Epidemiology of urethral strictures

Comprehensive proteomic characterization of urethral stricture disease in the Chinese population

Background

Male urethral stricture disease (USD) is predominantly characterized by scar formation. There are few effective therapeutic drugs, and comprehensive molecular characterizations of USD formation remain undefined.

Methods

The proteomic profiling of twelve scar tissues and five matched normal adjacent tissues (NATs). Proteomic analysis methods were applied to explore the molecular characterizations of USD formation, including uncovering mechanistic pathways and providing novel biomarkers for scar formation.

Results

Comparative proteomic analysis showed that the extracellular matrix (ECM) and complement cascade signaling were predominant in scar tissues. COL11A1 and CD248 significantly contributed to the accumulation of ECM components. Our study presented diverse molecular mechanisms of scar formation across different ages and suggested the potential effects of PXK in Age 1 (<45) patients. Furthermore, immune infiltration studies indicated the therapeutic potential of inhibiting the complement system (C4A, C4B) in Age 2 (≥45) patients, providing a potential clinical strategy for USD.

Conclusion

This study illustrated the pathogenesis of USD formation and the diverse characteristics of USD patients with different ages, enhancing our understanding of the disease's pathogenesis and providing a valuable resource for USD treatment.

Current urethroplasty trends in recent GURS fellowship graduates

PURPOSE

To assess self-reported urethroplasty success rates and outcomes of recent GURS fellowship graduates and compare these data to the large body of published urethroplasty outcomes literature.

METHODS

A voluntary survey was distributed from June 1 to June 30, 2023 to GURS fellowship graduates of the last 5 years. Participants were surveyed on time since graduation, operative volume, outcomes, and quoted success rates for urethroplasty. Data were then analyzed using descriptive statistics, binary logistic regression, and correlative analyses.

RESULTS

We received responses from 49/101 (48.5%) GURS graduates. Five-year post-graduates were most represented (44.7%). The majority (52.2%) consider 81-90% of urethroplasty successful, without significant change with years in practice. Approximately 65% quoted excision and primary anastomosis (EPA) as > 90% successful. Over half of the respondents had performed > 60 urethroplasties since graduation. Only 31.3% of respondents reported re-intervening in > 10% of their postop patients, with a weak positive correlation between years in practice and need for re-intervention (p 0.01). Nearly 20% of respondents referred patients to an external reconstructionist.

CONCLUSION

Increased length of time in practice does not result in higher reported urethroplasty success rates, counseling on successful outcomes, or rates of re-intervention and complications. Our survey highlights that the traditionally used success rates for urethroplasty may not be reflective of new graduates and lower volume reconstructive surgeons in their early career.

Deep Phenotyping the Anterior Urethral Stricture: Characterizing the Relationship Between Inflammation, Fibrosis, Patient History, and Disease Pathophysiology

PURPOSE

Anterior urethral stricture disease (aUSD) is a complex, heterogeneous condition that is idiopathic in origin for most men. This gap in knowledge rarely affects the current management strategy for aUSD, as urethroplasty does not generally consider etiology. However, as we transition towards personalized, minimally invasive treatments for aUSD and begin to consider aUSD prevention strategies, disease pathophysiology will become increasingly important. The purpose of this study was to perform a deep phenotype of men undergoing anterior urethroplasty for aUSD. We hypothesized that unique biologic signatures and potential targets for intervention would emerge based on stricture presence/absence, stricture etiology, and the presence/absence of stricture inflammation.

MATERIALS AND METHODS

Men with aUSD undergoing urethroplasty were recruited from one of 5 participating centers. Enrollees provided urethral stricture tissue and blood/serum on the day of surgery and completed patient-reported outcome measure questionnaires both pre- and postoperatively. The initial study had 3 aims: (1) to determine pediatric and adult subacute and repeated perineal trauma (SRPT) exposures using a study-specific SRPT questionnaire, (2) to determine the degree of inflammation and fibrosis in aUSD and peri-aUSD (normal urethra) tissue, and (3) to determine levels of systemic inflammatory and fibrotic cytokines. Two controls groups provided serum (normal vasectomy patients) and urethral tissue (autopsy patients). Cohorts were based on the presence/absence of stricture, by presumed stricture etiology (idiopathic, traumatic/iatrogenic, lichen sclerosus [LS]), and by the presence/absence of stricture inflammation.

