Urethral Stricture

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Meatal & Fossa Navicularis Strictures

Management:

Dilation 

Meatotomy

Urethroplasty: For recurrent strictures.

Penile Urethral Strictures

Management:

Substitution Urethroplasty

Penile strictures are rarely cured by dilatation or urethrotomy.

Urethroplasty is needed for all strictures of the penile urethra.

Stricturotomy and patch:

Stricturotomy and patch is preferable to excision and a tube‐graft flap.

Grafts (like buccal mucosa) and flaps are equally good.

Grafts are easier to use. Occasionally, when the local conditions are not favorable for a graft, a flap must be used. Like when there is extensive scarring from previous surgery or radiotherapy.

Genital skin flaps should be avoided in Lichen sclerosis.

Circumferential repair:

Is needed if urethral segment needs to be excised due to irretrievably scarred  urethra after previous surgeries, or  irretrievably fibrotic in lichen sclerosis.

When a circumferential repair is needed, a two stage reconstruction is more reliable than a one stage technique.

In such circumstances a graft is interposed as a flat plate. The flat plate is then rolled in to form a tube and closed in layers at a second stage three to six months later.

Bulbar Urethral Stricture
< 2 cm

Management:

Urethral dilation

Direct visual internal urethrotomy (DVIU):

Urethral catheter maybe removed within 72 hours.

Self-catheterization maybe advised.

Anastomotic urethroplasty 
Bulbar Urethral Stricture

≥2cm

Management:

Anastomotic urethroplasty 

Excision with primary anastomosis is the gold standard.

Previously, excision with primary anastomosis was limited to strictures shorter than 1.5 to 2 cm. However, in some cases, strictures up to 3 to 5 cm can be totally excised, and a primary anastomosis can be performed.

Stricturotomy and patch

If a bulbar stricture is too long for anastomotic urethroplasty.

We will usually use a buccal mucosal graft as a patch.

Pelvic Fracture Urethral Injury (PFUI)

Delayed anastomotic urethroplasty after major injuries stabilize
should be done.

Bladder Neck Contracture

Etiology:

Surgical treatment of benign prostatic enlargement.

Management:

Dilation: 

First-line treatment. 

Up to 90% may recur within the first two years. 

Bladder neck incision:

Hot-knife, cold-knife, or laser techniques. 

Self-catheterization maybe advised after procedure.

Transurethral resection

Permanent suprapubic catheters 

Open reconstruction: 

For recalcitrant stenosis. 

Y-V plasty techniques. 

Bladder neck ablation with injection of cytotoxic agents like mitomycin C can be associated with significant complications, including extravasation or bladder neck necrosis. 

Vesicourethral Anastomotic Stenosis

Etiology: Post radical prostatectomy anastomotic stricture.

Management:

Dilation

Incision:

Fistulation to the pubic symphysis is a rare but serious complication after endoscopic procedures in patients with history of radiation therapy. 

Patient will have severe pelvic pain. MRI should be done. 

Urinary diversion is required.

Resection

Intermittent catheterization 

Open reconstruction:

Require placement of an artificial urinary sphincter.
 

Post Instrumentation Urethral Stricture

Etiology:

Instrumentation as in transurethral resection of prostate. 

Most common site: membranous urethra

Management:

Urethral dilatation: 

It is the treatment of choice.

Radiation-Induced Urethral Stenosis

Most common Location: 

proximal bulbar urethra to prostatic apex.

Management:

Endoscopic techniques: 

Usually refractory to them.

Urethroplasty: 

If endoscopic treatments fails.

Urinary diversion: 

If there is extensive prostate necrosis, cavitation, prostatosymphyseal fistula, osteomyelitis, or a small functional bladder capacity.