The surgical treatment of urethral strictures

The authors reviewed the results of surgical management of 233 patients aged 8-76 years who had suffered urethral strictures. A total of 266 operations were made in the period of 1970-1989. Urethral tunneling which had been widely used in clinical practice for strictures of the urethra until 1980 yielded 91.2% recurrences of the disease, which made surgeons modify the surgical policy. During the past decade 127 patients with urethral strictures and obliterations have undergone 138 surgical interventions: 91 (65.9%) urethral resections, 34 (24.6%) internal optical urethrotomies and transurethral resections of scarring tissue, 7 (5.1%) cutaneous urethral plastic surgeries and only 6 (4.4%) urethral tunnelings. The number of relapses was reduced to 13.4%. The authors consider that urethral resection should be the operation of choice in urethral strictures and obliterations. Endoscopic treatment techniques (urethrotomy and transurethral resection) are indicated in short strictures and scarring deformity of the posterior urethra after prostate operation. It is advisable to apply cutaneous urethral plastic surgery in case of extended strictures.     

Endoscopic treatment of urethral strictures

The present article reviews the literature regarding the endoscopic treatment of urethral strictures. Only few prospective randomised clinical trials with sufficient power have been performed and most of the literature provides evidence of only level 3 and 4. Since length, location, extent and calibre of the urethral stricture have an important impact on prognosis, diagnosis and the role of ultrasonography are discussed. Pathophysiology of wound healing is discussed in relation to urethrotomy, as it explains the outcomes of the procedure. Operative techniques using cold knife and laser, use of endoprostheses, indications, complications, results and postoperative management are described. The possible role of urethral catheters, hydraulic dilatations and corticosteroid applications are discussed.     

New treatment for urethral strictures

A new operative technique using synthetic, absorbable mesh for grafting a urethral defect was applied in 7 mongrel male dogs. The ventral half of the urethral circumference with its surrounding corpus spongiosum was excised for a length of 3 to 4 cm. A Dexon mesh of the same dimensions, woven in our laboratory from polyglycolic acid fibers, was sutured to the defective area. A perineal urethrotomy was established, and no splints were left behind. Dogs were studied between two and six months. Retrograde urethrography showed that the operative area healed without strictures or irregularities. Intravenous urography showed no back pressure effects, and cultured urine was always sterile. Histologic examination two months after surgery showed that the urothelium was completely healed, without inflammatory changes or disruption. Suburothelial tissues were replaced by dense collagenous connective tissue. The excised corpus spongiosum did not regenerate. After six months, the area of dense collagen described was diminished in size so that the operative area could be hardly identified except by the absence of corpus spongiosum.     

Guidelines for the treatment of urethral strictures

Over a period of 12 years 467 patients with urethral stricture were treated surgically at Tygerberg Hospital. The following surgical guidelines were developed: visual cold-knife urethrotomy should be the first line of treatment; urethroplasty is indicated when urethrotomy fails or is unfeasible; the urethroplasty of choice should be a single-stage operation; and staged procedures should be reserved for complicated cases.     

Surgical treatment of urethral strictures in children

Under analysis were results of treatment of posttraumatic strictures of the urethra in 34 children. A method of treatment of the urethra structures has been developed in experiments in dogs with the use of permanent magnet. Comparison of results of treatment of 2 groups of patients treated by traditional methods (19 patients) and by the proposed method (15 patients) has shown that using the new method is followed by two times less amount of recurrences and complications.     

Etiology, treatment and recurrence of urethral strictures

This is a study of urethral strictures in 50 Jordanian patients. The etiology, treatment and recurrence were discussed. The commonest causative agent was iatrogenic trauma and the commonest way of treatment was direct vision internal urethrotomy with an 80% non-recurrence rate.     

Anterior urethral strictures

Aim

The aim of the present study was to determine the practice patterns in the management of anterior urethral strictures among urologists in Hong Kong.

Patients and Methods

A 14‐item questionnaire was delivered either directly or by mail to all 126 registered urologists in Hong Kong. Information including demographic data, number of anterior urethral strictures treated, diagnostic methods, treatment options and follow‐up strategy were collected. The questionnaire also asked for the personal opinion about the treatment plan of two stricture case scenarios.

