Management of urethral stricture: translating guidelines into clinical practice.

Background and Objective Urethral stricture in the male population is one the oldest described urological condition. Significant vari-ability in clinical practice means that standardized management of urethral stricture remains controversial. Since the first description of modern-day direct visual internal urethrotomy (DVIU) by Sachse in 1974, this, alongside with various endoscopic treatment techniques, continues to be by far the most commonly performed procedures for the management of urethral strictures. This article aims to summarise and review the latest literature on endoscopic management of urethral strictures. Material and Methods We conducted a Pubmed and Medline search to identify publications related to endoscopic management of male urethral strictures between 1980 and 2019. Preference was given to recent and larger studies. Original research articles, review articles, abstracts, and opinion articles were included. Keywords used for the search were “male urethral stricture,” “urethrotomy,” “DVIU,” “urethral dilation,” “urethral stent”, “intermittent self-catheterisation”, “mitomycin C”, “steroids”, and “urethroplasty.” Recent Findings The long-term efficacy of endoscopic management of urethral stricture is poor. Recent novel advances with adjunct treatment have yet to demonstrate improvement in long-term treatment success. Repeated endoluminal or endoscopic treatments, especially for long and recurrent urethral strictures, are ineffective. They appear to delay patients from receiving definitive treatments, and potentially increase complexity and decrease the success rate of any future urethral reconstructive treatment. Summary There is overwhelming evidence to suggest limited long-term efficacy of endoluminal or endoscopic treat-ments for urethral stricture. Novel adjunctive therapies showed promising initial results, but none have yet to demonstrate durable efficacy. Endoscopic treatment of urethral stricture disease should only be reserved for patients who are not willing to undergo reconstructive surgery, or not fit for anesthetics.

INTRODUCTION: Urethral stricture is characterized by fibrosis of the urethral epithelium and underlying corpus spongiosum, resulting in a pathological narrowing of the urethral lumen and subsequent obstruction of urinary flow. Conventional treatments for urethral stricture, including urethral dilatation, direct visualized internal urethrotomy, and urethroplasty, are associated with recurrence, necessitating implementation of alternative therapeutic approaches. According to Acharya Sushruta, the urethral stricture can be correlated with Mutrotsanga, a subtype of Mutraghata. Uttar Basti is indicated as a key therapeutic intervention in the management of Mutraghata and is often used in Ayurvedic clinical practice for similar conditions. PATIENT INFORMATION: A 65-year-old male presented to the Shalyatantra outpatient department with complaints of increased urinary frequency, urgency, a weak urine stream, and a sensation of incomplete voiding persisting for the past 9 months. His surgical history included a transurethral resection of the prostate (TURP) 1 year ago, followed by direct visual internal urethrotomy and intermittent self-catheterization 7 months ago. The retrograde urethrogram (RGU) examination revealed a beaded appearance of the anterior urethra with multiple areas of narrowing in the mid-urethra, along with a narrowed bulbar urethra lacking normal dilatation, suggesting significant stricture formation. The posterior urethra appeared wide, likely due to prior TURP, and free contrast spillage was observed in the bladder, indicating possible high intravesical pressure due to urethral obstruction. THERAPEUTIC INTERVENTION: The patient underwent two cycles of Uttar Basti, each lasting 7 days, with a 7-day interval between the cycles, using Apamarga Kshara Taila (15 mL), Madhu (honey) (5 mL), and Saindhava Lavana (rock salt) (500 mg). Varunshigravadi Ghanvati (500 mg) was administered orally three times daily after food for 21 days. RESULTS: Following the completion of the treatment protocol, significant clinical and diagnostic improvements were observed in the patient. The International Prostate Symptom Score assessment indicated a reduction in symptoms, with the severity improving from severe to mild, reflecting enhanced quality of life. The urine flow rate showed improvement, suggesting better urinary passage. RGU findings demonstrated an increase in the lumen of the bulbous urethra compared to pretreatment imaging, indicating a reduction in stricture severity. CONCLUSIONS: The findings of this case report suggest that the combination of Uttar Basti with Varunashigravadi Ghanvati may be an effective intervention for managing urethral stricture, as evidenced by symptomatic relief, improved urinary flow rate, and an increased urethral lumen on imaging. These results highlight the therapeutic potential of Ayurveda in alleviating recurrent urethral stricture, offering a promising and accessible alternative to conventional treatments.

