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Objective: The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology)., Material and Methods: These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables., Results: Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms., Conclusion: Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Stricture of the male urethra is a frequent and regularly iatrogenic pathology in industrialized countries. The urologist's surgical arsenal is wide and the choice of an operative technique is made at the end of an assessment where urethrocystography is the main radiological examination. The conditions to achieve the examination, its different stages, the normal aspects and anatomical variants as well as the limitations to its interpretation, should therefore be known by the urologist and the radiologist, in order to assess correctly this pathology.

Introduction: The indication of the buccal mucosal graft for urethroplasty has evolved over recent years. The ease of its harvesting, availability, and immunohistological properties, as well as its satisfactory results, has made the buccal mucosal graft the current procedure of choice. We report a case of use of a buccal mucosal graft to treat an urethral stricture correction., Case Report: A 48-year-old man underwent a buccal mucosal graft for post-infectious urethral stricture correction. An inner right cheek graft of 50 × 30 mm was harvested and inserted into place after complete excision of the stricture. Postoperative evolution was satisfactory with no pain at the 5th day, resumption of normal diet at the 12th day, a significant improvement of peak flow rate at the 21st day. Follow-up examination at the 7th week revealed a mouth opening to 40 mm with complete healing., Discussion: Buccal mucosal graft has currently the highest success rate compared to other surgical techniques as full thickness skin graft from hair or graft of bladder mucosa. Its harvesting can be single or multiple, however care must be taken as regards Stenon's duct and to the labial commissure. The complications of the donor site are infrequent and can be characterized by numbness and limited mouth opening. Tissues that contain immunohistological properties, which are similar to those of the urothelium, buccal mucosal graft, have become the gold standard for this type of correction., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objectives: To determine the value of perineal sonography in the diagnosis of urethral stenosis and evaluation of surrounding fibrosis. Materials and methods. Fifty-eight healthy subjects underwent urethral sonography. Thirty-two patients with suspected urethral stenosis underwent sonography after retrograde distension of the urethra using normal saline and retrograde urethrogram and voiding cystourethrogram., Results: The mean diameters of the healthy urethra varied from 11 to 15 mm. The mean thickness of normal periurethral tIssue was between 2 and 4mm. Sonography detected 34 stenoses (97.4%). The length of the stenosis was significantly longer at sonography compared to retrograde urethrogram and voiding cystourethrogram. No significant difference was found between both techniques when measuring urethral diameter. In all cases, the thickness of periurethral tIssues was greater at the stenotic level than at a normal level, irrespective of the involved segment. There was no correlation between the thickness of periurethral tIssues and the degree of stenosis., Conclusion: Urethral sonography is a method that permits diagnosis of urethral stenosis and evaluation of periurethral fibrosis. It may replace retrograde urethrogram and voiding cystourethrogram in the diagnosis of post infectious stenosis.

Introduction: Experience of the use of the Holmium: Yttrium-Aluminium-Garnet (Ho:YAG) laser in children has been limited. However, the Ho:YAG laser has been in clinical use in urology for several years but has mainly been used for the treatment of renal stones and benign prostatic hyperplasia. Due to its unique combination of vaporization and coagulation, the Ho:YAG laser allows a precise cutting action. The depth of penetration in water and tissue is limited to < 0.5 mm and therefore provides a safety margin. The Ho:YAG laser can be used in children, as the energy can be delivered via fibers that range from 200 to 1000 mu in diameter., Materials and Methods: We used the Ho:YAG laser in 5 children (2-15 years): one child (2 years) with bladder exstrophy had a urethral stricture after bladder neck reconstruction, two children (6 years and 14 years) had ureteropelvic junction (UPJ) stenosis and refused open surgery and two children (5 years and 15 years) suffered from cystine stones (ESWL failed). The urethral stricture was incised in a retrograde fashion. We performed an antegrade incision of the UPJ with the Ho:YAG laser in the 6-year-old child and a retrograde incision in the 14-year-old child. We removed the stones in antegrade fashion in the 5-year-old child and in retrograde fashion in the 15-year-old child., Results: All children now have more than 12 month's follow-up. There were no immediate or late complications. The boy with urethral stricture remained free of recurrence, the boy with UPJ stenosis obtained improved drainage on the excretory renogram and the two children with cystine stones remained stonefree., Conclusion: We have shown that the safety and efficacy of the Ho:YAG laser is also reproducible in urologic pathology in children. In addition, due to its vaporizing quality, the Ho:YAG laser is more effective in the treatment of cystine stones and allows minimaly invasive treatment in children.

