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

===== 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.