Etiology, Presentation, and Treatment of Urethral Stricture in Females: A Systematic Review

The study presented by A.A. Katib and A.Al-Adawi “Bougie urethral dilators; revival or survival?” in this issue of Central European Journal of Urology has a very interesting and promising title [1]. We know that there is still a place for less invasive interventions such as urethral dilatation and internal urethrotomy in the initial management of urethral strictures in selected patients [2, 3]. Simple dilatation or urethrotomy are standard treatment options, but these procedures are associated with a high failure rate and very often require repeated treatment. The authors present the technique of bougie dilatation, reintroduced after years in their department. This old procedure is well–known by urologists, but the precise description of the technique and detailed protocol of urethral dilatation showed by the authors can be used successfully for teaching purposes (e.g. for students, young urologists). The strength of the study is the high number of patients analysed, but the results should be interpreted with caution due to the retrospective design of the study. The high recurrence rate does not seem very surprising, as the poor effectiveness of simple dilatation in the treatment of urethral stricture disease is well–known. The main concern is the high complication rate (with 6.6% cases of perforation!). Bougie dilatation is routinely used in the authors’ department and has replaced internal urethrotomy. Should it really be the first–step procedure for the majority of cases? This is difficult to answer because of a lack of evidence–based data on that topic. According to the authors’, bougie dilatation is above–all simple, low–cost and time–saving. Furthermore, it can also be performed as an office procedure with no need for operating room equipment and staff. The benefits of internal urethrotomy, which offers better visual assessment of all anatomic conditions than urethrography alone, are not mentioned. Visual evaluation of the stricture can be helpful in decision making after the failure of initial treatment. Moreover, placement of the guide wire makes the procedure safer and helps to avoid false passage and perforation. Attempts were made to establish which surgical method is the most effective and cost–effective in the treatment of male urethral strictures, but as the clinical data is very limited, a meta–analysis was not feasible [4]. There is only one randomised, prospective trial comparing the efficacy of dilatation versus internal urethrotomy as initial treatment for urethral strictures. The study revealed that both methods offer equivalent outcomes, but their effectiveness is reduced with increasing stricture length. Therefore, the authors recommend these methods only for strictures shorter than 2 cm and from 2 to 4 cm; strictures longer than 4 cm should be treated with primary urethroplasty [5]. There is no evidence that internal urethrotomy is better than dilatation, but many urologists intuitively believe so. Some experts recommend dilatation for meatal strictures, as it is a simple office procedure. They also advise dilatation for sphincter strictures after transurethral resection of the prostate (TURP) because dilatation, unlike internal urethrotomy, does not risk sphincter damage. On the other hand, urethrotomy is advised in any long or “difficult” stricture. Yet again, however, the authors emphasize that there is no evidence to support such intuitive recommendations [6]. The initial question remains unanswered. Well–designed and adequately powered clinical studies are needed to assess which method is most effective in the treatment of urethral strictures. The next clinical problem that might be noteworthy is the failure after initial treatment. What should be the next step: redilation, repeated urethrotomy or urethroplasty? In this case, the answer seems to be very simple. We know from a few studies that repeated urethrotomy and dilatation for the treatment of urethral strictures are neither clinically effective nor cost–effective [6, 7]. Most urologists in Europe and the United States believe that urethroplasty is the best option after failed dilatation or urethrotomy [8, 9]. Yet everyday urological practice shows lack of understanding of such knowledge. Redilatations and repeated endourological procedures are commonly performed despite very poor long–term outcomes. The first reason can be the patients’ preferences or co–morbidities disqualifying them from operative treatment. The second, can be inexperience with urethroplasty surgery and that only a small group of urologists frequently perform such operations. That is why this issue should be addressed during fellowship training.

