Innovative Approaches for Complex Penile Urethral Strictures
Innovative Approaches for Complex Penile Urethral Strictures
Initial management of anterior urethral strictures often involves trials of minimally invasive therapies such as dilation and internal urethrotomy. Dilation techniques may involve catheters, filiforms with followers, balloon dilators, and/or urethral sounds. Direct vision internal urethrotomy (DVIU) involves incising the narrowed urethral segment endoscopically and then allowing the urethral segment to heal at a larger diameter. Despite similarly poor long-term success rates with these options (0–30% for DVIU). they continue to be the most common treatment applied to strictures of the anterior male urethra.
Multiple studies have demonstrated declining efficacy after repeated DVIU attempts, with success rates as low as 0% at four years reported after a second procedure. It also appears that multiple internal urethrotomy procedures promote increased scar formation and the possibility of a longer, more dense stricture at the time of open repair. This adverse effect, though, does not appear to effect success rates for subsequent open repair. Some reports have suggested that a single initial attempt with DVIU in the appropriate stricture is a cost effective approach prior to attempted open urethroplasty. Others have argued for urethroplasty as an initial management strategy in situations DVIU is likely to fail, such as cases of long strictures (>2 cm) or those located in the penile urethra.
Open urethral reconstruction has a high rate of success in treating strictures, with long-term patency achieved in 85–90%. As such, multiple urethroplasty techniques may be employed based on the characteristics of the strictured segment. With a high success rate (90–95%), excision and primary anastomosis (EPA) involves transection of the urethra with removal of the diseased urethra segment and reanastomosis of the spatulated urethral segments. Unfortunately EPA is limited to short bulbar strictures of 1–2 cm, where the excision will not result in penile shortening or chordee. Augmented anastomotic urethroplasty represent a viable option in cases where the stricture defect is 2 to 4 cm long. Longer strictures often require tissue substitution with grafts or flaps.
Complex anterior urethral strictures, including those resulting from failed hypospadias repair, prior urethroplasty, or those with obliterative urethral segments, provide a unique challenge to reconstructive urologists. These difficult cases often require complete excision of long urethral segments as well as circumferential tissue substitution. Tubularized flaps and grafts have been attempted in the past but were abandoned due to high recurrence rates approaching 50%. Given the poor results observed in initial small series, these cases have typically been managed with improved success using a 2-stage Johanson technique. This technique requires a 6-month interval between the first stage grafting and the subsequent completion stage where the neourethra is tubularized. This time interval with a severely hypospadic urethra is often undesirable to many patients. Furthermore, recent reports have shown that a large number of these patients undergoing "two-stage repair" will actually require far more procedures than just the name implies. The need for multiple procedures in patients undergoing two-stage repair as well as patient unwillingness has led to the development of some innovative approaches for challenging, long strictures of the anterior urethra.
Management Approach to Anterior Urethral Strictures
Initial management of anterior urethral strictures often involves trials of minimally invasive therapies such as dilation and internal urethrotomy. Dilation techniques may involve catheters, filiforms with followers, balloon dilators, and/or urethral sounds. Direct vision internal urethrotomy (DVIU) involves incising the narrowed urethral segment endoscopically and then allowing the urethral segment to heal at a larger diameter. Despite similarly poor long-term success rates with these options (0–30% for DVIU). they continue to be the most common treatment applied to strictures of the anterior male urethra.
Multiple studies have demonstrated declining efficacy after repeated DVIU attempts, with success rates as low as 0% at four years reported after a second procedure. It also appears that multiple internal urethrotomy procedures promote increased scar formation and the possibility of a longer, more dense stricture at the time of open repair. This adverse effect, though, does not appear to effect success rates for subsequent open repair. Some reports have suggested that a single initial attempt with DVIU in the appropriate stricture is a cost effective approach prior to attempted open urethroplasty. Others have argued for urethroplasty as an initial management strategy in situations DVIU is likely to fail, such as cases of long strictures (>2 cm) or those located in the penile urethra.
Open urethral reconstruction has a high rate of success in treating strictures, with long-term patency achieved in 85–90%. As such, multiple urethroplasty techniques may be employed based on the characteristics of the strictured segment. With a high success rate (90–95%), excision and primary anastomosis (EPA) involves transection of the urethra with removal of the diseased urethra segment and reanastomosis of the spatulated urethral segments. Unfortunately EPA is limited to short bulbar strictures of 1–2 cm, where the excision will not result in penile shortening or chordee. Augmented anastomotic urethroplasty represent a viable option in cases where the stricture defect is 2 to 4 cm long. Longer strictures often require tissue substitution with grafts or flaps.
Complex anterior urethral strictures, including those resulting from failed hypospadias repair, prior urethroplasty, or those with obliterative urethral segments, provide a unique challenge to reconstructive urologists. These difficult cases often require complete excision of long urethral segments as well as circumferential tissue substitution. Tubularized flaps and grafts have been attempted in the past but were abandoned due to high recurrence rates approaching 50%. Given the poor results observed in initial small series, these cases have typically been managed with improved success using a 2-stage Johanson technique. This technique requires a 6-month interval between the first stage grafting and the subsequent completion stage where the neourethra is tubularized. This time interval with a severely hypospadic urethra is often undesirable to many patients. Furthermore, recent reports have shown that a large number of these patients undergoing "two-stage repair" will actually require far more procedures than just the name implies. The need for multiple procedures in patients undergoing two-stage repair as well as patient unwillingness has led to the development of some innovative approaches for challenging, long strictures of the anterior urethra.