Internal Urethrotomy in the Management of Anterior Urethral Strictures: Long-Term Followup

Etiology of panurethral strictures in a low socioeconomic status population

INTRODUCTION

Panurethral strictures represent the most severe form within the anterior urethral stricture spectrum, requiring more technically complex repairs and resulting in poorer outcomes compared to localized anterior urethral strictures (penile or bulbar). This abstract aims to describe the distinct characteristics of patients with panurethral strictures in a low socioeconomic status population.

METHODS

Patients presenting with localized anterior (penile or bulbar) or panurethral strictures at University Hospital in Newark, NJ, between 2021 and 2023 were retrospectively identified. Data were extracted from electronic medical records and analyzed statistically using IBM SPSS Software.

RESULTS

Among the patients, 33 had localized anterior urethral strictures, and 22 had panurethral stricture disease. Hispanic and African American patients accounted for the majority of stricture cases (63.6%), including 59% of the panurethral stricture cohort. The only statistically significant factor contributing to panurethral disease was lichen sclerosis (p < 0.05). Patients with panurethral strictures had a higher incidence of inflammatory and systemic diseases such as STDs, recurrent UTIs, diabetes, and hypertension, while those with localized anterior urethral strictures showed a higher incidence of iatrogenic factors, including prior catheterizations and transurethral surgeries. However, these factors did not reach a statistical significance. Hypospadias repair was observed in 6% of localized anterior urethral stricture cases, compared to 13.6% of panurethral stricture cases.

CONCLUSION

While iatrogenic causes remain the predominant contributors, inflammatory and systemic conditions, particularly lichen sclerosis, significantly influence the development of panurethral strictures. Early surgical intervention and better management of systemic diseases may prevent the progression of localized anterior urethral strictures to panurethral disease, but further studies utilizing larger number of patients may shed light on the significance of these systemic factors.

Evaluation of the etiological profile, age and findings in retrograde and voiding urethrocystography of men with urethral stricture

This study aims to establish a profile of the urethral stricture disease in the studied population, in addition to evaluating the correlation between the etiology of urethral stricture, age and findings evidenced in the retrograde and voiding urethrocystography (RVUC) examination. This observational study was conducted at a single institution and included 135 men with urethral stricture. Patient's age and the etiology of stricture were determined. RVUC findings such as length, number, location, and degree of urethral lumen obstruction of urethral stricture, as well as other associated pathological urological findings, were also analyzed. The correlation between demographic parameters, including age and etiology, and RVUC findings was then statistically analyzed. Median age of the patients was 64 years (range: 18-89 years). The most frequent etiologies were iatrogenic (51.9%), idiopathic (20.0%), inflammatory (15.6%) and external traumatic (12.6%). The subgroup of patients over 45 years of age had higher percentages of urethral stricture regardless of the etiology. In the comparative analysis between the four etiology categories, age group and location were the two variables with a statistically significant association (p = 0.001 and < 0.001, respectively). The penile urethral segment represented almost half of the cases of stricture of inflammatory etiology (47.6%). In the membranous urethral segment, almost all cases of stricture were of iatrogenic etiology, representing 24.3% of all cases of iatrogenic etiology in the study. Comparative statistical analysis between the traumatic and non-traumatic etiology categories found that location and length were the only variables with a statistically significant association (p < 0.001 and = 0.005, respectively). In the penile urethral segment, stricture of non-traumatic etiology was the most frequent (33.3% versus 11.5%). In this study, strictures were only of traumatic etiology in the membranous (20.7%) and prostatic (6.9%) urethral segments. Strictures of non-traumatic etiology were the longest. In another supplementary analysis, a statistically significant association was evidenced between age group and the specific cause of urethral stricture (p < 0.001). Prostatectomy was the main specific cause of urethral stricture considering all age groups, representing 20.7% of all cases in the study and 25.2% of patients aged over 45 years. The idiopathic and urethral catheterization were more frequent causes proportionally in the subgroup of patients aged 45 years or less than in the subgroup aged over 45 years (41.7% versus 15.3%, 29.2% versus 6.3%, respectively). A more severe disease profile of urethral stricture was evidenced, with 83% of cases causing obstruction in more than 2/3 of the urethral lumen. In our study, there was a significant statistical association between the etiology and patient's age, and also between the etiology and stricture's location and length as demonstrated by the RVUC exam.

Predictors of urethral stricture recurrence following internal urethrotomy: A systematic review

OBJECTIVE

To estimate the factors associated with urethral stricture recurrence in patients undergoing internal urethrotomy by direct vision.

METHODS

A systematic review was performed in MEDLINE (Ovid), EMBASE, LILACS, and central databases. Clinical, quasi-experimental, cohort, case-control, and cross-sectional trials were included.

RESULTS

The search strategy found 402 studies, and 6 were finally included. All of them were clinical trials. A total of 1723 patients diagnosed with urethral stricture undergoing internal urethrotomy were included. The primary associated factor was the association between the length of stricture and recurrence. Other factors described were post-RTU as etiology, previous interventions for urethral stricture management, and previous Qmax on uroflowmetry less than 5 ml/s.

CONCLUSION

The length of urethral stricture was identified as the leading association with stricture recurrence following internal urethrotomy. Other associated factors were post-URT as etiology, previous interventions for managing stricture, and Qmax less than 5 ml/s. However, studies with better methodology are required.

Patient satisfaction and feasibility with a novel drug-injectable urethral catheter set for hyaluronic acid administration: a multicenter randomized trial

Reducing the risk of urethral strictures after transurethral surgery for patients with bladder cancer requires effective strategies. We compared the clinical outcomes of a novel drug-injectable urethral catheter set (NIUS) with hyaluronic acid (HA) with those of the conventional intraurethral HA injection method. This six-center, prospective, randomized, single-blind trial included 192 male patients aged ≥ 20 years scheduled to undergo transurethral surgery. The primary outcome was patient-reported satisfaction. Secondary outcomes were patient-reported pain intensity, clinician-reported convenience, and urethral strictures. Cystourethroscopy was performed under direct visualization. Outcomes of the experimental (NIUS with HA) and control (HA) groups were compared using the chi-square test and t-test. The post-transurethral surgery rate was significantly higher in the experimental group than in the control group (p < 0.001). Overall, 40% and 21.7% of patients in the experimental and control groups, respectively, were very satisfied (p < 0.001). The experimental group had lower postoperative pain intensity scores (p < 0.001), higher clinician-reported convenience scores (p < 0.001), and fewer urethral strictures within 3 months postoperatively (p < 0.001) than the control group. The NIUS with HA after transurethral surgery significantly enhanced patient satisfaction, reduced pain, improved clinician convenience, and was associated with a reduction in grade 1 urethral strictures. Thus, NIUS with HA enhances post-surgery outcomes through improved patient satisfaction and reduced urethral strictures.Trial registration: Cris.nih.go.kr (KCT0007010).

Comparative Analysis of Dorsal Onlay Buccal Mucosal Graft and Vaginal Wall Graft Urethroplasty for Female Urethral Stricture at a Tertiary Care Centre

OBJECTIVE

To compare dorsal onlay Buccal Mucosal Graft (BMG) and Vaginal Wall Graft (VWG) urethroplasty in the management of Female Urethral Stricture (FUS).

METHODS

A retrospective analysis was conducted on 33 women undergoing dorsal onlay urethroplasty using BMG (n = 17) and VWG (n = 16) for urethral stricture at a tertiary care centre. Data including patient demographics, comorbidities, stricture characteristics, preoperative, and postoperative Female Sexual Function Index (FSFI) scores and operative outcomes were analyzed. Their preoperative diagnosis was confirmed with uroflowmetry, micturating cystourethrogram, urethral calibration, and urethrocystoscopy. Per urethral catheter was removed after 3 weeks and patients were followed up at regular intervals with urine analysis, uroflowmetry and post void residual urine assessment.

RESULTS

The overall mean age was 47 years (range: 21-75) and follow-up was 16 months (range: 6-26). The overall change in American Urological Association (AUA) symptom score was from 18 to 4, maximum flow rate (Q max) from 5 mL/s to 24 mL/s, Post Void Residual Urine (PVRU) from 110 mL to 10 mL, average operative time of 97 minutes (range: 80 to 118 minutes) with no statistical difference between the 2 groups. Other parameters showed no difference. The overall urethral patency rate was 93.9% with no statistical difference in these groups (0.862). None of the patients developed urinary incontinence.

