Urethral Stricture Research Articles

The use of amniotic membrane injection as an adjunct in endoscopic urethral stricture management

ABSTRACT Introduction: Endoscopic urethral stricture treatment has high recurrence rates. Due to research supporting amniotic membrane’s (AMs) anti-inflammatory and anti-fibrotic properties reducing scar tissue formation, AM has generated interest in reconstructive urethral surgery. To the best of our knowledge, we performed the first investigation of the success rate of urethral dilation when combined with micronized AM injection for the treatment of urethral stricture. Methods: Eligible patients were adult males with anterior strictures meeting strict criteria for diameter, length, International Prostate Symptom Score (IPSS), and flow rate. Micronized AM was injected in the stricture region during urethral dilation. The primary study endpoint was an anatomical success (≥14Fr) at 6 months. Secondary endpoints were evaluated with the IPSS, urethral stricture surgery – patient-related outcome measure, International Index of Erectile Function, flow rate, and postvoid residual. Outcomes were assessed at baseline and multiple points postinjection. Injection safety was analyzed. Results: Ten men with a mean age of 52 years were included in the study. At 6 months, 7 of 10 patients demonstrated recurrence of the urethral stricture on cystoscopy. Improvements in secondary endpoints were noted in 10 of 10 patients at 3 months and 3 of 10 patients at 6 months. No adverse events were observed. Conclusions: To the best of our knowledge, this is the first study evaluating micronized AM injection as an adjunct treatment at the time of urethral dilation. The urethral stricture recurrence rate did not improve with the injection of AM despite the hypothesized benefits of anti-fibrotic and anti-inflammatory properties.

Changes in practices concerning urethral stricture surgery: Analysis of French data for the period 2013–2022

IntroductionThe prevalence of urethral stricture is estimated at 0.9%. American, European and French recommendations have reduced the place of endoscopic treatments due to their poor outcomes, especially in the case of repeated procedures. Urethroplasty is the new reference treatment for urethral stricture. Our aim was to assess the evolution of national practices from 2013 to 2022. Material and methodsWe collected national CCAM coding data for all procedures involving urethral stricture surgery using the Scansanté internet platform produced by the Technical Agency for Information on Hospitalization, which prospectively collects all procedures coded according to CCAM coding from public, liberal and ESPIC healthcare structures. ResultsThe overall number of urethral surgical procedures has been steadily increasing over the past 10 years. Endoscopic procedures remain largely predominant in 2022, totaling 23,982, but have remained stable over the decade. Urethroplasties have been on the rise since 2019, reaching 1600 cases in 2022 compared with 1100 cases in 2020. Although urethrotomies currently outnumber urethroplasties by a factor of 10, this ratio has been consistently decreasing since 2016. The most significant contributor to the 10-year increase is urethroplasty by augmentation, particularly free flap techniques on the anterior urethra. Resection-anastomosis and urethrostomy techniques have remained stable. DiscussionIn 2022, endoscopic treatments remain by far the majority, but urethroplasties are on the increase. A significant number of patients can benefit from initial endoscopic treatment because short bulbar localization is the most common presentation, but long-term success rates are poor compared to urethroplasty, which boasts approximately 80% success rates. Urethroplasty should no longer be considered a last-resort surgery but rather a reference technique in treating urethral stricture.

El uso de la cirugía robótica para el tratamiento de estenosis uretrales y contracturas del cuello vesical: una revisión sistemática

The use of robotic surgery for the management of urethral strictures and bladder neck contractures: a systematic reviewObjective: The aim of this systematic review is to offer a comprehensive view of the current use of robotic surgery for the treatment of urethral strictures and bladder neck contractures.Methods: A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Embase databases in December 2023. Keywords used were “robotic” and “robotic-assisted” combined with “urethroplasty”, “urethral stricture”, and “bladder neck contracture”. All papers published after 2000, concerning studies conducted on humans for urethral strictures and bladder neck contractures managed with robotic surgery were considered for the review. Only procedures involving a direct approach to urethra/bladder neck and/or graft harvesting for urethroplasty have been included.Results: A total of 275 articles were evaluated after the strategy search and only 11 articles were considered eligible for the final analysis. The studies included a series of between a minimum of 1 and a maximum of 104 patients, for a total of 203 patients. The robotic surgery was performed mainly for the treatment of bladder neck contracture and posterior urethra. In some reports, the robotic system was used for graft harvesting, subsequently used with an open perineal technique. The follow-up presented in the different studies is very heterogeneous. However, most studies have high success rates, with recurrence and redo surgery rates generally below 20%. Likewise, post-procedure incontinence rates are low.Conclusions: The outcomes presented in the literature, combined with the minimally invasive nature, suggest a possible growing role for robotic surgery in the coming years in the treatment of these diseases.

Eficacia y Seguridad del Balón de Dilatación Uretral Optilume® en la práctica clínica real: Análisis multicéntrico en España

Introduction: The Optilume® Paclitaxel-coated urethral dilatation balloon is an alternative to conventional endoscopic treatments that combines mechanical dilatation with local delivery of paclitaxel.Objective: To describe the success rate and analyze the safety of the device in real clinical practice. To evaluate possible predictors of treatment failure.Materials and methods: Retrospective multicenter study in patients diagnosed with urethral stricture and treated with an Optilume® balloon in routine clinical practice. Data were collected from flowmetry, questionnaires (PROM and IPSS) and cystoscopy before surgery, and 3, 6 and 12 months after the procedure, according to standard practice. Surgical success was defined as the absence of subsequent urethral manipulation and a Qmax > 10 ml/s.Results: 238 patients treated with Optilume® in 12 Spanish hospitals between May 2021 and April 2024 were included in the study. Of these, 156 who had a minimum follow-up of 3 months, were analyzed. Median stricture length: 1.5 cm (0.5 - 5.3), mainly in bulbar urethra (87.7%). Of the total, 12.8% of patients had a history of pelvic radiotherapy, and 81.4% had undergone prior urethral manipulation. Postoperative complications were reported in 14.2% of the total. The treatment success rate was 73.8%, with a median follow-up of 8 months (5-12). No predictors of stricture recurrence were identified. Recurrence rates were higher in strictures located in the posterior versus anterior urethra (42.9% vs. 24.6%, p=0.126). No significant differences were observed between patients with and without prior urethral manipulation.Conclusion: Treatment with Optilume® has been shown to be safe and effective in short-term routine clinical practice.

Efficacy and safety of Optilume® Paclitaxel-coated urethral dilatation balloon in real-life: Experience in a Spanish Multicenter Study.

The Optilume® Paclitaxel-coated urethral dilatation balloon is an alternative to conventional endoscopic treatments that combines mechanical dilatation with local delivery of paclitaxel. To describe the success rate and analyze the safety of the device in real clinical practice. To evaluate possible predictors of treatment failure. Retrospective multicenter study in patients diagnosed with urethral stricture and treated with an Optilume® balloon in routine clinical practice. Data were collected from flowmetry, questionnaires (PROM and IPSS) and cystoscopy before surgery, and 3, 6 and 12 months after the procedure, according to standard practice. Surgical success was defined as the absence of subsequent urethral manipulation and a Qmax > 10 ml/s. 238 patients treated with Optilume® in 12 Spanish hospitals between May 2021 and April 2024 were included in the study. Of these, 156 who had a minimum follow-up of 3 months, were analyzed. Median stricture length: 1.5 cm (0.5 - 5.3), mainly in bulbar urethra (87.7%). Of the total, 12.8% of patients had a history of pelvic radiotherapy, and 81.4% had undergone prior urethral manipulation. Postoperative complications were reported in 14.2% of the total. The treatment success rate was 73.8%, with a median follow-up of 8 months (5-12). No predictors of stricture recurrence were identified. Recurrence rates were higher in strictures located in the posterior versus anterior urethra (42.9% vs. 24.6%, p = 0.126). No significant differences were observed between patients with and without prior urethral manipulation. Treatment with Optilume® has been shown to be safe and effective in short-term routine clinical practice.

Rationale of restaging transurethral resection of bladder tumor in patients with nonmuscle invasive bladder cancer in the current era

Background: We present retrospective data of patients with nonmuscle invasive bladder cancer (NMIBC) who underwent restaging transurethral resection of bladder tumor (Re-TURBT) at a tertiary care center. Materials and Methods: Records of all NMIBC patients undergoing Re-TURBT between March 2021 and September 2023 were retrospectively analyzed. Patients were risk stratified based on TURBT pathology. Re-TURBT was performed between 4 and 6 weeks. Adverse features such as number, size, and appearance were noted. Patients with persistent disease at Re-TURBT were counseled for early cystectomy with urinary diversion or intravesical Bacillus Calmette–Guerin (BCG). In case of disease upstaging, patients were counseled for radical cystectomy. Results: Thirty-eight NMIBC patients (30 males and 8 females) underwent Re-TURBT. Six patients had residual/persistent disease at 6 weeks, all high risk and high grade (HG, P value not significant, P = 0.31). There was no association with number and appearance of tumors with residual/persistence at 6 weeks. The mean lesion size on imaging in cases with and without residual disease was 3.32 ± 0.86 versus 3.39 ± 0.92 cm, respectively, P value not significant (0.868). There was no residual disease in the low-grade (LG) pT1 group, but HG pTa and pT1 (n = 3) had residual disease. Four HG pT1 patients opted for early cystectomy. Two patients each had pT0 and two pT2. At 3 months of follow-up, urethral strictures were seen both in high risk and intermediate risk. Among four patients who had stricture, meatal stenosis was common (50%, n = 2). Two patients had long-segment stricture requiring perineal urethrostomy with stage I Johannsen repair. All HG pT1 lesion patients eventually underwent cystectomy (3 were under staged and two treated completely with TURBT, one with TURBT + BCG and one patient progressed to metastasis). Conclusion: Re-TURBT is essential for the management of HG pTa and HG pT1 lesions for accurate staging and treatment of residual disease. However, LG pT1 patients can safely be excluded from Re-TURBT.

Feasibility, efficacy, and safety of retrograde intrarenal surgery in <1-year age group: A single-center experience

Purpose: Urolithiasis in infants is uncommon. Percutaneous nephrolithotomy, extracorporeal shockwave lithotripsy, and retrograde intrarenal surgery (RIRS) are the management options. RIRS is the least studied of these options in infants. In our series of 23 cases, we aim to assess the feasibility, efficacy, and safety of RIRS in <1-year age group. Materials and Methods: This was a retrospective analysis of a series of 23 infants who underwent RIRS in our hospital from January 2018 to March 2021. Children who were <12 months of age and had the largest stone size of <20 mm were included in the study. Results: Twenty-three patients (male – 15; female – 8) were included in the study. The mean age was 10 ± 2.31 months (range, 4–12 months). The mean stone size was 11.6 ± 2.96 mm (range, 7.5–19 mm). The mean operative time was 29.44 ± 7.45 min (range, 17–42 min). Six patients (22.2%) had mild hematuria (Clavien I), and seven patients (25.9%) had postoperative fever. Stone size had a significant positive correlation with laser time, operative time, and intraoperative intravasation, but no significant association with stone-free rate. At 2-month follow-up, 4 (three patients) out of 27 renal units had residual stones (stone-free rate [SFR] – 85.1%). No patient had long-term complications like urethral or ureteric stricture or stone recurrence during the given follow-up period. Conclusion: RIRS is a feasible and minimally invasive treatment for renal stones in infants with acceptable SFRs.

259 - Ventral inlay versus dorsal onlay buccal mucosal graft urethroplasty for female urethral stricture; Randomized control trial

259 - Ventral inlay versus dorsal onlay buccal mucosal graft urethroplasty for female urethral stricture; Randomized control trial

From failure to success: management of recurrent urethral strictures with buccal mucosa graft

From failure to success: management of recurrent urethral strictures with buccal mucosa graft

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

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

Patient-reported outcomes after one-stage neourethral reconstruction in transmen with phalloplasty-associated strictures and fistulas

IntroductionUrethral strictures and fistulas arising after gender-affirming surgery in transmen require meticulous management strategies. This study evaluates the safety and efficacy of urethral reconstruction and patient satisfaction post-surgery.MethodsA retrospective analysis examined peri- and postoperative data from transmen undergoing urethral reconstruction for urethral fistula and/or strictures at the distal urethral anastomosis between December 2017 and April 2023. Follow-up involved clinical examinations, uroflowmetry, and voiding cystourethrography. Patient satisfaction and quality of life were assessed using USS PROM and ICIQ-S questionnaires.ResultsAmong 25 patients, 88% (n = 23) had urethral fistulas, and 48% (n = 12) had urethral strictures. 41% of fistula patients also had strictures, while 75% of stricture patients had concurrent fistulas. Previous surgeries for fistula or stricture repair were noted in 26% of cases. Techniques for stricture included modified flap (50%), buccal oral mucosal grafting (33%), and primary anastomosis (17%). Post-operative urethrogram revealed urethral strictures in 15% (n = 3) and urinary extravasation in an equal number. Postoperative uroflow parameters showed improvement (Qmax 18 ml/s, Qave 7.9 ml, time 37 s, volume 332 ml). Perioperative complications were low (n = 6, 24%), all grade one (Clavien-Dindo). Follow-up revealed that 33% required another surgical intervention. The mean six-item LUTS score was 6.7 (SD 3.9). Mean ICIQ-S overall satisfaction score was 8.6 (SD 1.6) and outcome score was 20 (SD 2.8).DiscussionOur study found a significant recurrence rate of urethral strictures and fistulas post-surgery. Despite this, patient satisfaction remains high and complications are generally low-grade, highlighting the importance of expert surgical intervention.

Correlation Between Urethral Length and Urethral Stricture After Transurethral Resection of Prostate

Aim: To show the effects of urethral length, and surgical or patient related parameters on urethral strictures after Transurethral Prostate Resection (TURP). Materials and Methods: The study included 127 patients who underwent TURP for benign prostate hyperplasia (BPH) unresponsive to medical treatment in our clinic between May XXX and February XXX. The patients were separated into two subgroups as those who underwent second surgery because of urethral stricture and those who did not. These two groups were compared in respect of age, height, weight, total prostate specific antigen, fall in hemoglobin values, increase in urine peak flow rate, decrease in the post-micturition residual volume, prostate volume, operating time, tissue amounts, resection rate, and urethral length. Results: Urethral stricture was determined in 13.4% of the patients. A statistically significant difference was determined between the two groups in respect of age and urethral length (p

Применение большого количества методов оперативного лечения стриктуры уретры у одного пациента: клинический случай

Introduction. Insufficient surgical experience and inadequate choice of surgical treatment options may be the reasons for the failure of treatment of urethral stricture. In this regard, a clinical case from our practice is very indicative. Case: The article is devoted to the description of a clinical case of urethral injury in a man who, at the age of 22 years, suffered a fracture of the pelvic bones as a result of a traffic accident. From the moment of injury to the final operation, the following types of surgical interventions were sequentially performed in this patient: anastomotic endto-end urethroplasty, augmentation urethroplasty using a skin graft, augmentation urethroplasty using a graft of the tunica vaginalis of the testicle, bougienage of the urethra, urethroplasty with a vascularized radial fasciocutaneous flap on a vascular pedicle, 2-stage urethroplasty using a graft of the buccal mucosa according to the type of Bracka I and II operations, perineal urethrostomy. Urethrostomy became the final option for urine diversion; no recurrence of urethral stricture was observed during 4 years of follow-up after urethrostomy. Conclusion. Until recently, the lack of uniform approaches to the treatment of urethral stricture has led to the use of inadequate methods of surgical treatment in various clinics. The recent approval of federal clinical guidelines for urethral stricture should help optimize the treatment of this disease. Keywords: urethral stricture, urethroplasty, urethrostomy

The relationship between heart failure and smoking, and development of urethral stricture

The relationship between heart failure and smoking, and development of urethral stricture