Historically, direct visual internal urethrotomy (DVIU) and balloon dilation (BD) have been preferred as first line interventions for certain urethral strictures. Urethroplasty is considered the gold standard following failed primary intervention; however, no recommendations exist for intervention following a failed urethroplasty.1 Thus far, DVIU and BD have been shown to display comparable outcomes as primary treatments in terms of freedom from recurrent stricture, time to recurrence, and complications.2 In this research letter, we provide evidence that in the case of secondary interventions following failed urethroplasty, BD shows significantly improved 3-year outcomes compared to DVIU. Urethral strictures are fairly common with a prevalence of 229–627 per 100 000 males.3 They typically impact men over the age of 65 and increase the risk for UTIs and incontinence. While some studies have compared the success of DVIU versus BD as primary interventions, reported success rates are highly variable with 32%–96% for DVIU and 35%–84% for BD.2, 4, 5 Conversely, urethroplasty has a high reported success rate of 96%, though is a more complicated procedure requiring longer recovery and a skilled surgeon.1 Due to the low frequency of recurrence following urethroplasty, recommendations for subsequent reoperations with DVIU or BD have not been adequately studied. Given the prevalence of urethral strictures and increasing use of urethroplasty, it is important to study the success of subsequent DVIU and BD. We performed a retrospective review using TriNetX (TriNetX, Inc., Cambridge, MA, USA), a clinical research platform that collects and stores over 125 million patients' electronic health record data, to determine whether urethroplasty patients with subsequent DVIU or BD had a higher chance of recurrent stricture. We are unaware of another study that directly compares success rates of DVIU versus BD as secondary interventions following urethroplasty. Cohorts were constructed for both DVIU following urethroplasty and BD following urethroplasty. Patient ages ranged from 21 to 90, and exclusion criteria included benign prostatic hyperplasia, neurogenic bladder and bladder neck contracture. Specific inclusion and exclusion criteria can be found in Appendix S1. Given the small sample sizes, cohorts were not matched for comorbidities. Outcomes were defined as ≥1 instance of urethral stricture or stenosis, or retention of urine between 1 month and 3 years after DVIU or BD. Outcomes were assessed with Kaplan–Meier, hazard ratios (HR) and log-rank tests to determine significance (p < 0.05), and a Kaplan–Meier curve was generated. DVIU (N = 45) had a significantly higher probability (p = 0.0353) of recurrent urethral stricture compared to BD (N = 25), with respective 3-year incidence probabilities of 95.15% and 69.05% (Figure 1). DVIU had a median survival of 99 days while BD had a median survival of 355 days. DVIU had an increased hazard compared to BD with a HR of 1.901 (95% CI: 1.034, 3.497). For both cohorts, the median time between initial urethroplasty and subsequent salvage intervention was comparable, with 177 days for DVIU and 153 days for BD. In conclusion, for patients experiencing recurrent urethral stricture post-urethroplasty, BD appears to have better 3-year outcomes compared to DVIU. Additionally, the data suggest that in the short term, BD may provide longer lasting symptom relief before recurrence of urethral stricture. Primary limitations of this study are attributed to the use of electronic health record data including: completeness and accuracy of medical records, loss to follow-up and billing code restrictions. Additionally, the heterogeneity of cohorts formed through TriNetX and not a single institution's data will have significant influence and cannot be ignored—this is of particular note given the highly surgeon and hospital-dependent outcomes of complex procedures such as urethroplasties. Lastly, due to the nature of TriNetX, we were unable to fully characterize strictures' length and location, type of urethroplasty or type of balloons used in BD. Future studies should prioritize larger sample sizes and consider a prospective randomized controlled trial to incorporate more granular data on strictures and interventional techniques, as the results of this research could change clinical management of urethral strictures. Appendix S1.: ICD and CPT Codes Used in Cohort Construction. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Introduction: Urethral stricture is a common cause of lower urinary tract symptoms in the middle aged and elderly men in our environment. Its diagnosis and management is hinged mainly on a retrograde urethrogram (RUG) that is associated with variable lengths and sites with that found intraoperatively due to difference in magnification (source patient as well as source image distance), penile stretch, and positioning during the procedure. We hereby sort to validate this tool in defining urethral strictures. Materials and Methods: Adult patients with lower urinary tract symptoms suspected to be due to urethral strictures who presented to the outpatient department and emergency departments of the hospital between January 2016 to December 2016 were recruited into the study. This was followed by obtaining an informed consent from the patient and ethical clearance from the institution. Patients who were not fit or not willing to have a urethroplasty were excluded from the study. The recruited patients had RUG to characterize the strictures. The intraoperative findings at urethroplasty were compared with that found on RUG. Data were collected and analyzed using SPSS version 23 to determine sensitivity specificity of the test. Results: A total of 84 patients were studied during the period. The mean age of the patients was 44.1 years. Bulbar strictures accounted for 65% of the strictures. Most of the strictures were single (72%) and long segment (52%). Sensitivity and specificity of RUG in determination of the length of stricture were 76.9% and 74.6%, respectively, whereas the sensitivity and specificity of RUG in determination of site of stricture were 92.9% and 96.4%, respectively. The determination of number of stricture on RUG has a sensitivity of 94.2% and specificity of 90.8%. Conclusion: RUG is a valuable tool in the management of urethral strictures with a higher sensitivity and specificity for the determination of site and number of strictures as compared to length of stricture that is more affected by magnification and techniques in contrast administration. This should be considered during procedure as well as during interpretation of images.