One-Stage Urethral Reconstruction for Stricture Recurrence After Urethral Stent Placement

Male Urethral Stricture: American Urological Association Guideline

The human urethra seems remarkably tolerant of foreign material within its lumen. Providing that a stricture has been adequately cut by means of urethrotomy, or dilated with bougies, the majority of urethras will tolerate both permanent and temporary stents with few problems. Temporary stents have the obvious advantage over permanent stents that no foreign material is left in the urethra but before these can be recommended it is essential that more clinical experience is gained and that long term results up to ten years after removal of the stent are published. Great care is also needed in the use of any sort of permanent device, either the Urolume stent, or varieties of the Strecker such as the Memotherm device. These should not be used in children and should be probably be avoided in young adults. The majority of strictures in this age group are in any case treated more easily by single stage urethroplasty procedures. The use of permanent epithelial covering stents should be limited to the bulbo-membranous urethra, with the possible exception of carefully selected sphincters strictures used in combination with an artificial urinary sphincter. Better results will be obtained by using these stents in strictures with a short history before multiple urethrotomies and dilatations have been carried out and before extensive urethral and periurethral fibrosis has occurred. This means that urethral rupture strictures are unsuitable, and in any case these are simple to deal with be means of stricture excision and primary end to end anastomosis of the urethra particularly when the stricture is in the bulbar urethra. Care must also be taken in using these devices in post-urethroplasty strictures if extensive periurethral fibrosis exists, although it has to be admitted that these stents may be very successful in some of these patients. The difficulty at the present time is our inability to define exactly which traumatic stricture or post-urethroplasty stricture will succeed and which will fail. Metal urethral stents should not be used for the first treatment of a urethral stricture. Depending on the aetiology, the site and the length of the stricture there is always a 40-50% chance that the stricture may be cured by means of a simple urethrotomy or dilatation and this should always be tried at least once before resorting to urethral stenting. There is no doubt that permanent urethral stents have an important role to play in the treatment of recurrent urethral strictures. Careful patient selection is essential in order to achieve the best results and we need more long term results before the final role of these devices in the treatment of urethral strictures can be determined. Temporary stenting of the urethra with non-epithelial covering stents is a simpler and safer treatment but at this point in time we cannot be sure how effective this treatment is and for which patients it is most successful. Long term results must be awaited before the place of these temporary devices can be defined.

The limited coverage of female infravesical obstruction has led to the absence of a clear algorithm for the diagnosis and treatment of urethral strictures in women. Currently, various treatment methods are used—from urethral dilation to urethroplasty—with their effectiveness and indications remaining the subject of ongoing discussion. The article discusses the issues of etiology, diagnosis, and treatment of urethral strictures in women and examines the effectiveness of various invasive methods for managing narrowing of the female urethra. The required information was searched in PubMed, Web of Science, CyberLeninka, eLibrary, and Scopus databases for the period 1999–2022 using the following keywords: стеноз меатуса (meatal stenosis), стриктура уретры у женщин (female urethral stricture), стриктурная болезнь уретры (urethral stricture disease), вентральная уретропластика слизистой половой губы и влагалища (ventral urethroplasty using labial and vaginal mucosa), дорсальная буккальная уретропластика (dorsal buccal urethroplasty), пластика уретры лоскутом стенки влагалища (urethral reconstruction using vaginal wall flap), бужирование (urethral dilation), обструктивное мочеиспускание у женщин (female obstructive voiding), and инфравезикальная обструкция у женщин (female infravesical obstruction). It was noted that urethral dilation and internal optical urethrotomy are often used as initial treatments and demonstrate satisfactory results, though they are associated with a relatively high recurrence rate. In patients with partial urethral obliteration and recurrent stricture after previous interventions, subsequent surgical options may include urethral reconstruction using flaps of the anterior or lateral vaginal wall, vestibular flaps, or free grafts (in dorsal or ventral position). The choice of surgical technique may be influenced by several factors—location and length of the stricture, presence of trophic changes in the mucosa, mechanism of development, as well as the surgeon’s experience and preferences. Urethrotomy and dilation may be used as initial treatment methods in some cases; however, in the presence of recurrence, marked fibrotic changes, and significant stenosis, urethroplasty is considered more appropriate. Flap-based urethroplasty techniques have demonstrated effectiveness and safety and may therefore represent a preferred treatment method for female urethral strictures.

