Anterior urethral stricture review

Male anterior urethral stricture disease is a commonly encountered condition that presents to many urologists. According to a National Practice Survey of Board Certified Urologist in the United States most urologists treat on average 6-20 urethral strictures yearly. Many of those same urologists surveyed treat with repeated dilation or internal urethrotomy, despite continual recurrence of the urethral stricture. In point of fact, the urethroplasty despite its high success rate, is underutilized by many practicing urologists. Roughly half of practicing urologist do not perform urethroplasty in the United States. Clearly, the reconstructive ladder for urethral stricture management that was previously described in the literature may no longer apply in the modern era. The following article reviews the etiology, diagnosis, management and comparisons of treatment options for anterior urethral strictures.     

Anterior urethral strictures: a brief review of the current surgical treatment

A review of the recent literature on the surgical management of anterior urethral stricture was performed. The literature was searched via PubMed using the search terms 'urethral stricture' and 'urethroplasty' from 1996 to 2009. The management of anterior urethral strictures is changing rapidly in the sense that the reconstructive procedures have evolved greatly. Penile skin, because of its location and because it is hairless, has been popular and used for a long time. Since the early 1990s, buccal mucosa graft (BMG) was introduced in urethral reconstructive surgery and has become the first choice of most practicing urologists. Recently, there has been an increase in the use of lingual mucosa graft with various doctors reporting easy harvesting and lesser morbidity in comparison to BMG. Also, fibrin glue has recently been used to fix the graft with promising results. With the success of tissue-engineered materials that are still in the experimental phase, the urologist would no longer be limited by the quantity of the graft. These substitutes will also boost the appealing scarless endoscopic urethroplasty. This article provides a brief up-to-date review of the main surgical techniques in the management of anterior urethral stricture disease for the contemporary practicing urologists. Present controversies have been given special emphasis. The possible future techniques and the future of the anterior urethral stricture surgery are also discussed in brief.     

Anterior urethral strictures

Aim

The aim of the present study was to determine the practice patterns in the management of anterior urethral strictures among urologists in Hong Kong.

Patients and Methods

A 14‐item questionnaire was delivered either directly or by mail to all 126 registered urologists in Hong Kong. Information including demographic data, number of anterior urethral strictures treated, diagnostic methods, treatment options and follow‐up strategy were collected. The questionnaire also asked for the personal opinion about the treatment plan of two stricture case scenarios.

Results

The response rate was 48 per cent. The majority (87 per cent) of urologists treated <10 anterior urethral strictures per year. Minimal invasive procedures, including urethral dilatation using metal sounds (77 per cent) or cystoscopy‐guided (74 per cent) and direct visual internal urethrotomy (57 per cent), were more commonly performed by urologists to treat urethral strictures. The majority of urologists (82.6 per cent) performed less than five urethroplasties per year. In the two case scenarios of long bulbous urethral stricture and recurrent short urethral stricture, approximately 10 per cent of respondents would refer the cases to other urologists and approximately 75 per cent would choose to perform reconstructive surgeries. The remaining 15 per cent of respondents would choose minimally‐invasive procedures for these strictures. Nearly two‐thirds (62.3 per cent) of urologists believed that urethroplasty should be proposed only after failed endoscopic treatment. Workups for urethral stricture disease were consistent, while the modalities to access the outcome were highly heterogeneous.

Conclusion

In Hong Kong, the majority of urologists choose to perform urethroplasty for long bulbous urethral strictures and recurrent short bulbous urethral strictures in a case scenario situation. However, in actual practice, most perform less than five urethroplasties per year. A small caseload, lack of experience and understanding of urethral reconstructive surgery means that most urologists in Hong Kong would hesitate to carry out primary urethroplasty in correctly‐selected patients for whom primary reconstruction would have been the treatment of choice.     

Treatment of Urethral Stricture Disease by Internal Urethrotomy,Dilation, or Stenting

Management of urethral strictures depends on the characteristics of each individual case and remains a great challenge in reconstructive urology. Treatment of anterior urethral strictures usually starts with minimally invasive procedures, such as urethral dilatation or internal urethrotomy. The popularity of these methods is based on the simple application, the low complication rate, and the fact that most general urologists do not perform open urethroplasty. These methods offer faster recovery, minimal scarring, and fewer infections, although recurrence is always possible. Success depends on adequate vascularity within the underlying spongiosal tissue, which may substantially increase the failure rate. Because the recurrence rate has remained higher than it was in past decades, various modifications of urethral stricture treatment have been suggested, including laser urethrotomy and urethral stents. Since the late 1980s, two different approaches have been studied to prevent scaring contraction: permanent stent versus temporary stents left indwelling for a limited time and then removed. Although the first reports seemed to promise excellent outcomes, longer follow-up began to cast doubt on the usefulness of urethral stenting as a primary treatment modality for urethral stricture disease. The purpose of our study was to evaluate the published literature with respect to any new information on minimally invasive procedures in the treatment of urethral strictures.Patient summaryThe optimal indications for dilatation or internal urethrotomy are simple bulbar strictures <2 cm without spongiofibrosis or history of previous treatment. Recurrent urethral strictures after repeated interventions are usually more complex and can render the definite open urethral surgery more difficult.     

