Management options for penile urethral strictures.
Penile urethral strictures are common and impact on quality of life and health-care costs. Management of penile urethral strictures is complex and depends on the physical characteristics of the stricture. Contemporary studies show no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes. Overall, long-term success rates range from 20 to 30%. However, their recurrence rate is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures, which make them less cost-effective. Surgical urethroplasty is associated with higher long-term success rates, averaging from 85 to 90%, mostly in virgin or noncomplex cases. Historically, modern urethral reconstruction has evolved from 1950s with the revolutionary introduction of Johanson’s technique for staged urethral reconstruction. Since then, many techniques have been developed and employed for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.
- anterior urethra
- urethral stricture
Urethral strictures have been common since ancient times. Knowledge was gathered about the treatment of urethral stricture disease by ancient Egyptians and other civilizations more than two millennia ago. Nonetheless, little has changed until about 60 years ago. Since then, the management of urethral strictures, including the penile urethral segment, has been in continuous and rapid evolution. Although various reconstructive techniques are available for the treatment of penile urethral stricture, no single technique has been identified as the method of choice. An understanding of the penile urethral anatomy is important for the diagnosis and treatment of penile urethral stricture disease.
Urethral strictures, in general, are associated with significant impact on patients’ quality of life. Penile urethral strictures, in particular, due to their exposed anatomic location and their surgical treatment, may cause significant impact on patients’ sexual function and perception of (un)satisfactory penile cosmesis.
The anatomical and physical characteristics of the penile urethra are associated with additional challenges when compared to other urethral locations, especially due to its unsuitability for anastomotic repair and its relatively thinner corpus spongiosum. The choice of penile urethroplasty technique is largely influenced by etiology, location, length of the stricture, as well as prior surgical treatments. There are a number of challenges and controversies in the surgical reconstruction of penile urethral strictures, such as the use of grafts vs. flaps, use of skin vs. oral mucosa graft (OMG) tissue for augmentation or substitution techniques, the most appropriate indications for a single or a staged (at times, multiple) reconstruction, and, lastly, the management of particularly complex cases such as panurethral stricture disease and hypospadias “cripples” to achieve the best possible outcome.
Although penile urethral strictures can be managed by any of the above-mentioned procedures individually, they can also be more adequately treated by a combined approach. Among the various procedures available for treating urethral stricture, one-stage buccal mucosal graft urethroplasty is the current standard practice. The selection of technique for penile urethroplasty for an individual patient largely depends not only on the expertise of the surgeon but also upon the stricture’s etiology, pathological characteristics, and location. Therefore, contemporary reconstructive urologists working in this field should be aware of, and permanently keep themselves updated on, the numerous surgical techniques required to deal with any condition of the urethra that might surface at the time of surgery.
This review provides a brief update of the options for the surgical reconstruction of different types and sites of penile urethral stricture as well as discussing current controversies, innovations, and possible future research in urethral reconstruction of the penile urethra.
2. Anatomical considerations
Classically, the anterior urethra is divided, at the level of the penoscrotal junction inferiorly and the suspensory ligament superiorly, into bulbar and penile segments, the penile part consisting of the external meatus, fossa navicularis, and the penile shaft urethra. The penile urethra extends from the distal margin of the bulbospongiosus (or penoscrotal junction) to the external meatus. The bulbar (proximal) segment is the shorter of the two and is located in the midline between both the penile crural and the cavernosal bodies. The penile urethra (distal segment of the anterior urethra), also called pendulous, lies in a dorsal groove between the two corpora cavernosa and extends from the penoscrotal junction to the tip of the glans penis. It is surrounded in its full length by the corpus spongiosum; it is mobile and stretches during penile erection; and its length varies according to the penile length. The caliber of the anterior urethral lumen is relatively uniform, widening distally to form the fossa navicularis, and narrowing again to end at the external meatus (Figure 1).
Histologically, the penile (distal anterior) urethra is surrounded by five tissue layers: urethral epithelium and lamina propria (urethral mucosa), corpus spongiosum, tunica albuginea, and Buck’s fascia . Most of the penile shaft urethra is lined by a stratified and pseudostratified columnar epithelium, except for the distal penile urethra, including the fossa navicularis, which is lined by ciliated stratified columnar epithelium or stratified nonkeratinizing squamous epithelium. The lamina propria of the penile urethra is a fibroconnective tissue with elastic fibers and scattered, longitudinally oriented smooth muscle fibers. Multiple mucus-secreting glands drain into the anterior urethral lumen, known as Cowper’s glands in the bulbar urethra and Littre’s glands in the penile urethra.
The anterior urethra obtains its blood supply from the first of three penile branches of the internal pudendal artery, which in turn is a branch of the internal iliac artery. The internal pudendal artery travels through the Alcock canal and gives the inferior rectal artery, posterior scrotal artery and perineal artery, and then terminates as the common penile artery. Three branches arise from the common penile artery: the paired urethral or, most commonly, bulbourethral arteries that pierce the perineal body at a posterolateral location and supply the urethra, spongiosum, and the glans. The other branches are the paired cavernosal arteries that pierce the penile hilum to travel in the center of the erectile tissue, and the deep dorsal penile artery that travel between the crura and beneath the pubic bone to run under the Buck’s fascia sending multiple circumflex branches to the corpus spongiosum and terminal branches to the glans penis, thus providing in a retrograde fashion a dual blood supply to the corpus spongiosum and urethra. It also sends cavernosal branches to contribute to the hemodynamics of the erection (Figure 2A and B). The venous drainage is through the emissary veins into the circumflex branches of the deep dorsal penile vein as well as through the urethral and bulbar veins into the internal pudendal vein. The anterior urethra is innervated by the urethrobulbar nerve, a branch of the perineal nerve derived from the pudendal nerve. The bulbocavernosus nerve, which is a branch of the pudendal nerve, gives off two branches that penetrate the rhabdosphincter at the three and nine o’clock positions. The pudendal nerve, gathering fibers from the second, third and fourth sacral spinal nerve, is both motor to the urethral rhabdosphincter and sensory to the urethra and glans penis (Figure 3). The lymphatic drainage of the anterior urethra is via the superficial and deep inguinal nodes, whereas the lymphatic drainage of the more proximal (the bulbar, membranous, and prostatic) urethra can take three routes: to the external iliac nodes, to the obturator and internal iliac nodes, or to the presacral nodes .