CONCLUSION

Dorsal onlay substitution with BMG and VWG shows equivalent outcomes with low complication rate. Substitution urethroplasty elicits a robust and enduring therapeutic response and should be offered to patients presenting with FUS to avoid the adversities of repeated urethral dilatations.

A Comprehensive Comparative Study of Direct Vision Internal Urethrotomy and Urethroplasty in Short-Segment Bulbar Urethral Strictures

Background Currently, there is no data on the prevalence of urethral stricture illness in India. For short-segment bulbar urethral stricture, end-to-end anastomosis is the gold standard of care. The purpose of this study was to find where the direct vision internal urethrotomy (DVIU) exists in today's era. Also, it compared DVIUs with urethroplasty. Further, the comparison was performed in the urethroplasty group which was converted into two sub-groups; buccal mucosal graft (BMG) and anastomotic urethroplasty. Materials and methods It was a randomized prospective interventional study. The study was conducted at the Department of Urology at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, India. The total duration of the study was one year and six months. Ethical approval for the conduction of the study has been obtained from the institutional ethics committee (IEC) of IGIMS, Patna, Bihar, India under letter number 840/IEC/IGIMS/2022 dated 10 December 2022. Results The study included two comparisons, one between urethrotomy and urethroplasty, that found significant differences in the International Prostate Symptom Score (IPSS) scores at three months. However, the IPSS scores were found to be insignificant between the groups at six months. Also, no statistically significant difference was observed in the International Prostate Symptom Score-Quality-of-Life (IPSS-QOL) between the two groups at three and six months. The statistically significant difference between them was observed in the maximum urinary flow rate (Qmax) and the International Index of Erectile Function-5 (IIEF-5) scores at three and six months, respectively. Another comparison was done between BMG and the excision and primary anastomosis (EPA) groups, where there was no statistical difference observed between the groups in terms of IPSS, IPSS-QOL, Qmax, and recurrence at three and six months. However, there was a statistical difference observed in IIEF-5 scores between the groups at three and six months, respectively. The mode of anaesthesia in the DVIU group was either total intravenous anaesthesia (TIVA) or spinal anaesthesia. On the other hand, all cases of BMG urethroplasty required general anaesthesia with nasal intubation and all cases of EPA required spinal anaesthesia. Conclusion It has been concluded that in today's era, DVIU can be considered for de-novo short-segment bulbar urethral stricture in individuals who are concerned about sexual life. And, for short-segment bulbar urethral stricture less than 2 cm, BMG is a better alternative to EPA as it is associated with less erectile dysfunction. A decrease in erectile function is more common in anastomotic urethroplasty as compared to BMG urethroplasty. Further studies comparing muscle sparing, nerve sparing, and vessel sparing are required to address this problem.

Urethral stricture management knowledge survey among Spanish urology residents

INTRODUCTION AND OBJECTIVE

Assessment of urethral stricture (US) management in a specific group of professionals, Urology Residents, in a specific region (Spain), seems to be important to determine the quality of the educational program and design educational interventions to improve it. We aim to investigate diagnosis and therapeutics practices among Urology Residents for the US management.

MATERIALS AND METHODS

20-question on-line survey was conducted among residents and junior consultants registered on the mailing list of residents and young urologists of the Spanish Association of Urology (RAEU) group of the educational period 2018-2023. We evaluated demographic, educational, surgical technics and experience data during the training period. 290 questionnaires were mailed between May-August 2023. Data was collected in a prospective way between May-December 2023.

RESULTS

The survey obtained 86 responders, with 29,7% (86/290) response rate. Two first sections were answered by all the responders, however, from the assessment section on, only 57 responders completed the survey, which represents 66,3% of them.

CONCLUSIONS

Educational program in Reconstructive Urology among Urology Residents in Spain has an improvement margin. We must dedicate our efforts to standardize the educational process and facilitate access to formation to and increasing area of interest among residents.

Effects of Two Decellularization Protocols on the Mechanical Behavior and Structural Properties of the Human Urethra

This study evaluates the effects of two decellularization protocols, enzyme-detergent (ED) and detergent-detergent (DD), on the structural and biomechanical properties of human urethral tissue. Urethral samples from 18 individuals were divided into ED (n = 7) and DD (n = 11) groups, with native samples (n = 3) serving as controls. Histological and ultrastructural analyses confirmed that both protocols effectively removed cellular content while preserving essential extracellular matrix (ECM) elements, such as collagen and elastic fibers. Immunohistochemical staining for collagen IV and fibronectin revealed no significant differences between decellularized and native tissues, indicating intact ECM structure. Biomechanical testing demonstrated that DD-treated tissues had significantly lower Cauchy stress (1494.8 ± 518.4 kPa) when compared to native tissues (2439.7 ± 578.7 kPa, p = 0.013), while ED-treated tissues were similar to both groups. Both decellularized groups exhibited reduced stretch at failure and elastic modulus compared to native tissues. Cytotoxicity assays using adipose-derived stem cells demonstrated no signs of toxicity in either protocol. Overall, both ED and DD protocols effectively preserved the urethral ECM structure and mechanical properties, making them suitable for potential use in tissue-engineered grafts and for biobanking purposes. Further research is needed to refine and optimize decellularization methods to improve scaffold recellularization and ensure clinical safety and efficacy.

Efficacy and safety of Optilume® paclitaxel-coated urethral dilatation balloon in real-life: experience in a Spanish multicenter study

INTRODUCTION

The Optilume® Paclitaxel-coated urethral dilatation balloon is an alternative to conventional endoscopic treatments that combines mechanical dilatation with local delivery of paclitaxel.

OBJECTIVE

To describe the success rate and analyze the safety of the device in real clinical practice. To evaluate possible predictors of treatment failure.

MATERIALS AND METHODS

Retrospective multicenter study in patients diagnosed with urethral stricture and treated with an Optilume® balloon in routine clinical practice. Data were collected from flowmetry, questionnaires (PROM and IPSS) and cystoscopy before surgery, and 3, 6 and 12 months after the procedure, according to standard practice. Surgical success was defined as the absence of subsequent urethral manipulation and a Qmax >10 ml/s.

RESULTS

238 patients treated with Optilume® in 12 Spanish hospitals between May 2021 and April 2024 were included in the study. Of these, 156 who had a minimum follow-up of 3 months, were analyzed. Median stricture length: 1.5 cm (0.5-5.3), mainly in bulbar urethra (87.7%). Of the total, 12.8% of patients had a history of pelvic radiotherapy, and 81.4% had undergone prior urethral manipulation. Postoperative complications were reported in 14.2% of the total. The treatment success rate was 73.8%, with a median follow-up of 8 months (5-12). No predictors of stricture recurrence were identified. Recurrence rates were higher in strictures located in the posterior versus anterior urethra (42.9% vs. 24.6%, p = 0.126). No significant differences were observed between patients with and without prior urethral manipulation.

CONCLUSION

Treatment with Optilume® has been shown to be safe and effective in short-term routine clinical practice.

Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures

Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.

Long-term outcomes of urethral balloon dilation for anterior urethral stricture: A prospective cohort study

Objective

To prospectively follow up a cohort of anterior urethral stricture disease patients managed with balloon dilation (BD) for 3 years to evaluate the long-term outcomes and to study factors that contribute to recurrence.

Methods

This study included men who had urethral BD for significant anterior urethral stricture disease between January 2017 and March 2019. Data about the patient age, stricture characteristics, and recurrence date were recorded, along with information on postoperative indwelling catheter use and operative complications. Furthermore, information about the self-calibration procedure was collected and where available, free flow (FF) measurements during the follow-up period were recorded and analyzed. Success was defined as a lack of symptoms and acceptable FF rates (maximum flow rate>12 mL/s).

