eMedicine Specialties > Urology > Strictures

Urethral Strictures, Male: Follow-up

Author: Angelo E Gousse, MD, Professor of Urology and Gynecology, Director of Urology Residency Program, University of Miami School of Medicine; Director, Urodynamics Laboratory, Miami Veterans Affairs Medical Center
Coauthor(s): Daniel J Caruso, MD, MBA, Clinical Instructor, Division of Female Urology, Voiding Dysfunction, and Pelvic Floor Reconstruction, Department of Urology, University of Miami/Jackson Health Systems; Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine; Joshua A Broghammer, MD, Resident Physician, Department of Urology, Wayne State University; Jon Timothy Posey, MD, Staff Physician, Department of Urology, University of Miami School of Medicine
Contributor Information and Disclosures

Updated: Jun 24, 2009

Outcome and Prognosis

Urethral dilation and internal urethrotomy

A prospective randomized comparison of internal urethrotomy and urethral dilation for male urethral strictures found no significant difference in efficacy between the two procedures when used as initial treatment.17 Recurrence rates increased as the length of the stricture increased. Recurrence rates at 12 months were 40%, 50%, and 80% for stricture lengths of less than 2 cm, 2-4 cm, and greater than 4 cm, respectively. The recurrence rate for strictures 2-4 cm long increased to 75% at 48 months of follow-up.

Permanent urethral stents

Five-year follow-up data demonstrated a long-term success rate of 84% and high level of patient satisfaction.10 Failures typically occurred in patients with extensive stricture disease. The North American Study Group 11-year data demonstrated an overall success rate of less than 30%.16 A European group reported 2 out of 15 satisfied patients 10 years postimplantation.5 An Italian multicenter study following 94 cases reported on the short- and long-term complications.12 Short-term complications (7-28 d following the procedure) included perineal discomfort (86%) and dribbling (14%). Long-term complications included painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%). Additionally, some unique complications are associated with permanently implantable stents. The stents are designed for placement within the bulbous urethra. If they are placed distally, there is a risk of pain upon sitting and intercourse.

Excision with primary anastomosis

This form of repair for anterior urethral strictures is considered to be the criterion standard. Historically, this technique has been reserved for strictures shorter than 2 cm. Better understanding of the anatomy has led to successful application of this repair to longer strictures. Jordan and Schlossberg (2007) reported 3 recurrences among 220 patients undergoing primary repair, with a mean follow-up period of 44 months.9 Mundy (2006) performed an analysis of a large series of urethral reconstructions and described a durable rate after primary repair that does not deteriorate with time.13

Free graft repair

These procedures have an overall success rate of 84.3%. Mundy's analysis demonstrated a 95% success rate with graft reconstructions when the follow-up was limited to 1 year. Longer follow-up showed deterioration over time.13

Pedicled skin flaps

The overall success rate is 85.5%. Skin island onlay flap with preservation of the urethral plate provides better success rates than the tubularized flap. Tubularized island flaps have lower success rates than skin island onlay flaps secondary to stricture formation at the site of anastomosis with the native urethra.2

A meta-analysis showed equivalent results when comparing graft versus flap reconstruction.18 Many authors believe grafts are better suited for proximal reconstruction than flaps for distal reconstruction when all other variables are equivalent.8

Postoperative erectile dysfunction

Overall, the rates of erectile dysfunction after urethral reconstruction are low. Reported rates are as low as 2%.9 Patients with severe straddle injuries were particularly at risk. A series of 200 patients who underwent anterior urethroplasties demonstrated that the rate of erectile dysfunction was comparable to that after circumcision. Patients who had longer segments of their urethra reconstructed were at higher risk. In this analysis, erectile dysfunction did improve over time.4

Future and Controversies

Many techniques are available for the treatment of urethral stricture disease. Based on the literature, each technique clearly cannot be applied successfully to every situation. Urologist who treats patients with urethral strictures must be experienced in several techniques. Each technique has advantages and disadvantages. Recently, buccal mucosa free graft urethroplasty has received favorable attention because of its excellent early results and decreased level of difficulty compared with those of pedicled skin flaps. So far, a prospective randomized study comparing free grafts with tissue flaps has not been conducted.

The role of tissue engineering and stem cells in urethral reconstruction

Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering with the objective of creating functional replacement tissue. El Kassaby et al recently published a randomized comparative study of buccal mucosal and acellular bladder matrix grafts. An off-the-shelf matrix derived from the bladder was used. This biomaterial was obtained from donors and prepared via a multistep process, resulting in the removal of all cellular components. The tissue matrix that remains consists of collagen, elastin, growth factors, and macromolecules. Predicated on biocompatibility and the ability to recruit urethral tissue growth in several experimental and clinical studies, this matrix was used.

With a mean follow-up period of 25 months in patients with a healthy urethral bed, the success rates for the acellular bladder matrix were similar to those using buccal mucosa. In patients who had undergone two or more prior urethral surgeries with significant spongiofibrosis, the success rate significantly deteriorated for the acellular matrix relative to buccal mucosa. This study demonstrates promise for the use of acellular matrices as a viable option for urethral repair in patients with a healthy urethral bed, no fibrosis of the corpora spongiosis, and good urethral mucosa.7

The Wake Forest Institute for Regenerative Medicine recently published an article discussing the potential applications of stem cells in urology. Many of the successful experiments using stem cells for regenerative medicine have been within the field of urology using bladder, kidney, and urethral tissue.1 Without question, this is an exciting and interesting field that may revolutionize the way urethral stricture disease is treated in the future.

