Deep Phenotyping the Anterior Urethral Stricture: Characterizing the Relationship Between Inflammation, Fibrosis, Patient History, and Disease Pathophysiology

PURPOSE

Anterior urethral stricture disease (aUSD) is a complex, heterogeneous condition that is idiopathic in origin for most men. This gap in knowledge rarely affects the current management strategy for aUSD, as urethroplasty does not generally consider etiology. However, as we transition towards personalized, minimally invasive treatments for aUSD and begin to consider aUSD prevention strategies, disease pathophysiology will become increasingly important. The purpose of this study was to perform a deep phenotype of men undergoing anterior urethroplasty for aUSD. We hypothesized that unique biologic signatures and potential targets for intervention would emerge based on stricture presence/absence, stricture etiology, and the presence/absence of stricture inflammation.

MATERIALS AND METHODS

Men with aUSD undergoing urethroplasty were recruited from one of 5 participating centers. Enrollees provided urethral stricture tissue and blood/serum on the day of surgery and completed patient-reported outcome measure questionnaires both pre- and postoperatively. The initial study had 3 aims: (1) to determine pediatric and adult subacute and repeated perineal trauma (SRPT) exposures using a study-specific SRPT questionnaire, (2) to determine the degree of inflammation and fibrosis in aUSD and peri-aUSD (normal urethra) tissue, and (3) to determine levels of systemic inflammatory and fibrotic cytokines. Two controls groups provided serum (normal vasectomy patients) and urethral tissue (autopsy patients). Cohorts were based on the presence/absence of stricture, by presumed stricture etiology (idiopathic, traumatic/iatrogenic, lichen sclerosus [LS]), and by the presence/absence of stricture inflammation.

RESULTS

Of 138 enrolled men (120 tissue/serum; 18 stricture tissue only), 78 had idiopathic strictures, 33 had trauma-related strictures, and 27 had LS-related strictures. BMI, stricture length, and stricture location significantly differed between cohorts (P < .001 for each). The highest BMIs and the longest strictures were observed in the LS cohort. SRPT exposures did not significantly differ between etiology cohorts, with > 60% of each reporting low/mild risk. Stricture inflammation significantly differed between cohorts, with mild to severe inflammation present in 27% of trauma-related strictures, 54% of idiopathic strictures, and 48% of LS strictures (P = .036). Stricture fibrosis did not significantly differ between cohorts (P = .7). Three serum cytokines were significantly higher in patients with strictures compared to stricture-free controls: interleukin-9 (IL-9; P = .001), platelet-derived growth factor-BB (P = .004), and CCL5 (P = .01). No differences were observed in the levels of these cytokines based on stricture etiology. However, IL-9 levels were significantly higher in patients with inflamed strictures than in patients with strictures lacking inflammation (P = .019). Degree of stricture inflammation positively correlated with serum levels of IL-9 (Spearman's rho 0.224, P = .014).

CONCLUSIONS

The most common aUSD etiology is idiopathic. Though convention has implicated SRPT as causative for idiopathic strictures, here we found that patients with idiopathic strictures had low SRPT rates that were similar to rates in patients with a known stricture etiology. Stricture and stricture-adjacent inflammation in idiopathic stricture were similar to LS strictures, suggesting shared pathophysiologic mechanisms. IL-9, platelet-derived growth factor-BB, and CCL5, which were elevated in patients with strictures, have been implicated in fibrotic conditions elsewhere in the body. Further work will be required to determine if this shared biologic signature represents a potential mechanism for an aUSD predisposition.

Urethral carcinoma after skin substitution urethral reconstruction

Urethral cancer after urethral reconstruction is an under-recognized, uncommon disease associated with significant morbidity and mortality. The survival rates of patients with carcinoma of the bulbar urethra are as low as 20%-30%. Stricture recurrence and unrecognized malignant changes present prior to reconstruction are major risk factors for urethral cancer. Skin substitution urethroplasty is subjected to higher rates of recurrence, which lends to the potential for carcinogenesis. We present a case of a 59-year-old male who underwent multi-stage skin substitution urethroplasty who developed urethral carcinoma 20 years later.

UrethroNAV: the aetiology and extent of idiopathic urethral stricture in an Australian population

Background

Lichen sclerosus (LS) is considered a causative factor in 10% of cases of idiopathic urethral stricture disease (IUSD), which is important for determining management strategies due to the underlying pathophysiology. Traditional excision urethroplasty may not be effective as inflammation often extends beyond the macroscopic stricture. This pilot study aims to answer two research questions: is LS an underlying cause of some idiopathic cause of strictures, and, if there is histological evidence suggesting predisposition of the surrounding tissue to strictures.

Methods

Biopsies were taken from the stricture site as well as 1 and 2 cm proximal and distal in patients with IUSD. Histological features, including macroscopic and microscopic findings, were reported, including the presence of LS, hyperkeratosis, epidermal changes, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was used to aid in locating damaged urothelium. Patients were prospectively followed up after urethroplasty.

Results

From 109 urethroplasties performed between 2019 to 2022, 15 male patients were enrolled after meeting specific inclusion criteria. These criteria included a diagnosis of IUSD and the absence of any evidence of trauma, macroscopic inflammatory disease, or previous endoscopic instrumentation of the urethra. Patients had to be at least 16 years old and medically suitable for undergoing urethroplasty. The study was approved by the hospitals ethics committees. None had macroscopic evidence of LS. One patient had microscopic evidence of LS at the 2 cm proximal biopsy only. A total of 93% of patients had scarring proximal and distal to the stricture, while 20-40% had inflammatory change. The patient with microscopic LS and two inflammatory change patients had stricture recurrence after urethroplasty. Additionally, one patient with inflammatory changes was diagnosed with penile intraepithelial neoplasia (PeIN) and underwent partial penectomy.

Conclusions

Findings suggest that an underlying cause of IUSD could be LS. Additionally, the pathophysiology may involve scarring and inflammation beyond the limits of the stricture with extension distal from the stricture site. Careful evaluation for concomitant urethral pathology should be considered in cases of inflammatory changes. These findings should be considered in the surgical management of IUSD and warrant further research into the role of routine biopsy and drug targets in USD.

Impact of a clinical care pathway developed through the action research method on the psychological well-being and quality of life in male patients with urethral stricture

BACKGROUND

The objective of this study is to examine the development of a clinical care pathway utilizing an action research methodology for male patients with urethral stricture, and to assess the psychological and quality of life outcomes following the implementation of this pathway.

METHODS

Ninety patients diagnosed with urethral stricture, admitted to our hospital between May 2021 and May 2022, were selected as the study cohort. Employing a random number method, these patients were allocated into an observation group and a control group, each comprising 45 individuals. The control cohort employs standard care protocols for individuals with urethral stenosis, while the experimental group employs an action research methodology to develop a clinical care pathway specific to the management of patients with urethral stenosis, with an intervention cycle of 3 months. The investigation evaluated the impact of the intervention by scrutinizing pre- and post-intervention data through the utilization of the WHO Quality of Life Scale (WHOQOL-BREF), in addition to the Anxiety Rating Scale and the Depression Rating Scale.

RESULTS

Prior to the intervention, no significant differences were observed in WHOQOL-BREF scores across dimensions, as well as anxiety and depression scores between the 2 groups (P > .05). Subsequent to the intervention, the patients in the observation group exhibited significantly higher scores across all WHOQOL-BREF dimensions and total scores compared to the control group, with statistical significance (P < .05). Moreover, anxiety and depression scores in the observation group were markedly lower than those in the control group, demonstrating statistical significance (P < .05).

CONCLUSION

The implementation of a clinical nursing pathway rooted in action research methodology proves to be an effective strategy for enhancing clinical nursing practices, elevating patient quality of life, and diminishing the prevalence of anxiety and depression.

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.

Affirming Long-Term Outcomes After Contemporary Urethroplasty: The Adverse Impact of Increasing Stricture Length, Lichen Sclerosus, Radiation, and Infectious Strictures

PURPOSE

There is a paucity of reported long-term outcomes after contemporary urethroplasty. Our objective is to determine the long-term success of modern urethroplasty and identify factors associated with stricture recurrence in this context.

MATERIALS AND METHODS

Patients undergoing urethroplasty from July 2003 to May 2013 with at least 100 months of follow-up were identified. Long-term outcomes including stricture recurrence and patient satisfaction were evaluated by review of regional/provincial electronic records and telephone interview. Urethroplasty failure was defined as a recurrent stricture (<16F) confirmed on cystoscopy. Cox regression was used to evaluate variables associated with long-term stricture recurrence.

RESULTS

A total of 733 patients were identified with ≥ 100 months follow-up. Median patient age was 45 years, stricture length was 4.7 cm, and 85.8% failed prior endoscopic treatment. At a median follow-up of 12.3 years, 89 recurrences were observed. Cumulative incidence of stricture recurrence was 6%, 10%, and 12% after 1, 5, and 10 years, respectively. From a patient-reported perspective, 89% of patients reported being satisfied with the outcome of surgery. On multivariable analyses, increasing stricture length (HR 1.1, 95% CI 1.05-1.15; P < .001) and stricture etiology (P < .001), in particular lichen sclerosus (HR 4.46, 95% CI 2.25-9.53), radiation (HR 4.25, 95% CI 1.65-10.9), and infectious strictures (HR 5.27, 95% CI 2.03-13.7), were independently associated with stricture recurrence.

CONCLUSIONS

This study affirms the widely held belief that modern urethroplasty provides high long-term patency and patient-reported satisfaction. Patients with longer strictures as well as those with lichen sclerosus, radiation, and infectious etiologies have a higher hazard of stricture recurrence in the long term.

Rectourethral Fistula after Posterior Urethral Valves Ablation in an Infant: A Rare Complication

Acquired rectourethral fistula (RUF) is a rare but major complication of posterior urethral valve ablation. We present a case of a 1-year-old boy managed in a staged manner by completion of posterior urethral valves ablation, colostomy, RUF division through anterior sagittal transanorectal approach, and stoma closure. The child is continent for urine and feces.

Patient Interaction With the Health Care System Following a Nonopioid Discharge Strategy for Anterior Urethroplasty

INTRODUCTION

Continued efforts have been made to minimize postoperative opioids following urologic interventions. Studies show that patient-reported pain outcomes are similar between those patients discharged with and without opioids following anterior urethroplasty, but we do not know what impact this has on health care utilization. We aim to show that a nonopioid discharge following anterior urethroplasty does not increase postoperative health care utilization.

METHODS

Five hundred patients who underwent anterior urethroplasty from January 2016 to October 2022 were identified from retrospective chart review. Patient demographic information, surgical characteristics, and postoperative interactions with the health care system were extracted from the electronic medical record. We then compared these outcomes by discharge opioid prescription status.

RESULTS

A total of 253 patients were discharged without an opioid prescription. Patients who received an opioid were more likely to have had a perineal incision (73% vs 64%, P = .02), more likely to have had an overnight hospital stay (30% vs 14%, P < .01), and were more likely to have been prescribed an opioid preoperatively (13% vs 7%, P = .03). There were overall low rates of interaction with the health system in both groups with no significant difference in 30-day unplanned office visits, emergency department visits, or office phone calls. Overall, by the end of our study period 97% were discharged without an opioid and 94% of patients were discharged the same day.

CONCLUSIONS

Patients undergoing anterior urethroplasty can safely be discharged home without opioids following surgery without undue postoperative burden on the health care system.

[Non-transecting anastomotic urethroplasty for strictures of the bulbar urethra. Systematic review]

The results of using non-transecting anastomotic urethroplasty in men with bulbous urethral strictures are presented in the review. A total of 25 original publications were found, including 20 foreign and 5 Russian articles. The studies included from 1 to 358 patients who underwent anastomotic urethroplasty without transection of the corpus spongiosum (average number of patients in a study was 54). Etiological factors were indicated in 17 articles. Most studies (10 out of 17) indicated idiopathic etiology as the predominant one. There was no correlation between the results of the procedure and the etiology of urethral stricture. The mean length of urethral stricture in the vast majority of studies was less than 2 cm, and only in a few studies it was larger, with a maximum mean value of 3.9 cm. Postoperative complication rates were reported in 20 studies and ranged from 0% to 23.9% within one study (median 8.4%). In general, mild complications occurred, corresponding to category I-II according to the Clavien-Dindo classification. The incidence of erectile dysfunction was evaluated in 18 studies and ranged from 0% to 23% (average value of 6.5%). The success of non-transecting anastomotic urethroplasty averaged 94.7% (82-100%) with a median postoperative follow-up of 24.5 months (3-150 months). In 9 out of 25 studies, an additional comparison with transecting technique was done. In 6 studies, the superiority of the non-transecting technique in terms of treatment success and preservation of sexual function was found. The obtained results showed the high efficiency and safety of non-transecting anastomotic urethroplasty in case of short strictures of the bulbous urethra.

Development of a Nomogram Model to Predict the Risk of Stricture Recurrence after Urethroplasty: A Retrospective Study

OBJECTIVE

A retrospective study was performed to analyse the influencing factors of stricture recurrence after urethroplasty and to establish a predictive nomogram model.

METHODS

The clinical data of patients who underwent urethroplasty in our hospital from January 2021 to June 2023 were retrospectively analysed. Depending on whether stenosis occurs six months after surgery, the patients were divided into recurrence and nonrecurrence groups. Logistic regression analysis was performed on the indicators with statistically significant differences between the two groups in single factor analysis to analyse the influencing factors of postoperative recurrence risk of stricture. X64.4.1.3 version R language and external source packages were used to build the nomogram model. The nomogram was internally validated through 10-fold cross-validation, and C-index was calculated. The area under the curve (AUC) of the receiver operating characteristic curve was employed to evaluate the results of the internal validation.

RESULTS

Amongst 105 patients who underwent urethroplasty in our hospital, 15 patients with recurrence were included in the recurrence group, and 90 patients without recurrence were included in the nonrecurrence group. The length of stricture segment, history of urethroplasty and smoking history within 3 months before surgery were risk factors for stricture recurrence, with odds ratio (OR) values of 1.874 (95% CI: 1.103-5.725), 1.670 (95% CI: 1.105-2.904) and 1.740 (95% CI: 1.456-5.785), respectively. The constructed nomogram obtained an average AUC of 0.842 and an average C-index of 0.794, calculated after 200 times of 10-fold cross-validation.

CONCLUSIONS

From the data of this study, it can be deduced that the influencing factors of stricture recurrence after urethroplasty include the length of stricture segment, history of urethroplasty and smoking history of 3 months before surgery. Using the above factors as a basis to construct a predictive nomogram model is helpful to screen high-risk patients with recurrence of stricture after urethroplasty.

Conservative Management of Penile and Urethral Lichen Sclerosus: A Systematic Review

PURPOSE

We evaluate the efficacy and safety profiles of currently available conservative management options for penile and urethral lichen sclerosus.

MATERIALS AND METHODS

A systematic review of existing literature on lichen sclerosus was conducted utilizing the PubMed, Embase, and Web of Science databases. References were assessed for relevance to nonsurgical management of male genital lichen sclerosus by title and abstract by 3 independent reviewers, then reviewed in full and in duplicate by 5 independent reviewers.

RESULTS

Seventeen studies describing conservative management of histologically confirmed penile and urethral lichen sclerosus in male patients were included in the final review. We present available evidence supporting the use of 4 major treatment modalities represented in the existing literature: topical corticosteroids, tacrolimus, platelet-rich plasma, and CO2 laser. We also briefly discuss the limited studies on the use of oral acitretin and polydeoxyribonucleotide injections. Outcomes assessed include symptoms, clinical appearance, quality of life, sexual satisfaction, adverse effects, and long-term efficacy of treatment.

CONCLUSIONS

Topical corticosteroids remain the mainstay of conservative management of penile and urethral lichen sclerosus, with current literature supporting the use of other therapies such as tacrolimus and platelet-rich plasma as alternatives or adjuvant treatments when escalation of treatment is necessary. Future research should further explore the efficacy and safety of newer therapies through additional controlled clinical trials in the targeted population.

Transperineal anastomotic posterior urethroplasty with bulbocavernosus flap and fibrin sealant in the complicated posterior urethral stricture reconstruction: a retrospective cohort study

BACKGROUND

Management of complicated posterior urethral stricture is challenging. Modified transperineal anastomotic urethroplasty (TAU) with bulbocavernosus flap interposition and human fibrin sealant provides another treatment option. The authors aimed to evaluate whether this technique could improve the success rate in the complicated posterior urethral stricture reconstruction in this study.

MATERIALS AND METHODS

Between 2016 and 2019, 48 patients underwent either conventional or modified TAU. The criteria for success included both the absence of clinical symptoms and no need for further surgical intervention during follow-up.

RESULTS

Twelve patients underwent the modified TAU (group A) using bulbocavernosus flap interposition and human fibrin sealant. Thirty-six patients underwent the traditional end-to-end anastomotic urethroplasty (group B). Follow-up was 24.3-57.2 months. The patients in group A had a higher surgery success rate compared to the patients in group B (91.7 vs. 63.9%, P =0.067), with a quasi-significant result. Besides, no postoperative complications were observed in group A, while two individuals in group B had urinary incontinence, but the difference was not significant (0 vs. 5.6%, P =0.404).

CONCLUSION

Based on the preliminary results, modified TAU with bulbocavernosus flap interposition and human fibrin sealant is a safe and feasible technique for complicated posterior urethral stricture reconstruction.

Bilateral Buccal Mucosa Graft for Urethroplasty: A Versatile Graft

Male urethral stricture is scarring of the urethral tissue that narrows the urethral lumen causing reduced urinary flow. Urethral reconstruction or substitution urethroplasty using oral mucosa graft, especially from the buccal mucosa, is one of the most widely known techniques to manage urethral stricture. However, studies using bilateral buccal mucosa are still limited. Therefore, this study aims to report our experience and technique of bilateral buccal mucosa grafting for urethroplasty. The authors described a 66-year-old man with long-segment urethral stricture that was successfully treated with urethral reconstruction harvested from bilateral buccal mucosa.

The role of gel-infused translabial ultrasound as a new modality in evaluation of female urethral stricture

Introduction

To investigate the role of trans-labial ultrasound study in detection of female urethral stenosis (FUS) compared to former cysto-urethroscopy as the currently available definitive diagnostic modality.

Material and methods

In this cross-sectional study, 60 consecutive patients with bladder outlet obstruction diagnosed by clinical symptoms and urodynamic study, were included from 2019 to 2022. For additional assessment, all these patients underwent gel-Infused trans-labial ultrasound (GITLUS) and cystourethroscopy. Trans-labial real-time ultrasonography was performed following the insertion of 20 ml steady stream viscous jelly into the urethral meatus to assess the length of the urethra and exact location and length of the probable narrowing, as well as the presence of peri-urethral fibrosis (PUF).

Results

In GITLUS evaluation, urethral stricture was found in 27 patients. Mean urethral length and stricture length were 35.63 ±4.78 and 17.04 ±10.59, respectively. All these stenosis were confirmed via cysto-urethroscopy. PUF was found in 20 of 27 patients. In cysto-urethroscopy, urethral stricture was confirmed in 40 patients: 13 in urethral meatus and 27 in other parts or pan-urethra. GITLUS could not reveal urethral stricture in 13 patients with meatal stenosis, confirmed with cystoscopy. GITLUS detected FUS less accurately when it involves pure distal urethra compared to other parts of urethra or pan-urethral stenosis (p value = 0.002).

Conclusions

GITLUS is a safe, non-invasive, and valuable technique for detecting FUS. The location and the length of the stricture and probable peri-urethral fibrosis can be identified by this method. However, in meatal or pure short-length distal urethral strictures, this method should be used with caution.

Urethral Microenvironment Adapted Sodium Alginate/Gelatin/Reduced Graphene Oxide Biomimetic Patch Improves Scarless Urethral Regeneration

The nasty urine microenvironment (UME) is an inherent obstacle that hinders urethral repair due to fibrosis and swelling of the oftentimes adopted hydrogel-based biomaterials. Here, using reduced graphene oxide (rGO) along with double-freeze-drying to strengthen a 3D-printed patch is reported to realize scarless urethral repair. The sodium alginate/gelatin/reduced graphene oxide (SA/Gel/rGO) biomaterial features tunable stiffness, degradation profile, and anti-fibrosis performance. Interestingly, the 3D-printed alginate-containing composite scaffold is able to respond to Ca2+ present in the urine, leading to enhanced structural stability and strength as well as inhibiting swelling. The investigations present that the swelling behaviors, mechanical properties, and anti-fibrosis efficacy of the SA/Gel/rGO patch can be modulated by varying the concentration of rGO. In particular, rGO in optimal concentration shows excellent cell viability, migration, and proliferation. In-depth mechanistic studies reveal that the activation of cell proliferation and angiogenesis-related proteins, along with inhibition of fibrosis-related gene expressions, play an important role in scarless repair by the 3D-printed SA/Gel/rGO patch via promoting urothelium growth, accelerating angiogenesis, and minimizing fibrosis in vivo. The proposed strategy has the potential of resolving the dilemma of necessary biomaterial stiffness and unwanted fibrosis in urethral repair.

Diagnosis of traumatic urethral stricture in a canine patient with contrast-enhanced voiding urosonography : A case report

A 5-year-old intact male mixed-breed dog presented with a 3-day history of stranguria and dysuria. Results of physical examination, plain radiographs, and ultrasonography were consistent with a traumatic urethral stricture in the prescrotal urethra just under the previous trauma region, resulting in partial obstruction of urine outflow. Contrast-enhanced voiding urosonography (CE-VUS) was performed, and a urethral stricture was confirmed. The dog underwent surgery. A scrotal urethrostomy was performed. After 3 days of hospitalization, the dog was discharged from the Clinic. Based on an extensive literature review, this is the first report using CE-VUS to evaluate urethral pathology in a canine patient.

Qualitative Analysis of Patient Experiences Reaching Urethroplasty for Recurrent Urethral Stricture Disease

PURPOSE

Despite the inferior outcomes, urethral stricture patients often undergo multiple endoscopic procedures prior to undergoing definitive urethroplasty. We sought to qualitatively evaluate the patient experience of obtaining urethroplasty to better understand the impact of this experience on quality of life.

MATERIALS AND METHODS

Patients treated with urethroplasty between September 2019 and July 2021 were identified and invited to participate in our study if they had undergone ≥ 2 endoscopic procedures prior to urethroplasty. Semistructured telephone interviews were conducted, coded, and analyzed using an iterative inductive-deductive approach.

RESULTS

Of the 105 urethroplasty patients during the study period, 50 (47.6%) had undergone ≥ 2 endoscopic procedures prior (IQR 3-5), of whom 20 participated in the study. Qualitative themes related to repeat endoscopic procedures included unmet treatment expectations, dissatisfaction with catheterization and repeat procedures, and negative impacts of recurrent stricture symptoms and treatments on quality of life. External factors associated with a delay to urethroplasty included financial constraints, surgeon access, and time off work.

CONCLUSIONS

A trajectory of declining quality of life and unmet treatment expectations are the primary factors driving the decision to proceed with urethroplasty. However, external factors such as recovery costs and access to specialists play important roles in delaying surgery. These findings illustrate the need for improved community provider education and patient counseling to better inform expectations of both patients and providers with various treatment outcomes. Furthermore, these data highlight the need to improve access to specialized care for urethral stricture patients.

Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis

BACKGROUND

Sexual function after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of nontransecting bulbar urethroplasty (ntBU) in terms of erectile dysfunction (ED).

AIM

This meta-analysis aimed to compare the efficacy and safety of ntBU with that of transecting bulbar urethroplasty (tBU).

METHODS

The PubMed, Web of Science, Cochrane, and Embase databases were searched and reviewed up to October 31, 2022. Quality evaluation was performed using the Newcastle-Ottawa scale system and Cochrane tools for the nonrandomized and randomized studies, respectively. Baseline characteristics, preoperative information, and postoperative outcomes were collected.

OUTCOMES

Outcomes included success rate, ED, overall complication, and maximum urinary flow.

RESULTS

Thirteen studies comprising 1683 patients met the inclusion criteria, with 596 and 1087 patients undergoing ntBU and tBU, respectively. The results revealed that compared with the tBU group, the patients who underwent ntBU had a significantly lower incidence of ED, while there were no significant differences in the other perioperative outcomes. In subgroup analysis, the nontransecting anastomotic urethroplasty group had a lower incidence of ED than excision and primary anastomosis, and other perioperative outcomes were similar between the 2 groups.

CLINICAL IMPLICATIONS

The results of the study may help clinicians choose procedures that protect sexual function in the treatment of urethral stricture.

STRENGTHS AND LIMITATIONS

The strength of this study is that it is, to our knowledge, the first meta-analysis to evaluate the efficacy and safety of ntBU. A limitation is that most of the included studies were retrospective cohort studies.

CONCLUSION

ntBU preserves the high efficacy of its transecting counterpart while reducing postoperative ED.

Bladder outlet obstruction in women: Scope of the problem and differential diagnosis

INTRODUCTION

The prevalence, formal definition, and diagnostic criteria of bladder outlet obstruction in owmen have not been clearly defined.

METHODS

This is a literature review of the definition of BOO in women, its prevalence, as well as its differential diagnosis.

RESULTS

The main causes of BOO in women are divided into functional and anatomic conditions. Functional etiologies include detrusor external sphincter dyssynergia, dysfunctional voiding, Fowler's syndrome, and primary bladder neck obstruction. Anatomic causes can be further divided into extrinsinc and intrinsic conditions. Intrinsic etiologies include urethral stricture and urethral diverticula, whereas extrinsic causes comprise pelvic organ prolapse, post anti-incontinence surgery, and Skene's gland cyst or abscess.

CONCLUSIONS

There are multiple etiologies to BOO in women, and this condition is most probably underdiagnosed, owing to a lack of consensus for a standard definition.

Urethral management after artificial urinary sphincter explantation due to cuff erosion

Introduction

The artificial urethral sphincter (AUS) is the gold standard treatment in cases of moderate-to-severe stress urinary incontinence in males. Cuff erosions are one of the most important distant complications of AUS implantation. The optimal urethral management has still not been established.

Material and methods

Search terms related to 'urethral stricture', 'artificial urinary sphincter', and 'cuff erosion' were used in the PubMed database to identify relevant articles.

Results

In this mini review we identified 6 original articles that assessed the urethral management after AUS explantation due to cuff erosion and included urinary diversion by transurethral and/or suprapubic catheterization, urethrorrhaphy, and in situ urethroplasty. We summarized the results of different management methods and their efficacy in terms of preventing urethral stricture formation. We highlight the need for better-quality evidence on this topic.

Conclusions

The available data do not provide a clear answer to the question of optimal urethral management during AUS explantation. There is a great need to provide higher-quality evidence on this topic.

Is testosterone deficiency a predictive factor for recurrence of urethral stricture?

BACKGROUND

Testosterone plays a vital role in maintaining tissue homeostasis, and testosterone deficiency may potentially influence the likelihood of urethral stricture recurrence.

OBJECTIVES

To evaluate the prognostic value of testosterone levels in the recurrence after direct visual internal urethrotomy in primary short segment bulbar urethral strictures and its clinical reflections.

MATERIALS AND METHODS

A total of 723 patients who underwent direct vision internal urethrotomy between January 2000 and October 2022 were retrospectively analyzed. After implying exclusion criteria, 116 patients with available data were enrolled. Patients were divided into two groups as recurrence and no recurrence. Age, stricture length, etiology, time of recurrence, diagnosis of previous diabetes mellitus, hypertension, smoking, body mass index, and total testosterone levels were recorded. Free testosterone and bioavailable testosterone values were calculated using total testosterone, albumin, and sex hormone binding globulin values. Hypogonadism was considered as a total testosterone level less than 300 ng/dL. Demographic characteristics and total testosterone, free testosterone, and bioavailable testosterone levels were compared between the two groups for statistical significance. The recurrence rates of patients with and without hypogonadism were compared.

RESULTS

Recurrence was observed in 41.4% of the cases (n = 48). There was no statistically significant difference between the groups in terms of age, body mass index values, diabetes mellitus, hypertension, smoking status, presence of hypogonadism, and etiology (p = 0.745, 0.863, 0.621, 0.622, 0.168, 0.051, and 0.232). In terms of total testosterone levels and bioavailable testosterone levels, the recurrence group had significantly lower values (p = 0.018 and 0.04). There was no significant difference between the two groups in terms of stricture length (p = 0.071). Sixteen of 28 patients with hypogonadism had recurrence, whereas 32 of 88 patients without hypogonadism had recurrence (p = 0.051).

DISCUSSION

Testosterone levels have potential to predict recurrence in primary short-segment bulbar urethral strictures. This study represents the inaugural analysis of the impact of testosterone deficiency on recurrence within the cohort of patients with primary short-segment bulbar urethral strictures.

CONCLUSION

Testosterone levels and ratios may serve as predictive factors for identifying recurrent cases in primary short-segment bulbar strictures. For patients at a higher risk of recurrence, urethroplasty may be considered as an initial treatment option, even in cases of primary and short-segment strictures.

Risk-Factor Analysis and Prediction-Model Construction of Urethral Stricture after Hypospadias Surgery in Children: A Single-Centre Retrospective Study

OBJECTIVE

This study aimed to explore the incidence of postoperative urethral stricture in children after hypospadias surgery, analyse its risk factors, and construct a prediction model.

METHODS

We retrospectively analysed the clinical data of 402 children with hypospadias surgery in Hunan Children's Hospital from January 2022 to January 2023. To explore the risk factors of urethral stricture after hypospadias surgery in children, the incidence of postoperative urethral stricture in children was statistically analysed, and univariate and multivariate logistic regression analyses were adopted. A prediction model was established, and the prediction efficiency of the model was examined using a receiver operating characteristic curve.

RESULTS

The incidence of postoperative urethral stricture in children after hypospadias surgery was 9.20% (37/402). On this basis, the children were divided into stricture group (SG, n = 37) and normal group (NG, n = 365). Both groups had overt differences in disease classification, urinary tract infection, indwelling-catheter time, and surgical methods (p < 0.05). Logistic regression analysis showed that urinary tract infection, surgical methods, and long indwelling-catheter time were the risk factors (p < 0.001). The prediction model constructed based on the above results had certain prediction efficiency.

CONCLUSIONS

More attention should be paid to children with urinary tract infection, high-risk surgery, and long indwelling-catheter time after hypospadias surgery. Our prediction model can serve as an effective reference for evaluating the occurrence of postoperative urethral stricture.

De- and recellularized urethral reconstruction with autologous buccal mucosal cells implanted in an ovine animal model

OBJECTIVES

Patients with urethral stricture due to any type of trauma, hypospadias or gender dysphoria suffer immensely from impaired capacity to urinate and are in need of a new functional urethra. Tissue engineering with decellularization of a donated organ recellularized with cells from the recipient patient has emerged as a promising alternative of advanced therapy medicinal products. The aim of this pilot study was to develop an ovine model of urethral transplantation and to produce an individualized urethra graft to show proof of function in vivo.

METHODS

Donated urethras from ram abattoir waste were decellularized and further recellularized with autologous buccal mucosa epithelial cells excised from the recipient ram and expanded in vitro. The individualized urethral grafts were implanted by reconstructive surgery in rams replacing 2.5 ± 0.5 cm of the native penile urethra.

RESULTS

After surgery optimization, three ram had the tissue engineered urethra implanted for one month and two out of three showed a partially regenerated epithelium.

CONCLUSIONS

Further adjustments of the model are needed to achieve a satisfactory proof-of-concept; however, we interpret these findings as a proof of principle and a possible path to develop a functional tissue engineered urethral graft with de- and recellularization and regeneration in vivo after transplantation.

Inhibition of urethral stricture by a catheter loaded with nanoparticle/ pirfenidone complexes

Background: Urethral strictures are common injurious conditions of the urinary system. Reducing and preventing urethral strictures has become a hot and challenging topic for urological surgeons and related researchers. In this study, we developed a catheter loaded with nanoparticle/pirfenidone (NP/PFD) complexes and evaluated its effectiveness at inhibiting urethral stricture in rabbits, providing more references for the clinical prevention and reduction of urethral stenosis. Methods: Twelve adult male New Zealand rabbits were selected and divided into the following four groups in a ratio of 1:1:1:1 using the random number table method: Group A, sham; Group B, urethral stricture (US); Group C, US + unmodified catheter; and Group D, US + NP/PFD catheter. On the 30th day after modelling, retrograde urethrography was performed to evaluate urethral stricture formation, and histopathological examination was performed on the tissues of the corresponding surgical site. Meanwhile, changes in the expression level of Transforming growth factor β1 (TGF-β1) in the tissues were detected by immunohistochemistry. Results: The NP/PFD complexes adhered uniformly to the catheter surface. They remained on the surface of the catheter after insertion into the urethra. In addition, the NP/PFD complexes spread into the urethral epithelium 2 weeks after surgery. Ultimately, urethral strictures were significantly reduced with the placement of the NP/PFD complex catheter. Conclusion: Our catheter loaded with NP/PFD complexes effectively delivered PFD to the urethral epithelium through continuous local delivery, thereby reducing fibrosis and stricture after urethral injury, which may be associated with the inhibition of TGF-β1 expression.

Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures

OBJECTIVES

To present a surgical modification for the repair of bulbar urethral strictures containing short, highly obliterative segments and report on long-term objective and patient-reported outcomes.

PATIENTS AND METHODS

We considered patients undergoing bulbar buccal mucosal graft urethroplasty (BMGU) between July 2016 and December 2019. Eligibility criteria for mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty were strictures of ≥2 cm with an obliterative segment of ≤1.5 cm. The stricture is approached ventrally to avoid extensive dissection and mobilisation. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by ventral onlay graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated patient-reported outcome measures on voiding, erectile, and continence function. We evaluated functional follow-up, incorporating patient-reported (lower urinary tract symptoms [LUTS] score) and functional success. Recurrence was defined as need of re-treatment.

RESULTS

Of 641 men treated with anterior BMGU, 54 (8.4%) underwent MANTA urethroplasty. Overall, 26 (48%) and 45 (83%) had a history of dilatation and urethrotomy, respectively, and 14 (26%) were redo cases. Location was bulbar in 38 (70%) and penobulbar in 16 patients (30%), and the mean (SD) graft length was 4.5 (1.4) cm. At a median (interquartile range) follow-up of 41 (27-53) months, the functional success rate was 93%. Whereas the median LUTS score significantly improved from baseline to postoperatively (13 vs 3.5; P < 0.001), there was no change in erectile function (median International Index of Erectile Function - erectile function domain score 27 vs 24) or urinary continence (median International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form sum score 0 vs 0; all P ≥ 0.4). All patients were 'satisfied' (27%) or 'very satisfied' (73%) with the outcome of their operation.

CONCLUSION

With excellent long-term objective and patient-reported outcomes, MANTA urethroplasty adds to the armamentarium for long bulbar strictures with a short obliterative segment.

Short-term recurrence rate of male urethral stricture and its predictors after treatment with optical internal urethrotomy: Prospective Cohort Study at a tertiary center in Ethiopia

Abstract

Background

Although optical internal urethrotomy is popular among the urologists due to its simplicity and safety, urethroplasty is considered the gold standard treatment for urethral strictures. This study aims to determine the 1-year recurrence rate of urethral strictures after optical urethrotomy and identify predictors of recurrence in a tertiary center in Ethiopia.

Methods

A prospective observational cohort study was conducted on 80 male patients who underwent optical urethrotomy from November 2019 to August 2020 in a tertiary center in Ethiopia. Logistic regression was used to analyze the association between dependent and independent variables, with a P-value of <0.05 considered statistically significant.

Results

The mean and median age (±SD) of patients at the time of the procedure were 54.76 (±14.74) and 58 years with a range [20-78], respectively. Urethral discharge was the most common etiology identified in 39 (48.75%) of patients. Eleven (13.75%) patients had no identifiable etiology for their urethral stricture disease.The majority of patients presented with at least one voiding lower urinary tract symptoms.Sixty-eight (85%) patients out of the total had a single stricture and 12 (15%) had multiple strictures. The location of the stricture was in the bulbar urethra on cystourethrography in 83% of the patients. The 1-year recurrence rate of urethral stricture after optical urethrotomy was 35% in our study.The number of strictures and the presence of hypertension were independent predictors of recurrence of urethral stricture within 1-year after treatment with optical urethrotomy (AOR=15.35, 95% CI: 2.92-80.61, P=0.00; AOR=19.47, 95% CI: 2.11-178.98, P=0.01, respectively).

Conclusions

Our study identified that multiple strictures, and the presence of hypertension are associated with an increased recurrence rate in the first postoperative year.

DKK1 Ameliorates Myofibroblast Differentiation in Urethral Fibrosis in Vivo and in Vitro by Regulating the Canonical Wnt Pathway

Background: Urethral stricture is a common disorder of the lower urinary tract in men. A complex network of pathways and interactions are involved in the pathogenesis of urethral fibrosis. However, the mechanisms underlying urethral fibrosis remain poorly understood. Objectives: To investigate the critical role of the canonical Wnt pathway in development of urethral fibrosis and explore DKK1, the endogenous inhibitor of Wnt pathway, as a potential target to prevent urethral fibrosis in vitro and in vivo. Methods: Urethral fibrosis tissue derived from patients and rat models were harvested to assess the activation of the canonical Wnt pathway by using western blot, qRT-PCR and immunohistochemistryWe performed histological staining, western blot, qRT-PCR and immunohistochemistry to examine the effects of DKK1 treatment on in vivo rat urethral fibrosis models. In vitro, human urethral fibroblasts (HUFs) were cultured to examine the effects of DKK1 in TGFβ1-induced HUFs by CCK-8 assay, hydroxyproline assay, flow cytometry, cell migration assay, western blot, qRT-PCR and immunofluorescence. Results: The key components of Wnt signaling were upregulated in urethral fibrosis tissue derived from patients and rat models while DKK 1 was downregulated. DKK1 ameliorated TGFβ1-induced urethral fibrosis in rats. TGFβ1 induced myofibroblast differentiation by upregulating collagen I, collagen III, α-SMA, β-catenin and p-GSK-3β, while DKK1 was decreased. DKK1 significantly inhibited cell proliferation, collagen content, cell migration and promoted cell apoptosis in TGFβ1-induced HUFs. DKK1 significantly suppressed myofibroblast differentiation of TGFβ1-induced HUFs by downregulating collagen I, collagen III, α-SMA, β-catenin and p-GSK-3β with a mechanism independent of Smad2/3. Conclusions: Our study demonstrated that canonical Wnt pathway may be an essential mechanism underlying the pathogenesis of urethral fibrosis and explored the potential role of DKK1 participation in the development of urethral fibrosis.