Results

The final analysis was conducted on 187 patients. The mean follow-up period was 37 months. The long-term overall success rate at the end of our study was 66.8%. Our recurrence rate was 7.4% at 12 months, 24.7% at 24 months, and reached 33.2% at the end of our study. The time to recurrence ranged from 91 days to 1635 days, with a mean of 670 days. The stricture-free survival was significantly shorter with lengthy peno-bulbar (p=0.031) and multiple strictures (p=0.015), and in the group of patients who were not committed to self-calibration protocol (p<0.011). However, post-procedural self-calibration was the most important factor that may have decreased the incidence of recurrence (odds ratio=5.85). Adjuvant self-calibration after BD not only reduced the recurrence rate from 85.4% in the non-self-calibration group to 15.1% in the self-calibration one (p<0.001), but also improved the overall stricture-free survival and FF parameters.

Conclusion

Urethral BD has a high recurrence rate in the long-term, especially with long and multiple strictures. Adjuvant self-calibration has proven to reduce the recurrence risk and the need for re-intervention.

Comparison of laser versus cold knife visual internal urethrotomy in the treatment of urethral stricture (stricture length <2 cm): A systematic review and meta-analysis

PURPOSE

There is still controversy regarding the safety and efficacy of cold knife visual internal urethrotomy and laser incisions for the treatment of urethral stricture. This study aims to compare the results of postoperative long-term and short-term maximum urinary flow rates (Qmax), surgical time, postoperative complications, and 1-year recurrence rates between the cold knife and laser surgery.

METHODS

We searched databases including Embase, PubMed, Cochrane, and Clinical Trials.gov to identify relevant literature published in English up to September 2023. We used Stata to compare various parameters. This study is registered in PROSPERO (CRD42023471634). Nine comparative experiments were conducted, involving a total of 659 participants.

RESULTS

The laser group showed significantly better results compared to the cold knife group in terms of postoperative 12-month maximum urinary flow rate (mean differences [MD] 2.131; 95% [1.015, 3.249], P < .0001), postoperative bleeding (RR 0.277, 95% [0.079, 0.977], P = .046), and 1-year recurrence rate (RR 0.667, 95% [0.456, 0.976], P = .037). However, there were no significant differences in postoperative 6-month and 3-month Qmax, surgical time, urethral leakage complications, overall complications, and Visual Analog Scale (VAS) scores.

CONCLUSION

The current study results suggest that laser urethral incision has greater advantages in the long-term (12 months), 1-year recurrence rate, and bleeding complications compared to cold knife urethral incision in the treatment of urethral stricture (<2 cm). Therefore, laser urethral incision may be a better choice for patients with urethral stricture.

Patient reported outcomes of intermittent self-dilatation after direct vision internal urethrotomy

PURPOSE

Long-term results on quality of life (QoL) as well as clinical outcomes of intermittent self-dilatation (ISD) of the urethra after direct visual internal urethrotomy (DVIU) are scarce. The aim of this study was to prospectively evaluate patient reported outcomes (PROs) on voiding symptoms and QoL in a large cohort of urethral stricture patients performing ISD.

METHODS

We identified a total of 121 patients who performed ISD following DVIU between 2008 and 2013. Baseline assessment was conducted for each patient before ISD was started. Follow-up visits were scheduled in 6-month intervals. Each assessment included the following questionnaires: International prostate symptom score (IPSS), IPSS quality of life index (IPSS-QoL), patient global impression of severity (PGI-S), and patient global impression of improvement (PGI-I). Additional parameters were maximum urinary flow rate (Qmax ), postvoid residual urine, rate of complications, and stricture recurrence. Linear mixed models were used to examine the change over the course of the follow-up visits to the baseline.

RESULTS

The median age of the patients was 58 years (interquartile range [IQR]: 43-70). The median follow-up was 17 months (IQR: 7-30). Mean change from baseline IPSS was -6.1, -5.9, -4.2, and -4.8 points at 6, 24, 36, and 48 months. Mean change from baseline IPSS-QoL was -1.3, -1.4, -1.6, and -1.8 points, respectively. Mean PGI-I was 1.7 points at 6, 1.9 points at 24, 1.9 points at 36, and 2.2 points at 48 months after ISD initiation. Mean change of Qmax ranged from 1.7 at 6 to 2.2 mL/s at 48 months. The median complication rate was 3.3% per 6-month ISD interval. Overall, 11 patients developed stricture recurrence (9%).

CONCLUSION

ISD after DVIU had no negative impact on patients' QoL (IPSS-QoL, PGI-I, PGI-S). Urodynamic parameters remained stable for up to 48 months with low complications and an acceptable stricture recurrence rate.

Feasibility and Outcomes of Temporary Bulbar Urethral Stent Placement After Internal Urethrotomy in the Largest Multicenter Series

BACKGROUND

Recent years have seen the development of a new generation of temporary urethral stents as an adjuvant option after direct vision internal urethrotomy (DVIU). Despite some early promising results, large series addressing their safety and outcomes are still lacking.

OBJECTIVE

To report complications and outcomes from the largest series of patients receiving a temporary bulbar urethral stent to date.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective analysis of bulbar urethral stenting procedures after DVIU in seven centers. Patients either refused urethroplasty or were not fit for surgery. The stents were removed after at least 6 mo in place unless complications requiring earlier removal occurred.

SURGICAL PROCEDURE

DVIU with a cold knife or laser is performed, followed by stent placement. At the end of the treatment period, the stent is removed under cystoscopy with gripping forceps.

MEASUREMENTS

All patients underwent postoperative follow-up (FU) for assessment of complications while the stent was in place. After removal, the FU schedule consisted of office evaluation at 6 mo and 12 mo, and then annually. Failure was defined as any treatment for urethral stricture after stent removal.

RESULTS AND LIMITATIONS

A total of 49% of the patients experienced complications. The most frequent were discomfort (23.8%), stress incontinence (17.5%), and stent dislocation (9.8%). Some 85% of the adverse events observed were Clavien-Dindo grade <3. The overall success rate at median FU of 38.2 mo was 76.9%. The success rate was significantly lower if the stent was removed before 6 mo (53.3% vs 79.7%; p = 0.026).

CONCLUSIONS

Temporary urethral stents may be a safe choice with satisfactory results in patients not undergoing urethroplasty. A stent indwelling time shorter than 6 mo provides worse outcomes that are comparable to those with DVIU alone.

PATIENT SUMMARY

We assessed complications and outcomes after placement of a temporary narrow tube in the urethra after surgery to widen a narrowing of the urethra. The treatment is safe and easily reproducible with satisfactory results. Further studies are needed to confirm our findings.

Delineating Which Patient-reported Symptoms Are Associated with Satisfaction After Urethroplasty

OBJECTIVE

To determine which patient-reported symptoms are associated with satisfaction after urethroplasty.

METHODS

From 2011 to 2018, patients were offered enrollment in a prospective study assessing patient-reported outcomes after urethroplasty. Outcomes were assessed preoperatively and 6-months postoperatively including patient satisfaction, voiding function (International Prostate Symptom Score), erectile function (International Index of Erectile Function 5) and ejaculatory function (ejaculatory component of brief sexual function inventory). Additionally, penile curvature/appearance, genitourinary pain, postvoid dribbling, and standing voiding function were also evaluated using either 3 or 5 point Likert scales. Stricture recurrence was defined as the inability to easily pass a 16Fr flexible videocystoscope. Multivariable binary logistic regression was used to examine the associations between outcomes and patient satisfaction.

RESULTS

A total of 387 patients completed the study with a mean age of 49.5 years and a mean stricture length of 4.5 cm. Location was bulbar (59.4%), penile (19.6%), posterior (13.7%) and pan-urethral (7.2%). At 6-months, 96.1% of patients were stricture-free, 81.6% reported being satisfied with surgery and 8% were unsatisfied. On multivariable binary logistic regression, improvement in International Prostate Symptom Score (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.1-1.2, P = .04), new erectile dysfunction (OR: 0.5, 95% CI: 0.2-0.9, P = .04), new penile curvature (OR: 0.4, 95% CI: 0.2-0.9, P = .03) and improved standing voiding function (OR: 1.3, 95% CI: 1.1-1.5, P = .004) were associated with patient satisfaction. Cystoscopic success (P = .60), change in pain score (P = .14), postvoid dribbling (P = .69), change in penile length (P = .44), and ejaculatory dysfunction (P = .51) were not.

CONCLUSION

Improved voiding function, patient-reported penile curvature, new erectile dysfunction and improved standing voiding are independently associated with patient satisfaction after urethroplasty and should be incorporated into any patient-centered approach to urethral stricture management.

Optimizing decision-making after ventral onlay buccal mucosa graft urethroplasty failure

OBJECTIVES

To evaluate factors predicting recurrence after treatment and to assess the best rescue option for patients failing buccal mucosa graft (BMG) urethroplasty.

MATERIALS AND METHODS

We evaluated the data from 575 patients treated with ventral onlay BMG urethroplasty. Multivariable Cox regression analysis was performed to identify predictors of BMG urethroplasty failure, and their effect on failure risk was estimated using the Kaplan-Meier method and compared using log-rank tests. Then, for those patients who underwent a rescue treatment, namely, direct visual internal urethrotomy (DVIU) vs open urethroplasty, we assessed the probability of success after retreatment using the Kaplan-Meier method and regression tree analyses.

RESULTS

On multivariable Cox regression analysis, only stricture length ≥5 cm (hazard ratio 3.46, 95% confidence interval 1.50-7.94; P = 0.003) was a predictor of failure. A total of 103 patients had at least one re-intervention. Notably, 12-month success rates after first rescue DVIU, second rescue DVIU, third rescue DVIU, and fourth rescue DVIU were 66.3%, 62.5%, 37.5% and 25%, respectively. Conversely, for those patients who underwent open urethroplasty retreatment, success rates at 12 months were 83.3%, 79%, 92.3% and 75% after BMG ventral onlay, first rescue DVIU, second rescue DVIU and third rescue DVIU, respectively. These data were confirmed in regression tree analyses.

CONCLUSION

Ventral BMG urethroplasty fails in approximately one out of five patients. Despite DVIU as a rescue treatment being a good option, its success rate becomes lower as the number of DVIU treatments performed increases. Conversely, open urethroplasty improves patient outcomes in almost three out of four patients, even in the case of previous failed DVIU treatments for stricture recurrence.

Myofibroblast-dominant proliferation associated with severe fibrosis in bulbar urethral strictures

OBJECTIVES

Myofibroblast-dominant proliferation (relative to fibroblast proliferation) is the key process in urethral fibrosis, but its association with clinical features is not understood. We conducted a histological analysis of urethral strictures and examined the association between myofibroblast proliferation and stricture characteristics.

METHODS

Formalin-fixed, paraffin-embedded urethral sections sliced axially from 175 male patients with bulbar urethral strictures were retrospectively analyzed. All patients underwent excision and primary anastomosis between September 2008 and January 2021 by a surgeon (AH). Masson's trichrome stain was used to estimate the area of fibrosis. Corresponding unstained slides with the largest area of fibrosis were selected and double-immunostained with anti-smooth muscle actin (SMA) and anti-TE-7 mouse monoclonal antibodies for the assessment of myofibroblasts and fibroblasts, respectively. The ratio of the number of SMA-positive cells to the number of TE-7-positive cells (SMA/TE-7 ratio) was calculated.

RESULTS

The area of fibrosis in strictures due to perineal trauma (n = 85, median 108.9 mm2 ) was significantly larger than that in non-traumatic strictures (n = 90, median 42.9 mm2 , p < 0.0001). The area of fibrosis positively correlated with SMA expression (r = 0.35, p < 0.0001) and the SMA/TE-7 ratio (r = 0.36, p < 0.0001), but not with TE-7 expression (r = -0.01, p = 0.75). In a multivariate linear regression model, traumatic etiology (standard coefficient 0.37, t value 3.9, p < 0.0001) and increased SMA expression (standard coefficient 0.17, t value 2.1, p = 0.03) were the predictors of wide fibrosis area.

CONCLUSIONS

Myofibroblast-dominant proliferation may contribute to the pathogenesis of severe urethral fibrosis.

How to do a penile urethroplasty using a novel self-retaining penile retractor

Effective retraction and clear exposure of urethral tissue is essential in reconstructive penile surgery. The Joshi-Kulkarni retractor provides stable, bloodless operative exposure via non-traumatic tissue compression at the base of penis. The self-retaining design of this retractor also improves ergonomics thereby reducing surgeon fatigue. In this article, we describe how to do a penile urethroplasty by using the Joshi-Kulkarni penile retractor.

Comparative study between thulium laser and cold knife visual urethrotomy for treatment of short bulbomembranous urethral stricture

INTRODUCTION

The classical way to treat urethral stricture is the direct vision cold knife internal urethrotomy (DVIU). Along with advances in laser technology, laser urethrotomy is widely used, such as neodymium-doped yttrium aluminum garnet, argon, potassium titanyl phosphate, and thulium laser. We aimed to compare thulium laser urethrotomy (TLU) and cold knife visual urethrotomy (CKVU) in terms of short bulbomembranous urethral stricture management.

MATERIALS AND METHODS

This prospective interventional study was conducted for 24 months, from January 2018 to January 2020, on 60 patients with primary short bulbo-membranous urethral stricture who came to the Department of Urology of Al-Azhar University Hospital, New Damietta, Egypt. We divided these patients into 2 age-matched groups; 30 patients treated with CKVU and 30 patients with TLU.

RESULTS

Regarding efficacy, postvoid residual urine volume (PVR) was reduced significantly in both groups (P < .001) after 6 months of follow-up; however, the reduction in TLU was greater than CKVU (P = .008). The improvement of Qmax after 6 months was significant and comparable in both groups. Regarding the quality of life, both groups showed a significant (<0.05) improvement in international prostate symptom score (IPSS) and the Male Sexual Health Questionnaire (MSHQ) scale, without no significant difference between both groups (>0.05). TLU showed a significantly (P = .038) shorter operative duration (24 ± 4.17 min) than CKVU duration (33 ± 4.86 min). Compared with CKVU, TLU was associated with less blood loss during surgery (P = .001), lower recurrence rate (46.7% vs. 19.97%, respectively), and lower frequencies of urethral dilatation (P = .001).

CONCLUSION

TLU is an effective and safe therapy for managing bulbomembranous urethral strictures, with a relatively low recurrence rate. Further investigations of other techniques are recommended to look for the most appropriate procedure to combat the urethral stricture problem.

Effect of local steroids on urethral strictures: A systematic review and meta-analysis

PURPOSE

Urethral stricture disease is common and has high associated morbidity and impact on quality-of-life. This systematic review and meta-analysis aims to summarise current evidence on the efficacy of local urethral steroids post-direct vision internal urethrotomy (DVIU) for the treatment of urethral strictures in males.

MATERIALS AND METHODS

A comprehensive search was performed using reputable databases and registries, up to 22 February 2022. Only randomised control trials in which participants were randomised to DVIU plus local urethral steroids versus DVIU only were included. Statistical analyses were performed using a random-effects model. Quality of evidence was rated according to the GRADE approach.

RESULTS

The search identified seven studies in which 365 participants were randomised to DVIU plus local urethral steroids versus DVIU only. The application of local steroids appeared to reduce recurrence rates (risk ratio, 0.67; 95% confidence interval [CI], 0.49-0.90) and time-to-recurrence (hazard ratio, 0.58; 95% CI, 0.39-0.85). Qmax also improved following steroid application (mean difference, 0.82; 95% CI, -1.02-2.66); however, this was not statistically significant. No heterogeneity was identified between included studies for all outcomes. The certainty of evidence was downgraded due to study limitations with a small sample size and unclear risk-of-bias related to insufficient trial information.

CONCLUSIONS

Compared to DVIU alone, adjuvant steroids applied to the urethra may reduce risk of recurrence and time-to-recurrence. These findings were statistically significant and likely also clinically significant given low associated costs and risk. However, more robust randomised trials are necessary to enhance the validity of these outcomes.

A Drug-Coated Balloon Treatment for Urethral Stricture Disease: Three-Year Results from the ROBUST I Study

Introduction

Endoscopic management of male anterior urethral stricture disease is common; however, repeat treatment is associated with high recurrence rates. Here, we report the 3-year results of the ROBUST I trial, which evaluated the safety and efficacy of the Optilume^® drug coated balloon (DCB) in men with recurrent urethral strictures.

Methods

Adult men with recurrent bulbar urethral strictures ≤2 cm in length and 1–4 prior endoscopic interventions were treated with the Optilume DCB. Functional success was defined as ≥50% reduction in International Prostate Symptom Score (IPSS) without need for retreatment. Other outcomes included quality of life, maximum flow rate, post-void residual urine volume, erectile function, and freedom from repeat intervention.

Results

Of the 53 enrolled and treated men, 33 completed the 3-year visit, with 10 patients experiencing clinical failures at previous visits, giving a total of 43 subjects evaluable for the functional success endpoint. Functional success was achieved in 67% (29/43) and freedom from retreatment in 77% (33/43). Average IPSS improved from 25.2 at baseline to 5.5 at 3 years (p<0.0001). Significant improvements were observed in quality of life, flow rate, and post-void residual urine volume. Erectile function was not affected by treatment. Device-related adverse events were mild or moderate in nature and resolved quickly after onset. There were no serious treatment-related adverse events.

Conclusion

Symptomatic improvement after treatment with the Optilume DCB was maintained through 3 years in a population highly susceptible to recurrent urethral stricture disease. This minimally invasive therapy is safe with no negative impact on sexual function.

Contemporary Management of Male Anterior Urethral Strictures by Reconstructive Urology Experts-Results from an International Survey among ESGURS Members

Assessment of anterior urethral stricture (US) management of European urology experts is relevant to evaluate the quality of care given to the patients and plan future educational interventions. We assessed the practice patterns of the management of adult male anterior US among reconstructive urology experts from European countries. A 23-question online survey was conducted among European Association of Urology Section of Genito-Urinary Reconstructive Surgeons (ESGURS) members. A total of 88 invitations were sent by email at two different times (May and October 2019). Data were prospectively collected from May 2019 to December 2019. The response rate was 55.6%. Most of the responders were between 50 and 59 y.o. and mainly from University Public Teaching/Academic Hospitals. A total of 73.5% treated ≥20 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool, followed by uroflowmetry (UF) +/− post-void residual (PVR). Urethroplasty using grafts was the most frequent treatment (91.8%). Of responders, 55.3% performed >20 urethroplasties/year. Anastomotic urethroplasties were performed by 83.7%, skin flap repairs by 61.2%, perineal urethrostomy by 77.6% and non-transecting techniques by 63.3%. UF was the most common follow-up tool. Most of the responders considered urethroplasty as the primary option when indicated. Male anterior US among ESGURS members are treated mainly using urethroplasty graft procedures. RUG is preferred for diagnosis, and UF for follow-up.

[Urethroplasties for male urethral strictures: Success rates and predictive factors]

INTRODUCTION

Urethroplasty has reported success rates ranging from 60 to 98%. Predictive factors for recurrence are rarely studied, postoperative urinary drainage modalities are not investigated. The primary objective was to evaluate the success rate of urethroplasty in our center. Secondary objectives were to identify recurrence predictive factors.

METHODS

A single-center retrospective cohort including men treated with urethroplasty for stricture between 2007-2017, followed up for a minimum of 12 months. Recurrence was defined as the necessity of a new procedure (endo-urethral or surgical). Data from penile urethra (SUP) and bulbo-membranous urethra (SUBM) stenosis were analyzed separately. Recurrence-free survival (success) was analyzed according to the Kaplan-Meier model. The characteristics of the patients, the stenosis, the surgical technique, the modalities of postoperative urinary drainage were analyzed in subgroups for the bulbo-membranous urethra looking for a correlation with recurrence.

RESULTS

A total of 103 patients included: 25 with SUP, 78 with SUBM. The overall success rate was 69%, CI95% [60-79] with a mean follow-up of 62.85 months. The success was 68%, CI95%[46-82] for SUP, 69.23%, CI95% [58-78] for SUBM. Recurrences occurred during the first 12 months. Only postoperative suprapubic urinary drainage was a predictive factor (HR=0.947, CI95% [0.905-0.992]). A period longer than 14 days reduced recurrence by 37%.

CONCLUSION

Urethroplasty had a success rate of 69%, comparable to published series. Suprapubic urinary drainage improved the surgery outcomes.

LEVEL OF PROOF

2, Grade B.

[Management of urethral stricture]

Urethral strictures most frequently affect the bulbar but are also observed in the penile, glandular, or membranous urethra. They are often iatrogenic. Radiologic diagnosis can be established easily and safely by cystourethrography. Simple Sachse urethrotomy can result in permanent relief in the case of short bulbar strictures in initial findings. Recurrent structures or strictures in other locations should however be treated by open surgery, as cure cannot be achieved by other means. Depending on the diagnosis and comorbidities, end-to-end anastomosis, graft/flap urethroplasty, or perineal urethrostomy can be performed. If open surgery is delayed, aggravation of the diagnosis and worsening of the prognosis can be expected, regardless of the applied treatment.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

Advancements in transurethral management of urethral stricture disease

PURPOSE OF REVIEW

To explore and report the recent evolution of transurethral management of urethral stricture disease.

RECENT FINDINGS

In recent years, new promising techniques in the transurethral management of urethral stricture disease have emerged including adjuvant therapies to direct vision internal urethrotomy, regenerative therapy with buccal mucosa cells and minimally invasive transurethral urethroplasty procedures that avoid skin incisions.

SUMMARY

Although further work is needed, the expanding field of transurethral therapies for urethral stricture disease demonstrates early promising results through a variety of modalities.

A Systematic Review and Meta-analysis of Adjuncts to Minimally Invasive Treatment of Urethral Stricture in Men

CONTEXT

Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates.

OBJECTIVE

To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD.

EVIDENCE ACQUISITION

A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist.

EVIDENCE SYNTHESIS

A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.50; p <  0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11-0.48; p <  0.001; intraluminal injection: OR 0.11, 95% CI 0.02-0.61; p =  0.01). Urinary tract infection (2.9-14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen.

CONCLUSIONS

Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence.

PATIENT SUMMARY

We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.

Recurrent Anterior Urethral Stricture: Challenges and Solutions

Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.

Endoscopic urethrotomy versus open urethroplasty for men with bulbar urethral stricture: the OPEN randomised trial cost-effectiveness analysis

Background

Bulbar urethral stricture is a common cause for urinary symptoms in men and its two main treatment options both have drawbacks with little evidence on their relative cost-effectiveness. Current guidelines on the management of recurrent bulbar urethral stricture have been predominantly based on expert opinion and panel consensus.

Objective

To assess the relative cost-effectiveness of open urethroplasty and endoscopic urethrotomy as treatment for recurrent urethral stricture in men.

Methods

Set in the UK National Health Service with recruitment from 38 hospital sites, a randomised controlled trial of open urethroplasty and endoscopic urethrotomy with 6-monthly follow-up over 24 months was conducted. Two hundred and twenty-two men requiring operative treatment for recurrence of bulbar urethral stricture and having had at least one previous intervention for stricture were recruited. Effectiveness was measured by quality- adjusted life years (QALYs) derived from EQ-5D 5L. Cost-effectiveness was measured by the incremental cost per QALY gained over 24 months using a within trial analysis and a Markov model with a 10-year time horizon.

Results

In the within trial, urethroplasty cost on average more than urethrotomy (cost difference: £2148 [95% CI 689, 3606]) and resulted in a similar number of QALYs on average (QALY difference: − 0.01 [95% CI − 0.17, 0.14)] over 24 months. The Markov model produced similar results. Sensitivity analyses using multiple imputation, suggested that the results were robust, despite observed missing data.

Conclusions

Based on current practice and evidence, urethrotomy is a cost-effective treatment compared with urethroplasty.

Keypoints

Urethrotomy and urethroplasty both led to symptom improvement for men with bulbar urethral stricture—a common cause for urinary symptoms in men; Urethroplasty appeared unlikely to offer good value for money compared to urethrotomy based on current evidence.

Trial registration: ISRCTN: 98009168 (date: 29 November 2012) and it is also in the UK NIHR Portfolio (reference 13507).

