Urethral Strictures in Males Treatment & Management

There is no medical therapy to treat urethral stricture disease, however, urinary tract infections (UTIs) should be adequately treated prior to surgical intervention. Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding symptoms, bladder calculi, increased postvoid residual, urinary tract infection, or when conservative management fails.

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.

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). Urethral dilation is more likely to be successful in short, first-time, bulbar urethral strictures. Penile urethral strictures are unlikely to respond to dilation. The likelihood of success decreases with each subsequent dilation.  

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. Lasers (eg, Holmium) have also been used for the incision. There is no evidence that one modality is better than another. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction and increased blood loss.

Complications include recurrence of stricture, which is the most common complication; bleeding; and 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 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterization have been shown to increase failure rates. Counterintuitively, larger-caliber catheters have also been shown to increase recurrence rate, presumably because they incude ischemia induced by pressing against the mucosa. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen but it has been shown to worsen quality of life, and strictures typically return once the patient stops catheterizing. ^[10]

Permanent urethral stents

Permanent urethral stents (see the image below) 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 include pain while sitting or during intercourse, due to placement or migration of a stent distal to the bulbous urethra. 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. Because of complications, permanent urethral stents have been taken off the market in the United States.

Stent placement 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. ^[11]

Primary repair

Primary repair (excision and primary anastomosis [EPA]) involves complete excision of the fibrotic urethral segment with reanastomosis. EPA should not be done distal to the penoscrotal junction, as this will induce chordee.  

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 and Kizer reported success in 10 of 11 procedures for strictures ranging from 2.6 to 5.0 cm in young men with proximal bulbar strictures. ^[25] Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair.

The key technical points in EPA include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter.

Free graft repair

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. Most commonly buccal mucosa from the mouth is used but other options include lingual, bladder, or rectal mucosa. A urethrotomy is made either on the ventral or dorsal side of the urethra at the level of the scar, per surgeon preference. 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.

Full-thickness skin graft is most successful in the area of the bulbar urethra. 

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 or buccal mucosa graft is harvested. 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.   The skin s closed. A 16F 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

Buccal mucosa offers several advantages as grafting source. This tissue is adapted to a moist environment and 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. Care is taken to avoid the opening of the duct originating from the parotid gland (also known as Stensen's duct). Most surgeons prefer to close the buccal harvest site primarily, though it is becoming increasingly popular to leave the harvest site open.

The graft is sutured to the edge of the urethra. A 16F urethral catheter is left in place for 7-21 days. 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. ^[26] See the images below.

Bladder mucosal grafts are 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

A skin island tubularized flap can be used in combination with an 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. See the images below.

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Tissue engineering of grafts

Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering with the objective of creating functional replacement tissue. Tissue engineering of grafts for urethral strictures offers the potential benefit of eliminating the need for autologous tissue; this would be particularly useful in patients with long strictures, who would otherwise require harvesting of lengthy mucosal grafts. ^[27]

One tissue engineering approach is the use of acellular matrix bioscaffolds. El Kassaby et al reported successful treatment of urethral stricture with acellular bladder matrix grafts. ^[28] This biomaterial was obtained from cadaveric donors and prepared via a multistep process, resulting in the removal of all cellular components. The tissue matrix that remained consisted of collagen, elastin, growth factors, and macromolecules. In patients with a healthy urethral bed (those with less than 2 prior operations), the success rate for the acellular bladder matrix (8 of 9) was similar to that with buccal mucosa (10 of 10). In patients who had undergone two or more prior urethral surgeries with significant spongiofibrosis, the success rate was significantly inferior with the acellular matrix relative to buccal mucosa (2 of 6, versus 5 of 5). ^[28]

Another approach is the use of a bioscaffold seeded with stem cells, which is currently in the experimental stage. ^[27] For example, in vitro studies of human stem cells harvested from urine have demonstrated promising results. In a rabbit model, autologous urine-derived stem cells were shown to repair urethral defects. ^[29] None of those methods are close to clinical use, however. ^[27]

Patients typically spend one night in the hospital depending on the extent of the procedure.  Intravenous antibiotics are now usually only given at the time of surgery 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. 

Patients may be discharged when they meet the following criteria:

• Afebrile
• Ambulatory
• Tolerant of a regular diet
• 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. Patients undergoing open repair typically return at the time of catheter removal, with length of time being determined by type of repair.

Postoperative urethral evaluation is not standardized and physician dependent. One popular method is to perform retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively. Patients are usually followed subjectively after 1 year, as the highest risk of recurrence is within the first year.

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.

Urethral dilation complications

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.  Dilations can also rarely injure the rectum.This risk can be minimized with careful technique and appropriate selection of patients for dilation.

Internal urethrotomy complications

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.

Complications of 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. ^[30] Barbagli et al 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. ^{[31, 32]}

Postoperative chordee and penile shortening after an excision and primary anastomosis is a concern. Appropriate patient selection, avoiding dissection distal to the penoscrotal junction, 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.

Sparing periurethral musculature such as the bulbospongiosus muscle may 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; for example, Dublin and Stewart reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported that they would undergo the same procedure again. ^[33]

Nevertheless, buccal mucosal harvesting does carry a risk of long-term complications. 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. 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. ^[34]

Consultation with a urologist should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease.