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AUA: Urethral Stricture Disease (2023): Difference between revisions

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'''See [https://test.urologyschool.com/index.php/Penis_and_Urethra_Surgery#Urethral_stricture_disease Urethral Stricture Disease Chapter Notes]'''
'''See [https://test.urologyschool.com/index.php/Penis_and_Urethra_Surgery#Urethral_stricture_disease Urethral Stricture Disease Chapter Notes]'''
==Background==
==Background==
*'''See [https://test.urologyschool.com/index.php/Urethra Urethral Anatomy Chapter Notes]'''
*'''See [[Urethra|Urethral Anatomy Chapter Notes]]'''
*'''<span style="color:#ff0000">“Urethral stricture” is the preferred term for any abnormal narrowing of the anterior urethra</span>''', which is surrounded by the corpus spongiosum; urethral strictures are associated with varying degrees of spongiofibrosis.
*'''<span style="color:#ff0000">“Urethral stricture” is the preferred term for any abnormal narrowing of the anterior urethra</span>''', which is surrounded by the corpus spongiosum; urethral strictures are associated with varying degrees of spongiofibrosis.
**'''Narrowing of the posterior urethra, which lacks surrounding spongiosum, is referred to as a “stenosis.”'''
**'''Narrowing of the posterior urethra, which lacks surrounding spongiosum, is referred to as a “stenosis.”'''
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===Preoperative Assessment===
===Preoperative Assessment===
*'''<span style="color:#ff0000">Stricture characteristics important for subsequent treatment planning (3):</span>'''
*'''<span style="color:#ff0000">Important stricture characteristics for subsequent treatment planning (4):</span>'''
*#'''<span style="color:#ff0000">Stricture location in the urethra</span>'''
*#'''<span style="color:#ff0000">Stricture location in the urethra</span>'''
*#'''<span style="color:#ff0000">Length of the stricture</span>'''
*#'''<span style="color:#ff0000">Length of the stricture</span>'''
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#'''<span style="color:#ff0000">Cystourethroscopy</span>'''
#'''<span style="color:#ff0000">Cystourethroscopy</span>'''
#'''<span style="color:#ff0000">Ultrasound urethography</span>'''
#'''<span style="color:#ff0000">Ultrasound urethography</span>'''
*'''Retrograde urethrogram, with or without voiding cystourethrography'''
 
**'''Remains the study of choice for delineation of stricture length, location, and severity in men'''
* '''<span style="color:#ff0000">Males with a urethral stricture who have been managed with either an indwelling urethral catheter or self-dilation should generally undergo suprapubic cystostomy placement prior to imaging</span>'''
** This allows the full length of the stricture to develop to determine the true severity of the stricture including its degree of narrowing, and accurate determination of definitive treatment options
**'''A period of “urethral rest” between 4-6 weeks allows the stricture to mature prior to evaluation and management'''.
***A similar period of observation is recommended before reassessing a stricture after failure or dilation or DVIU.
**If a patient can forgo  clean intermittent catheterization (CIC) without acute urinary retention, a SP tube may be omitted during urethral rest.
 
==== Retrograde urethrogram, with or without voiding cystourethrography ====
*'''<span style="color:#ff0000">Remains the study of choice for delineation of stricture length, location, and severity in men'''
*'''Advantages'''
**'''Can be used to evaluate stricture'''
**'''Can be used to evaluate stricture'''
**#'''Location in the urethra'''
**#'''Location in the urethra'''
**#'''Length'''
**#'''Length'''
**#'''Degree of lumen narrowing'''
**#'''Degree of lumen narrowing'''
*'''Disadvantages'''
**'''Complete or near complete occlusion of the urethra may make the assessment of the urethra proximal to the stricture difficult.'''
***In this instance, RUG may be combined with antegrade VCUG or other methods to define the extent of the stricture.
**Image quality and accuracy of RUG is operator-dependent; surgical planning should be based on high quality images generated by experienced practitioners or the surgeon him/herself
**Image quality and accuracy of RUG is operator-dependent; surgical planning should be based on high quality images generated by experienced practitioners or the surgeon him/herself
**Risks
*Adverse Events
***Patient discomfort
**Patient discomfort
***UTI (rare)
**UTI (rare)
***Hematuria
**Hematuria
***Contrast extravasation (very rare)
**Contrast extravasation (very rare)
***Contrast reaction, should there be an allergy
**Contrast reaction, should there be an allergy
****Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers
***Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers
**Complete or near complete occlusion of the urethra may make the assessment of the urethra proximal to the stricture difficult. In this instance, RUG may be combined with antegrade VCUG or other methods to define the extent of the stricture.
 