RESULTS

Of 138 enrolled men (120 tissue/serum; 18 stricture tissue only), 78 had idiopathic strictures, 33 had trauma-related strictures, and 27 had LS-related strictures. BMI, stricture length, and stricture location significantly differed between cohorts (P < .001 for each). The highest BMIs and the longest strictures were observed in the LS cohort. SRPT exposures did not significantly differ between etiology cohorts, with > 60% of each reporting low/mild risk. Stricture inflammation significantly differed between cohorts, with mild to severe inflammation present in 27% of trauma-related strictures, 54% of idiopathic strictures, and 48% of LS strictures (P = .036). Stricture fibrosis did not significantly differ between cohorts (P = .7). Three serum cytokines were significantly higher in patients with strictures compared to stricture-free controls: interleukin-9 (IL-9; P = .001), platelet-derived growth factor-BB (P = .004), and CCL5 (P = .01). No differences were observed in the levels of these cytokines based on stricture etiology. However, IL-9 levels were significantly higher in patients with inflamed strictures than in patients with strictures lacking inflammation (P = .019). Degree of stricture inflammation positively correlated with serum levels of IL-9 (Spearman's rho 0.224, P = .014).

CONCLUSIONS

The most common aUSD etiology is idiopathic. Though convention has implicated SRPT as causative for idiopathic strictures, here we found that patients with idiopathic strictures had low SRPT rates that were similar to rates in patients with a known stricture etiology. Stricture and stricture-adjacent inflammation in idiopathic stricture were similar to LS strictures, suggesting shared pathophysiologic mechanisms. IL-9, platelet-derived growth factor-BB, and CCL5, which were elevated in patients with strictures, have been implicated in fibrotic conditions elsewhere in the body. Further work will be required to determine if this shared biologic signature represents a potential mechanism for an aUSD predisposition.

The Regenerative Microenvironment of the Tissue Engineering for Urethral Strictures

Urethral stricture caused by various reasons has threatened the quality of life of patients for decades. Traditional reconstruction methods, especially for long-segment injuries, have shown poor outcomes in treating urethral strictures. Tissue engineering for urethral regeneration is an emerging concept in which special designed scaffolds and seed cells are used to promote local urethral regeneration. The scaffolds, seed cells, various factors and the host interact with each other and form the regenerative microenvironment. Among the various interactions involved, vascularization and fibrosis are the most important biological processes during urethral regeneration. Mesenchymal stem cells and induced pluripotent stem cells play special roles in stricture repair and facilitate long-segment urethral regeneration, but they may also induce carcinogenesis and genomic instability during reconstruction. Nevertheless, current technologies, such as genetic engineering, molecular imaging, and exosome extraction, provide us with opportunities to manage seed cell-related regenerative risks. In this review, we described the interactions among seed cells, scaffolds, factors and the host within the regenerative microenvironment, which may help in determining the exact molecular mechanisms involved in urethral stricture regeneration and promoting clinical trials and the application of urethral tissue engineering in patients suffering from urethral stricture.

Imaging in urethral stricture disease: an educational review of current techniques with a focus on MRI

Urethral stricture disease refers to narrowing of the urethral lumen obstructing the flow of urine. Urethral strictures can significantly impact daily life due to incontinence, incomplete emptying, hesitancy, and increased risk of urinary tract infections. Imaging is central to the evaluation of suspected urethral stricture, as assessment of stricture length and severity is crucial for guidance of surgical management. The currently employed modalities include radiography, chiefly retrograde urethrography (RUG) and voiding cystourethrography (VCUG); magnetic resonance urethrography (MRU); and sonourethrography (SUG). MRU has become a recent focus of research as it provides high spatial resolution, multiplanar capacity, and soft tissue type differentiation for evaluation of periurethral compartments and concurrent soft tissue defects. The protocol for MRU has evolved over the years to now include dynamic micturition imaging and image reconstruction options. In this review, we discuss each of the imaging modalities used in the diagnosis and evaluation of urethral stricture and provide an overview of literature on MRU over the last decade, including suggested indications that have not yet been incorporated into current guidelines. We delineate scenarios where special diagnostic imaging beyond radiography is beneficial, providing examples from our practice and description of our techniques for each modality.