Understanding the penile anatomy and, in particular, the penile skin arterial blood supply is an important resource for penile urethral surgical reconstruction. The penis is covered with an elastic layer of skin that has no subcuticular adipose tissue: the dartos fascia, a layer of loose areolar subcutaneous connective tissue in the penis and scrotum. It lies immediately beneath the penile skin, allowing the skin to move freely over the shaft of the penis and is contiguous with Colles fascia in the perineum. The dartos, also with no adipose tissue, slides freely over the underlying Buck’s fascia and is an extension of Scarpa’s fascia of the abdominal wall, carrying superficial nerves, lymphatics, and blood vessels, which make this fascia extremely useful in bringing blood supply and preventing fistulation in urethral reconstruction. Beneath the dartos fascia lies the Buck’s fascia, which surrounds the tunica albuginea of the two corpora cavernosa and the corpus spongiosum.
The development of fasciocutaneous penile skin island flaps, either as a vertical flap (as in Orandi flap) or as a circular transverse flap (as in McAninch/Quartey flap), takes advantage of the natural anatomical, relatively avascular cleavage planes between the skin and the dartos fascia and another between the dartos fascia and Buck’s fascia.
The blood supply to the penile skin and anterior scrotal wall comes from the external pudendal arteries, whereas the inferior and posterior aspect of the scrotum derives its blood supply from the posterior scrotal arteries, which are branches of the perineal artery, which in turn is a further branch of the internal pudendal artery (Figure 4). The superficial/superior branches of the external pudendal artery travel from medially and across the femoral triangle and within Scarpa’s fascia to enter the base of the penis. After giving off anterior scrotal branches, they arborize to form an arterial network within the dartos fascia. Also, at the base of the penis, branches from the axial penile artery form a subdermal plexus to supply the distal penile skin and prepuce. Because the communicating vessels between the subcutaneous and subdermal arterial plexuses are minimal, a relatively avascular plane can be developed between the dartos and Buck’s fascia. This fascial plexus, that is considered axial, is the true blood supply to the penile island skin flaps used in urethroplasty and, therefore, they can be mobilized widely and transposed aggressively and reliably.
The venous drainage of the penis includes the superficial dorsal vein, the deep dorsal vein, and the crural veins. The superficial dorsal vein drains the skin of the penis and empties into the superficial external pudendal vein and then into the saphenous vein. The deep dorsal vein begins at the base of the glans and retro coronal area and then travels deep to the Buck’s fascia between the paired deep dorsal arteries. Along its course, it receives circumflex veins from the spongiosum until it passes under the pubic bone to join the periprostatic venous complex. The cavernosal veins drain into a subtunical venous plexus; then through emissary veins, they join the circumflex veins, which in turn empty into the crural vein and the periprostatic plexus or the internal pudendal veins. The lymphatic drainage of the penis is primarily to the superficial inguinal nodes.
A detailed understanding of the anatomy of the anterior urethra is a critical prerequisite for the accurate diagnosis and successful management of urethral strictures.
The etiology of contemporary urethral stricture disease involves a traumatic, iatrogenic, inflammatory, and idiopathic origin [3, 4]. Pathophysiology differs with age. The major causes of anterior urethral stricture in children are more likely to be trauma, mainly straddle injury, and complications from hypospadias surgery. Congenital and idiopathic strictures may also occur in children. In adult patients, most urethral strictures have an iatrogenic origin, mainly traumatic catheterization or transurethral manipulation or instrumentation. In the <10-year-old age group, strictures are mainly localized in the penile urethra, whereas in the >10-year-old age group, the bulbar urethra is the most common location .
|Combination of grafts and flaps|
In the past, inflammatory urethral strictures were predominantly associated with gonococcal urethritis, which has been effectively eradicated with penicillin-based antimicrobial agents. However, the emergence of resistant strains of
Stricture etiology is of particular significance in the penile urethra, as they tend to be more diffuse in nature (averaging 6.1 cm), especially if associated with LS, and shorter in the bulbar urethra (averaging 3.1 cm). Urethral strictures can be classified by their most common urethral location. Strictures involving the external meatus and fossa navicularis are predominantly inflammatory and iatrogenic in origin in 33–47% . In the series reported by Fenton et al., globally, the etiology of anterior urethral strictures was idiopathic in 34%, iatrogenic in 32%, inflammatory in 20%, and traumatic in 14% .
Iatrogenic strictures are typically associated with instrumentation, such as transurethral resection, prolonged catheterization, and cystoscopy, totaling 90% of all penile strictures. Prior hypospadias repair and radical prostatectomy contributed to 6.3 and 3.2%, respectively [3, 8]. Such strictures are mainly the result of an ischemic injury secondary to traumatic urethral manipulation or instrumentation, particularly when a large bore catheter or resectoscope is used. Therefore, whenever relatively prolonged catheterization is necessary, smaller caliber/Fr catheters are recommended. For more extended periods of time, a suprapubic catheter is a better option.
Malignant strictures should be approached in a different clinical context and most likely require mutilating radical surgery.