Context: Direct Visual Internal Urethrotomy (DVIU) has been a useful tool in the management of partial urethral strictures. There is limited data on its success rates in black populations. A successful DVIU will spare the patient the stress and rigours of undergoing a urethroplasty. This study intends to look at the outcomes of DVIU in our setting using uroflometry. Materials and Methods: This is an observational prospective study of 58 patients that underwent DVIU for short segment anterior Urethral strictures between January 2020 and January 2024 recruited using a consecutive sampling technique.. Patients were monitored after discharge through phone calls and post operative visits. Results: A total of 58 patients were involved in the study with a mean age of 65 years and mean BMI of 26.4 ± 3.2. Stricture of unknown aetiology (idiopathic) accounted for majority of the cases 31 (53.4%) followed by iatrogenic stricture, 11(19.0%) of all strictures. Traumatic stricture was responsible for (7) 12.1%, inflammatory (6) 10.3% while stricture due to malignancy accounted for 3(5.2%) of all cases The commonest stricture location was the proximal bulbar 36 (62.1%) followed by penile and distal bulbar representing (19%) of the strictures. Most of the patients 39 (67.2%) had a single stricture. The mean maximum flow rate pre DVIU was 9.6 ml/sec ±1.5 and the maximum flow rate at 6 months post DVIU was 29.3 ml/sec ± 6.1 representing an increase by 19.7ml/sec (95% CI 0.7 - 5.3) compared to the pre-intervention period (p=0.0059). Conclusion: DVIU seems to be a viable treatment option for patients with partial urethral strictures in our environment. Longer follow up of these patients may be required to substantiate our findings.

Direct vision internal urethrotomy (DVIU) has been considered to be a low invasive and widely used therapeutic modality for male urethral stricture. However, its efficacy is still controversial. We herein evaluated the efficacy of DVIU for male urethral stricture. Nineteen patients 27 to 78 years old (median age = 59) underwent DVIU for urethral strictures at our hospital were included in this study. Strictures were at bulbar urethra in 17 patients, membranous urethra in 1 patient, and pendulous urethra in 1 patient. The stricture lengths estimated on retrograde urethrography were less than 1 cm in 13 patients, 1-2 cm in 2 patients, and more than 2 cm in 4 patients. The etiology of stricture was straddle injury in 7 patients, post transurethral surgery in 7 patients, pelvic fracture in 1 patient, and unknown in 4 patients. The operation was done by cold knife incision using guidewire. The duration of postoperative urethral catheterization was 5 to 35 days (mean 12.8 days). Follow up duration ranged from 1 month to 139 months (mean 48.2 months). The definition of postoperative re-stricture was the confirmation of re-stricture on retrograde urethrography or deterioration of symptom. While no severe complication was observed, postoperative re-stricture was seen in 13 patients. Stricture-free rates at 3 months, 6 months, and 5 years after the first DVIU were 44.4%, 38.1%, 20.3% respectively. Although second DVIU was done for 7 patients with re-stricture, six patients resulted in failure. Stricture-free rates at 3 months, 6 months, and 5 years after the second DVIU were 42.2%, 28.6%, 14.3% respectively. Though the third DVIU was done for two of them, they were unable to void just immediately after the removal of urethral catheters. Stricture-free rate in stricture less than 1 cm was higher than that in 1 cm or longer, though it did not reach significant difference (p = 0.1813). The efficacy of DVIU is lesser than we expected. DVIU seems to be excessively applied to male urethral strictures and should not be performed for long and recurrent urethral stricture.

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

Background. For over a century retrograde urethrography (RUG) has offered the key method to diagnose urethral stricture (US). The disadvantage of the technique, however, is a potential high risk to underestimate the stricture length due to distorted visualization and eventual flawed surgical planning.Aim. To consider retrograde sagittal urethrography (RSU) and how it contributes to enhancing US preoperative diagnostics and treatment efficacy in clinical practice.Materials and methods. We compared the protocols of pre-op urethrograms performed by a radiologist and a urologist to surgery protocols for both patient groups. Group 1 included 154 patients who underwent US surgical treatment from 2017 to 2021 after using RSU as a diagnostic method (positioning 90°). Group 2 comprised 142 patients presented with identical disease who received surgery between 2012 to 2016 in our hospital after RUG using traditional technique (positioning 45°). Discrepancies of 5 mm and over in stricture length measurements between radiography protocols and intraoperative data were considered a diagnostic flaw (i.e. inconsistency). Treatment efficacy was compared across both groups.Results. In 87.6 % of cases in Group 1 (RSU) protocols provided by a radiologist matched intraoperative data versus45.7 % of cases receiving accurate protocol data in Group 2 (RUG) (χ2 = 59.15, p &lt;0.001). Urethrogram protocols prepared by a urologist pre-operatively were accurate in 95.4 % of cases in Group 1 versus 62.0 % in Group 2 (χ2 = 49.11, p &lt;0.001). The overall efficiency of surgery was higher in Group 1 (91.6 %), than in Group 2 (82.4 %) (χ2 = 5.54, p &lt;0.01).Conclusion. RSU is an innovative technique that allows to significantly improve the accuracy of urethral stricture length measurement, resulting in greater treatment efficiency in Group 1 of patients. The proposed urethrographic technique can be recommended as a basic diagnostic procedure for anterior US in men.

PurposeThis study aimed to assess the exposure and knowledge of urology residents in the management of urethral stricture (US) and to determine if they would be able to perform urethroplasty after graduation and whether urethroplasty should be included as a competency in the training program.Patients and MethodsAn online survey was sent to all residents enrolled in any urology training program in Saudi Arabia. Fifty-eight (approximately 50%) of the 114 residents who were sent the survey provided responses.ResultsMost of the residents (45 residents, 77.6%) who responded were exposed to fewer than ten cases of US during their last year of training. Fifty-six residents (96.6%) attended five or fewer urethroplasty procedures in their last year of training. Twenty-three (40%) residents did not attend any urethroplasty procedure in the last year. The most common procedures attended by the residents were minimally invasive treatments (89% cystoscopy with dilatation and 79% direct visual internal urethrotomy (DVIU)). Most residents responded that they would manage newly diagnosed 1 cm US with either cystoscopy and dilatation or with DVIU 53 (91%). For the first recurrence of US, 46 (79%) residents responded that they would still prefer dilatation or DVIU. For the second, third, and chronic recurrences of US, 20 (34.5%), 6 (10.3%), and 5 (8.6%) residents, respectively, responded that they would perform dilatation or DVIU. Residents had low expectations for the success rate of urethroplasty; only 32 (55.2%) residents thought it had a high success rate.ConclusionUrethroplasty is a specialized urological procedure, one that residents have variable exposure to. Privilege to perform such a procedure after graduating should be modified to ensure the best outcome for patients.

Introduction: Evaluation of long-term results, risk factors for treatment failure, and complications in a contemporary cohort of patients with bulbar urethral strictures managed with direct vision internal urethrotomy (DVIU). Methods: We retrospectively reviewed 140 consecutive patients who underwent internal urethrotomy in a single institution between January 2012 and October 2020, with a minimum follow-up of 24 months. Most urethral strictures had an iatrogenic origin (89.3%), length under 2 cm (75%) and were located in the mid-bulbar urethra (56.4%). The main variable was treatment failure, defined as recurrent urethral stricture at the same location in urethrography or urethroscopy, or the need for dilation, internal urethrotomy or open urethral reconstruction. Secondary variables analyzed were length of stricture, suspected etiology, previous endoscopic procedures, hospital stay, days of catheterization, and postoperative complications such as infections or hematuria. Results: Treatment failure occurred in 61.4% of patients (104). Idiopathic strictures and those under 2 cm had better outcomes. Strictures longer than 2 cm and those with previous endoscopic procedures demonstrated a higher failure rate. More than 90% of recurrences occurred within the first 2 years of follow-up. Complications of DVIU were scarce with postoperative urinary tract infection/urosepsis in 5.7% and prolonged hematuria in 10%. The mean hospital stay was 2.9 days. Conclusion: DVIU is a safe and simple technique, with reasonable efficacy in primary cases of bulbar urethral strictures under 2 cm in length. Strictures longer than 2 cm or recurrent cases might be better approached through drug-coated balloon dilation or open urethral reconstruction. Follow-up after DVIU must be at least 24 months.