Interventional urethral balloon dilatation before endoscopic visual internal urethrotomy for post-traumatic bulbous urethral stricture: A case report

BACKGROUND

While several treatment options are available for pediatric urethral strictures, the appropriate treatment must be based on several factors. Although endoscopic visual internal urethrotomy (EVIU) could be a first-line treatment option for short pediatric urethral strictures, it is not feasible if the urethroscope cannot pass through the stricture point. Herein, we present a pediatric case of severe post-traumatic bulbous urethral stricture that was successfully treated by EVIU after securing the urethral route via interventional balloon dilatation.

CASE SUMMARY

A 12-year-old boy presented at our outpatient clinic with the inability to urinate. He had sustained a straddle injury three months prior. The post-void residual urine volume was 644 mL, and retrograde urethrography confirmed severe stricture of the bulbous urethra. EVIU was planned; however, the first attempt to treat the stricture failed because the urethroscope could not pass through the stricture point. The urethral route was subsequently secured via balloon dilatation of the stricture, which was performed in collaboration with specialists from the department of interventional radiology. The urethroscope was then able to pass, and the repeat EVIU was successful.

CONCLUSION

Interventional urethral balloon dilatation before EVIU may help secure the urethral route in the treatment of pediatric urethral strictures.

Prospects and Challenges of Electrospun Cell and Drug Delivery Vehicles to Correct Urethral Stricture

Current therapeutic modalities to treat urethral strictures are associated with several challenges and shortcomings. Therefore, significant strides have been made to develop strategies with minimal side effects and the highest therapeutic potential. In this framework, electrospun scaffolds incorporated with various cells or bioactive agents have provided promising vistas to repair urethral defects. Due to the biomimetic nature of these constructs, they can efficiently mimic the native cells’ niches and provide essential microenvironmental cues for the safe transplantation of multiple cell types. Furthermore, these scaffolds are versatile platforms for delivering various drug molecules, growth factors, and nucleic acids. This review discusses the recent progress, applications, and challenges of electrospun scaffolds to deliver cells or bioactive agents during the urethral defect repair process. First, the current status of electrospinning in urethral tissue engineering is presented. Then, the principles of electrospinning in drug and cell delivery applications are reviewed. Finally, the recent preclinical studies are summarized and the current challenges are discussed.

Circ_0047339 promotes the activation of fibroblasts and affects the development of urethral stricture by targeting the miR-4691-5p/TSP-1 axis

Urethral stricture is related to scar tissue fibrosis, but its pathogenesis is still unclear. This study aims to explore the regulatory mechanism of circular RNA (circRNA) in the occurrence and development of urethral stricture. CircRNA microarray was employed to analyze circRNA expression profiles between human urethral scar tissue and normal urethral tissue. The results of circRNA microarray showed that there were 296 differentially expressed genes between urethral scar tissue and normal urethral tissue. The enrichment analysis of Kyoto encyclopedia of genes and genomes showed that these circRNAs were significantly correlated with ECM–receptor interaction. The first nine differentially expressed circRNA were selected to predict the circRNA–miRNA network. RT-qPCR results showed that circ_0047339 was upregulated considerably in urethral scar tissue. Urethral scar fibroblasts were isolated from human urethral scar tissue and cultured in vitro. After silencing circ_0047339, the proliferation of urethral scar cells decreased significantly, and the expressions of Collagen I (COL-1) and α-smooth muscle actin (α-SMA) also reduced. As a competing endogenous RNA, circ_0047339 could increase the expression of TSP-1 by competitively binding miR-4691-5p. In addition, miR-4691-5p mimic transfection could inhibit the proliferation of urethral scar fibroblasts and the presentation of thrombospondin-1 (TSP-1), α-SMA and COL-1, while circ_0047339 overexpression eliminated this inhibition. Our results showed that circ_0047339 might promote the growth and fibrosis of urethral scar fibroblasts through miR-4691-5p/TSP-1 axis, thus promoting the development of urethral stricture.