*'''Voiding Cystourethrography'''
==== Voiding Cystourethrography ====
*Technique
**Performed by passing a small catheter proximal to the stricture, by retrograde filling of the bladder during RUG, or by antegrade filling via a SP tube
**Performed by passing a small catheter proximal to the stricture, by retrograde filling of the bladder during RUG, or by antegrade filling via a SP tube
**Allows visualization of the urethra but is not always sufficient to completely delineate the distal extent of an urethral stricture.
*When used in conjunction with urodynamics to asses complex voiding dysfunction, elevated detrusor voiding pressures and urethral narrowing on VCUG indicate a clinically significant urethral stricture or other obstructive process.
**When used in conjunction with urodynamics to asses complex voiding dysfunction, elevated detrusor voiding pressures and urethral narrowing on VCUG indicate a clinically significant urethral stricture or other obstructive process.
**In females, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG)
***In females, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG)
*'''Advantage'''
*'''Urethroscopy'''
**'''Allows visualization of the urethra'''
**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber, but the length of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases.'''
*'''Disadvantage'''
**'''Not always sufficient to completely delineate the distal extent of an urethral stricture'''
 
==== Urethroscopy ====
*'''Advantage'''
**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber'''
*'''Disadvantage'''
**'''Length of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases'''
***When flexible cystoscopy does not allow visual assessment proximal to the urethral stricture, small caliber cystoscopy with a ureteroscope or flexible hysteroscope can be useful adjuncts.
***When flexible cystoscopy does not allow visual assessment proximal to the urethral stricture, small caliber cystoscopy with a ureteroscope or flexible hysteroscope can be useful adjuncts.
*Ultrasound Urethrography
 
**Can be used to evaluate stricture
==== Ultrasound Urethrography ====
**#Location in the urethra
*'''Can be used to evaluate stricture'''
**#Length
*#'''Location in the urethra'''
**#Degree of lumen narrowing
*#'''Length'''
**High sensitivity and specificity in the male anterior urethra
*#'''Degree of lumen narrowing'''
**Adverse events
*High sensitivity and specificity in the male anterior urethra
***Patient discomfort
*Adverse events
**Dependent on a skilled ultrasonographer
**Patient discomfort
**Further studies are needed to validate its value in clinical practice.
*Dependent on a skilled ultrasonographer
*'''<span style="color:#ff0000">Males with a urethral stricture who have been managed with either an indwelling urethral catheter or self-dilation should generally undergo suprapubic cystostomy placement prior to imaging</span>'''
*Further studies are needed to validate its value in clinical practice.
**This allows the full length of the stricture to develop to determine the true severity of the stricture including its degree of narrowing, and accurate determination of definitive treatment options
**'''A period of “urethral rest” between 4-6 weeks allows the stricture to mature prior to evaluation and management'''.
***A similar period of observation is recommended before reassessing a stricture after failure or dilation or DVIU.
**If a patient can forgo  clean intermittent catheterization (CIC) without acute urinary retention, a SP tube may be omitted during urethral rest.


