Urethral Strictures in Males Treatment & Management

There is no medical therapy to treat urethral stricture disease.

Urethral dilation

Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial strictures (no involvement of corpus spongiosum).

Internal urethrotomy

Internal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision allows for release of scar tissue. Success depends on the epithelialization process finishing before wound contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the 12 o'clock position, either with a “cold” knife or urethrotome or a “hot” knife that uses electrocautery to cut through the scar tissue. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction.

Complications include recurrence of stricture, which is the most common complication, bleeding, or extravasation of irrigation fluid into perispongial tissues, thus increasing the fibrotic response. The curative success rate is reported as 20%-35%, with no increase in the success rate with a second internal urethrotomy procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen. However, strictures typically return once the patient stops.^[3]

Permanent urethral stents

Permanent urethral stents are placed endoscopically. Stents are designed to be incorporated into the wall of the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated in patients with dense strictures and in patients with prior substitution urethral reconstruction because it elicits a hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo lengthy open urethral reconstruction procedures.^[4]

Primary repair

Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis. The key technical points that must be followed include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. Primary repair is typically used for stricture lengths of 1-2 cm. With extensive mobilization of the corpus spongiosum, strictures 3-4 cm in length can be repaired using this technique. Morey et al (2004) reported on a series of patients who underwent excision with anastomosis for strictures up to 5 cm.^[5] Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter.

Repairs involving tissue-transfer techniques

• Technical points for free graft repair

  • Success depends on the blood supply of local tissues at the site of placement.
  • Pendulous urethral strictures may be repaired with the patient in the supine or split-legged position. Bulbar or membranous urethral strictures are repaired with the patient in the exaggerated lithotomy position.
  • The urethra is exposed through a penile or perineal incision.
  • The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from the desired non–hair-bearing location. For example, bladder, buccal, or rectal mucosa are potential options. The graft is sutured to the edges of the urethrotomy. The graft is covered by the dartos fascia of the pendulous or bulbous urethra. Incisions are closed in 2 layers with an absorbable suture, and a Penrose drain is placed through a separate incision in the suprapubic or perineal areas.
• Full-thickness skin graft: Non–hair-bearing skin should be used. It is most successful in the area of the bulbar urethra.
• Split-thickness skin graft: The split-thickness skin graft is not preferred with a single-stage repair because of the contraction characteristics of the graft. It is typically reserved for use in patients for whom multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is conducted as a 2-stage procedure.

  • First stage: The urethra is opened via a ventral midline incision down to the level of healthy urethra. The scarred urethra is excised completely. The dartos fascia is mobilized bilaterally and then closed in the midline over the scarred urethral bed. A split-thickness skin graft is harvested from a desired non–hair-bearing location. The graft is transferred to the ventrum of the penis and sutured to the dartos-covered urethral bed, and the proximal aspect is anastomosed in a spatulated fashion to the proximal urethral stump. Xeroform gauze and Dacron padding are used to cover the graft and are secured with supporting sutures. A 14F soft silicone catheter is placed into the urethra and bladder for stenting. Urine is diverted with a suprapubic tube. The Dacron and Xeroform padding is removed after 5-6 days. The suprapubic tube is removed after 2 weeks.
  • Second stage: Closure takes place in 6-9 months if the graft has succeeded. A 3-cm–wide strip of skin is marked along the ventrum of the penis, which is to be used as the neourethra. A superficial, skin-deep incision is made along the marked lines. Care must be taken to spare the underlying dartos fascia. The skin strip is developed using the tissue plane between the penile skin and dartos fascia. The skin strip is fashioned into a neourethra as it is inverted using interrupted absorbable sutures. This is followed by a watertight closure using absorbable sutures in a running fashion. A small suction drain is left in the periurethral area, and the skin is closed. The drain is removed on postoperative day 3. A 14F soft silicone catheter is passed through the reconstructed urethra for stenting purposes. Urinary diversion is accomplished via a suprapubic tube for 3 weeks.
• Buccal mucosal graft: This tissue is resistant to infection and trauma.

