Editing AUA: Urethral Stricture Disease (2023) (section)

==Management==

=== Urgent ===

====Indications====
#'''Discovery of symptomatic urinary retention'''
#'''Need for catheterization prior to another surgical procedure'''
====Options====
#'''Endoscopic'''
##'''Urethral dilation'''
##'''Direct visual internal urethrotomy [DVIU]'''
#'''Immediate suprapubic cystostomy'''
*Dilation and DVIU have similar success and complication rates
*Dilation
**Dilation over a guidewire is recommended to prevent false passage formation or rectal injury
**If the stricture is too dense to be adequately dilated, internal urethrotomy may be performed
*DVIU
**Different methods of performing DVIU, but cold knife and laser incision of the stricture scar appear to have similar success rates and may be used interchangeably
**Pharmacological agents (mitomycin C, steroids) may be injected into a urethral stricture at the time of DVIU to reduce risk of stricture recurrence.
*if these initial maneuvers are unsuccessful, or when subsequent definitive treatment for urethral stricture is planned in the near future, SP cystotomy may be performed
===Delayed===
===General Principles===
*'''When evaluating a patient with a recurrent urethral stricture, a physician who does not perform urethroplasty should consider referral to a surgeon with experience in this technique due to the higher rate of successful treatment compared to repeat endoscopic management.'''
===Approaches===
====Options====

# '''Endoscopic'''
## '''Dilation'''
## '''Direct visual internal urethrotomy [DVIU]'''
# '''Urethroplasty'''

===== Urethroplasty =====

* '''<span style="color:#ff0000">Generally divided into tissue transfer vs. non-tissue transfer techniques</span>'''
** '''<span style="color:#ff0000">Non-tissue transfer procedures</span>'''
***'''<span style="color:#ff0000">Primary anastomotic urethroplasty'''
***'''<span style="color:#ff0000">Can be performed in both a transecting (removing spongiosum) and non-transecting manner.</span>'''
****'''Transecting anastomotic urethroplasty: involves removal of the narrowed segment of the urethra and corresponding spongiofibrosis with anastamosis of the two healthy ends of the urethra'''
****'''Non-transecting anastomotic urethroplasty: preserves the corpus spongiosum''', thus allowing the strictured urethra to be excised and reanastamosed, or incised longitudinally through the narrowed segment of the urethra and closed in a Heineke-Mikulicz fashion.
**'''<span style="color:#ff0000">Tissue transfer procedures</span>'''
***'''Categorized into (2):'''
****'''Single stage'''
****'''Multi-stage procedures'''
***'''<span style="color:#ff0000">Grafts for substitution urethroplasty</span>'''
****'''<span style="color:#ff0000">Oral mucosa</span>'''
*****'''<span style="color:#ff0000">Should be used as the first choice</span>'''
*****'''<span style="color:#ff0000">May be harvested from the</span>'''
*****#'''<span style="color:#ff0000">Inner cheeks</span>'''
*****##Provide the largest graft area
*****##Results in fewer complications and better outcomes as compared to a lower lip donor site
*****##When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily
*****#'''<span style="color:#ff0000">Undersurface of the tongue</span>'''
*****#'''<span style="color:#ff0000">Inner lower lip</span>'''
*****Lingual mucosa is thinner than buccal mucosa, and thus may provide an advantage in reconstructive procedures of the distal urethra and meatus by causing less restriction of the urethral lumen.
*****When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily.
*****Adverse Events
******Buccal mucosal grafts
*******Donor site swelling
*******Oral numbness
*******Difficulty with mouth opening
******Lingual mucosal grafts
*******Difficulty with speech
*******Difficulty with tongue protrusion
******Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.
****'''Should not be performed with hair-bearing skin'''
*****Hair-bearing skin for substitution urethroplasty may result in urethral calculi, recurrent UTI and a restricted urinary stream due to hair obstructing the lumen
****'''Should not be performed with allograft, xenograft, or synthetic materials''' except under experimental protocols
***'''A single-stage tubularized graft urethroplasty should not be performed'''.
****Tubularized urethroplasty consists of a technique in which a graft or flap is rolled into a tube over a catheter to completely replace a segment of urethra. This approach, when attempted in a single stage, has a high risk of restenosis and should be avoided.
****When no alternative exists, a tubularized flap can be performed with '''results that are inferior to onlay flaps.'''
***'''In LS proven urethral stricture, genital skin should not be used for reconstruction'''.
****Treatment of genital skin LS reduces symptoms, such as skin itching and bleeding, and may serve to prevent meatus stenosis and progression to extensive stricture of the penile urethra. '''Current therapies rely heavily on topical moderate- to high-potency steroid creams, such as clobetasol or mometasone creams.'''
****The use of genital skin flaps and grafts should be avoided given that LS is a condition of the genital skin with very high long-term failure rates.
***'''Long multi-segment strictures (panurethral) may be reconstructed with one stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps or a combination of these techniques.'''
****Multi-segment strictures (frequently referred to as panurethral strictures) are most commonly defined as strictures >10cm spanning long segments of both the penile and bulbar urethra.
*****Several treatment options exist including long-term endoscopic management, , with or without a self-dilation protocol, urethroplasty, or perineal urethrostomy.
*****Very unlikely to be treated successfully with endoscopic means, which offer only temporary relief of obstruction
*****Urethroplasty in these instances is also more complicated, time-consuming, and has a higher failure rate as compared to urethroplasty for less complicated strictures
******Reconstruction of panurethral strictures should be addressed with all of the tools in the reconstructive armamentarium including fasciocutaneous flaps, oral mucosal grafts, or other ancillary tissue sources, and may require a combination of these techniques.
*'''Adverse Events'''
**'''<span style="color:#ff0000">Erectile dysfunction'''
***'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''
***'''The risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%'''
***'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''
**'''<span style="color:#ff0000">Ejaculatory dysfunction'''
***Signs (4):
***#Pooling of semen
***#Decreased ejaculatory force
***#Ejaculatory discomfort
***#Decreased semen volume
***Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction
****Has been reported by up to 21% of men following bulbar urethroplasty
***Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.

