What is the treatment approach for perineal urethrotomy in patients with urethral strictures?

Perineal Urethrostomy for Urethral Strictures

Perineal urethrostomy should be offered as a long-term treatment alternative to urethroplasty for patients with complex anterior urethral strictures, particularly those with recurrent strictures, extensive lichen sclerosus, multiple failed urethroplasties, significant medical comorbidities, advanced age, or patient preference for a definitive single-stage solution. 1

Clinical Indications for Perineal Urethrostomy

Perineal urethrostomy serves as either a staged or permanent option to establish unobstructed voiding and improve quality of life in specific patient populations 1:

• Recurrent or primary complex anterior strictures requiring multiple prior interventions 1
• Advanced age where extended operative time poses excessive risk 1
• Medical comorbidities precluding extended operative time under general anesthesia 1
• Extensive lichen sclerosus affecting the anterior urethra 1
• Numerous failed attempts at urethroplasty where tissue quality is compromised 1
• Patient choice when definitive single-stage treatment is preferred over complex reconstruction 1
• Long multi-segment strictures (>6-10 cm) or panurethral strictures where reconstruction success rates are lower 2, 3, 4

Treatment Algorithm

First-Line Considerations

For most urethral strictures, urethroplasty remains the gold standard with superior long-term success rates 1:

• Short bulbar strictures (<2 cm): May initially attempt dilation or direct visual internal urethrotomy (DVIU), though success rates are only 35-70% 1
• Long bulbar strictures (≥2 cm): Urethroplasty should be offered initially, with success rates of 90-95% for excision and primary anastomosis and >80% for buccal mucosa graft urethroplasty 1
• Penile urethral strictures: Urethroplasty should be offered at diagnosis due to expected high recurrence rates (often related to hypospadias, lichen sclerosus, or iatrogenic causes) 1

When to Choose Perineal Urethrostomy

Perineal urethrostomy becomes the preferred option when:

1. Patient has suffered through multiple failed procedures and desires definitive single-stage resolution 2, 4
2. Stricture length exceeds 6 cm or involves panurethral disease (57.8% of cases in one series) 4
3. Patient age >50-55 years with comorbidities making prolonged anesthesia risky 2, 4
4. Extensive lichen sclerosus compromises tissue quality for reconstruction 1
5. Patient explicitly prefers a straightforward solution over staged reconstruction 5, 2, 4

Expected Outcomes

Success Rates

• Overall success rate: 70-90% when defined as no need for further intervention 2, 4
• Cumulative failure rate at 2 years: 14.5% (95% CI 4.8-39.1), comparable to long stricture anterior urethroplasty at 30.2% 3
• Secondary intervention required in 14-15% of cases (primarily stomal dilation) 2

Functional Outcomes

• Urinary function improves significantly compared to baseline, with mean Qmax of 16-20 ml/s depending on age 2, 3
• Sexual function remains stable with no deleterious effects post-procedure 3
• Patient satisfaction is high: 78-91% report satisfaction with results 2, 4

Quality of Life Considerations

• 73.4% of patients with median age 57 years refuse second-stage reconstruction after perineal urethrostomy, indicating high satisfaction with the urethrostomy itself 4
• Patients report comparable quality of life improvements to those undergoing complex urethroplasty 3

Technical Approach

The Blandy technique with flap urethroplasty is the standard approach 2, 4:

• Creates a permanent perineal opening for voiding
• Can be combined with Johanson stage 1 procedure in younger patients who may desire future reconstruction 2
• Allows for staged reconstruction if patient later chooses to pursue urethral continuity 4

Critical Pitfalls to Avoid

1. Repeated endoscopic treatments in complex strictures: Multiple DVIUs or dilations compromise tissue elasticity and undermine chances for subsequent successful reconstruction 6
2. Attempting complex urethroplasty in poor surgical candidates: Patients with significant comorbidities or advanced age are better served with definitive perineal urethrostomy 1
3. Inadequate patient counseling: Patients must understand this may be permanent, though surgical revision may be necessary to maintain stomal patency 1
4. Using hair-bearing skin: This results in urethral calculi, recurrent UTI, and obstructed stream 1

Referral Considerations

Surgeons who do not perform urethroplasty or perineal urethrostomy should refer patients to surgeons with expertise in urethral reconstruction, particularly for recurrent strictures 1. High-volume reconstructive centers demonstrate superior outcomes for complex cases 1.