Urethrotomy Has a Much Lower Success Rate Than Previously Reported

BackgroundThe Optilume® drug-coated balloon is a urethral dilation balloon with a paclitaxel coating that combines mechanical dilation for immediate symptomatic relief with local drug delivery to maintain urethral patency. The ROBUST III trial concludes that Optilume is safe and superior to standard direct vision internal urethrotomy/dilation for the treatment of recurrent anterior urethral strictures <3 cm in length. However, there have been limited studies to show efficacy in the treatment of urethral stricture in the setting of post-radiation patients. This study aimed to clarify the safety and early efficacy of Optilume balloon dilation for urethral strictures in post-radiation patients.MethodsAll patients undergoing Optilume balloon dilation with at least 3 months of follow-up were evaluated over 27 months in a retrospective multi-institutional setting. Thirty patients who received pelvic radiation and subsequently developed symptomatic urethral strictures were selected from a total of 246 patients identified with symptomatic urethral strictures. Success was defined as the absence of recurrence of original presenting symptoms, no need for intermittent self-dilation, and no requirement for surgical intervention within the follow-up period for their urethral stricture.ResultsSuccessful Optilume balloon dilations without recurrence of symptoms were achieved in 24/30 (80%) patients. Failures with recurrence of strictures occurred in 20% (6/30) of cases. At a median follow-up of 353 (range: 91–818) days, 80% (24/30) of radiated patients had successful Optilume balloon dilation. Our data showed that 83% (5/6) of patients who experienced recurrence did so after 12 months. Among radiated patients without baseline incontinence, new stress incontinence developed postoperatively in 20% (3/15), while one patient had improved stress incontinence.ConclusionsOptilume balloon dilation is a safe mechanism of treatment for urethral stricture disease in radiated patients. Early follow-up data of the treatment of urethral strictures in radiated patients suggests similar efficacy. However, long-term follow-up data is needed.

Актуальність. Пошкодження уретри при пошкодженні кісток таза в дітей відмічається рідше, ніж у дорослих (менше 1 %) (Tarman G.J. et al., 2002). Посттравматична стриктура уретри в дітей є досить рідкісною та складною урологічною патологією. З урахуванням анатомічних особливостей лікування стриктури уретри в дітей відрізняється від її лікування в дорослих (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). М.М. Koraitim (2012) описав досвід лікування 20 хворих з ускладненнями після трансперинеальної пластики уретри. Автор відмітив, що у разі відсутності необхідності реконструкції шийки сечового міхура достатньо ефективним є ендоскопічне розсічення стриктури уретри. Т.Е. Helmy, А.Т. Hafez (2013) теж описали результати успішного застосування ендоскопічного обладнання (пряма візуальна уретротомія) після відкритих уретропластик. Важливим моментом, що спонукає до пошуку ефективних малоінвазивних методів лікування посттравматичних стриктур уретри в дітей, є розвиток еректильної дисфункції у подальшому, що, за даними деяких авторів (Koraitim M.M., 2014), становить до 47 %. Мета дослідження: на основі доступних літературних даних і власних результатів лікування дітей із стриктурами задньої уретри установити роль ендоскопічного лікування вказаної складної патології як методу профілактики та лікування нервово-м’язової дисфункції сечового міхура. Матеріали та методи. На базі хірургічних відділень Житомирської обласної дитячої клінічної лікарні широко впроваджені малоінвазивні ендоскопічні методи діагностики та лікування патології нижніх сечових шляхів. Наявне обладнання дає можливість проводити діагностичні процедури, починаючи з місячного віку. Виконується цілий ряд ендоскопічних оперативних втручань на нижніх сечових шляхах, а саме: видалення конкрементів, розсічення клапанів та стриктур задньої уретри, розсічення кіст уретри та ектопічних уретероцеле тощо. Також у 2010 році вперше виконано спробу за допомогою черезшкірної трипортової цистоскопії видалити вклинений у рубцево-змінену задню уретру конкремент. З 2013 року розпочато лікування посттравматичних стриктур задньої уретри під ендоскопічним контролем. Результати. Подано результати успішного малоінвазивного лікування із застосуванням сучасного ендоскопічного обладнання у двох хворих із посттравматичними стриктурами задньої уретри. Особливо наголошено на ефективності методу в діагностиці та лікуванні нервово-м’язової дисфункції сечового міхура в даної категорії хворих. Висновки. Отже, застосування сучасного малоінвазивного обладнання не лише дає можливість ефективно діагностувати пошкодження нижніх сечових шляхів, а й може бути дієвим механізмом малотравматичного хірургічного лікування при коротких посттравматичних стриктурах уретри в дитячому віці. Своєчасне якісне лікування рубцевих стриктур уретри в дітей зведе до мінімуму розвиток інфравезикальної обструкції та порушення евакуаторної функції сечового міхура із розвитком його нервово-м’язової дисфункції.

