Review ArticleUrethroplasty for Stricture Disease: Contemporary Techniques and Outcomes
Section snippets
Anatomical Considerations
The extensive vascular supply to the bulbar urethra affords a variety of definitive treatment options based on stricture length and etiology. The bulbar arteries directly supply the proximal corpus spongiosum, while retrograde flow is also contributed from the dorsal penile arteries via the glans to the spongiosum. Additionally, there are circumflex branches of the dorsal arteries that run from dorsal to ventral within Buck's fascia,3 and perforating vessels traversing the corpora cavernosa.
The
Penile Urethral Strictures
Stricture etiology is particularly important in the penile urethra, where strictures tend to be diffuse in nature—especially those associated with lichen sclerosus (LS), alternatively known as balanitis xerotica obliterans. LS is thought to be an autoimmune disease associated with extensive scarring and functional loss of the penile skin, urethral meatus, and/or anterior urethra. Urethroplasty techniques using penile skin as grafts and/or flaps have up to 100% stricture recurrence rate and
Excision with Primary Anastomosis (EPA) Urethroplasty
For patients presenting with short bulbar strictures, EPA remains the standard and definitive option for urethral reconstruction with a greater than 90% success rate.23, 24, 25 As the name implies, EPA involves transection of the corpus spongiosum and excision of the urethral stricture with distal and proximal mobilization of the urethra prior to creation of a tension-free anastomosis. EPA for strictures in the proximal bulbar urethra enables greatest use of the elastic lengthening gained from
Perineal Urethrostomy
Many men with severe or panurethral stricture disease, primarily those with LS or recurrent diffuse stricture after hypospadias repairs, may be best served by perineal urethrostomy instead of complex reconstruction or staged urethroplasty.40 Rather than seeing this as “defeat,” urologists should see this as a simple and practical option to offer in patients presenting with highly refractory or complex strictures. Elderly patients and those with multiple comorbidities along with extensive/severe
Radiation-associated Bulbomembranous Urethral Stricture
Pelvic radiation for prostate or rectal cancer has increasingly been associated with subsequent bulbomembranous urethral stricture. EPA has been reported with success rates of 70% at a median follow-up of 3.1 years with de novo incontinence observed in 18.5%.44 In contrast to anterior urethral strictures, radiation-induced strictures do not have healthy tissue on the proximal side of the stenosis, which is one possible explanation for the higher failure rate. Another technique to address this
Conclusion
Tissue transfer techniques for urethral reconstruction continue to expand, and a wide variety of good options now exist for stricture patients, regardless of stricture location, severity, and etiology. In many men with recurrent severe strictures, consideration should be given to preliminary suprapubic tube diversion, which enables precise imaging and a controlled preparation for elective reconstruction. Whereas buccal mucosal graft urethroplasty is a highly versatile technique for longer
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Financial Disclosure: Allen F. Morey is Consultant and Lecturer for Coloplast and American Medical Systems. The remaining authors declare that they have no relevant financial interests.