The contribution of the immune system to genitourinary fibrosis

Fibrotic diseases of the genitourinary tract are devastating and incompletely understood pathologies. These diseases include urethral and ureteral strictures, retroperitoneal fibrosis, and Peyronie's disease. They can contribute to obstructive uropathy and sexual dysfunction. Poor understanding of the pathophysiology of these diseases severely limits our ability to prevent and treat them. Genitourinary fibrotic diseases likely represent related pathologies that share common underlying mechanisms involving wound healing in response to injury. These diseases share the common feature of extracellular matrix abnormalities-such as collagen deposition, transforming growth factor-β accumulation, and dysregulation of collagen maturation-leading to abnormal tissue stiffness. Given the association of many of these diseases with autoimmunity, a systemic pro-inflammatory state likely contributes to their associated fibrogenesis. Herein, we explore the immunologic contribution to fibrogenesis in several fibrotic diseases of the genitourinary system. Better understanding how the immune system contributes to fibrosis in these diseases may improve prevention and therapeutic strategies and elucidate the functions of immunologic contributors to fibrosis in general.

Histopathologic and clinical comparison of recurrent and non-recurrent urethral stricture disease treated by reconstructive surgery

Background

Urethral stricture is a relatively frequent problem often requiring multiple surgical interventions. The objective of this study was to compare the clinicopathologic features of urethral resections from patients who underwent open end-to-end anastomotic urethroplasty and later recurred compared to those who did not.

Methods

A retrospective review of the pathology files identified 36 consecutive patients who underwent urethroplasty. The histopathological analysis included evaluation of the inflammatory infiltrate based on the predominant (>50%) cell type: lymphocyte-rich, neutrophil-rich, plasma cell-rich, and mixed; length and thickness of the fibrous plaque; and the cellularity of the fibrous plaque: cellular (>40 stroma nuclei/HPF) or paucicellular (<40 stroma nuclei/high power field).

Results

Ten (28%) patients recurred, and 26 (72%) did not. There was no significant difference between recurrent and non-recurrent cases in age, race, comorbidities, location of the stricture, and etiology. All patients with recurrent strictures showed dense paucicellular fibrotic plaques (10/10; 100%), while this was seen in 14/26 (53.8%) non-recurrent cases (P=0.01). Only one patient with cellular fibrosis showed recurrence during follow-up. The log-rank test shows that time to recurrence is significantly shorter in patients with paucicellular fibrosis compared to those with cellular fibrosis (P=0.036). The inflammation consisted of a mixed population of CD3(+) T-lymphocytes, CD20(+) B-lymphocytes, and CD68(+) histiocytes, and there was no difference in the composition of the inflammation between groups. All cases with plasma cell-rich infiltrate showed normal IgG4:IgG.

Conclusions

Our study supports reporting cellularity of the fibrous plaque as a potential predictor of outcome in patients undergoing reconstructive urethroplasty. Patients with paucicellular fibrosis are at increased risk of recurrence.

Comparison of Epidural Dexmedetomidine Versus Ropivacaine Infusion Effectiveness in Preventing Erection Following Reconstructive Urethral Surgery: A Randomized Clinical Trial

Background

One of the most common devastating problems that occur after urethroplasty is erection, which causes surgical complications (fistula, wound dehiscence, and surgical graft failure) and the need for repairing the complications. We attempted to compare the effect of continuous epidural infusion of dexmedetomidine and ropivacaine as a post-surgical erection prevention strategy.

Objectives

In this study, we aimed to compare the effect of dexmedetomidine and ropivacaine epidural infusion on the incidence of erection after reconstructive urethral surgery.

Methods

An RCT was conducted on 45 patients who were scheduled for reconstructive urethral surgery. They were randomly divided into three groups: (1) control (n = 15), (2) epidural dexmedetomidine (n = 15), (3) and epidural ropivacaine (n = 15). The control group received oral medication after surgery according to the conventional method (cyproterone compound tablets 50 mg BD and diazepam tablets 2 mg TDS for a week) to prevent erection. The DEX group received dexmedetomidine as continuous epidural infusion, and the ROP group received ropivacaine in addition to the conventional method. The occurrence of erection during day and night was recorded separately until the seventh day after surgery. Due to the long-time interval between case selection, participants from different groups were not matched with each other.

Results

The incidence of erection in the dexmedetomidine group was lower than that in the ropivacaine group per person (0.87) and significantly lower than in the control group (2.8 per person). Also, there was significantly less erection in the ropivacaine group (1.2 per person) than in the control group. Our study showed that erection after surgery significantly decreased with the continuous epidural infusion of dexmedetomidine and ropivacaine.

Conclusions

Dexmedetomidine seems to have a significant preventive effect on erection after reconstructive urethral surgery.