====Selecting Approach====
*'''<span style="color:#ff0000">Initial treatment based on location of stricture</span>'''
=====Meatal or Fossa navicularis=====
*'''<span style="color:#ff0000">Initial treatment of uncomplicated urethral stricture confined to the meatus or fossa navicularis: simple dilation or meatotomy,</span>''' with or without guidewire placement
*'''<span style="color:#ff0000">Completely obliterated strictures or associated with previous hypospadias repair, prior failed endoscopic manipulation, previous urethroplasty, or LS: urethroplasty'''
**Meatal and fossa navicularis strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments.
**Some patients may opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment such as urethroplasty.
*Options for the surgical treatment of meatal and fossa strictures
**Meatoplasty
**Extended meatotomy
**Variations of urethroplasty
*Important to consider both aesthetic and functional outcomes when reconstructing strictures involving the glanular urethra.
=====Penile urethra=====
*'''<span style="color:#ff0000">Initial treatment: urethroplasty</span>'''
**'''High recurrence rates are expected with endoscopic treatments,''' except in select cases of previously untreated short strictures.
*'''Penile urethral strictures are more likely to'''
**'''Be related to hypospadias, LS, or iatrogenic etiologies when compared to strictures of the bulbar urethra'''
**'''Require tissue transfer and/or a staged approach''' '''compared to bulbar urethral strictures'''
=====Bulbar urethra=====
*'''<span style="color:#ff0000">Initial treatment of stricture < 2cm: endoscopic management or urethroplasty</span>'''
**'''<span style="color:#ff0000">Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''
***'''<span style="color:#ff00ff">ROBUST III'''
****Patients with recurrent anterior urethral strictures <3cm in length
****Randomized to endoscopic treatment of the stricture combined with paclitaxel-coated urethral balloon versus DVIU/dilation
****Primary outcome: urethral patency at 6 months
****Secondary outcome: freedom from retreatment at 1 year
****Results
*****Drug-coated balloon had improved freedom from intervention at 1 year compared to DVIU/dilation alone (83.2% versus 21.7%)
****[https://pubmed.ncbi.nlm.nih.gov/34854748/ Elliott, Sean P., et al. "One-year results for the ROBUST III randomized controlled trial evaluating the Optilume® drug-coated balloon for anterior urethral strictures." ''The Journal of urology'' 207.4 (2022): 866-875.]
***Men receiving paclitaxel-coated urethral balloon should use contraception through 6 months posttreatment if their partner has child-bearing potential
****Significant levels of paclitaxel were measured in semen
*'''<span style="color:#ff0000">Initial treatment of stricture ≥2cm: urethroplasty</span>'''
**Longer strictures are less responsive to endoscopic treatment
**Urethroplasty may be performed using a variety of techniques based on the experience of the surgeon, most often through substitution or augmentation of the narrowed segment of the urethra.
*'''Urethroplasty should be offered following failed endoscopic management of anterior urethral strictures'''
**Urethral strictures that have been previously treated with dilation or DVIU are unlikely to be successfully treated with another endoscopic procedure with failure rates of >80%.
**'''Repeated endoscopic treatment may''' 
***'''Cause longer strictures'''
***'''Increase the complexity of subsequent urethroplasty'''
**In patients who are unable to undergo, or who prefer to avoid urethroplasty, repeated endoscopic procedures, or intermittent self-catheterization may be considered as palliative measures.