Functional outcomes after supra-pubic phalloplasty

BACKGROUNDA thorough evaluation of the functional outcomes resulting from supra-pubic phalloplasty (SPP) assessing different aspects of the phalloplasty has not been reported. PURPOSE OF THE STUDYTo report the outcomes on sexuality, urinary function, satisfaction, and regrets following an SPP performed at our centre. SUBJECTS STUDIEDAll consecutive patients who underwent the 3-steps technique of pre-expanded SPP between 2007 and 2018 and who had at least 1 year of follow-up. METHODSQuestionnaires were sent to analyse several domains of penile reconstruction: sexuality, urinary function, perceived sensitivity, and satisfaction. Sexuality was evaluated using the Self Esteem and Relationship (SEAR) questionnaire. Urinary function was analysed based on the urethral stricture surgery PROM (USS-PROM) questionnaire. MAIN FINDINGSA total of 77 patients were included, 92.2% were transmen, and 33 (42.9%) responded to the questionnaire. Urethral lengthening (UL) was performed in 28 (36.4%) procedures and erectile prosthesis was implanted in 42 patients (54.5%). The mean length of the neophallus was 15.3cm (SD 2.6) and the mean girth was 11.8cm (SD 2.1). The mean total SEAR score (/100) was 73.8 (SD 26.7). The mean six-item LUTS score (/24) was 8.4 (SD 4.6). The standing position was the usual voiding position reported by 11 patients (73.3%). CONCLUSIONPre-expanded SPP is a robust technique that can achieve substantial flap dimensions, leading to high satisfaction with neophallus appearance and the choice of the phalloplasty technique. Overall sexual outcomes are mostly favourable. UL is feasible and effective in terms of voiding in a standing position.

A pilot study to evaluate the combination of surgery and brachytherapy for local tumor control in young children with perianal rhabdomyosarcoma

BackgroundPerianal rhabdomyosarcoma ((P)RMS) are rare and have a poor prognosis. Data in young children are limited and local therapy is not well defined. Combined brachytherapy and surgery is routinely being used for RMS at other sites in children as it provides good oncologic outcomes and allows for organ-sparing surgery. The objective of this study was to evaluate this combination treatment for local tumor control and organ-sparing surgery in young children with (P)RMS. MethodsA retrospective review of the medical records of all children who underwent surgery and brachytherapy for (P)RMS at our institution since 2009 was conducted. ResultsSurgery for (P)RMS was performed in 6 patients at a median age of 19 months (range 8–50). Embryonal RMS was diagnosed in 4 patients and alveolar RMS in 2 patients, of which 1 patient had FOXO1 fusion-positive RMS. All patients underwent postoperative high-dose rate (HDR) brachytherapy. Organ-preserving surgery was achieved in 5 of 6 patients (83 %). In 1 patient, the entire sphincter was infiltrated, making organ-preserving resection impossible. 5 of 6 patients (83 %) exhibited an event-free and overall survival at a median follow-up of 26 months (range 8–107). One patient died due to locoregional recurrence. Complications were urethral leakage in 1 patient followed by urethral stenosis and delayed wound healing and vaginal stenosis in another patient. No patient reported fecal incontinence. ConclusionsCombined treatment with surgery and HDR brachytherapy is feasible in very young children with (P)RMS and leads to a favorable oncologic outcome. Preliminary data show a good functional preservation.

Application of modified grafted tubularized incised plate urethroplasty in hypospadias

To investigate the clinical feasibility and effectiveness of the modified grafted tubularized incised plate urethroplasty (G-TIP), namely "glans G-TIP (GG-TIP) ", in treatment of hypospadias. A clinical data of 137 children with hypospadias qualified by the selection criteria between January 2021 and June 2023 was retrospectively analyzed. Among them, 75 children were treated with GG-TIP (GG-TIP group) and 62 with G-TIP (G-TIP group). There was no significant difference ( P>0.05) between the two groups in terms of age, hypospadias type, penile length, penile head width, penile head height, penile curvature, meatus-apex distance, urethral plate width, and distance from the distal endpoint of navicular groove to the dorsal or ventral midline point of the glans corona, and the difference between the two. The operation time, reconstructed urethral length, distance from meatus to ventral glans corona, postoperative complications, maximum urinary flow rate at 2 weeks after operation, and the hypospadias objective scoring evaluation (HOSE) score at 6 months after operation in the two groups were recorded and analyzed. The operation time was significantly shorter in GG-TIP group than in G-TIP group ( P<0.05); but there was no significant difference ( P>0.05) between the two groups in terms of reconstructed urethral length and distance from meatus to ventral glans corona. All urinary meatus located at the tip of glans with vertical fissure shape. All children in the two groups were followed up 6-35 months (median, 26 months). During follow-up, there were 3 cases of urethral fistula, 2 cases of urethral stricture, and 1 case of glans separation in GG-TIP group, and 3, 3, and 1 cases in the G-TIP group, respectively. There was no significant difference in the incidence of complications between the two groups ( P>0.05). The maximum urinary flow rate at 2 weeks and the HOSE score at 6 months after operation were significantly higher in GG-TIP group than in G-TIP group ( P<0.05). GG-TIP is safe and effective for repairing hypospadias in children. Compared with G-TIP, it has the advantages of relatively simple operation, shortened operation time, significant improvement in urinary flow rate, and better cosmetic results.