 


More on Urethral Strictures, Male

Overview: Urethral Strictures, Male
Workup: Urethral Strictures, Male
Treatment: Urethral Strictures, Male
Follow-up: Urethral Strictures, Male
Multimedia: Urethral Strictures, Male
References
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References

  1. Aboushwareb T, Atala A. Stem cells in urology. Nat Clin Pract Urol. Nov 2008;5(11):621-31. [Medline].

  2. Angermeier KW, Jordan GH, Schlossberg SM. Complex urethral reconstruction. Urol Clin North Am. Aug 1994;21(3):567-81. [Medline].

  3. Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term follow-up of bulbar end-to-end anastomosis: a retrospective analysis of 153 patients in a single center experience. J Urol. Dec 2007;178:2470-3. [Medline].

  4. Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol. Dec 2001;166(6):2273-6. [Medline].

  5. De Vocht TF, van Venrooij GE, Boon TA. Self-expanding stent insertion for urethral strictures: a 10-year follow-up. BJU Int. May 2003;91(7):627-30. [Medline].

  6. Dublin N, Stewart LH. Oral complications after buccal mucosal graft harvest for urethroplasty. BJU Int. Oct 2004;94(6):867-9. [Medline].

  7. El Kassaby AW, Abouschwareb T, Atala A. Randomized comparative study between buccal mucosal and acellular bladder matrix grafts in complex anterior urethral strictures. J Urol. April 2008;179:1432-6. [Medline].

  8. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. Apr 1999;83(6):631-5. [Medline].

  9. Jordan GH, Schlossberg SM. Surgery of the penis and urethra. In: Wein AJ, et al, eds. Campbell-Walsh Urology. Vol 1. 9th ed. Philadelphia, Pa: WB Saunders Co; 2007:1023-97.

  10. Milroy E, Allen A. Long-term results of urolume urethral stent for recurrent urethral strictures. J Urol. Mar 1996;155(3):904-8. [Medline].

  11. Morey AF, Metro MJ, Carney KJ, et al. Consensus of genitourinary trauma: External genitalia. BJU Int. Mar 2004;94:507-15. [Medline].

  12. Morgia G, Saita A, Morana F, et al. Endoprosthesis implantation in the treatment of recurrent urethral stricture: a multicenter study. Sicilian-Calabrian Urology Society. J Endourol. Oct 1999;13(8):587-90. [Medline].

  13. Mundy AR. Management of urethral strictures. Postgrad Med J. Aug 2006;82(970):489-9. [Medline].

  14. Ouattara DN, N'zi KP, Diabaté AS, Coulibaly N, Dédé NS, Yapo P, et al. Value of perineal ultrasonography for diagnosing anterior urethral strictures. J Rad. May 2004;85:639-42. [Medline].

  15. Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P. Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures. J Urol. May 1999;161(5):1501-3. [Medline].

  16. Shah DK, Paul EM, Badlani GH. North American Study Group. 11-year outcome analysis of endourethral prosthesis for the treatment of recurrent bulbar urethral stricture. J Urol. Mar 2003;170(4 Pt 1):1255-8. [Medline].

  17. Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: a prospective, randomized comparison. J Urol. Jan 1997;157(1):98-101. [Medline].

  18. Wessells H, McAninch JW. Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction. World J Urol. 1998;16(3):175-80. [Medline].

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Further Reading

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Keywords

urethral stricture, urethral strictures, urethral obstruction, urethral scar, anterior urethral stricture disease, scarring in the corpus spongiosum, internal urethrotomy, permanent urethral stents, primary repair, full-thickness skin graft, split-thickness skin graft, buccal mucosal graft, bladder mucosal graft, pedicled skin flaps, skin island onlay flaps, hairless scrotal island flap, skin island tubularized flap

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Contributor Information and Disclosures

Author

Angelo E Gousse, MD, Professor of Urology and Gynecology, Director of Urology Residency Program, University of Miami School of Medicine; Director, Urodynamics Laboratory, Miami Veterans Affairs Medical Center
Angelo E Gousse, MD is a member of the following medical societies: American Spinal Injury Association, American Urological Association, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel J Caruso, MD, MBA, Clinical Instructor, Division of Female Urology, Voiding Dysfunction, and Pelvic Floor Reconstruction, Department of Urology, University of Miami/Jackson Health Systems
Daniel J Caruso, MD, MBA is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, and Florida Urological Society
Disclosure: Nothing to disclose.

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Joshua A Broghammer, MD, Resident Physician, Department of Urology, Wayne State University
Joshua A Broghammer, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Urological Association
Disclosure: Nothing to disclose.

Jon Timothy Posey, MD, Staff Physician, Department of Urology, University of Miami School of Medicine
Jon Timothy Posey, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Daniel B Rukstalis, MD, Director of Urological Services, Geisinger Medical Center, Geisinger Medical Group
Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science and American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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