroplasty is only performed after repeat failure of endoscopic methods.
CONCLUSIONS: Most urologists in the United States have little experience with urethroplasty surgery. Most urologists erroneously believe that the literature supports a reconstructive surgical ladder for urethral stricture management. Unfamiliarity with the literature and inexperience with urethroplasty surgery have made the use of endoscopic methods inappropriately common.

PMID 17222657  J Urol. 2007 Feb;177(2):685-90. doi: 10.1016/j.juro.200・・・
著者: Laura S Leddy, Alex J Vanni, Hunter Wessells, Bryan B Voelzke
雑誌名: J Urol. 2012 Jul;188(1):174-8. doi: 10.1016/j.juro.2012.02.2567. Epub 2012 May 15.
Abstract/Text PURPOSE: We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma.
MATERIALS AND METHODS: A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal.
RESULTS: A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years.
CONCLUSIONS: Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 22591965  J Urol. 2012 Jul;188(1):174-8. doi: 10.1016/j.juro.2012・・・
著者: Karen Fransis, Kathy Vander Eeckt, Hendrik Van Poppel, Steven Joniau
雑誌名: BJU Int. 2010 Apr;105(8):1170-2. doi: 10.1111/j.1464-410X.2009.08848.x. Epub 2009 Oct 10.
Abstract/Text OBJECTIVES: To report the medium-term results at our institution of repairing long bulbar urethral strictures with buccal mucosal grafts.
PATIENTS AND METHODS: Between January 2003 and June 2007, a buccal mucosa graft repair was used in 34 patients with recurrent bulbar strictures >2 cm. The follow-up included uroflowmetry with an ultrasonographic estimate of residual volume at 3 months, 1 year and yearly thereafter, or at the onset of obstructive voiding symptoms. A retrograde urethrogram with a voiding cysto-urethrogram was taken at 6 months. Flexible urethroscopy was used whenever a recurrent stricture was suspected. A successful outcome was defined as normal voiding with no stricture on the voiding cysto-urethrogram and no need for subsequent instrumentation.
RESULTS: The median (range) age of the patients was 55.5 (23-74) years. The mean (sd) preoperative maximum flow rate was 6.6 (2.5) mL/s with a mean (sd) residual volume of 51.7 (89.7) mL. Seven patients (21%) had had one or more previous urethral dilatations, 15 (44%) had undergone one or more internal urethrotomies and 10 (30%) received both treatments. Eight patients (24%) had previous open urethral surgery; two had no previous treatment. A dorsal onlay technique was used in 30 patients, a ventral onlay in one, a combined technique (dorsal onlay and ventral fasciocutaneous flap) in two and a two-stage buccal mucosa urethroplasty in one. The mean (sd) operative duration was 147 (36) min, and the stricture length and buccal mucosa graft length were, respectively, 3.2 (1.2) cm and 4.4 (0.6) cm. Follow-up was available in 33 patients (97%) with a mean of 23 (15.4) months. The success rate was then 94%. Both failures occurred within the first year and were managed successfully by internal urethrotomy. The mean (sd) postoperative maximum flow rate was 20 (11) mL/s with a mean (sd) residual volume of 46 (68) mL. There were no medium-term donor-site complications. Postmicturition dribbling was noted in eight patients (24%). None of the patients had de novo impotence or urinary incontinence, and to date no patient has needed a repeat open reconstruction.
CONCLUSION: Our results show that in patients with bulbar urethral strictures of >2 cm, urethroplasty using buccal mucosa is feasible, with very encouraging medium-term results. We confirm that this type of reconstruction could be considered the standard of care for bulbar strictures of >2 cm.