A Systematic Review on Postoperative Antibiotic Prophylaxis after Pediatric and Adult Male Urethral Reconstruction

In the era of antibiotic overuse and increasing antibiotic resistance, there is a gap in evidence regarding antibiotic stewardship, and in particular, perioperative antibiotic prophylaxis after urethral reconstruction. The aim of this systematic review was to evaluate the effectiveness and relevance of postoperative antibiotic prophylaxis after male pediatric and adult urethral reconstruction. An online search of MEDLINE database via PubMed was performed. The systematic review was registered in PROSPERO (CRD42022348555) and was conducted according to the PRISMA guidelines and AMSTAR 2 checklist. A narrative synthesis of included studies was performed. After the screening of 1176 publications, six studies regarding antibiotic prophylaxis after hypospadias reconstruction and two studies regarding antibiotic prophylaxis after urethroplasty in adults were eligible to be included in the systematic review. All but one of the studies on hypospadias repair showed no benefit from postoperative antibiotic prophylaxis. The level of evidence on postoperative antibiotic prophylaxis after urethroplasty in adults is low. Neither of the two studies included in the review showed a benefit from antibiotic use. Postoperative prophylaxis after hypospadias repair is not effective in preventing urinary tract infections and wound infections. It seems that the use of postoperative prophylaxis after urethroplasty in adults is also not beneficial, but there is a high need for high-quality scientific data.

Pharmacotherapy of urethral stricture

ABSTRACT

Urethral stricture is characterized by the chronic formation of fibrous tissue, leading to the narrowing of the urethral lumen. Despite the availability of various endoscopic treatments, the recurrence of urethral strictures remains a common challenge. Postsurgery pharmacotherapy targeting tissue fibrosis is a promising option for reducing recurrence rates. Although drugs cannot replace surgery, they can be used as adjuvant therapies to improve outcomes. In this regard, many drugs have been proposed based on the mechanisms underlying the pathophysiology of urethral stricture. Ongoing studies have obtained substantial progress in treating urethral strictures, highlighting the potential for improved drug effectiveness through appropriate clinical delivery methods. Therefore, this review summarizes the latest researches on the mechanisms related to the pathophysiology of urethral stricture and the drugs to provide a theoretical basis and new insights for the effective use and future advancements in drug therapy for urethral stricture.

Safety of Xiaflex® (Collagenase Clostridium histolyticum) Treatment for Adult Anterior Urethral Stricture Disease

Male urethral stricture disease is highly prevalent and difficult to treat due to potential complications. Minimally invasive treatments tend to have high recurrence rates, keeping urethroplasty as the gold standard. Collagenase Clostridium histolyticum (CCH) has been used in humans to treat fibrosis in a minimally invasive manner. Herein, we present the preliminary results from treatments of three males with urethral stricture as a feasibility and safety evaluation of the first-in-human CCH treatment for male urethral stricture disease.

Proposal to decrease incidence, morbidity, and associated healthcare costs regarding difficult and traumatic urethral catheterization - a protocol for DMC hospitals: A pilot study

INTRODUCTION

Difficult and traumatic urethral catheterization is a common reason for urologic consult. Catheter insertion and management is common for patients who are managed in the hospital setting.

MATERIALS AND METHODS

A four-question survey was distributed across three hospitals at a single-institution.

RESULTS

A total of 41 nursing staff responses were recorded. Forty-four percent of the nursing staff reported prior participation in a traumatic catheter insertion. Ninety percent of total responders reported a prior involvement with a difficulty catheter.

CONCLUSION

Patient morbidity and healthcare costs regarding traumatic and difficult catheterization is significant. Utility of protocols and education could potentially reduce these burdens and enhance patient care.

[Giant prostate stones: case report]

Small prostate stones are often found incidentally during clinical and radiological examination. Large stones, however, also may develop, replacing completely the prostate tissue and causing various symptoms. Such a large stones are commonly formed due to chronic urine reflux. There are 20 publications in the literature devoted to the patients with giant prostate stones. Open as well as endoscopic procedures can be performed. In our clinical case both approaches were done simultaneously. Such tactic was chosen in order to carry out a single-stage intervention, immediately solving two problems, i.e., urethral stricture and a giant prostate stone.

A Prospective Multi-institutional Study Using a Novel Safety Valve for the Prevention of Catheter Balloon Inflation Injury of the Urethra

PURPOSE

We prospectively assessed the ability of a novel transurethral catheterization safety valve to prevent urethral catheter balloon injury in a multi-institutional clinical setting.

MATERIALS AND METHODS

A prospective, multi-institution study was conducted. The safety valve was introduced for urinary catheterization in 6 hospital groups (4 in Ireland; 2 in the UK). The safety valve allows fluid in the catheter system to vent through a pressure relief valve if attempted intraurethral inflation of the catheter's anchoring balloon occurs. Device usage was studied over a 12-month period, with data recorded using a 7-item data sticker containing a scannable QR code. "Venting" through the safety valve during catheterization was indicative of prevention of a urethral injury. An embedded 3-month study was conducted in 3 centers, with any catheter balloon injuries occurring during catheterization without safety valve use referred to the on-call urology team recorded. Health economic analyses were also performed.

RESULTS

During the overall 12-month device study phase, 994 urethral catheterizations were performed across study sites. Twenty-two (2.2%) episodes of safety valve venting were recorded. No urethral injuries occurred in these patients. In the embedded 3-month study, 18 catheter balloon injuries were recorded in association with catheterizations performed without the safety valve. Based on confirmed and device-prevented urethral injuries, the injury rate for urethral catheterization without safety valve use was calculated to be 5.5/1,000 catheterizations.

CONCLUSIONS

The safety valve has the potential to eliminate catheter balloon injury if widely adopted. It represents a simple, effective, and innovative solution to this recurring problem applicable to all patient cohorts.

Urethral Stricture Formation After Artificial Urinary Sphincter Cuff Erosion Is Uncommon in the Absence of Pelvic Radiation

PURPOSE

Reported rates of urethral stricture development after artificial urinary sphincter erosion are highly variable. We hypothesized that the risk of stricture is commensurate with the degree of erosion.

MATERIALS AND METHODS

We reviewed our prospectively maintained quality improvement database for all patients with artificial urinary sphincter erosion from 2011 to 2022. The incidence of postoperative stricture development was compared to the severity of erosion using a graded scale: 1, <25% circumference; 2, 25%-50% circumference; 3, >50% and <100% circumference; and 4, 100% circumference. From 862 artificial urinary sphincter surgeries, 102 erosion cases were identified, and 63 with documented erosion severity were included for analysis. Additional analysis was performed on 28 cases without documented erosion severity for validation.

RESULTS

Within the main cohort, urethral stricture developed in 22 (34.9%) patients. The incidence of stricture did not vary by grade of erosion (P = .73) and was not significantly higher in men with grade 4 erosion vs lower-grade erosions (32.7% vs 50.0%, P = .34). Radiation exposure was associated with a 41.1% higher incidence of stricture (P < .01) and nearly every stricture occurred in the setting of prior radiation (21 of 22; 95.5%). In the validation group, 10 (35.7%) developed stricture, mostly in the setting of radiation (8 of 10; 80%). Overall, 29 of 32 (90.6%) cases of stricture involved a history of radiation.

CONCLUSIONS

Artificial urinary sphincter erosion does not lead to urethral stricture formation in most cases and is not associated with degree of erosion. Those who develop strictures nearly always have a history of pelvic radiation.

Urethral Stricture Disease Guideline Amendment (2023)

PURPOSE

The symptoms of urethral stricture are non-specific and may overlap with other common conditions that can confound diagnosis. Urologists play a key role in the initial evaluation of urethral stricture, currently provide all accepted treatments, and must be familiar with the evaluation, diagnostic tests, and surgical treatments for urethral stricture.

MATERIALS AND METHODS

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates January 1, 1990 to January 12, 2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment was modified to included females and males (search dates December 2015-October 2022 for males; January 1990-October 2022 for females) and a new Key Question on sexual dysfunction was added (search dates: January 1990-10/2022). After inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base.