4. Diagnostic evaluation
Any relevant past history of urethral instrumentation, hypospadias surgery, and genital trauma should be obtained. Obstructive voiding symptoms should be assessed with a validated questionnaire. Presence of risk factors and comorbidities that may provoke ischemia or impair wound healing should be probed for. These include obesity, diabetes mellitus, severe peripheral vascular disease, cigarette smoking, long-distance bicycle riding, horseback riding, and sexually transmitted infections.
Physical examination should include palpation of the penile shaft for nodules or dense urethral scarring or constriction. The urethral meatus should be examined for narrowing and the surrounding glans for signs of LS. The penis should be examined to assess whether the patient has been circumcised, or there is sufficient shaft skin to allow development of a penile skin flap. The bladder should be assessed for potential detrusor hypocontractility, distention, and presence of an abdominal scar from a previous suprapubic cystostomy.
5. Preoperative planning and intraoperative decision-making
Any appropriate treatment plan needs accurate identification of the stricture characteristics: location, length, depth, and thickness of fibrotic tissue (spongiofibrosis). It is critical that both the proximal and distal ends of a urethral stricture are completely and accurately assessed with endoscopy and bougienage during reconstruction as to not miss any diseased segment of the urethra. Both patient and urethral reconstructive surgeons must understand completely the goal(s) of treatment before a decision is made. The decision to choose urethroplasty over another approach to a specific urethral stricture depends on patient expectations, goals, and comorbidities. In elderly or frail patients, an expectant or conservative management is more likely to be offered. Therefore, treatment options and their individual potential outcomes in terms of cure, or simply palliation, and complications should be carefully discussed with the patients and their family. On the other hand, urethral reconstructive surgeons need to keep themselves updated and abreast regarding the vast array of treatment options and their precise and specific indications and, therefore, should be flexible enough to intraoperatively adapt and/or adopt a different strategy for a specific scenario, which was not anticipated preoperatively. Thus, it is only legitimate and ethical to embark on urethral reconstruction if one can master and offer the patient all necessary surgical options to treat his specific urethral problem. It is very important to bear in mind that the penile urethra is the most exposed segment of the male urethra, and any surgical procedure or technique should achieve not only a satisfactory functional outcome but also a cosmetic one.
6. Management options
The key techniques include mainly urethral dilatation, endoscopic urethrotomy, anastomotic repairs (rarely in the penile urethra), substitution repairs (ventral, dorsal, double-faced), free grafts of skin (full thickness and split thickness skin), oral mucosa, lingual mucosa, bladder mucosa, retroauricular skin (Wolf’s graft), and skin flap repairs (circumferential, longitudinal and variants) from penile and (less commonly) scrotal skin, as well as the use of adjunctive maneuvers such as the use of advancement flaps for additional blood supply or defect coverage (Table 1).
A meta-analysis of outcomes and complications of laser versus cold-knife urethrotomy compared unfavorably regarding laser: 12 versus 6.5%, respectively . Laser urethrotomy may look appealing for the anterior urethra but with no definitive benefit over cold-knife urethrotomy.
Oral mucosal graft is currently the graft of choice, owing to their short harvest time, easy harvest technique, and the physical characteristics including resistance, durability, immunogenic properties, excellent vascularity, hairlessness, low oral morbidity, concealed donor site and high success rates [24, 25]. For these reasons, over the past 20 years, oral mucosal grafts have shown better handling characteristics and long-term stricture-free outcomes, and have replaced both penile skin grafts and flaps. However, patients with long and complex urethral abnormalities or with contraindications to oral mucosal graft use, such as those with leukoplakia, systemic skin disease of the oral cavity or history of chronic tobacco chewing may still necessitate split or full thickness skin grafts.
One controversy in anterior urethral grafting is related to dorsal or ventral placement of the graft on the urethra. Some urethral surgeons favor dorsal placement in both bulbar and urethral strictures, whereas others opt for ventral placement [26, 27, 28, 29, 30, 31]. Although several studies have demonstrated comparable success rates for dorsal and ventral onlay grafting, the author of this chapter favors the use of dorsal placement of the graft in the penile urethra because the spongiosal vascularity in the ventral urethra is thinner and the graft support is less reliable when compared to the dorsal urethral surface.
Various penile skin flaps have been described, which can be raised ventrally or dorsally on the penile shaft and taken longitudinally or circumferentially [37, 38, 39]. These flaps are fasciocutaneous in nature and are based on dartos fascia pedicle. The ventral, longitudinal flap, as described by Orandi, is best suited for penile shaft urethral strictures that do not reach the base of the penis or any part proximal to the penoscrotal angle because hair-bearing skin will inevitably be involved in the reconstruction. On the contrary, the transverse, circumferential preputial/distal penile skin flaps are long enough to bridge defects of the entire penile urethra and most of the bulbar urethra for example in panurethral defects. Ideally, flaps should be hairless, adapted to a moist environment, with a reliable vascular pedicle, mobile, and cosmetic. In general, anterior urethral reconstruction with the use of flaps has become less prevalent due to the increased popularity of oral mucosa grafts. A rise in prevalence of genital and urethral LS has also contributed to the near abdication of the use of flaps. Nonetheless, island skin flaps still find an important indication in reoperative cases with extensive spongiofibrosis and ischemic urethral mucosal plates where chances of graft take are minimal. These circumstances occur after irradiation, severe trauma, or infection.