===Pre-operative Considerations===

==== Antibiotic Prophylaxis ====
*'''<span style="color:#ff0000">Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.</span>'''
**'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''
*'''[https://www.auanet.org/documents/Guidelines/PDF/Antimicrobial%20Prophylaxis%20Table%20V.pdf 2016 AUA Antibiotic Prophylaxis Guidelines]'''
**'''<span style="color:#ff0000">Antibiotic of choice: cefazolin'''
***'''With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins'''
*'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''
*To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours. 
**Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter

==== Deep Venous Thromboembolism Prophylaxis ====
*Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries.
*Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.

==== Positioning ====
*'''When using the lithotomy position, positioning of the extremities should be careful to avoid pressure on (3)'''
*#'''Calf muscles'''
*#'''Peroneal nerve'''
*#'''Ulnar nerve'''

===Post-operative Care===
*'''<span style="color:#ff0000">Following urethral stricture intervention, either a urethral catheter or suprapubic cystostomy catheter should be placed to divert urine from the site of intervention and prevent urinary extravasation</span>'''
**A urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal
*'''<span style="color:#ff0000">Duration of catheterization</span>'''
**'''<span style="color:#ff0000">Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours</span>'''
***There is no evidence that leaving the catheter longer than 72 hours improves safety or outcome, and catheters may be removed after 24-72 hours.
***Catheters may be left in longer for patient convenience or if in the surgeon’s judgment early removal will increase the risk of complications.
**'''In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after DVIU to maintain temporary urethral patency'''.
***The optimal protocol for DVIU plus self-catheterization remains uncertain. However, data suggests that performing self-catheterization for > 4 months after DVIU reduced recurrence rates compared to performing self-catheterization for < 3 months.
***Even though the risk of UTI does not appear to be increased in patients performing self-catheterization after DVIU, the ability to continue with self-catheterization may be limited in some patients by manual dexterity or pain with catheterization
**'''<span style="color:#ff0000">Following open urethral reconstruction, the catheter is maintained typically 2-3 weeks until urethrography or voiding cystography, demonstrates complete urethral healing</span>'''
***'''Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula.'''
***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''
*'''<span style="color:#ff0000">Antibiotic prophylaxis at the time of urethral catheter removal'''
**'''<span style="color:#ff0000">Recommended in patients with certain risk factors'''

===Post-operative follow-up===
*'''<span style="color:#ff0000">Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''
**'''Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.'''
***Other descriptions for successful treatment:
****Absence of postoperative or post-procedural patient reported obstructive voiding symptoms
****Patient-reported improvement in LUTS
****Peak uroflow >15m/sec
****PVR urine <100mL
****"Unobstructed" flow curve shape on uroflowmetry
****Absence of UTI
****Ability to pass a urethral catheter
**Consider more frequent follow-up intervals in '''males at an increased risk for stricture recurrence (7):'''
**#'''Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)'''
**#'''Long stricture'''
**#'''Repair involving a flap or graft'''
**#'''LS-related stricture'''
**#'''Hypospadias-related stricture'''
**#'''Smoking''' (tobacco use)
**#'''Diabetes'''
*Urethral Stents
**Although stents are not currently recommended for the treatment of urethral stricture, patients treated with a urethral stent after dilation or internal urethrotomy should be monitored for recurrent stricture and complications as these can occur at any time point after stent placement.
**Patients with completely obstructed stents may require open urethroplasty and removal of the stent.
**'''Stents do not need to be prophylactically removed and should be followed conservatively unless associated with significant urethral or voiding symptoms.'''