Canadian Urological Association guideline on male urethral stricture

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum which in turn causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors including the accuracy of cystoscopy as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient’s quality of life. Endoscopic treatment either as dilation or internal urethrotomy is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus) or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.

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Penile urethral stricture disease

Journal of Clinical Urology ◽

10.1177/2051415818774227 ◽

2018 ◽

Vol 12 (2) ◽

pp. 145-157

Author(s):

Marco Spilotros ◽

Suzie Venn ◽

Paul Anderson ◽

Tamsin Greenwell

Keyword(s):

Urethral Stricture ◽

Lichen Sclerosus ◽

Corpus Spongiosum ◽

Hypospadias Repair ◽

Internal Urethrotomy ◽

Level Of Evidence ◽

Urethral Stricture Disease ◽

Urethral Strictures ◽

Considerable Cost ◽

The Uk

Patients affected by a urethral stricture account for a considerable cost to all healthcare systems. The estimated prevalence of all urethral stricture in the UK is 10/100,000 men during youth, increasing to about 40/100,000 by age 65 years and to more than 100/100,000 thereafter. A penile urethral stricture is a narrowing of the lumen of the urethra due to ischaemic fibrosis of the urethral epithelium and/or spongiofibrosis of the corpus spongiosum occurring within the penile urethra. Its aetiology is largely idiopathic but other important causes are failed hypospadias repair and lichen sclerosus, which account for 60% of all cases. Strictures of the anterior urethra account for 92% of cases: bulbar strictures are more frequent (46.9%), followed by penile (30.5%) and combined bulbar/penile (9.9%), that is, 40.4% of all men presenting with stricture will have a penile urethral stricture alone or in combination with a bulbar urethral stricture. There are several options for the treatment of penile urethral strictures ranging from less invasive treatments, including urethral dilatation and direct vision internal urethrotomy, to more complex augmentation graft and flap urethroplasty. The aim of the present review is to describe the aetiology and epidemiology of anterior urethral strictures and the available options reported in literature for their treatment. Level of evidence: 1a

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Endoluminal and Endoscopic Management of Urethral Stricture

Journal of Endoluminal Endourology ◽

10.22374/jeleu.v3i1.74 ◽

2020 ◽

Vol 3 (1) ◽

pp. e9-e18

Author(s):

Siu Yip Martin Mak ◽

Wayne Lam ◽

James Hok-Leung Tsu

Keyword(s):

Urethral Stricture ◽

Endoscopic Treatment ◽

Treatment Success ◽

Endoscopic Management ◽

Original Research ◽

Male Population ◽

Term Efficacy ◽

Urethral Strictures ◽

Long Term Treatment

Background and ObjectiveUrethral stricture in the male population is one the oldest described urological condition. Significant vari-ability in clinical practice means that standardized management of urethral stricture remains controversial. Since the first description of modern-day direct visual internal urethrotomy (DVIU) by Sachse in 1974, this, alongside with various endoscopic treatment techniques, continues to be by far the most commonly performed procedures for the management of urethral strictures. This article aims to summarise and review the latest literature on endoscopic management of urethral strictures. Material and MethodsWe conducted a Pubmed and Medline search to identify publications related to endoscopic management of male urethral strictures between 1980 and 2019. Preference was given to recent and larger studies. Original research articles, review articles, abstracts, and opinion articles were included. Keywords used for the search were “male urethral stricture,” “urethrotomy,” “DVIU,” “urethral dilation,” “urethral stent”, “intermittent self-catheterisation”, “mitomycin C”, “steroids”, and “urethroplasty.” Recent FindingsThe long-term efficacy of endoscopic management of urethral stricture is poor. Recent novel advances with adjunct treatment have yet to demonstrate improvement in long-term treatment success. Repeated endoluminal or endoscopic treatments, especially for long and recurrent urethral strictures, are ineffective. They appear to delay patients from receiving definitive treatments, and potentially increase complexity and decrease the success rate of any future urethral reconstructive treatment. SummaryThere is overwhelming evidence to suggest limited long-term efficacy of endoluminal or endoscopic treat-ments for urethral stricture. Novel adjunctive therapies showed promising initial results, but none have yet to demonstrate durable efficacy. Endoscopic treatment of urethral stricture disease should only be reserved for patients who are not willing to undergo reconstructive surgery, or not fit for anesthetics.