Repairs in adults who failed hypospadias repair in childhood pose a particular reconstructive challenge because of dense scarring, tissue inelasticity, inflammation, impaired blood supply, and penile and urethral shortening from previous, often multiple, operations [44, 45, 46, 47]. Penile urethroplasty should be performed in a single stage, whenever feasible, to avoid discomfort and disability to the patient from a multistage repair. Most strictures associated with trauma, infection, or instrumentation, where the penile skin, dartos fascia and spongiosum are not significantly damaged, can be approached through a single-stage procedure. On the other hand, presence of local infection or inflammation associated with a specific underlying disease process obliterated urethral segments with dense surrounding fibrosis, and a history of prior interventions, especially prior flap or hypospadias repairs, are contraindications for single-stage repairs and, therefore, should not be advised. The two-stage reconstruction involves surgical opening of the stricture, augmentation, or substitution (more commonly with use of oral mucosa grafting) of the diseased urethral segment and creation of temporary urethrostomy for drainage (first stage), followed between 4 and 6 months later by neourethral tubularization (second stage). Therefore, it should be confined to situations where it is inappropriate to maintain the axial integrity of the urethral plate and a full circumference urethral reconstruction is mandatory.
7. Urethral reconstruction by stricture location
In order to facilitate description and discussion of the various surgical procedures used for adult penile urethral reconstruction, we will group them according to stricture location in the urethra: (1) external meatus and fossa navicularis and (2) penile shaft urethra. Furthermore, a separate section will be devoted to procedures used for previously failed repairs or reoperative procedures (Table 2).
• Longitudinal skin flap techniques
• Endourethroplasty techniques
• Flap reconstruction
7.1 External meatus and fossa navicularis
Strictures involving exclusively the external meatus may be treated with
In 2004, Malone described a technique to relieve stenosis of the external urinary meatus resulting from LS . The procedure is rapid and easy to perform on an outpatient basis, providing good cosmesis and functional voiding without spraying. The meatotomy is carried out dorsally avoiding a hypospadiac meatus. If the stricture extends into the fossa navicularis, oral mucosa graft reconstruction is performed. The final result is a slit-shaped with good caliber meatus at the tip of the glans. The procedure has been successfully reproduced by others .
Several variants have been reported. Cohney in 1963 described a penile flap procedure based on a circumferential elevated random penile skin flap. The distal urethra is well open, but the patient is left with a less appealing cosmetic result and a retrusive meatus (Figure 7A and B). Blandy-Tresidder in 1967 developed a flap procedure based on dartos fascia vascularity. It also provides good functional outcomes, but only modest improvement of the cosmetic final appearance. The meatus is usually left at the coronal level (Figure 7C and D). The Brannen flap repair , a modification of Blandy’s procedure, was described in 1976 to try to create a better cosmetic appearance of the glans and distal penile segment . However, some mechanical problems associated with the flap advancement make this procedure inefficient and, therefore, offer marginal improvement in terms of cosmesis (Figure 7E and F). Designed to create a cosmetically normal meatus and glans penis, De Sy in 1984 further modified the Blandy and Brannen techniques using an advancement midline skin island flap . However, the proximal portion of the flap is de-epithelialized leaving a distal skin island on dartos fascia (Figure 7G and H). Again, the mechanics of the flap advancement is inefficient.
7.2 Penile shaft urethra
For penile shaft urethral strictures, a stricturotomy and onlay or inlay patch graft, or alternatively a flap reconstruction, can be used for simple strictures. More complex cases may eventually require total excision of the strictured area and circumferential reconstruction with OM grafts or penile skin flap. In more complex situations, such as after previous failed repairs and compromised or obliterated urethras, a staged reconstruction is preferable. Penile urethral strictures are rarely cured by dilatation or DVIU. If either of these procedures fail once, the chance of a better outcome with a second attempt is almost nil, making urethroplasty the only curative option. Anastomotic urethroplasty should be avoided in the penile urethra, even in short strictures, as ventral curvature usually occurs.
Patient advanced age and comorbidities may steer the urologist away from open surgery. In these circumstances, periodic urethral (self)-dilatation or definitive urethrostomy should be strongly considered.
With the penis on stretch, a longitudinal nonhair-bearing skin island is marked on the ventral aspect of the penis. The description of the surgical technique is outlined in Figure 14. The penis is snugly dressed to avoid hematoma. Drains are rarely required. Patients are kept on strict bed rest for 3–5 days to minimize swelling. Intravenous antibiotics are administered for at least 48 h, followed by oral antibiotic prophylaxis for one additional week. Erections should be avoided. The use of a suprapubic catheter for urinary drainage is not mandatory but preferable, which should be kept for 2 weeks. The urethral catheter is left plugged to act as a stent only. After 2–3 weeks, the urethral catheter is removed and the patient is sent home with the suprapubic tube occluded, allowing the patient to resume urethral voiding. The suprapubic tube is removed after a few days of normal urethral voiding. If a fistula develops, the urethral catheter is not reinserted and the suprapubic diversion is maintained for another week. If still persistent, then it should be repaired after 4–6 months.
The Orandi flap is a reliable and relatively easy flap to harvest. It is a useful solution for a single-stage reconstruction of penile urethral strictures.
To generate new tissues, biomedical engineering investigators have utilized three basic tools: cells, scaffold, and growth factor. The earliest use of human cells dates back to approximately 30 years ago . Several different tissue-engineered grafts have been used for urethral reconstruction. There are two types of urethral grafts: (1) those that contain living autologous cells and (2) those that are cell free. The latter include grafts obtained from cadaveric or animal sources. This tissue undergoes treatment to become completely cell free. The resultant biological matrix is then implanted. A good vascular bed is needed to allow take and infiltration of host cells. As a rule, these techniques would only be expected to be particularly successful for substituting short urethral defects. In contrast, cellularized grafts contain a matrix populated with autologous cells, which are obtained from a small biopsy from the patient. The cells are cultured, expanded, and seeded onto the matrix. The matrix containing cells is then implanted onto the host bed .
A critical element required for successful tissue engineering is the cell source. Cells can be isolated from autologous urine-derived stems cells, smooth muscle cells, adipogenic, chondrogenic, and neural lineages . Because simple cell injection to a target site is rarely feasible, a scaffold, or a template, also called artificial extracellular matrix, is necessary. The major function of a scaffold is to assist proliferation, differentiation, and biosynthesis of cells [84, 85].