MRI in patients with urethral stricture: a systematic review

Magnetic resonance imaging (MRI) is gaining acceptance as a diagnostic tool in urethral stricture disease. Numerous publications emphasize on the advantages of MRI including its ability to determine periurethral spongiofibrosis, thus overcoming the main limitation of retrograde urethrography (RUG). It is also becoming an alternative for sonourethrography (SUG), which is a highly subjective examination. Magnetic resonance urethrography (MRU) has become an increasingly appreciated tool for diagnosing patients with urethral stricture disease. Obtained data provides radiologists and urethral reconstructive surgeons with additional information regarding anatomical relationships and periurethral tissue details, facilitating further treatment planning. Considering the great prevalence of urethral stricture disease and necessity of using accurate, and acceptable diagnostic method, this review was designed to provide radiologists and clinicians with a systematic review of the literature on the use of MRI in the urethral stricture disease.

Larger patients shouldn't have fewer options: urethroplasty is safe in the obese

Objective

To examine the impact of obesity on perioperative outcomes and urethral stricture recurrence after anterior urethroplasty.

Material and Methods

We reviewed our prospectively maintained single-surgeon database to identify men with anterior urethral strictures who had undergone anastomotic or augmentation urethroplasty between October 2012 and March 2018. In all, 210 patients were included for primary analysis of perioperative outcomes, while 193 patients with at least 12 months follow-up were included for secondary analysis of stricture recurrence. Patients grouped by BMI were compared using univariate and multivariate analyses for perioperative outcomes and log rank testing for recurrence-free survival.

Results

Overall, 41% (n=86) of patients were obese and 58.6% (n=123) had bulbar urethral strictures. Obese patients had significantly longer urethral strictures (mean=6.7cm±4.7) than nonobese patients (p <0.001). Though urethroplasty in obese patients was associated with increased estimated blood loss (EBL) relative to normal BMI patients on both univariate (p=0.003) and multivariate (p <0.001) analyses, there was no difference in operative time, length of stay, or complication rate between BMI groups. At a mean follow-up interval of 36.7 months, 15% (n=29) of patients had stricture recurrence, yet recurrence-free survival was not significantly different between groups (log rank p=0.299). Dorsal augmentation urethroplasty resulted in significantly fewer recurrences in obese patients compared to nonobese patients (p=0.036).

Conclusion

Despite the association with increased urethral stricture length and EBL, obesity is not predictive of adverse perioperative outcomes or stricture recurrence. Obese patients should be offered urethral reconstruction, but patient selection and preoperative counseling remain imperative.

Complicated bulbar urethral stricture successfully treated using augmented anastomotic urethroplasty: A case report

Introduction

Management of a complicated urethral stricture is a urological challenge. We present a case of a complicated urethral stricture successfully treated using augmented anastomotic urethroplasty.

Case presentation

A 48‐year‐old man visited our department for the treatment of urethral stricture, for which repeated transurethral procedures had failed. The operative view revealed that the urethral lumen was, in fact, completely obliterated over a 30‐mm segment. We proceeded with augmented anastomotic urethroplasty. After the excision of the obliterated lesion, the ventral half of the bulbar urethral ends was anastomosed and their dorsal half was subsequently augmented via buccal mucosa spread and then fixed to the corpus cavernosa. There has been no indication of recurrence, 4 months after the procedure.

Conclusion

Augmented anastomotic urethroplasty is a useful technique for repairing a complicated bulbar stricture. Urologists should understand appropriate indications for each treatment method so as to not make cases more complicated to treat.

Contemporary Management of Bulbar Urethral Strictures

Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.

Bioengineered Scaffolds as Substitutes for Grafts for Urethra Reconstruction

Urethral defects originating from congenital malformations, trauma, inflammation or carcinoma still pose a great challenge to modern urology. Recent therapies have failed many times and have not provided the expected results. This negatively affects patients' quality of life. By combining cells, bioactive molecules, and biomaterials, tissue engineering can provide promising treatment options. This review focused on scaffold systems for urethra reconstruction. We also discussed different technologies, such as electrospinning and 3D bioprinting which provide great possibility for the preparation of a hollow structure with well-defined architecture.

Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy

Context:

Clean intermittent catheterization (CIC) after direct vision internal urethrotomy (DVIU)

Aims:

The aim is to assess the quality of life (QOL) in patients with urethral strictures on CIC following DVIU.

