Management of 7 cm Penile Urethral Stricture
Urethroplasty should be offered as the primary treatment for a 7 cm penile urethral stricture due to the expected high recurrence rates with endoscopic treatments. 1
Rationale for Urethroplasty in Penile Urethral Strictures
The American Urological Association (AUA) guidelines provide clear recommendations for managing penile urethral strictures:
- Penile urethral strictures are more likely to be related to hypospadias, lichen sclerosus, or iatrogenic etiologies compared to bulbar urethral strictures
- These strictures have very poor response rates to dilation or urethrotomy
- The length of this stricture (7 cm) makes it particularly unsuitable for endoscopic management
- For strictures ≥2 cm, urethroplasty is strongly recommended as initial treatment 1
Surgical Approach for Long Penile Strictures
For a 7 cm penile urethral stricture, the following surgical considerations apply:
- Oral mucosa should be used as the first choice graft material for urethroplasty 1
- Long penile strictures typically require tissue transfer techniques and/or a staged approach
- Compared to bulbar strictures, penile urethral strictures generally have more complex reconstruction requirements 1
- Success rates for buccal mucosa graft urethroplasty for long strictures exceed 80% 1, 2
Specific Technique Recommendations
For a stricture of this length (7 cm) in the penile urethra:
- Two-stage dorsal onlay of buccal mucosa (after complete excision of scarred urethra) provides the best results for penile urethroplasty 3
- One-stage dorsal onlay may be possible in certain circumstances but is less common for strictures of this length
- Ventral onlay of buccal mucosa and tube graft procedures in the penile urethra should be avoided due to much higher recurrence rates 3
Alternatives to Consider
If the patient is not a candidate for urethroplasty due to medical comorbidities or other factors:
- Perineal urethrostomy may be offered as a long-term treatment option as an alternative to urethroplasty 1
- This approach establishes unobstructed voiding and can improve quality of life
- Reasons to consider perineal urethrostomy include advanced age, medical comorbidities, extensive lichen sclerosus, or patient preference 1
Important Caveats and Pitfalls
- Avoid repeated endoscopic treatments (dilation or DVIU) for penile urethral strictures, as they have very low success rates and may complicate future urethroplasty 1, 4
- Attempting endoscopic management of a 7 cm penile stricture would almost certainly fail and delay definitive treatment
- Patient satisfaction is higher with oral mucosa urethroplasty compared to skin flaps and skin grafts due to less post-void dribbling and fewer penile skin problems 1
- Recurrence surveillance is important after urethroplasty, as strictures can recur up to 10 years after surgery 4
Follow-up Considerations
After urethroplasty:
- A urinary catheter should be placed to divert urine from the intervention site
- Retrograde urethrogram or voiding cystourethrogram should be performed 2-3 weeks following reconstruction to assess urethral healing 1
- Monitor for potential complications including erectile dysfunction (usually transient) and ejaculatory dysfunction 1