Management of urethral strictures and stenosis caused by the endo-urological treatment of benign prostatic hyperplasia-a single-center experience

Abstract

Objective: Urethral stricture disease after endo-urological treatment of benign prostatic hyperplasia (BPH) is a sparsely described complication. We describe management of five categories of these strictures in this retrospective observational case series.

Methods: One hundred and twenty-one patients presenting with symptoms of bladder outflow obstruction after endo-urological intervention for BPH from February 2016 to March 2019 were evaluated. Among them, 76 were eligible for this study and underwent reconstructive surgery. Preoperative and postoperative assessments were done with symptom scores, uroflowmetry, ultrasound for post-void residue, and urethrogram. Any intervention during follow-up was classed as a failure. The recurrence and 95% confidence interval for recurrence percentage were calculated.

Results: The following five categories of patients were identified: Bulbo-membranous (33 [43.4%]), navicular fossa (21 [27.6%]), penile/peno-bulbar (8 [10.5%]), bladder neck stenosis (6 [7.9%]), and multiple locations (8 [10.5%]). The average age was 69 years (range: 60-84 years). Overall average symptom score, flow rate, and post-void residue changed from 21 to 7, 6 mL/s to 19 mL/s, and 210 mL to 20 mL, respectively. The average follow-up was 34 months (range: 12-58 months). Overall recurrence and complication rates were 10.5% and 9.2%, respectively. The recurrence in each category was seen in 3, 1, 2, 1, and 1 patient, respectively. Overall 95% confidence interval for recurrence percentage was 4.66-19.69.

Conclusion: Urethral stricture disease is a major long-term complication of endo-urological treatment of BPH. The bulbo-membranous strictures need continence preserving approach. Navicular fossa strictures require minimally invasive and cosmetic consideration. Peno-bulbar strictures require judicious use of grafts and flaps. Bladder neck stenosis in this cohort could be treated with endoscopic measures. Multiple locations need treatment based on their sites in single-stage as far as possible.

Keywords: Benign prostatic hyperplasia; Bladder neck stenosis; Holmium laser enucleation of prostate; Trans-urethral bipolar electro-enucleation; Transurethral resection of prostate; Urethral stricture; Urethroplasty.

Figure 1

Ventral onlay for bulbo-membranous stricture showing graft parachuted to the apex.

Figure 2

Trans-urethral ventral inlay for navicular stricture. (A) Initial appearance accommodating only a small guide wire; (B) Ventral excision of the stricture; (C) Triangular graft being parachuted; (D) Final appearance.

Figure 3

Graft and flap in long segment penile and peno-bulbar stricture. (A) Dorsal onlay buccal mucosal graft; (B) McAninch flap: circular penile fasciocutaneous flap on dartos; (C) McAninch flap: flap rotated and sutured to the urethral plate.

Figure 4

Double face substitution in near-obliterated stricture. (A) Dorsal approach showing grafting on dorsal and ventral side, approached from dorsal route; (B–H) All ventral approach: (B) Ventral urethrotomy; (C) Narrow urethral plate of near obliterated stricture; (D) Dorsal incision; (E) Dorsal inlay substitution; (F) Widened urethral plate after the substitution; (G) Ventral onlay substitution; (H) Spongioplasty.

Figure 5

Bladder neck stenosis.

Figure 6

Multiple locations: Transurethral resection of bladder neck stenosis through dorsal urethrotomy in a case of peno-bulbar stricture.