Urinary Leakage after Robot-Assisted Radical Prostatectomy: Is Always Predictive of Functional Results?

Introduction: The aim of the study was to evaluate if and when the presence of radiological urinary leakages of vesico-urethral anastomosis, after robotic radical prostatectomy, could provoke urethral strictures or affect continence recovery. Methods: We enrolled 216 patients, undergoing robot-assisted radical prostatectomy between January 2020 and December 2022 in three high-volume referenced centres for robotic surgery. Before removal of the bladder catheter, all patients underwent a cystourethrography in which the presence/absence of leakage was assessed at level of vesico-urethral anastomosis. Based on degree of severity of urinary leakage on cystourethrography, patients were classified as no leakage or grade 0, grade 1 with transversal diameter ≤1 cm, and grade 2 with transversal diameter ≥1 cm. At follow-up, urethral stenosis formation and urinary continence recovery were assessed; furthermore, post-operative 12-month functional outcome was determined using EORTC-QLQ-PR25 questionnaire. Results: Radiological urinary leakage was found in 30 patients with grade 1 and 33 patients with grade 2, for a total of 63 patients. Only 1 patient (1.5%), grade 2 urinary leakage, developed significant urethral stricture and required endoscopic urethrotomy after 6 months. Analysing the differences in those who removed the bladder catheter after 7–9 days and those who kept it longer, we found no statistically significant differences regarding recovery of continence (p = 0.23) or about urinary symptoms (p = 0.94). Conclusions: RARP remains gold-standard approach for treatment of localized prostate cancer and the superiority of this technique is safe in preventing urethral strictures and continence recovery, even in presence of significant anastomotic urinary leakage.

Heterogeneous porous hypoxia-mimicking scaffolds propel urethral reconstruction by promoting angiogenesis and regulating inflammation

The nasty urine microenvironment (UME) impedes neourethral regeneration by inhibiting angiogenesis and inducing an excessive inflammatory response. Cellular adaptation to hypoxia improves regeneration in numerous tissues. In this study, heterogeneous porous hypoxia-mimicking scaffolds were fabricated for urethral reconstruction via promoting angiogenesis and modulating the inflammatory response based on sustained release of dimethyloxalylglycine (DMOG) to promote HIF-1α stabilization. Such scaffolds exhibit a two-layered structure: a dense layer composed of electrospun poly (l-lactic acid) (PLLA) nanofibrous mats and a loose layer composed of a porous gelatin matrix incorporated with DMOG-loaded mesoporous silica nanoparticles (DMSNs) and coated with poly(glycerol sebacate) (PGS). The modification of PGS could significantly increase rupture elongation, making the composite scaffolds more suitable for urethral tissue regeneration. Additionally, sustained release of DMOG from the scaffold facilitates proliferation, migration, tube formation, and angiogenetic gene expression in human umbilical vein endothelial cells (HUVECs), as well as stimulates M2 macrophage polarization and its regulation of HUVECs migration and smooth muscle cell (SMCs) contractile phenotype. These effects were downstream of the stabilization of HIF-1α in HUVECs and macrophages under hypoxia-mimicking conditions. Furthermore, the scaffold achieved better urethral reconstruction in a rabbit urethral stricture model, including an unobstructed urethra with a larger urethral diameter, increased regeneration of urothelial cells, SMCs, and neovascularization. Our results indicate that heterogeneous porous hypoxia-mimicking scaffolds could promote urethral reconstruction via facilitating angiogenesis and modulating inflammatory response.

The Historical Origins and Contemporary Role of the Endoscopic Treatment for Urethral Stricture Disease

The Historical Origins and Contemporary Role of the Endoscopic Treatment for Urethral Stricture Disease