PurposeTo report our early experience with thermo-expandable urethral stents (Memokath) for the management of recurrent urethral stricture and to assess the efficacy of urethral stents.Materials and MethodsBetween March 2012 and February 2013, 13 patients with recurrent urethral stricture after several attempts with direct visual internal urethrotomy (DVIU) or failed urethroplasty underwent DVIU with thermally expandable, nickel-titanium alloy urethral stent (Memokath) insertion. Follow-up study time points were at 1, 3, 6, 9, and 12 months after stent insertion. Follow-up evaluation included uroflowmetry, retrograde urethrogram, plain radiography, and urinalysis.ResultsThe mean patient age was 47.7 years (range, 18 to 74 years). The mean urethral stricture length was 5.54 cm (range, 1 to 12 cm). There were six patients with bulbar, four patients with proximal penile, one patient with distal penile, and two patients with whole penile urethral strictures, respectively. The overall success rate was 69% (9/13) and the mean postoperative peak flow rate was 17.7 mL/s (range, 6 to 28 mL/s). Major complications occurred in four patients including one patient (7.7%) with urethrocutaneous fistula induced by the stent and three patients with urethral hyperplasia. The mean follow-up duration was 8.4 months.ConclusionsOur initial clinical experience indicates that thermo-expandable stents can be another temporary management option for recurrent urethral stricture patients who are unfit for or refuse urethroplasty. Distal or whole penile urethral stricture can be factors predicting poor results.

Introduction: Treatment methods of anterior urethral strictures in adults have undergone considerable changes in the recent past. Our goal was to determine national practice patterns among German urologists and to compare results with the results of prior international surveys. Methods: We conducted a survey on the management of urethral strictures among German urologists. Results: Eight hundred forty-five urologists, representing about 14.6% of German urologists, answered the survey. Most common procedures were direct vision internal urethrotomy (DVIU; 87.2%), blind internal urethrotomy (57.5%), dilatation (56.3%), ventral buccal mucosa graft urethroplasty (31.6%) and excision and primary anastomosis (28.9%). In case of a 3.5-cm bulbar stricture and in the case of a 1-cm bulbar stricture after 2 failed DVIUs, a consecutive urethroplasty was significantly more often favoured compared to transurethral treatment options (44.9 vs. 21.3% and 59.4 vs. 8.3%, both p < 0.001). Conclusion: Open urethral reconstruction reveals to be a more common method in practice nowadays. Adherence to recommended treatment algorithms improved in comparison to prior surveys.

Patient: Male, 24Final Diagnosis: Urethral strictureSymptoms: —Medication: —Clinical Procedure: —Specialty: UrologyObjective:Unusual or unexpected effect of treatmentBackground:The most dependable management of anterior urethral stricture is the complete excision of the area of fibrosis, with a primary reanastomosis of the normal ends of the anterior urethra.Case Report: A 24-year-old man had urethral stricture in the penoscrotal junction caused by catheterization approximately 3 years ago. After the resection of the urethral stricture segment and the end-to-end anastomosis were performed, in addition to stricture, urethrocutaneous fistula formation as another complication in the penoscrotal junction was confirmed. The direct vision internal urethrotomy did not improve all the above symptoms. The retrograde urethrogram and voiding cysto-urethrogram showed complete obliteration in the penile urethra, urethrocutaneous fistula, and proximal urethral bifurcation singularity. Intraoperatively, we found that the distal urethral end had been anastomosed to the proximal false passage in the initial surgery and the proximal urethra was located in the dorsal side of the false passage. Then, tubularized preputial flap urethroplasty was performed. The patient was followed up for 10 months. His peak urinary flow was 18.3 milliliter per second.Conclusions:We would remind urologists that urethral end intraoperatively anastomosed to the false passage is a rare, serious, avoidable, and elementary medical error. Urethroplasty is one of the curative choices for treatment of this unexpected condition.

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