To prevent terrorism during anti-terror war, we developed a reproducible animal model for the induction of a urethral stricture in a war wound rabbit, and to evaluate the feasibility and effect of using a biodegradable urethral stent in the prophylaxis and treatment of urethral strictures in a war wound (or traumatic) rabbit urethral model. The urethral stricture rabbit model was successfully performed by a self-control explosion destructor. New biodegradable urethral stents were placed in the urethras of 20 war wound (traumatic) rabbits, but no stent was used in the 8 rabbits which formed the control group. Follow-up investigation included assessment of procedure success, stent changes, urethrascopy and retrograde urethrography, and histological findings were obtained after sacrifice at 4, 6, 8 and 12 weeks after stent placement. The urethral stricture model owing to a war wound (trauma) was tested by tissue reactions and urethroscopy. The length of the urethral strictures was 5–10 mm; the coarctatetion of the urethral lumen was more than 50%. Biodegradable stent placement was technically successful in 20 rabbits. Urethral specimens obtained from the 4 week stent placement group showed diminished inflammatory cell infiltration and decreased thickness of the papillary projections of the epithelium. There was a strong tendency towards regression of the papillary projections and regeneration of urethral mucosa epithelium in the 8 week group. In particular, the injured urethra has recovered completely in the biodegradable stent groups compared with the control group at 12 weeks. The biodegradable urethral stent seems feasible for treating and preventing urethral strictures owing to a war wound (or traumatic) urethra. There are distinct advantages in terms of safe, effective and less-invasive treatment for the reconstruction of post-traumatic urethral strictures.

Traumatic Obliterative Urethral Strictures in Pediatric Patients: Failure of the Cut to Light Technique at Long-Term Followup

ObjectiveThe use of minimally invasive endoluminal treatment for urethral strictures has been a subject for debate for several decades. The aim of this study was to review and discuss the...

Treatment of Urethral Stricture Disease by Internal Urethrotomy, Dilation, or Stenting

A New Treatment for Urethral Strictures: A Permanently Implanted Urethral Stent

Internal Urethrotomy: Its Use in the Treatment of Urethral Strictures of the Male Patient

The treatment of urethral strictures has been greatly improved by the use of the optical urethrotome. However, there remains a group of patients with recurrent strictures for whom the alternatives remain long-term dilatation/urethrotomy or urethroplasty. Over the last 3 years we have treated 65 such patients using clean intermittent self-catheterisation as a method of self-dilatation. This has resulted in a dramatic decrease in the number of operations performed on these patients, with no significant reduction in urinary flow rate over an average follow-up period of 20 months. The method offers the possibility of long-term cure and should be offered to all all such patients, reducing still further the number of patients who require urethroplasty.