Scar modulation represents another potential development that may revolutionize urethral reconstruction. Antifibrotic injectables, acting as scar inhibitors, may be placed into the stricture after stricturotomy. Stents impregnated with tacrolimus or paclitaxel have been tried in animal and human models with apparently promising early results [86, 87].
Regenerative medicine (cell therapy and tissue engineering) has made solid progress over the last three decades. We cautiously hope that these technologies will finally enter the routine clinical environment and be applicable in the treatment of urethral strictures/stenosis.
8. Lower urinary tract symptoms (LUTS) and urethral strictures
The spectrum of lower urinary tract symptoms (LUTS) at initial presentation for urethral stricture disease (USD) is well described. Anterior urethral stricture disease most commonly presents as urinary obstruction and may occasionally present as acute urinary retention. However, there is little data addressing these symptoms in patients after urethroplasty. LUTS after urethroplasty for anterior USD and the relationship of these symptoms to USD recurrence has also been observed . It was reported that men with a successful outcome after urethroplasty tend to remain asymptomatic, whereas those who recur have LUTS, typically with weak urinary flow but without dysuria and hematuria. The authors supported the need for a USD-specific validated questionnaire to be used for follow-up after urethroplasty.
All men being evaluated for lower urinary tract symptoms (LUTS) should include urethral stricture in the differential diagnosis and include a combination of patient-reported symptom measures, uroflowmetry to assess severity of obstruction, and postvoid residual volume by ultrasound to determine degree of urinary retention. Patients with urethral stricture typically present a weak flow rate. However, evaluation of urethral stricture requires further specific testing to delineate the location, length of the stricture, and degree of narrowing such as urethroscopy and retrograde urethrogram with or without voiding cystourethrogram. LUTS are the usual clinical manifestation of urethral strictures, regardless of location, etiology, and severity. However, LUTS after urethral stricture repair are not uncommon. Urgency has been reported in 40% of men and urge incontinence in 12% of men after anterior urethroplasty. De novo urgency and urge incontinence is seen in 9 and 5% of men, respectively, after urethroplasty. Once a complication of urethroplasty (such as recurrent urethral stricture or diverticulum) has been excluded as a cause, evaluation of LUTS in such patients should focus on the differential diagnosis between bladder dysfunction (overactive bladder and underactive bladder) and other outlet obstructions (such as benign prostatic obstruction), dysfunctional voiding, or medical causes (such as nocturnal polyuria). Management of overactive bladder has different treatment options, which may include behavioral modification, physical therapy, anticholinergic, and/or beta-3 agonist medications. In more severe cases, intravesical onabotulinum toxin, sacral neuromodulation, or peripheral tibial nerve stimulation may be indicated. Definitive treatment for underactive bladder is limited in number and success. Although management of LUTS for patients after urethral stricture repair can usually proceed similarly as for patients without prior history of urethral reconstruction, special consideration and alterations in management need to be made when instrumenting the urethra, as the urethral lumen may be narrower in these patients.
Recently, an analysis of risk factors leading to postoperative urethral stricture and bladder neck contracture (BNC) following transurethral resection of prostate (TURP) has been performed . The authors have found that lower resection speed, intraoperative urethral mucosal rupture, and postoperative continuous infection were associated with a higher risk of urethral stricture, whereas more severe storage symptoms and smaller prostate volumes were associated with a higher risk of BNC after TURP.
9. Future directions and goals
Penile urethroplasty has evolved significantly over the last eight decades, since the first attempts at reconstruction using preputial tubes or a staged approach using penile skin . An improved understanding of the pathophysiology of LS and a high complication rate following skin-based reconstructions favored a shift to the use of oral mucosal grafts, particularly in LS strictures. To date, very little advances have been achieved with conservative/pharmacological therapeutic options to stabilize or modulate the scarring process of this recalcitrant cutaneous disease.
Currently, one of the critical limitations of penile urethroplasty is the common need for a staged reconstruction with all the inconveniences for the patient, and a 20–31% incidence of graft failure following the first stage, which leads to further revision(s) prior to the final tubularization . Insufficient oral mucosal grafts for panurethral stricture reconstruction, especially in redo cases, add serious problems.
Considerable research has been done in the areas of biomaterials, regenerative medicine, including scar modulation, and tissue engineering to overcome the limitations of current penile urethral stricture management. These experimental technologies appear exciting, revolutionary, and ripe with potential. The main goals of these research areas would be to produce scar inhibitors that might be placed into the stricture after urethrotomy, on the one hand, and to generate an ideal biomaterial in unlimited quantities, easily cultured in laboratory, readily available “off the shelf” and without the morbidity associated with graft harvesting, on the other hand. Unfortunately, we are not quite there yet.
The surgical treatment of penile urethral stricture is continually evolving. No one technique is appropriate for all situations, and the successful reconstructive urologist needs to be comfortable with a repertoire of different, versatile techniques in order to best treat each individual patient’s problem. Since the early 1990s, OMG was introduced in urethral reconstructive surgery and has become the first choice of most urethral surgeons.
Although all are grouped as anterior urethral strictures, penile urethral strictures are different from bulbar urethral strictures. Flaps are still preferred to grafts in long, recurrent penile urethral strictures by some surgeons. Recently, one-stage dorsal OMG urethroplasty via perineal approach has been suggested for the management of most strictures of the penile shaft urethra with both good functional and remarkable cosmetic outcomes. However, in patients who have experienced failed hypospadias repair or in whom the penile skin and urethral plate are not suitable for urethroplasty, two-stage (usually multistage) urethroplasty is recommended. Management of some lengthy, complex strictures remains a great challenge even for experienced reconstructive surgeons. Staged urethroplasty, such as the Johanson’s technique with or without the use of grafts, is still a good surgical option. Regenerative medicine continues to show promise, but further investigation is needed to reach clinical application in the future. All in all, these great improvements in penile urethral surgical technique should lead to optimization of the surgical treatment algorithm.