  • The epithelium is thick, making it easy to handle. The lamina propria is thin and highly vascular, thus allowing for efficient imbibition and inosculation. Harvesting is easier than with other free grafts or pedicled flaps. A 15- to 20-mm graft is harvested from the oral mucosa. Larger grafts can be harvested depending on the length of the stricture. Most surgeons prefer to close the buccal harvest site primarily. Care is taken to avoid the opening of the duct originating from the parotid gland. The duct for this salivary gland is also known as Stensen duct.
  • The graft is sutured to the edge of the urethra. A Penrose drain is left in the incision bed for 24 hours to allow drainage. A 16F urethral catheter is left for 7 days. Suprapubic urinary drainage is continued for 2 weeks. The suprapubic tube is removed in 2 weeks, after voiding cystourethrogram demonstrates no extravasation of urine. The graft may be placed as a ventral, dorsal, or lateral onlay. Dorsal and lateral onlay procedures allow for the advantage of securing the graft to the corpora cavernosa (dorsal) or the ischiocavernosus muscle (lateral). This technique is performed with the hope of improving graft host bed immobilization and approximation. If a ventral urethrotomy and onlay are to be used, then a spongioplasty maneuver should be used to facilitate graft immobilization. This requires a relatively normal corpus spongiosum without fibrosis. Some reports have demonstrated superiority of the dorsal onlay technique, whereas some data do not demonstrate a difference.^[6] Urethral strictures. A buccal mouth graft has been harvested from the inner aspect of the cheek. The graft size is measured to accommodate the length of urethra involved in the onlay. Urethral strictures. The buccal mucosal grafts have been secured to the corpora cavernosa. The anastomosis will run along either side of the dorsum of the urethral edges to complete the dorsal onlay. The glans penis (distal) is at the top of the picture. The catheterized urethra with a dorsal urethrotomy is on the left.
• Bladder mucosal graft: This is not as popular as other free tissue grafts because of difficulty in harvesting and handling the tissue.

Pedicled skin flaps

These procedures are based on the principal of mobilizing an island of epithelium-bearing tissue with a pedicle of fascia to provide its own blood supply. Penile skin represents an ideal tissue substitute because it is thin and mobile and has an excellent blood supply. Moreover, the distal penile skin is typically non–hair-bearing.

• Skin island onlay flaps: Transverse, longitudinal, and circumferential island flaps refer to the type of skin incision made to fashion the tissue flap. Dorsal and ventral onlay refer to the position in which the flap is sutured to the edge of the incised urethra, as in the dorsal or ventral position with respect to the urethra and corpora cavernosa. Penile incision is carried out through the skin, dartos fascia, and down to Buck fascia. A skin island flap is elevated on the penile dartos fascia, which serves as the vascular supply. A lateral urethrotomy is made along the course of the strictured area. The skin island flap is then transposed to the incised strictured area, oriented into proper position, and sutured to the edges of the urethrotomy incision with an absorbable monofilament suture. A watertight subepithelial suture line should complete the flap placement. The skin is closed with interrupted sutures.
• Hairless scrotal island flap: A non–hair bearing area of skin in the midline of the scrotum is used. The tunica dartos of the scrotum is used as the vascular pedicle. This procedure typically is used in complex urethroplasty procedures and is combined with penile skin island flaps to provide additional vascularized tissue for reconstruction.
• Skin island tubularized flap: It can be used in combination with onlay flap when a large obliterated segment of urethra is present. It involves tubularizing the pedicled skin flap over a sound and anastomosing the tubularized edge to the native urethral stump. Urethral strictures. Photograph of open urethroplasty depicting the pedicled flap. Urethral strictures. Photograph depicting pedicled flap anastomosed to the left side of the urethra. Suturing of the right side of the pedicled flap to the urethra completes the anastomosis. Urethral strictures. The anastomosis of the pedicled flap is complete. The pedicle of the flap (left side) originates from the dorsolateral aspect of the penis. The glans penis (distal) is at the top of the photograph.

The patient should be evaluated and deemed medically stable for the selected procedure. Urine culture should be sterile. Urethral stricture disease should be thoroughly evaluated with radiographic and/or endoscopic techniques. The procedure selection should be discussed thoroughly with the patient in advance, and the discussion should include information on the risks and benefits of the procedure and postoperative care. Risks include, but are not limited to, bleeding, infection, recurrence of stricture, and urethrocutaneous fistula formation.

Position the patient in the supine, split-legged, or exaggerated lithotomy position. Take great care to pad pressure points and position joints to avoid inappropriate strain or torque.

For open repair procedures, shave and prepare the perineum, penis, and scrotum.

Administer intravenous antibiotics prior to making the incision.

• Patients are placed on bedrest for 24-48 hours, depending on the extent of the procedure.
• Intravenous antibiotics are continued for 24 hours and then followed with oral culture-specific antibiotics or antibiotics with good gram-negative coverage.
• Antimuscarinic agents are often used to prevent bladder spasms.
• Drains, if necessary, are typically removed on postoperative day 1-3.
• Wounds should be washed with soap and water daily after drains are removed.
• The patient may be discharged when afebrile, ambulatory, tolerant of a regular diet, and competent in managing drains, catheters, and wound care.

• Patients undergoing internal urethrotomy should return to the outpatient clinic for catheter removal on postoperative day 3-5.
• Patients undergoing open repair should return to the outpatient clinic on postoperative day 3 for wound evaluation and removal of drains.
• Prior to removal of the suprapubic catheter, a voiding cystourethrogram is conducted with contrast, instilled through the suprapubic tube. If contrast extravasation is not evident and the suture line is intact, the urethral catheter is removed and the suprapubic tube capped.
• If the patient continues to void well, the suprapubic catheter is removed after 1 week.
• When all tubes are removed and no evidence of infection is present, antibiotics may be discontinued.
• Urethral evaluation should be conducted with retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively.