Long-term results of a self-expanding wallstent in the treatment of urethral stricture

OBJECTIVE: To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS: The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS: The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS: The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.     

Management of adult anterior urethral stricture disease: nationwide survey among urologists in the Netherlands

Background

Adult anterior urethral stricture disease is most often treated with dilatation or direct vision internal urethrotomy (DVIU). Although evidence suggests that anastomotic urethroplasty for short bulbar strictures is more efficient and cost effective in the long term, no consensus exists. It is unclear by whom and how often urethroplasties are performed in The Netherlands and how results are being evaluated.

Objective

To determine national practice patterns on management of anterior urethral strictures among Dutch urologists. This information will help to define the nationwide need for training in urethral surgery.

Design, setting, and participants

We conducted a 16-question survey among all 323 Dutch urologists.

Results and limitations

The response rate was 74%. DVIU was practised by 97% of urologists. Urethroplasty was performed at least once yearly by 23%, with 6% performing more than five urethroplasties annually. In the group of urologists younger than 50 yr of age, 13% performed urethroplasty, with 3% of those performing more than five annually. In the case of a 3.5-cm-long bulbar stricture, DVIU was preferred by 49% of responders. Even after two recurrences, 20% continued to manage a 1-cm-long bulbar stricture endoscopically. Of responders, 79% believed that urethroplasty should be proposed only after a failed endoscopic attempt. Diagnostic workup and evaluation of success varied greatly.

Conclusions

Most Dutch urologists believe that urethroplasty is an option only after failed DVIU. Endoscopic procedures are widely used, even when the risk of recurrence is virtually 100%. The definition of success is hampered by nonstandardised methods of follow-up. Only a small group of mainly older urologists frequently performs urethroplasties. Training programmes seem necessary to guarantee a high standard of care for stricture disease in The Netherlands. A pan-European practice survey might be interesting to clarify the need for centralised fellowship programmes.     

Low-power holmium:YAG laser urethrotomy for treatment of urethral strictures: functional outcome and quality of life

PURPOSE: To evaluate the efficacy of endourethrotomy with the holmium:YAG laser as a minimally invasive treatment for urethral stricture. PATIENTS AND METHODS: Between January 2002 and January 2004, 32 male patients with symptomatic urethral strictures (8 bulbar, 9 penile, 9 combined) were treated with Ho:YAG-laser urethrotomy in our department. The stricture was iatrogenic in 60% (N = 18), inflammatory in 16.6% (N = 5), traumatic in 13.3% (N = 4), and idiopathic in 7% (N = 3). The stricture was incised under vision at the 12 o'clock location or the site of maximum scar tissue or narrowing in asymmetric strictures. Laser energy was set on 1200 to 1400 mJ with a frequency of 10 to 13 Hz. Postoperatively, drainage of the bladder was performed for 4 days using a 18F silicone catheter. Triamcinolone was instilled intraurethrally after removal of the catheter in all patients. Patients were followed up by mailed questionnaire, including International Prostate Symptom Score and quality of life. RESULTS: Retrograde endoscopic Ho:YAG laser urethrotomy could be performed in all 32 patients. Most patients (22; 68.7%) did not need any reintervention. Ten patients developed recurrent strictures that were treated by another laser urethrotomy in 4 patients (12.5%), while 6 patients (18.7%) needed open urethroplasty with buccal mucosa. Including 2 patients treated with repeat laser urethrotomy, 24 patients (75%) were considered successful after a mean follow-up of 27 months (range 13-38 months). No intraoperative complications were encountered, although in 5% of patients, a urinary-tract infection was diagnosed postoperatively. No gross hematuria occurred. CONCLUSIONS: The Ho:YAG laser urethrotomy is a safe and effective minimally invasive therapeutic modality for urethral stricture with results comparable to those of conventional urethrotomy. Further data from long-time follow-up are necessary to compare the success rate with that of conventional urethrotomy and urethroplasty. Nevertheless, the Ho:YAG laser urethrotomy might at least be an alternative to urethroplasty in patients with high comorbidity who are not suitable for open reconstruction.     