Velasquez EF, Barreto JE, Cold CJ, Cubilla AL, et al. Penis and distal urethra. In: Mills SE, editor. Histology for Pathologists. Vol. 3. Philadelphia: Lippincott Williams and Wilkins; 2007. pp. 983-997
Dagrosa LM, Gormley A. Anatomy of the urethra. In: Keane TE, Graham SD, editors. Glenn’s Urologic Surgery. 8th ed. Philadelphia: Wolters Kluwer; 2016. pp. 311-314
Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: Etiology and characteristics. Urology. 2005; 65:1055-1058
Lumen N, Hoebeke P, Willemsen P. Etiology of urethral stricture in the 21st century. The Journal of Urology. 2009; 182:983-987
Palminteri E, Berdondini E, Verze P, Nunzio CD, Vitarelli A, Carmignani L. Contemporary urethral stricture characteristic in the developed world. Urology. 2013; 81:190-197
Barbagli G, Lazzeri M, Palminteri E, Turini D. Lichen sclerosus of male genitalia involving anterior urethra. Lancet. 1999; 354:429
Pugliese JM, Morey AF, Peteron AC. Lichen sclerosus: Review of the literature and current recommendations for management. The Journal of Urology. 2007; 178:2268-2276
Elliott S, Brandes SB. Etiology, histology and classification of urethral stricture disease. In: Brandes SB, Morey AF, editors. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. NY: Humana Press; 2014. pp. 95-102
Nuss GR, Granieri MA, Zhao LC. Presenting symptoms of anterior urethral stricture disease: A disease specific, patient reported questionnaire to measure outcomes. The Journal of Urology. 2012; 187:559-562
El-Ghar MA, Osman Y, Elbaz E, El-Diasty T. MR urethrogram versus combined retrograde urethrogram and sonourethrography in diagnosis of urethral stricture. European Journal of Radiology. 2010; 74:193-198
McAninch JW, Laing FC, Jeffrey RB Jr. Sonourethrography in the evaluation of the urethral strictures: A preliminary report. The Journal of Urology. 1988; 139:294-297
Nash PA, McAninch JW, Bruce JE. Sonourethrography in the evaluation of anterior urethral strictures. The Journal of Urology. 1995; 154:72-76
Sachse H. Treatment of urethral stricture: Transurethral slit in view using sharp section. Fortschritte der Medizin. 1974; 92:12-15
Steenkamp JW, Heyns CF, de Kock M. Internal urethrotomy versus dilatation ass treatment for male urethral strictures: A prospective, randomized comparison. The Journal of Urology. 1997; 157:98-101
Dubey D. The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures. Indian Journal of Urology. 2011; 27:392-396
Heyns CF, Steenkamp JW, de Kock ML, Whitaker P. Treatment of male urethral strictures: Is repeated dilatation or internal urethrotomy useful? The Journal of Urology. 1998; 160:356-358
Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: Long-term follow-up. The Journal of Urology. 1996; 156:73-75
Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. The Journal of Urology. 2010; 183:1859-1862
Naudé AM, Heyns CF. What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nature Clinical Practice. Urology. 2005; 2(11):538-545
Gallegos MA, Santucci RA. Advances in urethral stricture management. F1000Research. 2016; 5(F10000Faculty Rev):2913. DOI: 10.12688/f1000reearch.9741.1
Jin T, Ki H, Jiang L-H Wang L, Wang K-J. Safety and efficacy of laser and cold knife urethrotomy for urethral stricture. Chinese Medical Journal. 2010; 123:1589-1595
Bürger RA et al. The buccal mucosa graft for urethral reconstruction: A preliminary report. The Journal of Urology. 1992; 147:662-664
Dessanti A, Rigamonti W, Merulla V, Falchetti D, Caccia G. Autologous buccal mucosa graft for hypospadia repair: An initial report. The Journal of Urology. 1992; 147:1081-1084
Lumen N, Oosterlinck W, Hoebeke P. Urethral reconstruction using buccal mucosa or penile skin grafts: Systematic review and meta-analysis. Urologia Internationalis. 2012; 89:387-394
Markiewicz MR et al. The oral mucosa graft: A systematic review. The Journal of Urology. 2007; 178:387-394
Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. Current controversies in reconstructive surgery of the anterior urethra: A clinical overview. International Brazilian Journal of Urology. 2012; 38:307-316
Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU International. 2001; 88:385-389
Iselin CE, Webster GD. Dorsal onlay urethroplasty for urethral stricture repair. World Journal of Urology. 1998; 16:181-185
Wessells H. Ventral onlay graft techniques for urethroplasty. The Urologic Clinics of North America. 2002; 29:381-387
Elliot SP, Metro MJ, McAninch JW. Long-term follow-up of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. The Journal of Urology. 2003; 169:1754-1757
Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology. 1996; 48:194-198
Blandy JP, Singh M, Notley RG, Treidder GC. The results and complications of scrotal-flap urethroplasty for stricture. British Journal of Urology. 1971; 43:52-57
Yachia D. A new, one-stage pedicled scrotal kin graft urethroplasty. The Journal of Urology. 1986; 136(3):589-592
Provet JA. Scrotal island flap urethroplasty in the management of bulbar urethral strictures. The Journal of Urology. 1989; 142(6):1455-1457
Gil-Vernet A, Arango O, Gil-Vernet J Jr, Gelabert-Mas A, Gil-Vernet J. Scrotal flap epilation in urethroplasty: Concepts and technique. The Journal of Urology. 1995; 154(5):1723-1726
