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Urethral Strictures: State of the Art and New Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Nephrology & Urology".

Deadline for manuscript submissions: closed (10 July 2021) | Viewed by 18659

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Special Issue Editor

Prof. Dr. Nicolaas C. Lumen

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Guest Editor

Department of Urology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
Interests: uro-oncology; urogenital reconstruction; robotic surgery

Special Issue Information

Dear Colleagues,

Urethral strictures can affect males, females, and transgender individuals, and are not uncommon in urological practice. Adequate management diagnosis, treatment, and follow-up are necessary in order to relieve the patient’s symptoms, improve the quality of life, and avoid complications in the long-term. Different diagnostic modalities (urethroscopy, uroflowmetry, urethrography, sonography) are used to evaluate urethral stricture disease, but the exact place of each modality still needs to be assessed. Treatment encompasses minimally invasive treatments (dilatation, stents, internal urethrotomy), open reconstruction (urethroplasty), and urinary diversion. Several treatments are usually possible for a specific type of stricture, but some treatments are more suitable than others. Comparative studies in urethral stricture treatment are sparse and necessary to clarify the question of whether one treatment is better than the other. Urethral surgeons usually evaluate the outcome of treatment by patency of the urethra and define this as “success”. However, a patient might suffer from incontinence, impotence, and other functional disturbances despite having a patent urethra, and will not experience the treatment as successful. Patient-reported outcome measures (PROMs) are necessary in order to evaluate this. Clinical studies and reviews, preferably systematic, are invited to answer some of the questions highlighted above.

Prof. Dr. Nicolaas C. Lumen
Guest Editor

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Keywords

urethra
urethral stricture
urethroplasty
urethrotomy
urethral dilatation
urethrography

Published Papers (8 papers)

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Research

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10 pages, 244 KiB

Open AccessArticle

Contemporary Management of Male Anterior Urethral Strictures by Reconstructive Urology Experts—Results from an International Survey among ESGURS Members

by Felix Campos-Juanatey, Enrique Fes-Ascanio, Jan Adamowicz, Fabio Castiglione, Andrea Cocci, Guglielmo Mantica, Clemens Rosenbaum, Wesley Verla, Malte W. Vetterlein, Marjan Waterloos, Luis A. Kluth and on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists (EAU YAU)

J. Clin. Med. 2022, 11(9), 2353; https://doi.org/10.3390/jcm11092353 - 22 Apr 2022

Cited by 1 | Viewed by 1452

Abstract

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. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

10 pages, 1270 KiB

Open AccessArticle

Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply?

by Felix Campos-Juanatey, Ainara Azueta Etxebarria, Paola Calleja Hermosa, Sara Marcos Gonzalez, Eneko Alonso Mediavilla, Miguel Angel Correas Gomez, Jose Antonio Portillo Martin and Jose Luis Gutierrrez Baños

J. Clin. Med. 2022, 11(7), 2064; https://doi.org/10.3390/jcm11072064 - 6 Apr 2022

Cited by 2 | Viewed by 1580

Abstract

Comparable outcomes were published using a buccal mucosa graft (BMG) from the cheek and a lingual mucosa graft (LMG) from the sublingual area, for urethral augmentation or substitution. To date, no histological comparison between both grafts has been conducted. We histologically assessed BMG and LMG harvested during urethral surgeries, aiming to compare graft properties and vascular support. We conducted a prospective single cohort study, including oral mucosa urethroplasty patients. During surgery, graft dimensions and donor sites were collected, and a 0.5 × 0.5 cm sample was obtained from the prepared graft. Formalin-fixed paraffin-embedded samples were sliced at 4 micrometres (µm) and hematoxylin-eosin stained. Using a telepathology tool, all slides were digitalized and measured from 10× to 40× magnification. In each graft, global and individual layers thicknesses were assessed, including vascular density and area. Descriptive and comparative (parametrical and non-parametrical) statistical analysis occurred. We collected 57 grafts during 33 urethroplasties, with 30 BMG and 22 LMG, finally, included. The mean age was 56.6 (SD 15.2) years, and the mean graft length was 5.8 (SD 1.7) cm and the width was 1.7 (SD 0.4) cm. The median graft thickness was 1598.9 (IQR 1200–2100) µm, the mean epithelium layer was 510.2 (SD 223.7) µm, the median submucosa was 654 (IQR 378–943) µm. the median muscular was 477.6 (IQR 286–772) µm, the median vascular area was 5% (IQR 5–10), and the median adipose tissue area was 5% (IQR 0–20). LMG were significantly longer and narrower than BMG. Total graft thickness was similar between LMG and BMG, but the epithelium and submucosa layers were significantly thinner in LMG. The muscular layer was significantly thicker in LMG. Vascular density and vascular areas were not significantly different between both types of grafts. LMG showed significantly less adipose tissue compared with BMG. Our findings show LMG and BMG for urethroplasty surgeries share the same thickness and blood supply, despite having significantly different graft sizes as well as mucosal and submucosal layers thickness. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

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8 pages, 224 KiB

Open AccessArticle

Treatment of Meatal Strictures by Dorsal Inlay Oral Mucosa Graft Urethroplasty: A Single-Center Experience

by Michel Wirtz, Wietse Claeys, Philippe Francois, Marjan Waterloos, Mieke Waterschoot and Nicolaas Lumen

J. Clin. Med. 2021, 10(19), 4312; https://doi.org/10.3390/jcm10194312 - 22 Sep 2021

Viewed by 1754

Abstract

Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Methods: Patients who underwent a single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of a minimum of 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethroplasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients’ complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69–110) months. Seven (17.5%) patients suffered a stricture recurrence of which four (10%) needed re-intervention. The median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. The median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p = 0.03). Post-operative complications were identified in 11 (27.5%) patients with only one (2.5%) patient who had a grade 3a complication. Conclusions: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible technique for selected patients with meatal stenosis. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

11 pages, 557 KiB

Open AccessArticle

Adverse Features of Rectourethral Fistula Requiring Extirpative Surgery and Permanent Dual Diversion: Our Experience and Recommendations

by Francisco E. Martins, João Felicio, Tiago Ribeiro Oliveira, Natália Martins, Vítor Oliveira and Artur Palmas

J. Clin. Med. 2021, 10(17), 4014; https://doi.org/10.3390/jcm10174014 - 5 Sep 2021

Cited by 6 | Viewed by 2275

Abstract

Introduction: To report a series of men with a rectourethral fistula (RUF) resulting from pelvic cancer treatments and explore their therapeutic differences and impact on the functional outcomes and quality of life highlighting the adverse features that should determine permanent urinary or dual diversion. Methods: A retrospective database search was performed in four centers to identify patients with RUF resulting from pelvic cancer treatment. Medical records were analyzed for the demographics, comorbidities, diagnostic evaluation, fistula characteristics, surgical approaches and outcomes. The endpoints analyzed included a successful fistula closure following a repair and the impact of the potential adverse features on outcomes. Results: Twenty-three patients, aged 57–79 years (median 68), underwent an RUF reconstruction. The median follow-up (FU) was 54 months (range 18–115). The patients were divided into two groups according to the etiology: radiation/energy-ablation treatments with or without surgery (G1, n = 10) and surgery only (G2, n = 13). All of the patients underwent a temporary diverting colostomy and suprapubic cystostomy. Overall, a successful RUF closure was achieved in 18 (78%) patients. An interposition flap was used in six (60%) patients and one (7.7%) patient in groups G1 and G2, respectively (p = 0.019). The RUF was managed successfully in all 13 patients in group G2 as opposed to 5/10 (50%) in group G1 (p = 0.008). The patients in the radiation/energy-ablation group were more likely to require permanent dual diversion (50% vs. 0%, p < 0.0075). Conclusion: Radiation/energy-ablation therapies are associated with a more severe RUF and more complex reconstructions. Most of these patients require an abdominoperineal approach and flap interposition. The failure of an RUF repair with the need for permanent dual diversion, eventually combined with extirpative surgery, is higher after previous radiation/energy-ablation treatment. Therefore, permanent dual diversion as the primary treatment should always be included in the decision-making process as reconstruction may be futile in specific settings. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

