What are the treatment options for ureteral stricture?

Treatment Options for Ureteral Stricture

Urethroplasty should be offered as the initial treatment for ureteral strictures ≥2cm in length due to its superior success rates of 90-95% compared to endoscopic treatments, which have very low success rates for longer strictures. 1

Treatment Algorithm Based on Stricture Characteristics

Short Strictures (<2cm)

1. Initial Treatment Options:

   • Urethral dilation
   • Direct visual internal urethrotomy (DVIU)
   • Urethroplasty

   All three options are viable for initial treatment, with success rates for dilation and DVIU ranging from 35-70% 1. The choice depends on:

   • Patient preference
   • Surgeon experience
   • Stricture location (bulbar strictures <1cm respond best to endoscopic treatment)

2. Post-procedure Management:

   • Urethral catheter can be safely removed within 72 hours 1
   • For patients not suitable for urethroplasty, self-catheterization after DVIU may maintain temporary urethral patency 1

Long Strictures (≥2cm)

1. Recommended Treatment:
   • Urethroplasty as initial treatment 1
   • Success rates >80% for buccal mucosa graft urethroplasty 1
   • Endoscopic treatments have only 20% success for strictures >4cm 1

Stricture Location Considerations

Penile Urethral Strictures

• Recommended Treatment: Urethroplasty at time of diagnosis 1
• Rationale: These strictures are often related to hypospadias, lichen sclerosus, or iatrogenic causes and respond poorly to endoscopic treatments 1
• More likely to require tissue transfer and/or staged approach compared to bulbar strictures 1

Multi-segment/Panurethral Strictures (>10cm)

• Treatment Options:
  • One-stage or multi-stage techniques using oral mucosal grafts
  • Penile fasciocutaneous flaps
  • Combination of techniques 1

Bladder Neck Contractures

• Dilation, bladder neck incision, or transurethral resection are all viable options 1

Urethroplasty Techniques and Materials

1. Preferred Graft Material:

   • Oral mucosa should be first choice for grafts 1
   • Higher patient satisfaction compared to skin flaps/grafts (less post-void dribbling, fewer penile skin problems) 1

2. Materials to Avoid:

   • Allografts, xenografts, or synthetic materials (except under experimental protocols) 1
   • Hair-bearing skin (can cause urethral calculi, recurrent UTIs, and restricted urinary stream) 1
   • Tubularized urethroplasty in a single stage (high risk of restenosis) 1

3. Alternative Option:

   • Perineal urethrostomy as a long-term treatment option for patients with:
     • Complex anterior stricture
     • Advanced age
     • Medical comorbidities
     • Extensive lichen sclerosus
     • Multiple failed urethroplasties
     • Patient preference 1

Special Considerations

1. Recurrent Strictures:

   • Urethroplasty recommended after failed endoscopic treatment 1
   • Repeated endoscopic treatments may cause longer strictures and increase complexity of subsequent urethroplasty 2

2. Patients Dependent on Catheterization:

   • Consider suprapubic cystostomy prior to definitive urethroplasty 1

3. Balloon Dilation:

   • May be useful for elder and unfit patients 3
   • Reduces iatrogenic trauma by applying radial forces against the stricture 3
   • Most effective for short strictures with intact vascular supply (89.2% success) 4
   • Less effective for strictures with compromised vascular supply 4

Endoureterotomy for Ureteral Strictures

• Success rates of 75% reported with cold knife endoureterotomy and 60% with balloon dilation 5
• Holmium:YAG laser endoureterotomy shows 76% success rate in selected cases 6
• Most effective for short, non-ischemic strictures not associated with radiation therapy 5

Pitfalls and Caveats

1. Avoid repeated endoscopic treatments for recurrent strictures as they have high failure rates (>80%) and may complicate subsequent urethroplasty 2

2. Stricture length and etiology are the most important determinants of treatment success 6

3. Proper diagnostic evaluation with urethrocystoscopy, retrograde urethrography, and/or voiding cystourethrography is essential before selecting treatment 1, 2

4. Post-treatment surveillance is critical as recurrences typically happen within the first 3 months for complex or lengthy strictures 6