RESULTS

Once a urethral stricture is diagnosed, clinicians should determine the length and location of the stricture in order to inform treatment. After a period of urethral rest, patients with short (<2cm) bulbar urethral stricture may be treated endoscopically. Urethroplasty may be performed by an experienced surgeon in patients with first time or recurrent anterior and posterior urethral strictures. The best treatment option for urethral stricture in female patients is urethroplasty using oral mucosa grafts or vaginal flaps rather than endoscopic treatment.

CONCLUSION

This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment.

Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease

Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.

[Double to avoid trouble? An experience of double Memokath(tm) 044TW stents insertion for multiple anterior urethral stricture in hospital universiti sains Malaysia]

For the past two decades urethral stenting became more popular for treatment of urethral stricture. However, urethral stents still not widely used in view of good outcome from urethroplasty surgery. The MemokathTM stent is the most popular in this field. It is manufactured from a biocompatible alloy of nickel and titanium. Most of the studies have been limited to single stent insertion, and no studies done for double stents insertion. An 81-year-old man with history of multiple anterior urethral strictures since 2013. He underwent internal urethrotomy in the same year but failed and was on urinary catheter since then. The MemokathTM 044TW was the option due to patient has multiple comorbidities. The micturating cystourethrogram (MCUG) and ascending urethrogram showed multiple anterior urethral strictures. He underwent direct visual internal urethrotomy and two MemokathTM stents inserted in the whole length of urethral. However, one year after procedure, he had recurrent lower urinary tract symptoms and ultimately developed acute urinary retention (AUR). Patients stents were removed endoscopically. During endoscopic removal, he had encrustation of both stents that causing obstructive symptoms. He is under our follow-up with no recurrent urinary retention or urosepsis with satisfactory uroflowmetry. Stent encrustation is known to be a common late complication of urethral stents. Stent encrustation should be suspected if patient comes with obstructive symptoms. Endoscopic is shown to be the best method to detect the cause of obstructed stent.

Comparative effect of intraurethral clobetasol and tacrolimus in lichen sclerosus-associated urethral stricture disease

Background

Management of urethral stricture related to lichen sclerosus (LS) is now gradually changing from surgical to nonsurgical due to availability of anti-inflammatory agents such as corticosteroids and calcineurin inhibitors. We determined the clinical impact of these agents in such patients on outpatient department basis in terms of improvement in symptoms on International Prostate Symptom Score (IPSS), external skin appearance, and maximum urinary flow rate (Qmax).

Materials and Methods

Eighty patients of meatal stenosis and penile urethral stricture with histopathologically proven LS were divided into two groups, and clinical and predetermined parameters such as Qmax, IPSS, and changes in external appearance were compared between these groups after 3 months of topical and intraurethral application of clobetasol and tacrolimus with self-calibration.

Results

A significant intragroup difference was noted in IPSS (P < 0.001) as well as Qmax (P < 0.001); postintervention intergroup difference in IPSS was not significant (P = 0.94) and however postintervention intergroup difference in Qmax was significant in favor of clobetasol (P = 0.007). A significantly increased number of additional procedures were done in the group receiving intraurethral tacrolimus (P = 0.0473) with significantly less number of skin complication in the group with topically applied clobetasol (P = 0.003).

Conclusion

Though both clobetasol and tacrolimus, improved symptom score, Qmax and local external appearance yet topical and intra-urethral clobetasol application via urethral self calibration seems to be better option for lichen sclerosus related urethral stricture in terms cost and local complications.

Successful management of pelvic urethral strictures with balloon dilation in 3 cats

OBJECTIVE

To describe the successful management of pelvic urethral strictures in 3 young cats (1 after perineal urethrostomy, 1 after a third-time urethral obstruction, and 1 with prolonged lower urinary tract signs post-urethral obstruction) using balloon dilation and a short-term, indwelling urethral catheter.

CASE SUMMARIES

A 9-month-old neutered male domestic longhair cat with a urethral obstruction and a suspected congenitally narrowed urethra was treated via perineal urethrostomy. The cat later developed acute kidney injury, multidrug-resistant urinary tract infections, and a pelvic urethral stricture. A second case, a 2.3-year-old neutered male domestic shorthair cat, developed a stricture of the pelvic urethra after multiple obstructions and catheterizations. A third case, a 1.2-year-old neutered male domestic shorthair cat, had persistent and prolonged lower urinary tract signs after treatment for a urinary obstruction. The cat also had an abnormally small urethral opening and was ultimately found to have a proximal urethral stricture. The strictures in all 3 cases were successfully treated with a combination of fluoroscopic-guided balloon dilation and short-term indwelling urethral catheterization while managing any present infection.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first published case series of successful balloon dilations paired with the use of a short-term indwelling urethral catheter in cats that developed urethral strictures after catheterization due to urinary obstructions. This procedure appears safe and well tolerated and appears to offer a long-term, cost-effective solution to urethral strictures at the level of the pelvis.

Trends in Male and Female Urethral Endoscopic Management and Urethroplasty Using the TriNetX Database

BACKGROUND

How quickly providers adapt to new practice guidelines is not well known. The objective of this study was to evaluate temporal trends in the performance of urethral endoscopic management and urethroplasty surrounding the release of the American Urological Association (AUA) Male Urethral Stricture Guidelines in 2017. We also evaluate in parallel trends in female urethral stricture disease, where AUA guidelines are not present. We hypothesized that the ratio of urethroplasty versus urethral endoscopic management in both males and females is increasing and that guidelines do not result in immediate changes in management trends.

METHODS

Endoscopic management and urethroplasty data were collected from the TriNetX database on adult males and females five years before (starting 1 January 2012) and after (ending 31 December 2022) the 2017 AUA guidelines. Cohorts were built using Current Procedural Terminology (CPT) codes and grouped into urethral endoscopic management (Males: CPT 52275, 52281, 52282, 53600, 53601, 53620, 53621; Females: CPT 52270, 53660, 53661, 53665) or urethroplasty (Males: CPT 53000, 53010, 53400, 53410, 53415, 53420, 53450, 53460; Females: CPT 53430). Data on patient age, race, and geographic distribution were also collected.

RESULTS

In total, 27,623 (Males: 25,039; Females: 2584) endoscopic managements and 11,771 (Males: 11,105; Females: 666) urethroplasties were reviewed across 51 Health Care Organizations. The mean age of endoscopic management and urethroplasty patients was 67.1 and 55.7, respectively (p < 0.01). The urethroplasty-to-endoscopic management ratio decreased for males between 2012 and 2013 and then steadily increased until 2017. The ratio steadily increased for females from 2012 to 2017. The urethroplasty-to-endoscopic management ratio showed a slight decline from 2017 to 2020 across both males and females before rising again through 2022 to a study high (Males: 0.62; Females: 0.63). Regional differences were identified, with the West having the highest urethroplasty-to-endoscopic management ratios for both males and females, the Northeast having the lowest urethroplasty-to-endoscopic management ratio for males, and the Midwest having the lowest ratio for females.

CONCLUSIONS

The utilization of urethroplasty for males and females is increasing. An immediate benefit on post-guideline urethroplasty rates was not observed, and the utilization of female urethroplasty increased despite the absence of AUA guidelines. These illustrate that the impact of guideline dissemination takes time and supports the need for continued provider outreach and education on urethral stricture disease and management.

A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty

BACKGROUND

We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data.

METHODS

Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event.

RESULTS

There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01).

CONCLUSIONS

Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.

Male Urethral Stricture in Patients with Metabolic Syndrome

OBJECTIVE

Urethral stricture is characterized by fibrosis that decreases urine flow. Metabolic syndrome is a complex disorder that causes fibrosis in many organs. This study aimed to evaluate the relationship between metabolic syndrome and appearance of urethral stricture and effects of metabolic syndrome on the recurrence of urethral stricture in patients with primary urethral stricture who underwent direct visual internal urethrotomy.

MATERIALS AND METHODS

One hundred thirty-two male patients who underwent direct visual internal urethrotomy between 2014 and 2021 because of primary urethral stricture were included. Location, length, and type of urethral stricture, time from diagnosis to surgery, postoperative follow-up, time from surgery to recurrence, and postoperative follow-up duration with a urethral catheter were retrospectively analyzed and association with metabolic syndrome was evaluated.

RESULTS

The mean age was 50.48 ± 17.94 years. Recurrence was found in 34.1% and metabolic syndrome in 27.3%. Postoperative follow-up duration was significantly longer in patients with recurrence than in those without (P=.033). There was no statistically significant difference in terms of metabolic syndrome and postoperative urethral catheterization between patients with and without recurrence (P=.126, P=.714, respectively). Postoperative clean intermittent self-catheterization use was found to be statistically higher in patients with recurrence than in patients without recurrence (P=.018). Postoperative urinary tract infection rate was found to be significantly higher in patients with metabolic syndrome compared to patients without metabolic syndrome (P=.001).

CONCLUSION

Metabolic syndrome was not associated with recurrence. However, postoperative urinary tract infections were more common in patients with metabolic syndrome than in patients without. Clean intermittent self-catheterization used postoperatively may increase the risk of stricture.

Collagen is More Abundant and Structurally Altered in Lichen Sclerosus

OBJECTIVE

To test the hypothesis that genital skin and male urethra affected by lichen sclerosus (LS) has increased collagen content and altered collagen structure.

METHODS

We used picrosirius red to stain and image collagen in human urethral, vulvar, and foreskin specimens with and without LS. Using Image J software, we quantified and compared (1) collagen content (using 2o metrics: collagen proportionate area [CPA] and collagen fiber count), (2) collagen fiber length and width, and (3) collagen structure using the texture analysis technique gray level co-localization matrix (GLCM) with respect to LS status and tissue type.

RESULTS

We analyzed 23 LS specimens (vulva n=9, urethra n=7, foreskin n=7) and 29 non-LS specimens (vulva n=9, urethra n=7, foreskin n=13). Fiber count and CPA were significantly higher in all LS specimens compared to non-LS specimens (CPA: mean±SD 0.971±0.03 vs 0.948±0.02, P < .007; fiber count: mean±SD = 2906±127 vs 2509±78 fibers; P = .003). Collagen fiber width and length were similar with respect to LS status. GLCM analysis showed decreased inverse difference moment and increased entropy in LS tissues indicative of less homogeneous and more disorganized tissue structure (P<.001).

CONCLUSION

LS tissues have greater collagen content compared to non-LS tissues. Quantitative assessment of collagen organization, using GLCM, revealed less homogeneity and more disorganization of collagen in LS compared to non-LS tissues. Taken together, our findings suggest that alterations in physical tissue properties seen in LS may be due to both increased collagen abundance and altered structure.

Two brothers with congenital bulbar urethral stricture: case report of a very rare condition

Congenital urethral stricture is rare. It has been reported in only four sets of brothers. We report the fifth set of brothers. Cases of two brothers aged 23 and 18 years old diagnosed with low urinary tract symptoms are presented. We diagnosed an apparently congenital urethral stricture in both brothers. Internal urethrotomy was performed in both cases. Both are asymptomatic after 24 and 20 months of follow-up. Congenital urethral strictures are probably more frequent than we think. We suggest that a congenital origin should be considered if there is no history of infections or trauma.

Comparison of closure versus non-closure of the intraoral buccal mucosa graft site in urethroplasties. A systematic review and meta-analysis

Aim

To assess postoperative oral morbidity through meta-analysis of comparative studies for closure or non-closure of the buccal mucosa graft harvest area in patients undergoing urethroplasty.

Methods

A systematic literature review was conducted in January 2022. Randomized controlled studies were assessed according to the Cochrane collaboration guidelines. Postoperative pain, difficult mouth opening, alteration of oral salivation, perioral numbness, and tolerance of solid and liquid intake results were assessed. Standard mean differences and risk ratios with 95% confidence intervals were estimated for relative risk. Assessment was performed with subgroup analyses according to time points.

Results

This meta-analysis included 373 patients in 7 randomized studies. The oral pain overall pooled effect estimates were investigated for the time points of day 0-1, day 3-7 and months 1-6. According to corrected effect estimates after sensitivity analysis, at the day 0-1 time point, the non-closure group was significantly superior compared to the closure group. But there was no difference at the other time points and in total. The overall pooled effect estimates for difficult mouth opening were investigated at 4 time points (day 1, days 5-7, months 1-3 and months 6). After sensitivity analysis, the overall pooled effect estimates at 6 months were significantly superior for the non-closure group. There were no significant differences between the non-closed and closed groups based on the overall pooled-effect estimates for oral numbness, salivary secretion alteration, and tolerance of liquid and solid food variants.

Conclusion

The non-closure group was more advantageous in terms of oral pain in the early postoperative period. There were no differences between the groups in terms of alteration of salivation, oral numbness and toleration of liquid/solid food. Although the non-closed group seems more advantageous in terms of ease in mouth movements, more studies are needed to prove this.

Outcomes and predictive factors for re-stricture with urethroplasty methods for anterior urethra stricture

OBJECTIVES

We wished to compare the treatment success of urethroplasty methods (EPA and BMG) used for anterior urethra stricture after unsuccessful internal urethrotomy.

METHODS

A total of 85 and 51 patients, respectively, who underwent excision and primary anastomosis (EPA) and buccal mucosal graft (BMG) urethroplasty due to recurrent strictures after direct vision internal urethrotomy (DVIU) were evaluated retrospectively. On the uroflowmetry test, >15 ml/s urine flow and residual urine (PVR) below 50 ml were determined as success criteria. Cox regression analysis investigated the probable predictive factors for surgery success. Kaplan-Meier analysis assessed stricture free survival after redo-urethroplasty.

RESULTS

After surgery, EPA and BMG patients were followed for 31.9 ± 9.8 (4-40) and 30.7 ± 10.3 (4-40) months. At the end of this follow-up duration, success was obtained for 71 (83.5%) and 44 (86.3%) patients. Mean re-stricture times were 13.9 ± 6.0 (4-19) and 10.2 ± 5.1 (4-26) months. Most re-strictures had penile location (10 (71.5%) and 7 (100%)). After one session of DVIU, there was 100% success in both groups, but after >3 sessions of DVIU, success fell to 70.3% and 78.3% in the groups respectively. Patients with high numbers of DVIU sessions had longer durations for urethroplasty surgery. Apart from complications related to the donor field in the oral region with BMG and four patients who developed fistula (7.8%), complications were similar in both groups.

CONCLUSIONS

In this series of cases, it was not possible to identify which of the techniques employed provides the best result or predictive factors for stenosis recurrence after correction procedures for anterior urethral stenosis.

Tissue Engineering Graft for Urethral Reconstruction: Is It Ready for Clinical Application?

Despite developing surgical techniques in urethral surgery, the outcome and complications are still unsatisfactory. Alternative treatment modality has been coming up, particularly in patients with longer stricture, under revision surgery, and penile stricture. Tissue engineering grafts are a promising approach for substituting urethral reconstruction. Over the decades, numerous preclinical studies have been published to show the efficacy and safety of different origins of materials, the presence of autologous cells (acellular matrices or autologous cell-seeded matrices), and the construction of engineered tissue (patch or tubularized constructs) on animal models. However, the results of these studies have not yet reached the intended level for daily clinical practice. A PubMed database search was performed for articles, using specific keywords, published between 1998 and 2022, with a selection on using tissue-engineered grafts for urethroplasty. Many materials have been used as a graft, such as acellular bladder matrix, small intestinal submucosa, acellular dermal matrix, and polyglycolic acid with or without cells, and were evaluated according to the functional and anatomical outcomes comprising complications. According to current literature, tubularized scaffolds constructed from co-cultured cells have promising results for the future. However, high-quality evidence through randomized controlled studies with larger sample sizes, with a long-term follow-up is required to determine accurate outcomes.

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.