Gil-Vernet J, Arango O, Gil-Vernet A, Gil-Vernet J Jr, Gelabert-Mas A. A new biaxial epilated scrotal flap for reconstructive urethral surgery. The Journal of Urology. 1997; 158(2):412-420
Orandi A. One-stage urethroplasty: 4-Year follow-up. The Journal of Urology. 1972; 107(6):717-719
Quartey KM. One-stage penile/preputial island flap urethroplasty for urethral stricture. The Journal of Urology. 1985; 134(3):474-475
McAninch JW. Reconstruction of extensive urethral strictures: Circular fasciocutaneous penile flap. The Journal of Urology. 1993; 149(3):488-491
Johanson B. Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chirurgica Scandinavica. 1953; 176(Suppl. 176):1-89
Bracka A. Hypospadias repair: The two-stage alternative. British Journal of Urology. 1995; 76(Suppl. 3):31-41
Bracka A. A versatile two-stage hypospadias repair. British Journal of Plastic Surgery. 1995; 48:345-352
Bracka A. The role of two-stage repair in modern hypospadiology. Indian Journal of Urology. 2008; 24:210-218
Devine CJ, Franz JP, Horton CE. Evaluation and treatment of patients with failed hypospadias repair. The Journal of Urology. 1978; 119:223-226
Stecker JF, Horton CE, Devine CJ, McCraw JB. Hypospadias cripples. The Urologic Clinics of North America. 1981; 8:539-544
Barbagli G, De Angelis M, Palminteri E, Lazzeri M. Failed hypospadias repair presenting in adults. European Urology. 2006; 49:887-895
Tang S-H, Hammer CC, Doumanian L, Santucci RA. Adult urethral stricture disease after childhood hypospadias repair. Advances in Urology. 2008:150315. DOI: 10.1155/2008/150315
Malone P. A new technique for meatal stenosis in patients with lichen sclerosus. The Journal of Urology. 2004; 172:949-952
Navalón P, Ramada C, Ordono F, Pallas Y, Monllor ME. Long-term follow-up of malone meatoplasty for meatal stenosis in patients with lichen sclerosus. Journal of Anesthesia and Surgery. 2016; 4(2):121-124
Cohney BC. A penile flap procedure for the relief of meatal strictures. British Journal of Urology. 1963; 35:182-183
Blandy JP, Tresider GC. Meatoplasty. British Journal of Urology. 1967; 39:633-634
Brannen GE. Meatal reconstruction. The Journal of Urology. 1976; 116:319-321
De Sy WA. Aesthetic repair of meatal stricture. The Journal of Urology. 1984; 132:678-679
Jordan GH. Reconstruction of the fossa navicularis. The Journal of Urology. 1987; 138:102-104
Armenakas NA, Morey AF, McAninch JW. Reconstruction of the resistant strictures of the fossa navicularis and meatus. The Journal of Urology. 1998; 160:359-363
DeLong JM, Jordan GH. Reconstruction of the fossa navicularis. In: Smith JA Jr, Howards S, Preminger GM, Dmochowski RR, editors. Hinman’s Atlas of Urologic Surgery. 4th ed. Philadelphia: Elsevier; 2018. pp. 686-692
Devine CJ, Horton CE. A one stage hypospadias repair. Journal of Urology. 2002; 167:1169-1174 (reprinted from J Urol, 85: 166-172, 1961)
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. The Journal of Urology. 1994; 151(2):464-465
Asopa M, Garg M, Singhal GC, et al. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology. 2001; 58:657-659
Gaur DD. Endourethral urethroplasty—Use of a new catheter. The Journal of Urology. 1983; 130(5):905-908
Naudé JH. Endoscopic skin-graft urethroplasty. World Journal of Urology. 1998; 16(3):171-174
Kuyumcuoglu U et al. Antegrade endourethroplasty with free skin graft for recurrent vesicourethral anastomotic strictures after radical prostatectomy. Journal of Endourology. 2010; 24(1):63-67
Seth A, Saini AK, Dogra PN. Hybrid minimally invasive urethroplasty for pan-anterior urethral strictures: Initial results. Urologia Internationalis. 2012; 89(1):116-119
Nikolavsky D, Abouelleil M, Daneshvar M. Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: Surgical technique and preliminary results. International Urology and Nephrology. 2016; 48:1823. DOI: 10.1007/s11255-016-1381-1
Gelman J, Sohn W. One-stage repair of obliterative distal urethral strictures with buccal graft urethral plate reconstruction and simultaneous onlay penile skin flap. The Journal of Urology. 2011; 186(3):935-938
Tonkin JB, Jordan GH. Management of distal anterior urethral strictures. Nature Reviews. Urology. 2009; 6:533-538
Quartey JK. One-stage penile/preputial cutaneous island flap urethroplasty for urethral stricture: A preliminary report. The Journal of Urology. 1983; 129(2):284-287
Quartey JK. One-stage penile/preputial island flap urethroplasty for difficult posterior urethral strictures. World Journal of Urology. 1987; 5:37-40
Chapple C, Turner-Warwick. Substitution urethroplasty and the pedicle island skin procedure. In: McAninch JW, editor. Traumatic and Reconstructive Urology. Philadelphia: WB Saunders Company; 1996. pp. 571-594
Devine PC, Horton CE, Devine CJ Sr, et al. Use of full thickness skin grafts in repair of urethral strictures. The Journal of Urology. 1963; 90:67-71
Barbagli G, Pellegrini G, Corradini F, Montorsi F, Sansalone S, Butnaru B, et al. One-stage penile urethroplasty using oral mucosa graft and glue. European Urology. 2006; 70(6):1069-1075