Objective: Treatment of long or multiple anterior urethral stricture(s) when Monseur technique is not applicable. Our technique entails augmentation of the dorsally slit open stenosed urethra using pedicled non-hair bearing penile skin., Patients and Methods: Between June 1991 and May 1996, 26 men (median age 34 years) with anterior urethral strictures underwent roofing urethroplasty. Nine patients had long stricture (average 3.2 cm) and 17 had multiple short segment strictures (average 7 cm). All patients were circumcised, and dorsal urethral augmentation was performed using transversely oriented non-hair bearing penile skin pedicled flap., Results: Median follow-up was 38 months (range 3-50). A successful outcome with no recurrent stricture as evidenced by normal retrograde urethrography and voiding history was achieved in 23 of 26 men (88%). Two patients had fistula in early postoperative period; one of them needed surgical closure., Conclusion: Roofing urethroplasty is a practical alternative for repair of long anterior urethral stricture(s) when Monseur technique cannot be applied.

Objectives: The contribution of ultrasonography to pretreatment morphological assessment of strictures of the anterior urethra and assessment of the risk of recurrence after internal urethrotomy., Material and Methods: 33 patients (16-89 years) operated by internal urethrotomy for stricture of the anterior urethra and followed for at least 6 months. Preoperative urethral ultrasonography, recording the number, length and degree of strictures and echostructure of the peristenotic fibrosis of the corpus spongiosium., Results: Ultrasound visualization of all urethral strictures, with no false-positives and no false-negatives. 11 patients relapsed after a mean interval of 5.7 months (1-16 months), 22 patients did not present recurrence: mean interval: 15.5 months (6-36 months). Corpus spongiosum fibrosis associated with urethral stricture is isoechoic to the corpus spongiosum (19 cases) or hyperechoic to the corpus spongiosum (14 cases). No statistical correlation was observed between the echostructure of the fibrous tissue and the risk of recurrence after internal urethrotomy., Conclusion: Ultrasonography allows excellent analysis of the morphological characteristics of a stricture of the male anterior urethra. In our experience, and in contrast with the limited data of the literature, no correlation was observed between the echostructure of the peristenotic fibrosis and the risk of recurrence after internal urethrotomy.

The results observed in a series of 40 patients treated for urethral stricture by endoscopic resection of the callus after internal endoscopic urethrotomy (Guillemin's technique) are presented. The mean age of the patients was 57 years, with a follow-up of five years. The authors obtained 80% (32 patients) of very good results for urethral strictures less than 1 cm long. The success rate of the technique was 10% (4 patients) when the callus was between 1 and 2 cm long. The recurrence rate was high for strictures longer than 2 cm (4 patients) (10%). Complications consisted of 2 cases of acute epididymitis, 2 cases of urethral perforation, 2 cases of urethral haemorrhage, 2 cases of perineal haematoma and 3 cases of meatal stenosis. The indications of this original technique therefore depend more on the length of the urethral stricture than on its topography or its aetiology.

The management of posterior urethral injuries is still a matter of controversies. Some authors recommend a primary or delayed emergency repair procedure, while others prefer late repair. The analysis of our series of fifteen cases showed that when patients are treated by delayed emergency operation, the results are usually good. However, when repair is performed later, results are less satisfactory, and the rate of impotence is higher. We conclude that delayed emergency repair operation is the procedure of choice in the management of ruptured posterior urethra.

After stressing the importance of a precise diagnosis, the author defines the place of internal urethrotomy, which is certainly not always the first-line treatment that some would claim, due to its poor success rate and because an endoscopic reoperation is sometimes much less harmless than it appears. The importance of perfect anaesthesia for urethral surgery is then emphasised in view of the particular demands of this surgery. Finally, the author reviews the various approaches to the urethra and opening of the stricture.

Long urethral strictures raise serious problems in terms of appropriate treatment. Reconstruction techniques using scrotal skin have a high recurrence rate. In order to avoid complications, a dermoepidermal or preputial Meshgraft was used to reconstruct a new urethra in two stages. In the first stage, the graft was raised and transplanted onto the open urethra. 8 to 12 weeks later, in the second stage, the new urethra is closed. Since 1977, Meshgraft urethroplasty has been performed in 128 patients, using the skin of the foreskin (n = 75) or medial surface of the thigh (n = 53). A good anatomical and functional result was obtained in all but three cases, regardless of the graft donor site. This operative technique constitutes a very effective method for the lasting treatment of long or complicated urethral strictures, for example in patients with spinal cord injuries.