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7 pages, 15373 KiB

Open AccessArticle

Female Urethroplasty: Outcomes of Different Techniques in a Single Center

by Marjan Waterloos, Wesley Verla, Michel Wirtz, Mieke Waterschoot, Wietse Claeys, Philippe Francois and Nicolaas Lumen

J. Clin. Med. 2021, 10(17), 3950; https://doi.org/10.3390/jcm10173950 - 31 Aug 2021

Cited by 2 | Viewed by 1906

Abstract

Introduction: Female urethral strictures and injuries are relatively uncommon compared to males. A wide range of possible causes and treatment modalities have been described. Lately female urethral reconstruction is gaining attention and is fortunately no longer a neglected topic within the reconstructive urology. As such, we aimed to describe our surgical techniques and outcomes for female urethroplasty from a tertiary center. Materials and Methods: Records of female patients who underwent a urethroplasty between July 2018 and May 2021 in our tertiary referral center were reviewed. Patients were subdivided in two groups: patients who suffered from a urethral injury and received an early repair urethroplasty, and patients with a true urethral stricture who received a delayed urethroplasty. Preprocedural, surgical and postoperative data were collected and analyzed with descriptive statistics. Results: A total of five patients in group 1 and nine patients in group 2 were included. Etiology of the urethral injury in group 1 was iatrogenic in 80% and transitional cell carcinoma of the urethra in 20% of cases. A patency rate of 100% at a follow-up of 30 months was achieved with the different techniques. In group 2 etiology was idiopathic (44%), iatrogenic (44%) and due to external trauma in 12% of cases. Urethroplasty technique consisted of primary repair or dorsal onlay of a buccal mucosal graft. Patency rate was 100% at a median follow-up of 13 months. Three patients suffered from postoperative urinary incontinence, one in group 1 and two in group 2. Conclusion: Female urethroplasty is a relatively rare entity within reconstructive urethral surgery. This case series of 14 patients demonstrates that with appropriate surgical techniques, a high patency rate with a low complication rate can be achieved. Further prospective studies with standardized diagnostic workup and follow-up should be performed in order to optimize management strategy. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

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7 pages, 230 KiB

Open AccessArticle

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia

by Clemens M. Rosenbaum, Malte W. Vetterlein, Margit Fisch, Philipp Reiss, Thomas Stefan Worst, Jennifer Kranz, Joachim Steffens, Luis A. Kluth, Daniel Pfalzgraf and on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU)

J. Clin. Med. 2021, 10(13), 2884; https://doi.org/10.3390/jcm10132884 - 29 Jun 2021

Cited by 13 | Viewed by 2100

Abstract

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months; IQR 4–10) and those without BNC recurrence (10 months; IQR 6–20; p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months; IQR 6–9) compared to those treated successfully (median 12 months; IQR 9–25; p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months; IQR 2–12) and those without a recurrence (6 months; IQR 6–10; p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%; p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

Review

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18 pages, 1747 KiB

Open AccessReview

Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

by Francisco E. Martins, Henriette Veiby Holm and Nicolaas Lumen

J. Clin. Med. 2021, 10(21), 4920; https://doi.org/10.3390/jcm10214920 - 24 Oct 2021

Cited by 6 | Viewed by 3521

Abstract

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1–8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients’ quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

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16 pages, 1271 KiB

Open AccessReview

Treatment of Urethral Strictures in Transmasculine Patients

by Mieke Waterschoot, Wietse Claeys, Piet Hoebeke, Wesley Verla, Marjan Waterloos, Michel Wirtz, Marlon Buncamper and Nicolaas Lumen

J. Clin. Med. 2021, 10(17), 3912; https://doi.org/10.3390/jcm10173912 - 30 Aug 2021

Cited by 7 | Viewed by 2943

Abstract

Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters. Full article

(This article belongs to the Special Issue Urethral Strictures: State of the Art and New Perspectives)

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