Trial protocol: The latest version (1.8) of the full protocol is available at: www.journalslibrary.nihr.ac.uk/programmes/hta/105723/#/ and a published version is also available: Stephenson R, Carnell S, Johnson N, Brown R, Wilkinson J, Mundy A, et al. Open urethroplasty versus endoscopic urethrotomy—clarifying the management of men with recurrent urethral stricture (the OPEN trial): study protocol for a randomised controlled trial. Trials 2015;16:600. https://doi.org/10.1186/s13063-015-1120-4.

Trial main clinical results publication: Goulao B, Carnell S, Shen J, MacLennan G, Norrie J, Cook J, et al. Surgical Treatment for Recurrent Bulbar Urethral Stricture: A Randomised Open-label Superiority Trial of Open Urethroplasty Versus Endoscopic Urethrotomy (the OPEN Trial), European Urology, Volume 78, Issue 4, 2020, Pages 572–580.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00836-1.

Risk factors associated with urethral stricture recurrence after end-to-end urethroplasty and buccal mucosal graft urethroplasty

OBJECTIVES

(1) Assess risk factors associated with urethral stricture recurrence (USR). (2) Assess urethral stricture recurrence after end-to-end urethroplasty (EE) and buccal mucosal graft urethroplasty (BMG).

SUBJECTS AND METHODS

A total of 29 males with urethral stricture who underwent either an end-to-end urethroplasty or a buccal mucosal graft urethroplasty were included in this study and followed for 18 months. The association between risk factors and stricture recurrence was assessed.

RESULTS

Overall mean patient age was 51.69 ± 14.22 years, time to recurrence was 3 months (IQR: 1-6.25), and stricture length was 2.57 ± 1.30 cm. Important risk factors for USR were stricture length ⩾ 2 cm (p = 0.024), older age (p = 0.042), BMI > 25 kg/m² (p = 0.021), Q_max after catheter removal <15 ml/s (χ² = 14.87 p ⩽ <0.001) and previous urethral procedures adjusted for re-do BMG urethroplasty (χ² = 6.10, p = 0.021). End-to-end urethroplasty showed less USR than BMG, however, these differences were not statistically significant (41.6% vs 22.2%, respectively, p ⩾ 0.05).

CONCLUSIONS

Stricture length, age, BMI, and previous urethral procedures predict USR, furthermore, an initial Q_max after catheter removal is an objective measure predictive of USR. There's no difference in USR rate between BMG and EE urethroplasties.

A kaleidoscopic view of male urethral pathologies on 64-slice multidetector computed tomographic urethrography: A novel technique

Pathologies of the male urethra are mostly obstructive in nature and require imaging to delineate the lesion type, site, extent and associated abnormality of the urinary bladder. Contrast urethrography (CU) is the gold standard investigation for urethral assessment but has many limitations. Cross-sectional imaging is infrequently used for the evaluation of the urethra but has been gaining importance recently. Multidetector computed tomographic urethrography (MDCTU) has the capability of evaluating the entire length of a male urethra in a single setting and overcomes many technical and patient limitations of CU. Being a novel technique, most radiologists are not familiar with MDCTU and the imaging spectrum of various urethral and bladder pathologies. This pictorial review attempts to present the imaging appearance of the normal male urethra and spectrum of pathological findings, with highlights on its advantages over the CU technique.

The long-term outcome of urethrotomy for primary urethral strictures: a population-based analysis

OBJECTIVE

To determine the long-term outcome of endoscopic urethrotomy for primary urethral strictures based on a population-based approach.

PATIENTS AND METHODS

We analysed a nationwide database of all patients with urethral stricture disease who underwent endoscopic urethrotomy as a primary intervention between January 2006 and December 2007. All patients were followed individually for 7-9 years. Frequencies and types of surgical re-interventions were documented. Repeat surgical interventions were stratified into three treatment types: urethrotomy, urethroplasty, and end-to-end urethral anastomosis.

RESULTS

A total of 1203 men underwent urethrotomy during the index period. The median (SD, range) patient age was 63 (15.7, 20-85) years. A total of 136 patients (11%) died during follow-up. Within the follow-up period, 932 patients (78%) received no further surgical re-intervention for recurrent disease, and 176 patients (14.6%) required one, 53 (4.5%) two, and 41 (3.4%) three or more procedures. The mean number of re-interventions was 1.5/patient and the lowest re-intervention rate was in patients aged ≥80 years (13.9%). In 236 cases (68%) at least one repeat urethrotomy was performed. An open reconstruction was performed in 87 cases (32%), with urethroplasty in 21 patients (24%), and end-to-end anastomosis in 66 patients (76%). The mean interval until re-intervention was 29.5 months.

CONCLUSIONS

This long-term population-based study suggests that the invasive re-treatment rate in men following initial urethrotomy is 22% within 8 years and lowest in the advanced age cohort.

Management of Recurrent Urethral Strictures: A Therapeutic Challenge

Urethral stricture disease is relatively common, and its management remains a therapeutic challenge for urologists despite recent advancements in endoscopic and reconstructive surgery. The majority of the strictures are acquired from injury or infection. Urethral stent implantation, a minimally invasive procedure, can be safely and effectively used as a primary surgical procedure in treating recurrent urethral stricture. Herein, we present a case of a 43-year-old male patient with complaints of intermittent urination, oliguria, and incomplete voiding with urinary frequency. Further urological investigations, a uroflowmetry, and a urethrogram were carried out. Oliguria, along with a mid-bulbar urethral stricture at the previous excision anastomotic site, was diagnosed. Despite a higher success rate of urethroplasty and temporary stent placement, urethral stricture recurrences are still an occurring entity. No definite therapeutic strategy has been adopted to evaluate and approach the morbidity effectively. Implementation of an effective primary procedure with minimally based complications should be generated to avoid future stricture recurrences. Larger-scale studies involving urethral stricture patients can gather sufficient data to obtain a complete curative treatment option for the future.

Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT

BACKGROUND

Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men.

DESIGN

Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed.

SETTING

UK NHS with recruitment from 38 hospital sites.

PARTICIPANTS

A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture.

INTERVENTIONS

A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group).

MAIN OUTCOME MEASURES

The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence.

RESULTS

The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective.

LIMITATIONS

We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis.

CONCLUSIONS

The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective.

FUTURE WORK

Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98009168.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.

Bulbomembranous Urethral Strictures Repair After Surgical Treatment of Benign Prostatic Hyperplasia. Experience From a Latin American Referral Centre

OBJECTIVE

To evaluate stricture recurrence and urinary incontinence (UI) rates in patients who underwent bulbomembranous anastomosis for management of short (≤ 2cm) bulbomembranous urethral stricture (BMS) after benign prostatic hyperplasia (BPH) surgical treatment. In addition, we studied if there was any relation between post urethroplasty UI and the method employed for BPH surgical treatment.

MATERIALS AND METHODS

A retrospective study was conducted between January 2011 and October 2019. We included all patients who developed BMS after undergoing Transurethral Resection of the Prostate, Holmium Laser Enucleation of the Prostate or Open Simple Prostatectomy (OSP). We excluded patients with UI after BPH surgical treatment as well as patients who underwent a dorsal or ventral onlay oral graft urethroplasty for longer proximal bulbar strictures, and also patients with associated bladder neck contracture or other strictures locations. We defined failure as the need for any intervention to restore the urethral caliber.

RESULTS

Overall, 77 patients were included in the study with mean age 70 years (sd 8). Median BMS length was 1.5 cm (IQR 1-2). Median follow-up was 53 months (IQR 24 to 82). Of the patients, 74/77 (96.1%) were classified as success and 3/77 (3.9%), as failure. Out of the 6/77 (7.8%) patients who had postoperative UI, 5 of them had been treated for their BPH with OSP (p 0.001).

CONCLUSIONS

Bulbomembranous anastomosis is a suitable reconstructive option for short proximal bulbar urethral strictures after BPH surgical treatment. OSP was associated with postoperative UI more frequently than endoscopic treatments modalities.

Estado de la urología reconstructiva en Colombia: Tratamiento de la estrechez uretral anterior, una encuesta nacional

Purpose El tratamiento mínimamente invasivo de la estrechez uretral tiene altas tasas de recurrencia y re-operación a largo plazo, no obstante, encuestas realizadas en otros países han demostrado que los urólogos tienen poca experiencia con la uretroplastia abierta y hay una preferencia a la utilización de las terapias endoscópicas mínimamente invasivas. El objetivo de este estudio, es describir patrones de práctica del tratamiento de la estrechez de uretra anterior en nuestro país.

Métodos Se trata de un estudio observacional descriptivo y para ello se realizó un cuestionario adaptado a nuestro contexto nacional, basado en varios estudios previamente realizados acerca de la experiencia en Urología reconstructiva. Ese cuestionario incluía información sobre la edad, nivel de experiencia en urología general, la experiencia en urología reconstructiva, escenario de la práctica y las técnicas preferidas para el manejo de las estrecheces uretrales pendulares y bulbares. La información fue almacenada de forma anónima, los datos fueron analizados mediante el paquete estadístico SPSS y se realizó un análisis de distribución de frecuencias.

Resultados Se obtuvieron 106 respuestas de los urólogos encuestados. Para el tratamiento de la estrechez uretral pendular la mayoría de los urólogos prefiere el manejo endoscópico mínimamente invasivo, seguido de uretroplastia con injerto con porcentajes de 69,9% y 25,5% respectivamente. Solo el 5% prefiere derivar a sus pacientes a un centro especializado. Para la estrechez de la uretra bulbar se prefiere las técnicas mínimamente invasivas, uretroplastia y remisión a un centro especializado en un 44,3%, 41,5% y 14,2% respectivamente. La población más joven y con formación urológica más reciente tiende a hacer más a menudo la uretroplastia con injerto y menos manejo endoscópico, específicamente la uretrotomía interna. En las ciudades intermedias, hay una predilección por el tratamiento endoscópico, especialmente uretrotomía interna.

Conclusiones El enfoque de tratamiento mínimamente invasivo de la estrechez uretral es el más frecuentemente elegido a pesar de sus pobres tasas de éxito a largo plazo. Es de destacar que las nuevas generaciones de urólogos muestran más interés y dominio de las técnicas abiertas, tratamiento estándar hoy en día y con bajas tasas de recaídas y reoperación a largo plazo.

The standard for the management of male urethral strictures in the UK: a consensus document

Objective:

The aim of this study was to establish an evidence-based best clinical practice consensus for the management of urethral stricture disease in the UK.

Methods:

A systematic review of optimal management of urethral stricture generated a base document which was endorsed by the British Association of Urological Surgeons (BAUS) section of Andrology and Genito-Urinary Reconstructive Surgeons (AGUS). A two-round electronic mail modified Delphi survey of 43 consultant reconstructive urologists, members of the British Association of Genito-Urinary Reconstructive Surgeons (BAGURS), was then performed. The panel’s views about the base document was sought in seven domains: definition, diagnosis, investigation, conservative, endoscopic and reconstructive treatments, and follow up. Responses were collated and used to modify the base to achieve a consensus statement.

Results:

In round one of the Delphi process four panel members commented on the base document and seven in round two. Consensus was thereby reached on 38 statements regarding definition (one), diagnosis (three), investigation (two), conservative/endoscopic (five) and reconstructive (24) treatments and follow up (three) for the management of urethral stricture disease.

Conclusion:

This consensus statement will help standardise care, provide guidance on the management of urethral stricture disease, and assist in clinical decision-making for healthcare professionals of all grades.

Management of male anterior urethral strictures in adults. Results from a national survey among urologists in Spain

INTRODUCTION AND OBJECTIVE

Assessment of urethral stricture (US) management seems important to evaluate the quality of attention and plan educational interventions. We aim to investigate the practice patterns on diagnostic and therapeutic approaches to adult male anterior US among urologists in Spain.

MATERIALS AND METHODS

23-question on-line survey conducted among all members of AEU (Spanish Urological Association). Demography data and practices on evaluation and treatment of US were included. 1737 invitation letters sent by email, with 21.7% response rate. Data were prospectively collected during 2016. Descriptive analysis and univariate comparisons conducted using X² test. Statistical significance considered when P≤.05.

RESULTS

Responders were mainly from Tertiary and Teaching University Hospitals. 63.2% treated≥10 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool followed by uroflowmetry (UF), and internal urethrotomy under direct vision (DVIU) the most frequent treatment. 84.4% limited DVIU for US≤1.5cm. 62.3% performed≤5 urethroplasties/year. Anastomotic urethroplasties were performed by 75.7% and graft repairs by 68.9%. Dorsal grafting was preferred rather than ventral. Non-transecting techniques were used by 23.9%. UF was the most common follow-up tool. 88.4% felt that referral units were required. Tertiary hospitals used Patient Reported Outcome Measure (PROM) questionnaires more frequently than secondary centres. High-volume urologists were more likely to use non-transecting techniques and to choose urethroplasty as first choice procedure.

CONCLUSIONS

Male anterior US in Spain are treated by many urologists, mainly using endoscopic procedures. RUG is preferred for diagnosis, and UF for follow-up. A high percentage of urologists perform urethroplasties, mainly anastomotic repairs, but in low volume.

Using Time Trade-Off Methods to Elicit Short-Term Utilities Associated with Treatments for Bulbar Urethral Stricture

BACKGROUND

Recurrent urethral stricture is usually treated with either open urethroplasty or endoscopic urethrotomy. Both of the procedures cause short-term utility loss, which may not be captured by standard utility questionnaires due to the challenges of completing a standard instrument at the time of an acute episode of short duration, especially within a clinical trial setting. We propose to use time trade-off (TTO) methods to estimate these short-term utility losses.

OBJECTIVE

The aim was to compare the use of two alternative TTO methods to elicit patients' short-term utilities following surgical treatments for recurrent urethral stricture.

METHOD

Two variants of TTO (chained and conventional) were used. Six health profiles were developed-three for each procedure. Forty participants took part, with 20 randomly allocated to each TTO method.

RESULTS

Thirty-eight participants provided usable data for analysis. Estimated utility values decreased as the severity of the health profiles increased. There was no evidence that utility values differed between elicitation methods or procedures for mild {ranging from 0.79 (standard deviation [SD] 0.17) to 0.83 [SD 0.20]} and moderate (ranging from 0.54 [SD 0.24] to 0.67 [SD 0.21]) health states, although they appeared to differ for severe health states (ranging from 0.29 [SD 0.20] to 0.56 [SD 0.24]).

CONCLUSION

The study demonstrates the feasibility and value of eliciting patients' short-term utilities. Given the small sample size, the study findings are tentative. Further research with a larger sample size is needed to determine the appropriate TTO method to use and how the elicited utilities can be used in combination with standard cost-utility assessments to aid decision making.

Multimodality imaging of the male urethra: trauma, infection, neoplasm, and common surgical repairs

OBJECTIVE

The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction.

RESULTS

Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG.

CONCLUSIONS

Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

[Bulbar urethral strictures : A trivial urological disease or a surgical challenge?]

Urethral strictures are often located in the bulbar urethra, and bulbar strictures are commonly due to urethral trauma. Diagnosis is confirmed by radiographic imaging of the urethra. In cases of short primary bulbar strictures, a simple internal urethrotomy may be curative. In contrast, open surgery should be performed in long segment or recurrent strictures because recurrence rates are near 100% in these cases. Depending of the actual findings and comorbidities, end-to-end anastomosis, graft urethroplasty, flap urethroplasty, or perineal urethrostomy may be used. If definitive treatment using open surgery is delayed and multiple endoscopic treatments are tried, urethroplasty becomes more complex and success rates of definitive treatment decline.

Historical and Current Practices in the Management of Fossa Navicularis Strictures

PURPOSE OF REVIEW

Fossa navicularis strictures represent a surgically challenging disease process that requires detailed preoperative planning and an understanding of each patient's goals in order to achieve a satisfactory long-term outcome. This review summarizes the various approaches used in the management of fossa navicularis strictures over the past several decades.

RECENT FINDINGS

In addition to existing evidence to support open flap- and graft-based reconstruction, recent studies suggest a potential role for limited open repair via a transurethral approach. Open repair of fossa navicularis strictures has become the standard of care with high success rates using local skin flaps or tissue grafts. There remains a very limited role for minimally invasive techniques in definitive management of this disease.