Results

The response rate was 48 per cent. The majority (87 per cent) of urologists treated <10 anterior urethral strictures per year. Minimal invasive procedures, including urethral dilatation using metal sounds (77 per cent) or cystoscopy‐guided (74 per cent) and direct visual internal urethrotomy (57 per cent), were more commonly performed by urologists to treat urethral strictures. The majority of urologists (82.6 per cent) performed less than five urethroplasties per year. In the two case scenarios of long bulbous urethral stricture and recurrent short urethral stricture, approximately 10 per cent of respondents would refer the cases to other urologists and approximately 75 per cent would choose to perform reconstructive surgeries. The remaining 15 per cent of respondents would choose minimally‐invasive procedures for these strictures. Nearly two‐thirds (62.3 per cent) of urologists believed that urethroplasty should be proposed only after failed endoscopic treatment. Workups for urethral stricture disease were consistent, while the modalities to access the outcome were highly heterogeneous.

Conclusion

In Hong Kong, the majority of urologists choose to perform urethroplasty for long bulbous urethral strictures and recurrent short bulbous urethral strictures in a case scenario situation. However, in actual practice, most perform less than five urethroplasties per year. A small caseload, lack of experience and understanding of urethral reconstructive surgery means that most urologists in Hong Kong would hesitate to carry out primary urethroplasty in correctly‐selected patients for whom primary reconstruction would have been the treatment of choice.     

Anterior urethral strictures

The surgical treatment of adult anterior urethral strictures has developed continuously. Recently considerable changes have been introduced, involving the cause of the urethral disease and surgical techniques. The criteria for selecting the reconstructive surgical technique are presented according to the cause and a new classification of urethral strictures. The main surgical procedures are presented and fully illustrated, with an updated and comprehensive review of recent publications.     

A new treatment for urethral strictures: a permanently implanted urethral stent

We describe a new urethral stent, originally developed for endovascular use, that we have implanted into 8 patients with urethral strictures. The stent is woven in the form of a tubular mesh from surgical grade stainless steel wire and is self-expanding when released from its small diameter delivery catheter. All patients have been treated successfully with a good caliber urethra visible on urethrography and direct endoscopy, and with improved urine flow rates. Mean followup of these patients is 8 months (range 6 months to 1 year). Urethroscopy had demonstrated complete epithelial covering of the implant at 4 to 6 months. Although the followup is short it seems that this simple technique may offer a lasting treatment for many urethral strictures.     

Epidemiology of urethral strictures

Urethral stricture disease is relatively common and is associated with a significant financial cost and potentially debilitating outcomes. Understanding urethral stricture epidemiology is important to identify risk factors associated with the etiology or progression of the disease. This understanding may lead to better treatments and preventative measures that could ameliorate disease severity, produce better health outcomes, and reduce expenditures. We performed a comprehensive review of urethral stricture disease based on available published case series, identified gaps in knowledge of this disease, and recommend future directions for research.     

接触式激光治疗尿道狭窄（附23例报告）

１９９３年１２月～１９９５年８月，应用ＳＬＴ接触式激光（Ｎｂ：ＹＡＧ）治疗仪治疗尿道狭窄２３例，随访１４例排尿良好，９例狭窄复发，复发率３９．１％。接触式激光治疗尿道狭窄方法简便、安全有效、无痛苦、无出血，复发率低。     

Alternative endourological techniques in the treatment of urethral strictures

Summary Advances in endoscopic instrumentation and techniques offer new alternatives for safe and effective treatment of urethral strictures. Visual internal urethrotomy, the standard treatment modality, is associated with new scar formation with stricture recurrence. This experience has led to the investigation of alternative techniques which would avoid or ameliorate this result. This article reviews the current literature and discusses these newer approaches, including balloon dilatation, laser urethrotomy, endoscopic urethroplasty, ”cut to the light” and ”core through” procedures, and urethral wallstent implantation.