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Combined Endoscopic and Surgical Technique for the Repair of Posterior Traumatic Urethral Stricture

Urologia Journal ◽

10.1177/039156030907600304 ◽

2009 ◽

Vol 76 (3) ◽

pp. 192-197

Author(s):

G. Romano ◽

M. De Angelis ◽

G. Barbagli

Keyword(s):

Surgical Technique ◽

Urethral Stricture ◽

Guide Wire ◽

Voiding Cystourethrography ◽

Endoscopic Management ◽

Urethral Strictures ◽

Pelvis Fracture ◽

Post Traumatic ◽

Surgical Teams ◽

Proximal Urethra

The aim of this study is to show and evaluate the combined procedure, which uses an endoscopic suprapubic access and a surgical perineal access to repair posterior urethral stricture secondary to traumatic pelvis fracture. Material and Methods In the period from January 1989 to December 2007 eighty-nine patients underwent urethral surgery for post-traumatic posterior urethral stricture. From January 2003 all patients underwent combined endoscopic and surgical technique. According to this technique, the patient is placed in simple lithotomic position with the calves carefully placed in Allen stirrups. Two surgical teams work simultaneously. A middle-line perineal incision is made and the bulbar urethra is isolated proximally and the membranous urethra is transected at the strictured site. At the same time the second surgical team performs an endoscopic suprapubic access placing the “Amplatz” sheath, previous progressive dilation to 20/22 Ch. By using a rigid or flexible cystoscope the operator follows endoscopically the bladder neck and reaches the stenotic site performing an anterograde urethroscopy. At this point the perineum is transilluminated by the endoscope and the surgeon can easily identify the proximal urethral end. A soft guide wire is inserted at this point into the urethra through the endoscope to facilitate the dilation till a nose speculum can be inserted. At this point an end-to-end anastomosis is performed. A Foley 18 Fr catheter and a suprapubic cystostomy are left in place for 1 month; a voiding cystourethrography is then performed. Results The bulboprostatic anastomosis shows better results (65% of success) if compared with the other techniques (Badenoch, two stage urethroplasty, perineal urethrostomy). A definite increase in the success rate (10%) has been evident in the last five years, simultaneously to the use of combined technique. Conclusions The combined perineal and suprapubic access, in post-traumatic posterior urethral strictures repair, allows achieving a better and easy location and a better preparation of the proximal urethra. The final target is to obtain a better bulboprostatic anastomosis, with better results confirmed by long-term follow-up. In particular, the endoscopic management of the suprapubic access is possible and of minor invasiveness to the patient.

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Study of etiology, clinical presentation, management procedures performed and complications of urethral stricture patients at a tertiary hospital

Medpusle International Journal of Surgery ◽

10.26611/1061924 ◽

2021 ◽

Vol 19 (2) ◽

pp. 48-52

Author(s):

Vidyadhar P Kelkar ◽

Keyword(s):

Urinary Tract ◽

Urethral Stricture ◽

Postoperative Period ◽

Clinical Presentation ◽

Tertiary Hospital ◽

Corpus Spongiosum ◽

Internal Urethrotomy ◽

Female Ratio ◽

Satisfactory Outcome ◽

Management Procedures

Background: Urethral stricture is narrowing of a segment of the urethra which is surrounded by corpus spongiosum. The overall incidence of stricture disease varies from 0.6% to 0.9% worldwide. Urethral stricture obstructs lower urinary tract, causes micturition disturbances, can also damage the entire urinary tract, resulting in loss of renal function. In present study we aimed to study etiology, clinical presentation, management procedures and complications of urethral stricture at a tertiary hospital. Material and Methods: Present study was single-center, prospective, observational study, conducted patients diagnosed to have urethral strictures, underwent initial management during the study period and willing to participate. Patients treated by dilatation, Direct vision internal urethrotomy (DVIU), open surgery (urethroplasty). Results: This study included 50 patients of male and female genders of different age groups. Male to female ratio was 3.55 : 1. Maximum patients (32%) were from the age-group 31-40 years with mean age of 45.7 +16.59 years. Causes of urethral stricture in most of the patients were infections (30%) and trauma (50%). Most patients are treated by the serial urethral dilatation (58%). Other procedures were visual internal urethrotomy (VIU) (26%) and surgery including buccal mucosal graft (BMG) urethroplasty (16%). Postoperatively out of 50 patients 7 patients experienced Pain [14%] and 43 patients doesn‘t have pain in postoperative period. [86%]. About 8 patients have fever in postoperative period [16%] and hematuria is seen in 18 patients [36%]. Conclusion: Trauma and infections were the leading cause of urethral stricture. Visual Internal Urethrotomy and urethroplasty were the mainstay of treatment with satisfactory outcome.