© 2009 THE AUTHORS. JOURNAL COMPILATION © 2009 BJU INTERNATIONAL.
PMID 19818080  BJU Int. 2010 Apr;105(8):1170-2. doi: 10.1111/j.1464-41・・・
著者: Ehab A Eltahawy, Ramón Virasoro, Steven M Schlossberg, Kurt A McCammon, Gerald H Jordan
雑誌名: J Urol. 2007 May;177(5):1803-6. doi: 10.1016/j.juro.2007.01.033.
Abstract/Text PURPOSE: We report our experience and long-term followup of patients undergoing excision and primary anastomotic reconstruction for anterior urethral strictures.
MATERIALS AND METHODS: From July 1986 to May 2006 the charts of 260 patients who underwent excision with primary anastomosis at our center for bulbar urethral stricture were reviewed. Patient age ranged from 14 to 78 years (mean 38.4), stricture length ranged 0.5 to 4.5 cm (mean 1.9). Patients who had surgery within the last 5 years were contacted by telephone if their 6-month postoperative cystoscopic evaluation was patent and they had not visited the clinic afterward.
RESULTS: After a mean followup of 50.2 months 257 patients (98.8%) were symptom-free and required no further procedures. Recurrent stricture occurred early in 2 patients and late in 1 patient. Two patients opted for intermittent dilations, and a single direct visual internal urethrotomy was performed in 1 patient 4 years postoperatively. One of the patients who elected dilation subsequently elected urethral reconstruction, which was done successfully. Complications encountered were position related neuropraxia in 9 (3.4%), early urinary tract infection in 13 (5%), chest related in 5 (1.9%), scrotalgia in 4 (1.5%) and wound related in 4 (1.5%). All resolved within the early postoperative period. Erectile dysfunction was encountered in 6 (2.3%) patients, of whom 4 had a history of significant straddle trauma, 4 responded well to oral pharmacotherapy and 1 elected to not have the erectile dysfunction treated.
CONCLUSIONS: Excision with primary anastomosis for anterior urethral stricture has a high success rate of 98.8% with durable long-term results in most patients. Complications are few, of short duration and self-limited. Where applicable, we believe that the procedure clearly is the choice for short anterior urethral strictures.

PMID 17437824  J Urol. 2007 May;177(5):1803-6. doi: 10.1016/j.juro.200・・・
著者: Richard A Santucci, Layla A Mario, Jack W McAninch
雑誌名: J Urol. 2002 Apr;167(4):1715-9.
Abstract/Text PURPOSE: We reviewed our experience with anastomotic urethroplasty for anterior urethral stricture.
MATERIALS AND METHODS: A chart review revealed 168 patients 6 to 82 years old (mean age 38) with at least 6 months of followup (mean 70, range 6 to 291) after anastomotic urethroplasty.
RESULTS: Average stricture length was 1.7 cm. Of the 168 patients stricture recurred in 8 (5%) but was managed by direct vision internal urethrotomy or a single dilation in 5, while repeat urethroplasty was required in 3 (2%). In these 3 cases extenuating circumstances included patient dislodgment of the catheter with attempts to replace it that disrupted repair, a history of urethrocutaneous fistula and periurethral abscess, and previous irradiation complicating the stricture in 1 each. Other complications were uncommon, such as transient thigh pain or numbness in 3 patients (2%), small wound dehiscence in 2 (1%), and scrotal hematoma, erectile dysfunction and self-limited pulmonary edema in 1 (less than 1%) each.
CONCLUSIONS: Anastomotic urethroplasty for anterior stricture has a high success rate of 95%. It is technically straightforward and complications are uncommon. Cure by anastomotic urethroplasty should be strongly favored over long-term management by direct vision internal urethrotomy or dilation.

PMID 11912394  J Urol. 2002 Apr;167(4):1715-9.
著者: D E Andrich, C J Leach, A R Mundy
雑誌名: BJU Int. 2001 Sep;88(4):385-9.
Abstract/Text OBJECTIVE: To compare the surgical outcome using buccal mucosal free grafts in the Barbagli procedure (dorsal stricturotomy and patch technique) with the traditional ventral approach, for long bulbar urethral strictures.
PATIENTS AND METHODS: Over a period of 6 years, a total of 71 patients with bulbar urethral strictures underwent buccal mucosal graft urethroplasty. Twenty-nine patients had a traditional ventral urethroplasty and 42 were managed by the Barbagli procedure with the stricturotomy and patch on the dorsal aspect of the urethra.
RESULTS: At 5 years of follow-up 5% of patients who underwent the Barbagli procedure developed recurrent strictures, compared to 14% in the traditional ventral stricturotomy group. All patients developed postmicturition dribble of urine to some degree, which was troublesome in 17% in the Barbagli group and 21% in the ventral stricturotomy group. Complications attributable to out-pouching of the graft were not seen in either group.
CONCLUSIONS: The dorsal stricturotomy and patch (Barbagli) procedure had a higher success rate than the traditional ventral urethroplasty. Comparing these results with our experience of skin inlay urethroplasty, buccal mucosal grafts seem to have advantages however they are used.

PMID 11564027  BJU Int. 2001 Sep;88(4):385-9.
著者: Altaf Mangera, Jacob M Patterson, Christopher R Chapple
雑誌名: Eur Urol. 2011 May;59(5):797-814. doi: 10.1016/j.eururo.2011.02.010. Epub 2011 Feb 24.
Abstract/Text CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended.
OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery.
EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre.
EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo.
CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
PMID 21353379  Eur Urol. 2011 May;59(5):797-814. doi: 10.1016/j.eururo・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから