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Urethral Stricture

This is an excellent review of urethroplasty management.  (8)

ANTIBIOTICS POST URETHROPLASTY
One study found positive urine culture and UTI does not appear to impair urethral healing or influence wound healing, suggesting that postoperative antibiotic prophylaxis may in fact offer no benefit. (21)
​
ENDOSCOPIC VS. URETHROPLASTY
Multiple studies have shown the long term efficacy of urethroplasty and the high recurrence rate of endoscopic treatments (15- 18).  Repeat endoscopic treatment is associated with increased stricture length, complexity and prolonged disease duration (11,19) and studies have suggested it is associated with a higher failure rate of urethroplasty.  (12-14)

POST URETHROPLASTY RECURRENCE
One retrospective study showed recurrences most likely to occur within 12mo, with short type A strictures managed successfully with endoscopy. (20)

BURIED PENIS REPAIR
This is a good video and also shows how there is a high complication rate after buried penis repair. (9)

URETRAL DILATION VS. DVIU 
Some studies have shown there is no difference in recurrence rates in DVIU vs. dilation. (8) A recent retrospective study challenged that. (10)

Elder patients seem to perform as well as other patients and should be offered definitive treatment. Nearly half of men over 60 have strictures are from iatrogenic source. (4)

UREOTHROPLASTY AFTER AUS EROSION STRICTURE
A study of 31 men with AUS erosion causing stricture followed by urethroplasty found no stricture recurrence at 22.0mo (IQR 15-39) f/u in the 28 patients cystoscopy was performed in. 87%  of AUS were replaced after stricture repair at median of 6mo (IQR 4-7).  36% has revisions due to complications. 29% of patients had h/o radiation therapy.
The authors conclude that in patients with urethral stricture after AUS erosion, urethroplasty is successful. However, AUS replacement after urethroplasty has a high erosion rate even in the short-term. (5)

WAIT TIME FOR URETHROPLASTY
A 276 patient retrospective study showed median surgical wait time was 151 days and 16% of patients experienced a complication while awaiting urethroplasty.  This study found the optimal wait time should be less than 43 days. (6)

URETHRAL TISSUE ENGINEERING
Short review article. (22)

PER 2018 AUA UPDATE:
Normal urethral is ~24fr at fossa navicularis and 30fr along remainder of urethra. Caliber less than 16fr is likely to be clinically significant. The urethra should rest 2.5 to 3 months after urethral trauma or stricture treatment (including scope dilation or catheterization before performing an evaluation for surgical planning, allowing stricture to stabilize. Can place an SPT if patient at high risk for retention or other complications.
Most workups completed with cystourethroscopy, RUG and VCUG. However, if pelvic fracture (especially w/ ED), penile duplex can show how 30% of these cases w/ ED also have pudendal vascular disruption which may compromise blood flow to urethra in retrograde fashion. Anterograde blood through bulbar arteries should be confirmed and if dorsal penile artery supply is not adequate, revascularization can take place. This avoids ischemic stenosis.

EPA


  • Spatulate to >30fr
  • 97-98% success rate w/ short strictures, some report up to 5cm (1,2)

RUG: 1 obturator foramen should be viewed. Use cone shaped adapter (not balloon) w/ penis on stretch.
Bladder cancer is a contraindication to SPT placement
Wait 2.5 to 3 months after urethral stricture treatment for eval for surgical planning

Testosterone deficiency may play a role in urethral stricture disease by decreasing periurethral vascularity.  (3) One logical conclusion is to offer testosterone replacement for hypogonadal men.  (7)

  1. Terlecki RP, Steele MC, Valadez C et al: Grafts are unnecessary for proximal bulbar reconstruction. J Urol 2010; 184: 2395.
  2. Eltahawy EA, Virasoro R, Schlossberg SM et al: Longterm followup for excision and primary anastomosis for anterior urethral strictures. J Urol 2007; 177: 1803.
  3. Hofer, Matthias D., et al. "Low testosterone levels result in decreased periurethral vascularity via an androgen receptor-mediated process: pilot study in urethral stricture tissue." Urology105 (2017): 175-180.
  4. Levy, Mya, et al. "The impact of age on urethroplasty success." Urology 107 (2017): 232-238.
  5. Keihani, Sorena, et al. "Outcomes of Urethroplasty to Treat Urethral Strictures Arising From Artificial Urinary Sphincter Erosions and Rates of Subsequent Device Replacement." Urology 107 (2017): 239-245.
  6. Hoy, Nathan Y., et al. "Incidence and Predictors of Complications due to Urethral Stricture in Patients Awaiting Urethroplasty." The Journal of urology 199.3 (2018): 754-759.
  7. Morey, Allen F. "Re: Low Testosterone Levels Result in Decreased Periurethral Vascularity via an Androgen Receptor-Mediated Process: Pilot Study in Urethral Stricture Tissue." The Journal of urology 199.2 (2018): 334-335.
  8. Hampson, Lindsay A., Jack W. McAninch, and Benjamin N. Breyer. "Male urethral strictures and their management." Nature Reviews Urology 11.1 (2014): 43.
  9. Jun, Min S., Maxx A. Gallegos, and Richard A. Santucci. "Contemporary management of adult‐acquired buried penis." BJU international (2018).
  10. Sukumar, S., Elliott, S. P., Myers, J. B., Voelzke, B. B., Smith, T. G., Carolan, A. M. C., … Erickson, B. A. (2018). Multi-Institutional Outcomes of Endoscopic Management of Stricture Recurrence after Bulbar Urethroplasty. The Journal of Urology, 200(4), 837–842.
  11. Hudak, S. J., Atkinson, T. H., & Morey, A. F. (2012). Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration. The Journal of Urology, 187(5), 1691–1695.
  12. Hudak, S. J., Atkinson, T. H., & Morey, A. F. (2012). Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration. The Journal of Urology, 187(5), 1691–1695.
  13. Breyer, B. N., McAninch, J. W., Whitson, J. M., Eisenberg, M. L., Mehdizadeh, J. F., Myers, J. B., & Voelzke, B. B. (2010). Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome. The Journal of Urology, 183(2), 613–617.
  14. Horiguchi, A., Shinchi, M., Masunaga, A., Ito, K., Asano, T., & Azuma, R. (2018). Do Transurethral Treatments Increase the Complexity of Urethral Strictures. The Journal of Urology, 199(2), 508–514.
  15. Greenwell, T. J., Castle, C., Andrich, D. E., MacDONALD, J. T., Nicol, D. L., & Mundy, A. R. (2004). REPEAT URETHROTOMY AND DILATION FOR THE TREATMENT OF URETHRAL STRICTURE ARE NEITHER CLINICALLY EFFECTIVE NOR COST-EFFECTIVE. The Journal of Urology, 172(1), 275–277.
  16. Barbagli, G., Kulkarni, S. B., Fossati, N., Larcher, A., Sansalone, S., Guazzoni, G., … Lazzeri, M. (2014). Long-Term Followup and Deterioration Rate of Anterior Substitution Urethroplasty. The Journal of Urology, 192(3), 808–813.
  17. Santucci, R., & Eisenberg, L. (2010). Urethrotomy Has a Much Lower Success Rate Than Previously Reported. The Journal of Urology, 183(5), 1859–1862.
  18. Santucci, R. A., Mario, L. A., & Aninch, J. W. M. c. (2002). ANASTOMOTIC URETHROPLASTY FOR BULBAR URETHRAL STRICTURE: ANALYSIS OF 168 PATIENTS. The Journal of Urology, 167(4), 1715–1719.
  19. Viers, B. R., Pagliara, T. J., Shakir, N. A., Rew, C. A., Folgosa-Cooley, L., Scott, J. M., & Morey, A. F. (2018). Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs. The Journal of Urology, 199(2), 515–521.
  20. Kahokehr, Arman A., et al. “A Critical Analysis of Bulbar Urethroplasty Stricture Recurrence: Characteristics and Management.” The Journal of Urology, vol. 200, no. 6, 2018, pp. 1302–1307.
  21. Manjunath, Adarsh, et al. "Antibiotic prophylaxis after urethroplasty may offer no benefit." World journal of urology (2019): 1-7.
  22. ​Mangir, Naside, et al. "Current state of urethral tissue engineering." Current opinion in urology 29.4 (2019): 385-393.
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