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Comparing retrograde urethrography readings with intraoperative findings in urethral stricture

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20192523 ◽

2019 ◽

Vol 7 (6) ◽

pp. 2333

Author(s):

Tanvi Subhash Kelkar ◽

Anil Joshi

Keyword(s):

Urinary Tract ◽

Urethral Stricture ◽

Lower Urinary Tract ◽

Operating Characteristics ◽

Medical College ◽

Urethral Strictures ◽

Retrograde Urethrography ◽

Common Location ◽

Operative Findings ◽

Lower Urinary

Background: Urethral strictures are relatively common in men with most patients acquiring the disease due to injury or infection. The present study was conducted to assess the accuracy of retrograde urethrography (RGU) in diagnosing urethral strictures in patients presenting with lower urinary tract symptoms.Methods: All male patients presenting with lower urinary tract symptoms and referred for retrograde urethrogram to the Department of Radiodiagnosis, Bharati Vidyapeeth Medical College and Hospital (Deemed to be University), Sangli from November 2018 till January 2019 were included. The parameters of RGU were compared with intra-operative findings as gold standard to calculate the operating characteristics of RGU.Results: The present study included 42 patients, mean age 54.9±11.2 years. Grade I urethral stricture was observed in 42.8% and 26% had grade II stricture. Bulbar stricture was the most common location. The common presenting complaints were increased frequency (50%) and dribbling micturition (40.4%). Approximately one tenth of all patients had a history of trauma. RGU was 100% sensitive and 66.7% specific in detecting strictures of less than 2 cm. Overall accuracy of RGU in detecting urethral strictures of less than 2 cm was 83.3%.Conclusions: RGU is a reliable means for establishing the diagnosis of a suspected urethral stricture and also provides accurate staging information with regard to stricture number, length, location, and coexistent urethral pathology.

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Multiple urethral calculus misdiagnosed as urethral stricture: The role of imaging in unknotting the confusion

Asian Journal of Medical Sciences ◽

10.3126/ajms.v7i3.13874 ◽

2016 ◽

Vol 7 (3) ◽

pp. 118-120

Author(s):

M. Danfulani ◽

S.A. Saidu ◽

M.A. Musa

Keyword(s):

Urinary Tract ◽

Urethral Stricture ◽

Imaging Modality ◽

Signs And Symptoms ◽

Upper Urinary Tract ◽

Urethral Calculus ◽

Urinary Tract Calculi ◽

Urethral Diseases ◽

Prompt Diagnosis

Urinary Tract Calculi Impaction / finding in the male urethra is extremely uncommon and can usually be secondary to upper urinary tract calculus formation or primarily arising from the urethra either due to stricture or post-trauma. There is paucity of urethral stricture report in Nigeria, thus this case is reported to highlight the role of imaging in the prompt diagnosis and management of urethral diseases; and to advise urologists to at least always request for imaging modality in their routine evaluation of urethral pathologies. We report a case of a 55 years old male farmer who presented in the Accident and Emergency Unit of our facility with signs and symptoms of acute urinary retention. A working diagnosis of urethral stricture was entertained and prompt diagnosis was made on image. Existing literatures outlining the pathologies, clinical presentation, therapeutic consideration and imaging as it relates to urethral calculi were reviewed. We thus concluded that imaging is very vital and fundamental in order to correctly assess any form of urethral pathology.Asian Journal of Medical Sciences Vol. 7(3) 2016 118-120

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Faculty Opinions recommendation of SIU/ICUD Consultation on Urethral Strictures: Anterior urethra-lichen sclerosus.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718185751.793513209 ◽

2016 ◽

Author(s):

Altaf Mangera

Keyword(s):

Lichen Sclerosus ◽

Anterior Urethra ◽

Urethral Strictures

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Faculty Opinions recommendation of Insights into the Pathophysiology of Urethral Stricture Disease due to Lichen Sclerosus: Comparison of Pathological Markers in Lichen Sclerosus Induced Strictures vs Nonlichen Sclerosus Induced Strictures.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.735266258.793574384 ◽

2020 ◽

Author(s):

Suks Minhas

Keyword(s):

Urethral Stricture ◽

Lichen Sclerosus ◽

Urethral Stricture Disease

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Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM)

World Journal of Urology ◽

10.1007/s00345-020-03102-5 ◽

2020 ◽

Vol 38 (11) ◽

pp. 2863-2872 ◽

Cited By ~ 2

Author(s):

Malte W. Vetterlein ◽

◽

Luis A. Kluth ◽

Valentin Zumstein ◽

Christian P. Meyer ◽

...

Keyword(s):

Radiation Therapy ◽

Urethral Stricture ◽

Outcome Measure ◽

Patient Reported Outcome ◽

Patient Reported Outcome Measure ◽

Urethral Strictures ◽

Buccal Mucosal Graft ◽

Surgery Patient ◽

Patient Reported ◽

Radiation Induced

Abstract Objectives To evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty. Patients and methods Monocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan–Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM). Results Overall, 47 patients were available for final analyses. Median age was 70 (IQR 65–74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28–68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome. Conclusion The success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.

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