Martins FE, Oliveira T, Oliveira P, Felício J, Dave C, Martins NK. Perineal incision to repair penile urethral strictures is a versatile and cosmetic approach. In: Presented at the 37th Congress of the Societé Internationale d’Urologie; Lisbon, October 19-22. 2017
Martins F, Kulkarni S, Joshi P, Marcelino J, de Oliveira TR, Oliveira P, et al. Kulkarni technique of perineal approach with penile inversion for surgical repair of anterior urethral strictures: Functional and cosmetic outcomes. The Journal of Urology. 2016; 195(Suppl. 4):e1001-e1002
Kulkarni S, Barbagli G, Sansalone, Lazzeri M. One-sided anterior urethroplasty: A new dorsal onlay graft technique. BJU International. 2009; 104(8):1150-1155
Andrich DE, Greenwell TJ, Mundy AR. The problems of penile urethroplasty with particular reference to 2-tage reconstructions. The Journal of Urology. 2003; 170:87-89
Schreiter F, Noll F. Mesh graft urethroplasty using split thickness graft or foreskin. The Journal of Urology. 1989; 142(5):1223-1226
Carr LK, MacDiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. The Journal of Urology. 1997; 157(1):104-108
Mori RL, Angermeier KW. Staged urethroplasty in the management of complex anterior urethral stricture disease. Translational Andrology and Urology. 2015; 4(1):29-34
Sinha RJ, Singh V, Sankhwar SN, Dalela D. Donor site morbidity in oral mucosa graft urethroplasty: Implications of tobacco consumption. BMC Urology. 2009; 9:15
Vacanti JP, Morse MA, Salzman WM, Domd AJ, Perez-Atayde A, Langer R. Selective cell transplantation using bioabsorbable artificial polymers as matrices. Journal of Pediatric Surgery. 1988; 23:3-9
Mangera A, Chapple CR. Tissue engineering in urethral reconstruction—An update. Asian Journal Andrology. 2013; 15:89-92. DOI: 10.1038/aja.2012.91; published online 8 October 2012
Bharadwaj S, Liu G, Shi Y, et al. Multipotent differentiation of human urine-derived stem cells: Potential for therapeutic applications in urology. Stem Cells. 2013; 13(9):1840-1856
Ikada Y. Challenges in tissue engineering. Journal of the Royal Society Interface. 2006; 3:589-601
Orabi H, AbouShwareb T, Zang Y, Yoo JJ, Atala A. Cell-seeded tubularized scaffolds for reconstruction of long urethral defects: A preclinical study. European Urology. 2013; 63(3):531-538
Karatas OF, Cimentepe E, Bayrak O, et al. A new application for urethral strictures: Tacrolimus-eluting stent. Journal of Endourology. 2010; 24(6):1043-1044
Shin JH, Song HY, Chai CG, et al. Tissue hyperplasia: Influence of a paclitaxel-eluting stent—Preliminary study in a canine urethral study. Radiology. 2005; 234(2):438-444
Spencer J, Blakely S, Daugherty M, Angulo JC, Martins F, Venkatesan K, et al. Clinical and patient-reported outcomes of 1-sided anterior urethroplasty for long-segment or panurethral strictures. Urology. 2018; 111:208-213
Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. Journal of Urology. 2001; 166:2273-2276
Erickson BA, Granieri MA, Meeks JJ, McVary KT, Gonzalez CM. Prospective analysis of ejaculatory function after anterior urethral reconstruction. The Journal of Urology. 2010; 184:238-242
Erickson BA, Granieri MA, Meeks JJ, Cashy JP, Gonzalez CM. Prospective analysis of erectile dysfunction after anterior urethroplasty: Incidence and recovery of function. The Journal of Urology. 2010; 183:657-661
Patel DP, Elliott SP, Voelzke BB, Erickson BA, McClung CD, Presson AP, et al. Patient reported sexual function after staged penile urethroplasty. Urology. 2015; 86(2):395-400
Blaschko SD, Sanford MT, Cinman NM, McAninch JW, Breyer BN. De novo erectile dysfunction after anterior urethroplasty: A systematic review and meta-analysis. BJU International. 2013; 112(5):655-663
Granieri M, Webster G, Lentz A, Fraser A, Peterson A. Lower urinary tract symptoms associated with recurrence afterurethroplasstyfor anterior urethral stricture disease. The Journal of Urology. 2014; 191(4S):e123
Tao H, Jiang YY, Jun Q , Ding X, Jian DL, Jie D, et al. Analysis of risk factors leading to postoperative urethral stricture and bladder neck contracture following transurethral resection of prostate. International Brazilian Journal of Urology. 2016; 42(2):302-311. DOI: 10.1590/S1677-5538.IBJU.2014.0500
Campos-Juanatey F, Bugeja S, Ivaz SL, Frost A, Andrich DE, Mundy AR. Management of penile urethral strictures: Challenges and future directions. World Journal of Clinical Urology. 2016; 5(1):1-10. ISSN: 2219-2816 (online)
Jordan GH, McCammon KA. Surgery of the penis and urethra. In: Wein AJ, editor. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier; 2012
Armenakas NA, McAninch JW. Fossa navicularis and meatal stricture penile flap reconstruction. In: McAninch JW, editor. Traumatic and Reconstructive Urology. Philadelphia: W. B. Saunders Company; 1996
Elliott SP, McAninch JW. Reconstruction of strictures of penile urethra. In: Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, editors. Hinman’s Atlas of Urologic Surgery. 4th ed. Philadelphia: Elsevier; 2018
McAninch JW. Fasciocutaneous penile flap in reconstruction of complex anterior urethral strictures. In: McAninch JW, editor. Traumatic and Reconstructive Urology. Philadelphia: W. B. Saunders Company; 1996