Dorsal inlay buccal mucosal graft (Asopa) urethroplasty for anterior urethral stricture

Asopa described the inlay of a graft into Snodgrass’s longitudinal urethral plate incision using a ventral sagittal urethrotomy approach in 2001. He claimed that this technique was easier to perform and led to less tissue ischemia due to no need for mobilization of the urethra. This approach has subsequently been popularized among reconstructive urologists as the dorsal inlay urethroplasty or Asopa technique. Depending on the location of the stricture, either a subcoronal circumferential incision is made for penile strictures, or a midline perineal incision is made for bulbar strictures. Other approaches for penile urethral strictures include the non-circumferential penile incisional approach and a penoscrotal approach. We generally prefer the circumferential degloving approach for penile urethral strictures. The penis is de-gloved and the urethra is split ventrally to exposure the stricture. It is then deepened to include the full thickness of the dorsal urethra. The dorsal surface is made raw and grafts are fixed on the urethral surface. Quilting sutures are placed to further anchor the graft. A Foley catheter is placed and the urethra is retubularized in two layers with special attention to the staggering of suture lines. The skin incision is then closed in layers. We have found that it is best to perform an Asopa urethroplasty when the urethral plate is ≥1 cm in width. The key to when to use the dorsal inlay technique all depends on the width of the urethral plate once the urethrotomy is performed, stricture etiology, and stricture location (penile vs. bulb).     

Die bulbäre Harnröhrenstriktur

Urethral strictures are often located in the bulbar urethra, and bulbar strictures are commonly due to urethral trauma. Diagnosis is confirmed by radiographic imaging of the urethra. In cases of short primary bulbar strictures, a simple internal urethrotomy may be curative. In contrast, open surgery should be performed in long segment or recurrent strictures because recurrence rates are near 100% in these cases. Depending of the actual findings and comorbidities, end-to-end anastomosis, graft urethroplasty, flap urethroplasty, or perineal urethrostomy may be used. If definitive treatment using open surgery is delayed and multiple endoscopic treatments are tried, urethroplasty becomes more complex and success rates of definitive treatment decline.     

Surgical management of urethral strictures based on etiology. Where do urethral stents fit in?

Recent studies in the urologic literature indicate a renewed interest in the management of urethral stricture disease. Specifically, urologists are now treating all types of urethral strictures regardless of location, etiology, or extent with methods other than primary urethroplasty or direct vision internal urethrotomy (DVIU), i.e., balloon dilation or urethral stenting. To see which patients might best be managed by these new modalities, we reviewed our experience with urethral strictures at LAC-USC Medical Center.     

Urethroplasty for anterior urethral strictures in a community-based urology practice

Introduction The outcome of urethroplasty for the anterior urethral stricture is superior to internal urethrotomy. However, the excellent results are often reported by tertiary medical centres and most urologists in general urological practice do not offer urethroplasty. We review the results of our institution to ascertain whether equivalent results are achievable in a district hospital urology service. Methods Over a 22-month period, 26 urethroplasties were performed. Mean age was 44.2 years (range: 16–83 years) and median follow-up was 14.6 months (range: 0.6–40.2 months). Anastomotic repair was performed in five, substitution urethroplasty in 15 (nine flaps and six grafts) and␣staged urethroplasty in 6. Length of strictures ranged from less than 0.2 cm to greater than 10 cm. Results Stricture-free rate of 90.5% at 1 year was observed. Only two cases developed repeat stricture formation. Other minor complications included one epididymo-orchitis and one haematoma. Conclusion Good early outcome for urethroplasty for anterior urethral strictures is achievable in a district hospital practice. Keys to good outcome include having a dedicated team and a wide repertoire of urethral reconstructive techniques.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

Endoscopic urethroplasty with unseeded small intestinal submucosa collagen matrix grafts: a pilot study

PURPOSE: We evaluated small intestinal submucosa (SIS) as a substitute for skin in endoscopic urethroplasty performed as treatment for inflammatory and iatrogenic strictures of the male bulbar urethra, and in the early treatment of bulbomembranous urethral injuries associated with recent pelvic fractures. Tissue integration and epithelialization of SIS in endoscopic urethroplasty were assessed, as was the long-term maintenance of urethral patency following this treatment. MATERIALS AND METHODS: Nine patients with bulbar urethral strictures defined by urethrography were enrolled in the study. Following optical urethrotomy the SIS grafts were tubularized over a purpose specific graft carrying balloon device and secured into the opened urethra as described for endoscopic urethroplasty. Patients were followed with urethroscopy and urethrography at regular intervals as per protocol or when symptoms arose. Failure was defined as the need for any further intervention. RESULTS: Two patients with short inflammatory strictures maintained urethral patency without any intervention at 1 and 2 years, respectively. Stricture recurrence developed in 6 patients within 3 months of surgery. Of these, 3 have undergone subsequent open urethroplasty, 2 are currently awaiting urethroplasty and 1 is maintaining urethral patency with regular self-dilatation. One patient was lost to followup. CONCLUSIONS: Endoscopic urethroplasty with unseeded SIS grafts was unsuccessful in this study.     

尿道狭窄最佳术式选择的探讨

近半个世纪以来,尿道狭窄的手术方式已经发生了显著的变化。如今,绝大多数的尿道狭窄都可以通过手术进行修复重建。尿道狭窄的病因、长度和位置是选择手术方式的重要依据。操作者在术前必需熟悉多种尿道重建的手术方法以便处理术中遇到的各种情况。目前,反复的尿道扩张和尿道内切开是错误的,应该摈弃。开放性尿道手术成功率高,长期疗效确切,在很多情况下应该作为首选。本文就各种尿道狭窄手术方式的选择及操作要点做一介绍。     

Rational and selective management of patients with anterior urethral stricture disease

Introductionthe 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 methodsthe 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.Resultstraditionally, 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 1 cm in length, however its efficacy decreases drastically above 1.5 cm. Notwithstanding, urethroplasty is directly indicated for larger strictures, especially if prior urethrotomy failed.Conclusionthis 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.     

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction

PURPOSE: We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term. MATERIALS AND METHODS: In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture. RESULTS: Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure. CONCLUSIONS: Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.     

Muscle- and nerve-sparing bulbar urethroplasty: a new technique

BACKGROUND: To describe a new surgical technique for the repair of bulbar urethral strictures to preserve the bulbospongiosum muscle and its perineal innervation. OBJECTIVE: Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are described. The outcome is provided regarding semen sequestration and postvoiding dribbling. DESIGN, SETTING, AND PARTICIPANTS: We performed the procedure in 12 patients (average age: 43.58 yr) with bulbar urethral strictures (average stricture length: 4.47cm). SURGICAL PROCEDURE: Six patients underwent urethroplasty using a ventral oral mucosal onlay graft, and six patients underwent urethroplasty using a dorsal oral mucosal onlay graft. In all patients, the surgical approach to the bulbar urethra was made avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact. MEASUREMENTS: Clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the technical feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The secondary outcome examined the presence or absence of postoperative postvoid dribbling and semen sequestration using a nonvalidated questionnaire (Appendix). RESULTS AND LIMITATIONS: In all patients, postoperative voiding cystourethrography was performed 3 wk after surgery and no urethral sacculation was evident. Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or semen sequestration was demonstrated in all patients at 6 mo and 12 mo after surgery. No patient showed stricture recurrence. The average follow-up was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo). CONCLUSIONS: Bulbar urethroplasty preserving the bulbospongiosum muscle, the central tendon of the perineum, and the perineal nerves is a safe, feasible, minimally invasive alternative to traditional bulbar urethroplasty.     

Treatment of inflammatory urethral stenosis with endoscopic urethrotomy

Urethral stricture, mainly consisting of cases of inflammatory stricture, is a frequent occurrence in Morocco. Numerous techniques have been proposed to treat these disorders, including internal endoscopic urethrotomy (IEU). Initially described by Otis and Maisonneuve using a blind approach, IEU was then further developed by Saches who carried out direct vision urethrotomy. It rapidly became established as the method of choice for primary treatment of urethral stricture, and classical surgery was limited to those cases in which this method had failed. However, although this technique is relatively simple and appears to be efficient, there is in fact a high relapse rate, necessitating repeated IEU; therefore at present there is a tendency to return to the classical methods of anastomotic resection and urethroplasty after the second or third IEU. Although the relapse rate is low for short, single or bulbar strictures, it is high for penile strictures and for those with accompanying severe periurethral fibrosis. In this study, we have reported the results of a homogeneous series of 149 cases of urethral stricture treated by internal urethrotomy. The aim of this retrospective study was to better define the indications for adopting this technique, and also to determine the reasons for failure. The various alternatives to IEU (resection, plasty) have been examined, as has their respective failure rate.     

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two‐sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one‐stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one‐sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.