Male urethral strictures and their management

Abstract

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

Figure 1

Stricture pathogenesis. The pathological changes associated with strictures show that the normal pseudostratified columnar epithelium is replaced with squamous metaplasia. a | Small tears in this metaplastic tissue result in urinary extravasation, which causes a fibrotic reaction of the spongiosum. At the time of injury, this fibrosis can be asymptomatic, but the fibrotic process might cause b | further narrowing of the lumen of the urethra in the future, potentially resulting in c | spongiofibrosis d | and extra-spongiofibrosis, as well as symptomatic obstructive voiding symptoms.

Figure 2

Imaging for stricture. Imaging modalities such as a | retrograde urethrogram and b | intraoperative ultrasonography are important for determining the characteristics of the stricture and for evaluating the urethra both proximal and distal to the stricture in order to ensure that all portions of the urethra that are diseased are included in the repair.

Figure 3

Algorithm of general strategy for surgical management of common presenting problems in men with previous hypospadias treatment. Abbreviations: BMG, buccal mucosa graft; PSF, penile skin flap; PU, perineal urethrostomy. Permission obtained from Elsevier Ltd © Myers, J. B. et al J. Urol188, 459–463 (2012).