Settings and Design:

Prospective study.

Materials and Methods:

This prospective study was conducted between August 2013 and July 2015 in the Department of Urology at KGMU, Lucknow. We included patients above the age of 18 years with stricture urethra, who were on CIC following direct visual internal urethrotomy. Patients below the age of 18 years, noncompliance, concomitant neurogenic voiding dysfunction, multiple strictures, pan anterior strictures, and posterior stenosis were excluded from the study. A 16 French Foley catheter was used for CIC following DVIU. Patients were evaluated at follow-up visit at 3, 6, and 12 months. At each follow-up visits, patients were assessed using CIC-QOL questionnaire, maximum urine flow rate and complications related to CIC if any.

Statistical Analysis Used:

Unpaired t-test was used to compare continuous data, and Fisher's exact test was used to analyze categorical data.

Results:

Among total 144 male patients evaluated, we included 97 patients, who underwent DVIU. Mean age of the study population was 37.7 ± 14.03 years. Most urethral strictures were idiopathic (64.02%) followed by postinflammatory (24.25%). A significant number of patients reported difficulty in performing CIC, which hampered daily activities. No major procedure related complications were reported. Patients who were compliant to CIC reported no stricture recurrence till 6 months follow-up.

Conclusions:

CIC following DVIU remains a reasonable adjunctive option. All the parameters of CIC-QOL questionnaire had improved on continuing CIC. Young men on CIC had greater impairment of QOL when compared to aged patients.

Patient-Reported Outcome Measures in Urethral Reconstruction

PURPOSE OF REVIEW

Treatment of anterior urethral stricture disease (USD) has shifted from endoscopic approaches to urethroplasty with significantly higher success rates among reconstructive urologists. This academic stance has led to a critical evaluation of "success" and developing disease-specific instruments to assess surgical outcomes focusing on patients' satisfaction rather than the historical goal of avoiding secondary procedures.

RECENT FINDINGS

Many disease non-specific and/or non-validated patient-reported outcome measures (PROMs) have been utilized to evaluate the voiding symptoms and sexual of function of patients after urethroplasty in the literature. Urethral Stricture Surgery PROM (USS PROM) is the first validated, disease-specific PROM for anterior USD which has been designed in 2001. Urethral Stricture Symptoms and Impact Measure (USSIM) is a comprehensive PROM and is currently being validated at multiple institutions. This article reviews the tools used to assess success after urethroplasty and elaborates the need to develop a comprehensive USD-specific PROM.

Endoscopic Management of Urethral Stricture: Review and Practice Algorithm for Management of Male Urethral Stricture Disease

PURPOSE OF REVIEW

Male urethral stricture disease is characterized by the formation of scar tissue within the urethra resulting in lower urinary tract symptoms, infection, and potentially kidney dysfunction. There is significant variability in clinical practice for the treatment of urethral stricture. We sought to summarize the known data on endoscopic management of urethral stricture disease as part of this larger edition on urethral stricture management.

RECENT FINDINGS

Older studies quoted high rates of success with endoscopic management of urethral stricture, including repeated DVIU. There is now evidence to support a limited role of endoscopic intervention in the management of urethral stricture, and especially strong evidence that repeated endoscopic procedures are not effective. There is poor evidence to support the long-term efficacy of endoscopic urethral stricture management. Furthermore, novel advances in adjunctive therapies have not yet demonstrated durable patency. We discuss the limited role of endoscopic management and suggest an algorithm for its use in stricture management.

A 10-Year Review of Urethral Stricture Management in Irrua, Nigeria

BACKGROUND

Several authors have demonstrated regional and temporal changes in the demographics of urethral stricture and its management.

OBJECTIVES

To assess the changes in the demographics of the patients and the evolution of the management of urethral stricture in this institution.

SUBJECTS AND METHODS

This is a retrospective study. The files of all the men who were diagnosed with urethral stricture from May 2006 to April 2016 were retrieved from the database of the records department of the hospital. The predictor variables assessed included age at presentation, occupation, etiology, presenting symptoms, stricture site, length of stricture, treatment method, year of treatment, complications of treatment, result of urine microscopy and sensitivity, comorbidities, and social habits of the patients. The outcome variables were the proportion of men in relation to the predictor variables and the test of correlation (P = 0.05 and below significant). Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 21.