Postoperative urinary tract infection and wound infections are rare complications of surgery to repair urethral strictures. Although there is no universal protocol for prescribing antibiotics postoperatively, most surgeons provide a short course of antimicrobials to minimize infections. Importantly, a sterile culture should be documented prior to bringing the patient to the operating room. In the event that a urine culture is positive for bacterial growth, culture-specific antibiotics should be prescribed prior to the procedure.

Complications associated with individual procedures include the following:

• Urethral dilation: Recurrence of the urethral stricture is the most common complication. Dilation of a urethral stricture is appropriate for patients with isolated epithelial strictures without scarring of the corpus spongiosum. Although rare, dilations can lead to urethral trauma caused by passage of the instrument through the urothelium into the corpus spongiosum or perispongial tissues. This risk can be minimized with careful technique and appropriate selection of patients for dilation.
• Internal urethrotomy: Recurrence of the stricture is the most common complication, with up to 80% of strictures recurring after an internal urethrotomy. Persistent postoperative bleeding can occur. The placement of a urinary catheter postoperatively provides intraluminal tamponade of superficial blood vessels. Extravasation of irrigation can precipitate a fibrotic response within the perispongial tissues.
• Permanent urethral stents: Distal migration of a urethral stent can lead to the complications of pain while sitting or during intercourse. Large multicenter studies have identified short-term risks of perineal discomfort and dribbling. Long-term risks include painful erections, mucous hyperplasia, recurring strictures, and urinary incontinence.
• Open reconstructive techniques

  • Large series describing the use of an end-to-end anastomosis after excision of the strictured urethral segment report high success rates. Barbagli et al (2007) reported on a series of 153 patients undergoing this repair for bulbar urethral strictures. Most of the strictures were less than 2 cm in length. Ninety-one percent of patients responded after the single repair.^[7]
  • Postoperative chordee and penile shortening after an excision and primary anastomosis is a concern. Appropriate patient selection and mobilization of the distal urethra may minimize these risks. Younger patients are less likely to experience these complications, as they have more compliant urethral tissue.
  • Other reported complications include ejaculatory dysfunction. Recent reports assert that sparing periurethral musculature such as the bulbospongiosus muscle can minimize postoperative ejaculatory dysfunction. Less commonly, decreased penile glans sensitivity, coldness of the glans during erection, and a glans that is not swollen during erection have been documented.
  • Onlay procedures use tissue transfer techniques, including skin flaps, rather than a graft, such as buccal mucosa. Complications include postvoid dribbling caused by postoperative diverticulum, retraction of the ventral skin of the penis, and urethrocutaneous fistula. Most experts agree that surgical technique and experience with tissue transfer techniques play a large role in maximizing outcomes and minimizing complications.
  • Oral complications after buccal mucosal harvesting: Buccal mucosal harvesting is an important tool in the urologist’s armamentarium in treating urethral stricture disease. The harvesting procedure is considered well-tolerated but does carry a risk of long-term complications. Several authors have monitored patients postoperatively after a buccal mucosal harvesting procedure. Oral pain over the harvest site resolves within the first month postoperatively. Persistent numbness, tightness, or coarseness over the harvest site has been reported in patients as late as 2 years postoperatively. Dublin and Stewart (2004) reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported that they would undergo the same procedure again.^[8] Most experts agree that the potential for long-term complications such as persistent neurosensory deficits and tightness, albeit rare, should be discussed with the patient preoperatively.

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.^[3] 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.^[4] 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%.^[9] A European group reported 2 out of 15 satisfied patients 10 years postimplantation.^[10] An Italian multicenter study following 94 cases reported on the short- and long-term complications.^[11] 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.^[12] 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.^[14]

A meta-analysis showed equivalent results when comparing graft versus flap reconstruction.^[15] Many authors believe grafts are better suited for proximal reconstruction than flaps for distal reconstruction when all other variables are equivalent.^[16]

Postoperative erectile dysfunction

Overall, the rates of erectile dysfunction after urethral reconstruction are low. Reported rates are as low as 2%.^[12] 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.^[17]

A study to evaluate whether the type of one-stage urethroplasty has any influence on recovery from erectile dysfunction found that although the procedure has a probability of causing erectile dysfunction in as many as 20% of patients, the type of urethroplasty has no bearing on recovery, which generally occurs within 6 months.^[18]

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.^[19]

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.^[20] Without question, this is an exciting and interesting field that may revolutionize the way urethral stricture disease is treated in the future.