Penile urethral stricture disease

Patients affected by a urethral stricture account for a considerable cost to all healthcare systems. The estimated prevalence of all urethral stricture in the UK is 10/100,000 men during youth, increasing to about 40/100,000 by age 65 years and to more than 100/100,000 thereafter. A penile urethral stricture is a narrowing of the lumen of the urethra due to ischaemic fibrosis of the urethral epithelium and/or spongiofibrosis of the corpus spongiosum occurring within the penile urethra. Its aetiology is largely idiopathic but other important causes are failed hypospadias repair and lichen sclerosus, which account for 60% of all cases. Strictures of the anterior urethra account for 92% of cases: bulbar strictures are more frequent (46.9%), followed by penile (30.5%) and combined bulbar/penile (9.9%), that is, 40.4% of all men presenting with stricture will have a penile urethral stricture alone or in combination with a bulbar urethral stricture. There are several options for the treatment of penile urethral strictures ranging from less invasive treatments, including urethral dilatation and direct vision internal urethrotomy, to more complex augmentation graft and flap urethroplasty. The aim of the present review is to describe the aetiology and epidemiology of anterior urethral strictures and the available options reported in literature for their treatment.

Level of evidence: 1a

Specific characteristics of urethral strictures in a developing country (Brazil)

PURPOSE

Evaluate the main etiologies and clinical characteristics of male urethral stricture disease (USD) in Brazil.

METHODS

This multicentric study was performed using retrospective data collected from six Brazilian referral centers of urethral reconstruction. The database comprised data from 899 patients with USD who had undergone surgical treatment from 2008 to 2018. Age, stricture site and primary stricture etiology were identified for each patient.

RESULTS

The mean age was 52.13 ± 16.9 years. The most common etiology was iatrogenic (43.4%), followed by idiopathic (21.7%), trauma (21.5%) and inflammatory (13.7%). Of the iatrogenic causes, 59% were secondary to urethral instrumentation (60% by urethral catheterization and 40% by transurethral procedures), 24.8% by other procedures (prostatectomy, radiotherapy, postectomy) and 16.2% by failed hypospadia repairs. Pelvic fracture urethral distraction injuries were responsible for most of the trauma-related strictures (62.7%). When stratified by age, the most common stricture etiology was trauma in the 0-39 years old group (42.8%), idiopathic in the 40-59 years old group (32.4%) and iatrogenic in patients over 60 years old (68%). In regard to the stricture site, 80% presented with an anterior urethral stricture and 20% with a posterior stenosis. In the anterior stenosis group, the most common stricture site was bulbar (39.5%).

CONCLUSION

In Brazil, as in many developed countries, the most common cause of urethral stricture diseases is iatrogenic, especially urethral catheterization. These findings emphasize the need of a careful urethral manipulation and a better training of healthcare professionals. Trauma is still responsible for a great proportion of strictures and inflammatory etiologies are now less frequently observed.

Excision and Primary Anastomosis for Bulbar Urethral Strictures Improves Functional Outcomes and Quality of Life: A Prospective Analysis from a Single Centre

Background

Excision and primary anastomotic (EPA) urethroplasty remains the gold standard definitive treatment for short urethral stricture disease. For patients, postoperative erectile function and quality of life are the main goals of the surgery. Patient-reported outcome measures (PROMs) are therefore of major importance.

Objective

The objective of this study was to prospectively analyse functional outcomes and patient satisfaction.

Design Settings and Participants

We prospectively evaluated 47 patients before and after EPA from August 2009 until February 2017. The first follow-up visit occurred after a median of 2.2 months (n = 47/47), with the second and third follow-ups occurring at a median of 8.5 months (n = 38/47) and 20.2 months (n = 31/47). Before surgery and at each follow-up visit, the patients received five questionnaires: the International Prostate Symptom Score (IPSS), the International Prostate Symptom Score with the Quality of Life (IPSS-QOL) score, the Urogenital Distress Inventory Short Form (UDI-6) score, the International Index of Erectile Function-5 (IIEF-5) score, and the ICIQ-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) score.

Surgical Procedure

Surgery was performed in all cases using the same standardized EPA technique.

Outcome Measurements and Statistical Analysis

Voiding symptoms, erectile dysfunction, and quality of life were analysed using paired sample t-tests, with a multiple-testing Bonferroni correction. Any requirement for instrumentation after surgery was considered treatment failure.

Results and Limitations

Patients with mild or no baseline erectile dysfunction showed significant decline in erectile function at first follow-up (mean IIEF-5 of 23.27 [standard deviation; SD: 2.60] vs. 13.91 [SD: 7.50]; p=0.002), but this had recovered completely at the third follow-up (IIEF-5: 23.25 [SD: 1.91]; p=0.659). Clinically significant improvements were noted in IPSS, IPSS-QOL-score, UDI-6-score, and ICIQ-LUTS-QOL-score at the first follow-up (p<0.0001). These improvements remained significant at the second and third follow-ups (p<0.0001) for all PROMs. Three of the patients experienced stricture recurrence. The main limitations of this study were incomplete questionnaires, loss to follow-up, and low number of patients.

Conclusions

EPA results in an initial decline in erectile function, but full recovery occurred at a median of 20 months. Voiding improved significantly, and a major improvement in quality of life was noted, which persisted for up to 20 months after surgery.

Patient Summary

This study showed the importance of patient-reported outcome measures in indicating the actual outcome of urethral stricture disease surgery.

Population Analysis of Male Urethral Stricture Management and Urethroplasty Success in the United States

OBJECTIVE

To examine population-based practice patterns and outcomes related to urethroplasty for urethral stricture management.

METHODS

We conducted a retrospective study of adult males with urethral stricture disease treated from January 2001 to June 2015 using the Clinformatics Data Mart Database. Treatment was defined as urethral dilation, direct visualized internal urethrotomy, and urethroplasty. We then examined anterior or posterior urethroplasty outcomes defining failure as any subsequent procedure specific to urethral stricture disease occurring >30 days after urethroplasty. We used multivariable and time-to-event analysis to examine factors associated with failure.

RESULTS

We identified 75,666 patients treated for urethral stricture disease, with 420 and 367 undergoing anterior and posterior urethroplasty, respectively. Urethroplasty utilization doubled from 2005 to 2015. One- and 5-year failure rates for anterior and posterior urethroplasty were 25% and 18%, and 40% and 25%, respectively, with median times to failure of 5.1 and 4.1 months. Failures were salvaged primarily with direct visualized internal urethrotomy, with salvage urethroplasty in 19% and 12% of anterior and posterior repairs, respectively.

CONCLUSION

Despite increasing population-based urethroplasty utilization over the past decade in our insured cohort, we found higher rates of salvage treatments than reported by high-volume and expert surgeon reports. Further efforts appear warranted to balance workforce expertise and quality of urethroplasty care to meet increasing urethral stricture population needs.

Dorsal versus ventral strip augmented anastomotic bulbar urethroplasty: retrospective study

PURPOSE

The published literature shows controversies with regard to the treatment of choice for longer stricture. Augmented anastomotic urethroplasty (AAU) was described for long bulbar urethral strictures with an extended area of narrowing and fibrosis, the technique combines the advantages of both anastomosis and graft substitution. We aimed to compare the dorsal and ventral strip anastomosis in the AAU.

METHODS

A retrospective Review was conducted at the Department of Urology, Sohag University Hospital; we included adult patients with long bulbar urethral strictures (> 2 cm) who underwent dorsal or ventral strip AAU. Patients were followed at 1, 3, 6, and 12 months postoperatively for subjective improvements. The statistical analysis was carried with SPSS software version 24 for windows.

RESULTS

At the end of follow-up, stricture recurrence occurred in 5 (12.5%) in ventral strip group compared to 6 (23.1%) in dorsal group, the difference was not statistically significant (p = 0.5). With regard to safety outcomes, there was no statistically significant difference between both groups in any of the postoperative complications, except post-void dribbling which showed higher incidence in dorsal strip group (p < 0.001).

CONCLUSIONS

In conclusion, both dorsal strip and ventral strip techniques are feasible for long bulbar urethral strictures with comparable postoperative efficacy outcomes and high success rate.