RESULTS

Forty-six patients were diagnosed as having urethral stricture within the study period. All were males. The mean age was 53.11 years (standard deviation 17.63852) with a range from 19 to 96. There were 4 (8.7%) students, 11 (23.9%) civil servants, 4 (8.7%) businessmen, 3 (6.5%) military men, and 24 (52.2%) others who were essentially artisans. Majority of them (68.9%) presented with lower urinary tract symptoms while Escherichia coli was the most commonly cultured organism from their urine (17.4%). The most common single etiology was urethritis (30.4%). From 2013 onward, there was an abrupt transition from conservative treatment using dilatation which dropped from 38.9% to 17.9%. More complex surgeries such as buccal mucosal graft urethroplasty for bulbar strictures and two-stage repair for penile strictures increased from 11.1% to 57.1%.

CONCLUSION

Urethritis is still the most common single etiological factor in urethral stricture disease in this rural community. Artisans such as drivers and mechanics were the most commonly afflicted. There was an abrupt transition from the old conservative methods of treatment to complex urethroplasties within the study period.

Results of Use of Tissue-Engineered Autologous Oral Mucosa Graft for Urethral Reconstruction: A Multicenter, Prospective, Observational Trial

BACKGROUND

Harvest of oral mucosa for urethroplasty due to urethral stricture is associated with donor-site-morbidity. We assessed functionality and safety of an authorized tissue-engineered oral mucosa graft (TEOMG) under routine practice in stricture recurrences of any etiology, location, length and severity (real-world data).

METHODS

99 patients from eight centers with heterogenous urethroplasty experience levels were included in this prospective, non-interventional observational study. Primary and secondary outcomes were success rate (SR) and safety at 12 and 24months.

FINDINGS

All but one patient had ≥1, 77.1% (64 of 83)≥2 and 31.3% (26 of 83)≥4 previous surgical treatments. Pre- and postoperative mean±SD peak flow rate (Qmax) were 8.3±4.7mL/s (n=57) and 25.4±14.7mL/s (n=51). SR was 67.3% (95% CI 57.6-77.0) at 12 and 58.2% (95% CI 47.7-68.7) at 24months (conservative Kaplan Meier assessment). SR ranged between 85.7% and 0% in case of high and low surgical experience. Simple proportions of 12-month and 24-month SR for evaluable patients in all centers were 70.8% (46 of 65) and 76.9% (30 of 39). Except for one patient, no oral adverse event was reported.

INTERPRETATIONS

TEOMG is safe and efficient in urethroplasty.

Incidence of Urethral Stricture in Patients with Adult Acquired Buried Penis

Introduction. Concealed-buried penis is an acquired condition associated with obesity, challenging to both manage and repair. Urethral stricture is a more common disorder with multiple etiologies. Lichen sclerosus is a significant known cause of urethral stricture, implicated in up to 30%. We hypothesize that patients with buried penis have a higher rate of urethral stricture and lichen sclerosus than the general population. Methods. We retrospectively reviewed a single surgeon's (CM) case logs for patients presenting with a buried penis. All patients were evaluated for urethral stricture with cystoscopy or retrograde urethrogram either prior to or at the time of repair for buried penis. Those that had surgical repair or biopsy were reviewed for presence of lichen sclerosus. Results. 39 patients met inclusion criteria. Of these, 13 (33%) had associated stricture disease. The location of the strictures was bulbar urethra (38%), penile urethra (15%), and meatus or fossa navicularis (62%). Five patients had lichen sclerosus and urethral stricture disease, while 3 had lichen sclerosus without stricture. 11/13 stricture patients were treated. Six underwent dilation, 3 underwent meatotomy, and 2 underwent urethroplasty. No significant recurrences of stricture were seen. Conclusion. Patients with a concealed penis are more likely than the general population to have a urethral stricture and/or LS. Patients presenting with concealed penis should also be evaluated for a urethral stricture.

W-V flap: a new technique for reconstruction of female distal urethral stricture using vestibular mucosa

A premenopausal woman having a totally occlusive distal urethral stricture, with suprapubic catheter (SPC) in situ, was referred to us for a definitive procedure. On discussion of the treatment options, the patient refused for a buccal or vaginal flap procedure. Thus, a local W-V flap was fashioned from the periurethral vestibular mucosa with seemingly excellent results, both in terms of resolution of her symptoms and a forwardly directed stream of urine without incontinence.