==Management==
==Management==
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*****#'''<span style="color:#ff0000">Inner lower lip</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.
*****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.
*****Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.
*****Buccal mucosal grafts carried a higher risk of donor site swelling, oral numbness, and difficulty with mouth opening, while patients undergoing lingual mucosal grafts demonstrated higher risk of difficulty with speech and difficulty with tongue protrusion
*****When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily.
*****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'''
****'''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
*****Hair-bearing skin for substitution urethroplasty may result in urethral calculi, recurrent UTI and a restricted urinary stream due to hair obstructing the lumen
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******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.
******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'''
*'''Adverse Events'''
**'''Erectile dysfunction'''
**'''<span style="color:#ff0000">Erectile dysfunction'''
***'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''
***'''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%'''
***'''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'''
***'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''
**'''Ejaculatory dysfunction'''
**'''<span style="color:#ff0000">Ejaculatory dysfunction'''
***Signs (4):
***Signs (4):
***#Pooling of semen
***#Pooling of semen
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=====Bulbar urethra=====
=====Bulbar urethra=====
*'''<span style="color:#ff0000">Initial treatment of stricture < 2cm: endoscopic management or urethroplasty</span>'''
*'''<span style="color:#ff0000">Initial treatment of stricture < 2cm: endoscopic management or urethroplasty</span>'''
**'''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:#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.'''
***ROBUST III
***'''<span style="color:#ff00ff">ROBUST III'''
****Patients with recurrent anterior urethral strictures <3cm in length
****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
****Randomized to endoscopic treatment of the stricture combined with paclitaxel-coated urethral balloon versus DVIU/dilation
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***'''Increase the complexity of subsequent urethroplasty'''
***'''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.
**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===
===Pre-operative Considerations===


==== Antibiotic prophylaxis ====
==== 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>'''
*'''<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'''
**'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''
**'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''
*'''[https://www.auanet.org/documents/Guidelines/PDF/Antimicrobial%20Prophylaxis%20Table%20V.pdf 2016 AUA Antibiotic Prophylaxis Guidelines]'''
**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
**'''<span style="color:#ff0000">Antibiotic of choice: cefazolin'''
**'''With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins'''
***'''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 ====
==== Deep Venous Thromboembolism Prophylaxis ====
*Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries.
*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.
*Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.


==== Positioning ====
==== Positioning ====
*Positioning of the extremities should be careful to avoid pressure on the calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position.
*'''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===
===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>'''
*'''<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>'''
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***'''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.'''
***'''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.'''
***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''
*'''Antibiotic prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors'''.
*'''<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===
===Post-operative follow-up===
*'''Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''
*'''<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.'''
**'''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:
***Other descriptions for successful treatment:
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=== Causes ===
=== Causes ===
*Most common etiology is iatrogenic
*'''Most common etiology is iatrogenic'''
**Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.
**Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.
*Other causes can include blunt pelvic trauma, obstetric complications, particularly cephalopelvic disproportion, as well as malignancy, radiation, urethral or/and vaginal atrophy, recurrent infections, and skin disease such as lichen planus and LS.
*Other causes
*Idiopathic
**Blunt pelvic trauma
**Obstetric complications, particularly cephalopelvic disproportion
**Malignancy
**Radiation
**Urethral or/and vaginal atrophy
**Recurrent infections
**Skin disease such as lichen planus and LS.


=== Diagnosis and Evaluation ===
=== Diagnosis and Evaluation ===
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**History
**History
***Storage or voiding symptoms
***Storage or voiding symptoms
****Patients may present with LUTS, recurrent UTI, hesitancy, poor flow, frequency urgency, urethral pain, high PVR, or acute urinary retention.
****LUTS
*****Hesitancy, poor flow, frequency urgency
****Recurrent UTI
****Urethral pain
****Acute urinary retention
***Can impact QoL
***Can impact QoL
**Physical exam
**Physical exam
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*Imaging
*Imaging
**Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities
**Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities
*Other
**Post-void residual
***High PVR
*An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.
*An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.


=== Management ===
=== Management ===
*Urethroplasty should be offered to patients with female urethral strictures
*'''Urethroplasty should be offered to patients with female urethral strictures'''
**Low efficacy of endoscopic treatment
**'''Low efficacy of endoscopic treatment'''
*Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.
*Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.
==Questions==
==Questions==
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#What is the risk of new onset erectile dysfunction following anterior urethroplasty?
#What is the risk of new onset erectile dysfunction following anterior urethroplasty?
#*1%
#*1%
== References ==
* [https://pubmed.ncbi.nlm.nih.gov/27497791/ Wessells, Hunter, et al. "Male urethral stricture: American urological association guideline." ''The Journal of urology'' 197.1 (2017): 182-190.]
* [https://pubmed.ncbi.nlm.nih.gov/37096574/ Wessells, Hunter, et al. "Urethral stricture disease guideline amendment (2023)." ''The Journal of Urology'' 210.1 (2023): 64-71.]
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