AUA: Male Urethral Stricture (2016)

See Original Guideline

See Urethral Stricture Disease Chapter Notes

Background

• See Urethral Anatomy Chapter Notes
• “Urethral stricture” is the preferred term for any abnormal narrowing of the anterior urethra, 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.”

Risk Factors

• Trauma History Increases Loo Time (5):

1. Trauma
2. Hypospadias surgery
3. Instrumentation or urethral catheterization
4. Lichen sclerosus (LS)
5. Transurethral surgery

• Most common cause
  • In developed countries: idiopathic (41%) followed by iatrogenic (35%), with transurethral surgery as the most common iatrogenic cause.
  • In developing countries: trauma (36%)

• Strictures related to hypospadias and lichen sclerosus are generally located in the penile urethra, while traumatic strictures and stenoses tend to be located in the bulbar and posterior urethra
• LS-related strictures
  • Less common etiology
  • Tend to be longer and may have a higher association with urethral cancer
    • For suspected LS, biopsy may be performed; if urethral cancer is suspected, biopsy must be performed
      • The rate of squamous cell carcinoma in male patients with LS has been reported to be 2-9% thus further indicating the need for biopsy in selected cases both to confirm the diagnosis as well as to exclude malignant or premalignant changes.

Diagnosis and Evaluation/Preoperative Assessment

• Mandatory (2): history and physical exam, urinalysis

1. History and Physical Exam
   • History
     • Consider urethral stricture in the differential diagnosis of men who present with:
       1. Decreased urinary stream
       2. Incomplete emptying
       3. Dysuria
       4. Urinary tract infection (UTI)
       5. Rising post void residual.
     • Assess preoperative erectile function and urinary continence
     • In the case of pelvic fracture urethral injury (PFUI), document all associated injuries and angiographic embolization of any pelvic vessels
   • Physical exam
     • Abdomen, genitals, digital rectal exam, and assessment of lower extremity mobility for operative positioning.
2. Laboratory
   • Urinalysis

• Optional (3): uroflowmetry, post-void residual, and patient reported measures

• Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture by (4):

1. Cystourethrscopy
2. Retrograde urethrography
   • See Figures of retrograde urethrogram demonstrating post-radiation stricture
3. Voiding cystourethrography
4. Ultrasound urethography

• 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.
  • This allows the full length of the stricture to develop, and accurate determination of definitive treatment options
  • A period of “urethral rest” between 4-12 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.

Management

• Options for urgent management (discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure):
  1. Endoscopic (e.g. urethral dilation or direct visual internal urethrotomy [DVIU])
  2. Immediate suprapubic cystostomy
• Options for delayed management:
  1. Endoscopic (e.g. urethral dilation or direct visual internal urethrotomy [DVIU])
  2. Urethroplasty
     • Generally divided into tissue transfer vs. non-tissue transfer techniques
       • Non-tissue transfer: anastomotic urethroplasty is a non-tissue transfer procedure and can be performed in both a transecting (removing spongiosum) and non-transecting manner.
         • Excision and primary anastomosis urethroplasty involves transection and 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.
       • Tissue transfer procedures can be categorized into single stage and multi-stage procedures.
• Initial treatment based on location of stricture
  • Fossa navicularis
    • Initial treatment of uncomplicated urethral stricture confined to the meatus or fossa navicularis: simple dilation or meatotomy, with or without guidewire placement
    • 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. Furthermore, urethroplasty is the best option for completely obliterated strictures or strictures associated with previous hypospadias repair or LS.
  • Penile urethra
    • Initial treatment: urethroplasty
      • High recurrence rates are expected with endoscopic treatments.
    • Penile urethral strictures are more likely to require tissue transfer and/or a staged approach compared to bulbar urethral strictures
  • Bulbar urethra
    • Initial treatment of stricture < 2cm: endoscopic management or urethroplasty
      • Dilation and DVIU have similar success and complication rates and can be used interchangeably.
        • Few studies exist that compare 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.
      • 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, and may 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.
    • Initial treatment of stricture ≥2cm: urethroplasty
      • Longer strictures are less responsive to endoscopic treatment
• 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.
  • Oral mucosa should be used as the first choice when using grafts for urethroplasty.
    • Oral mucosa may be harvested from the inner cheeks, which provide the largest graft area, the undersurface of the tongue, or the inner lower lip.
      • Harvest of buccal mucosa from the inner cheek 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.
    • Hair-bearing skin should not be used for substitution urethroplasty.
    • Substitution urethroplasty 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, surgeons should not use genital skin 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 due to very high long-term failure rates.
• Perineal urethrostomy
  • May be offered as a long term treatment option to patients as an alternative to urethroplasty.
  • Indications (6):
    1. Recurrent or primary complex anterior stricture
    2. Numerous failed attempts at urethroplasty
    3. Extensive LS
    4. Advanced age
    5. Medical co-morbidities precluding extended operative time
    6. Patient choice
• Urethroplasty may be offered as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization (e.g. neurogenic bladder)
• Operative Considerations
  • Antibiotic prophylaxis
    • Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.
      • 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.
      • With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins

Pelvic fracture urethral injury (PFUI)

• Retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy should be used for preoperative planning of delayed urethroplasty after PFUI
  • The VCUG may include a static cystogram to determine the competency of the bladder neck mechanism and the level of the bladder neck in relation to the symphysis pubis.
• The acute treatment of PFUI includes endoscopic primary catheter realignment or insertion of a SP tube. The resulting distraction defect, stenosis or obliteration should be managed with delayed perineal anastomotic urethroplasty.
• Delayed urethroplasty, instead of delayed endoscopic procedures, should be performed after urethral obstruction/obliteration due to PFUI
  • Repeated endoscopic maneuvers including intermittent catheterization should be avoided because they are not successful in the majority of PFUI, increase patient morbidity, and may delay the time to anastomotic reconstruction.
• Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.

Bladder Neck Contracture/Vesicourethral Stenosis

• Dilation, bladder neck incision or transurethral resection may be performed for bladder neck contracture after endoscopic prostate procedure. Repeat endoscopic treatment may be necessary for successful outcomes
• Dilation, vesicourethral incision, or transurethral resection may be performed for post-prostatectomy vesicourethral anastomotic stenosis. Patients should be made aware of the risk of incontinence after any of these procedures.
• For recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis, open reconstruction may be performed.
  • The treatment of recalcitrant vesicourethral anastomotic stenosis must be tailored to the preferences of the patient, taking into consideration prior radiotherapy and the degree of urinary incontinence.
  • For the patient who does not desire urethroplasty, repeat urethral dilation, incision or resection of the stenosis is appropriate. Intermittent self-dilation with a catheter may be used to prolong the time between operative interventions. Suprapubic diversion is an alternative.

Post-operative Care

• Either a urethral catheter or suprapubic cystostomy catheter should be placed following urethral stricture intervention to divert urine from the site of intervention and prevent urinary extravasation
• Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours
  • 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.
  • 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
• Following open urethral reconstruction, urethrography or voiding cystography is typically performed 2-3 weeks to assess for complete urethral healing. The cather is removed if the urethra has healed adequately.
  • 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.
• Antibiotic prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors.

Complications

• 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

Post-operative follow-up

• 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.
  • Consider more frequent follow-up intervals in males at an increased risk for stricture recurrence (7):
    1. Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)
    2. Long stricture
    3. Repair involving a flap or graft
    4. LS-related stricture
    5. Hypospadias-related stricture
    6. Smoking (tobacco use)
    7. Diabetes
• 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.

Questions

1. List risk factors associated with urethral stricture disease
2. What is the most common cause of urethral stricture disease in the developed vs. developing world?
3. What investigations are recommended in patients with suspected urethral stricture disease?
4. What are different methods to characterize a urethral stricture pre-operatively?
5. As per the 2016 AUA Guidelines, what is the management of urethral stricture disease involving the fossa navicularis? Penile urethra? Bulbar urethra?
6. Following uncomplicated DVIU, when should the foley catheter be removed?
7. Which are indications for a perineal urethrostomy?
8. What is the preferred site to harvest a graft for use during anterior urethroplasty?
9. What is the risk of new onset erectile dysfunction following anterior urethroplasty?

Answers

1. List risk factors associated with urethral stricture disease
   • Trauma History Increases Long Pee Time
   1. Trauma
   2. Hypospadia
   3. Idiopathic
   4. LS
   5. Prostate cancer treatment
   6. Transurethral surgery
2. What is the most common cause of urethral stricture disease in the developed vs. developing world?
   1. Developed: idiopathic
   2. Developing: trauma
3. What are the initial investigations recommended in patients with suspected urethral stricture disease?
   1. History and physical exam
   2. Urinalysis
4. What are different methods to characterize a urethral stricture pre-operatively?
   1. Cystourethrscopy
   2. Retrograde urethrography
   3. Voiding cystourethrography
   4. Ultrasound urethography
5. As per the 2016 AUA Guidelines, what is the management of urethral stricture disease involving the fossa navicularis? Penile urethra? Bulbar urethra?
   • Fossa navicularis: dilation, if fails urethroplasty
   • Penile urethra: urethroplasty
   • Bulbar urethra:
     • Stricture <2cm: endoscopic or urethroplasty
     • Stricture >2cm: urethroplasty
6. Following DVIU, when should the foley catheter be removed?
   • Within 72 hours
7. Which are indications for a perineal urethrostomy?
   1. Recurrent or primary complex anterior stricture
   2. Numerous failed attempts at urethroplasty
   3. Extensive LS
   4. Advanced age
   5. Medical co-morbidities precluding extended operative time
   6. Patient choice
8. What is the preferred site to harvest a graft for use during anterior urethroplasty?
   • Oral mucosa (inner cheek, undersurface of tongue, inner lower lip)
9. What is the risk of new onset erectile dysfunction following anterior urethroplasty?
   • 1%