What are the most effective methods for correcting urinary strictures in men?

Treatment of Male Urethral Strictures

Urethroplasty is the most effective method for correcting urethral strictures in men, with success rates of 90-95% for excision and primary anastomosis and >80% for buccal mucosa graft techniques, compared to only 35-70% success with endoscopic approaches. 1

Treatment Algorithm Based on Stricture Location and Length

Short Bulbar Strictures (<2 cm)

• For first-time, short bulbar strictures (<2 cm), either endoscopic treatment (dilation or DVIU) or urethroplasty may be offered initially, though urethroplasty has superior long-term success (90-95% vs 35-70%). 1
• The choice between endoscopic treatment and urethroplasty must weigh the higher success rate of urethroplasty against increased anesthesia requirements, cost, and morbidity. 1
• Dilation and DVIU have equivalent success and complication rates and can be used interchangeably; cold knife and laser incision techniques also show similar outcomes. 1
• For recurrent short bulbar strictures, urethroplasty should be offered rather than repeat endoscopic management, as repeated endoscopic treatments have >80% failure rate. 2

Long Bulbar Strictures (≥2 cm)

• Urethroplasty should be offered as initial treatment for bulbar strictures ≥2 cm, given the very low success rate (only 20% for strictures >4 cm) with endoscopic approaches. 1
• Excision and primary anastomosis achieves 90-95% success rates for appropriate strictures. 1
• Buccal mucosa graft urethroplasty achieves >80% success rates for longer strictures. 1

Penile Urethral Strictures

• Urethroplasty should be offered at initial diagnosis for penile urethral strictures due to expected high recurrence rates with endoscopic treatments. 1
• Penile strictures are more commonly related to hypospadias, lichen sclerosus, or iatrogenic causes and are unlikely to respond to dilation or urethrotomy except in select cases of previously untreated, short strictures. 1
• These strictures more frequently require tissue transfer and/or staged approaches compared to bulbar strictures. 1

Meatal and Fossa Navicularis Strictures

• First-time uncomplicated meatal or fossa navicularis strictures may be treated with simple dilation or meatotomy. 1
• For recurrent meatal or fossa navicularis strictures, urethroplasty should be offered, as these strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments. 1
• Patients with previous hypospadias repair, prior failed endoscopic manipulation, previous urethroplasty, or lichen sclerosus should be offered urethroplasty. 1

Multi-Segment and Panurethral Strictures

• Long multi-segment strictures (>10 cm spanning penile and bulbar urethra) may be reconstructed with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or combinations. 1
• Success rates appear similar across different technique combinations in available case series. 1

Special Considerations

Lichen Sclerosus-Related Strictures

• Non-genital tissue grafts (buccal mucosa preferred) should be used for strictures due to lichen sclerosus. 2
• Staged repair with complete excision of the urethral plate may be considered. 2

Complex Recurrent Strictures

• Perineal urethrostomy should be offered as a long-term alternative to urethroplasty for patients with complex anterior urethral strictures, particularly those with multiple failed urethroplasties, extensive lichen sclerosus, significant medical comorbidities, advanced age, or patient preference for definitive single-stage solution. 3

Critical Evidence Comparison

The 2017 American Urological Association guidelines 1 provide the primary framework, supported by a 2020 randomized controlled trial 4 that directly compared urethroplasty to urethrotomy for recurrent bulbar strictures. This trial found that while both treatments improved voiding symptoms, urethroplasty resulted in significantly fewer reinterventions (hazard ratio 0.52,95% CI 0.31-0.89). 4

The Canadian guidelines 5 suggest endoscopic treatment for initial management of undifferentiated urethral strictures, but this recommendation does not apply to trauma-related injuries, penile strictures, or suspected malignancy. 5

Common Pitfalls to Avoid

• Do not perform repeated endoscopic treatments for recurrent strictures, as this approach has >80% failure rate and may compromise subsequent reconstructive surgery success. 1, 2
• Do not use hair-bearing skin for perineal urethrostomy, as this results in urethral calculi, recurrent UTI, and obstructed stream. 3
• Do not attempt complex urethroplasty in poor surgical candidates with significant comorbidities or advanced age; consider perineal urethrostomy instead. 3
• Patients who choose repeat endoscopic treatments or intermittent self-dilation over urethroplasty should be counseled that success of subsequent reconstructive procedures may be lower. 1

Postoperative Management

• Urethral catheter may be safely removed within 72 hours following endoscopic stricture treatment. 1
• For open urethroplasty, catheter should remain in place with retrograde urethrography or voiding cystourethrography performed at 2-3 weeks post-operatively before catheter removal. 2
• Monitor patients at 3,6,9, and 12 months with symptom assessment, uroflowmetry, post-void residual measurement, and flexible cystoscopy if non-invasive parameters are concerning. 2
• Erectile dysfunction may occur transiently after urethroplasty but typically resolves within 6 months. 2
• Ejaculatory dysfunction occurs in up to 21% of men after bulbar urethroplasty. 2