The authors have developed a new model of flewible metal prosthesis to maintain the urethral calibre throughout the period of healing and epithelial restoration following internal urethrotomy. It consists of a large intravesical spiral, a shaft within the prostatic and sphincteric urethra and a spiral in the bulbar and anterior urethra. This prosthesis, implanted in 7 patients for periods ranging from 2 to 5 months, provides additional calibration following internal urethrotomy, but a longer follow-up is necessary to assess its real efficacy.

The author reports his experience and the results of a series of 104 patients suffering from urethral strictures, operated by the same operator from September 1984 to March 1990 and treated by the same surgical method: one stage urethroplasty using a pedicled skin graft. The principles which guided his technique are: complete exposure of the pathological tissue, appropriate size and cut of the graft from a healthy skin zone, careful dissection of the pedicle, elliptical anastomosis at each end and sparing of the corpora cavernosa. Eighty percent of the urethral strictures encountered in the series were complex and situated in various locations: 19 were penile, 55 were bulbar perineal, 30 were bulbar membranous. The urethral strictures were fistulated for 31 cases, multi-operated in 32 case, half of the cases had upstream repercussions from the stenosed zone, and 17 cases had an accompanying pathology. Ninety-one percent of the patients benefited from a patch graft designed to widen the stenosed zone, while a tubular graft was performed for 13 patients to reconstitute a neo-urethra. For a large number of the cases studied, postoperative follow-up was done for two years and for some cases exceeded two years. The operative results were quickly obtained. Good results observed after 3 months generally did not deteriorate thereafter, whereas bad results observed immediately after operation are not definitive since they can be reoperated by the same technique. For 82.7% of the patients, definitive cure was obtained, while 96% of the total number of patients showed considerable improvement. The intermediate results, average (13.6%) and the bad results (3.6%) both show the same inducing factors: past history of localized dilatory manipulations, infected areas but mostly defective application of management techniques. The superiority of this type of surgical technique and its reliability are stressed in the discussion. Also analysed are the following: the difficulty encountered in the management of stenoses of penile sites, the images which appear on the urethrographic controls and the cases where the choice of the tubular graft is appropriate, the problem of draining and the appropriate type and method of draining. Six years of experience in the utilisation of our technique, one-stage urethroplasty using a pedicled skin graft, leads the author to consider the technique as reliable and useful for the management of urethral strictures, especially for difficult multi-operated, infected, fistulated strictures. For these cases, our technique constitutes the best indication.

In this study of seventy-one cases, the authors report the characteristics of the clinical course and treatment of urethral stricture in tropical Africa. In this special context, only 38% cases could benefit from a curative procedure on the urethra, whereas in 43.6% of patients, local complications only allowed palliative treatment (periodic dilatation of urethra, perineal uretherostomy or definitive cystostomy).

Many patients are condemned to repeated urethral dilatations because of the poor efficacy of treatment for male urethral stricture. The authors have recently used a new urethral prosthesis: a metal-reinforced, meshed tube which opens in the urethra and maintains a it open allowing the urothelium to grow over. The prosthesis therefore becomes incorporated in the wall of the urethra. they have implanted this prosthesis in 21 patients with a mean age of 61 years, essentially in the bulbar urethra, for longstanding strictures measuring 5 to 35 mm and unresponsive to currently available treatments. The endoscopic insertion of the prosthesis is performed after dilatation. The mean follow-up is 9 months. The stricture was correctly treated in all patients (three patients required two sessions). The follow-up of these patients is short and the stability of these favourable results needs to be confirmed by a longer follow-up.

The technique of one stage operations using pedicled skin grafts represent an undeniable progress in the treatment of urethral strictures. The same operator in 1984-1990 performed 104 urethroplasties by using this technique. The proposed technique, originally inspired by Orandi and Blandy was performed as surgical treatment to all of the urethral strictures encountered most often, to broaden a stenosed urethra by the use of the pedicled skin graft as a patch, for other cases, by making a tubular graft meant to replace a segment of the urethra and for 2 extreme cases to replace pratically the entire damaged urethra. The urethral strictures were of different localisations: 19 were penien, 55 were bulbar perineal, 30 were bulbar membranous. The majority of the cases were qualified as "difficult and complex urethral strictures" due to: accompanying infections and iatrogenic diseases, 31 of them were fistular stenosis, 37 were multi-operated, half of the total number of the cases suffered upstream repercussions of the stenosis, and 17 cases had an associated pathology. The author used the pedicled skin graft as a patch to broaden the stenosed urethra on 91 patients, made a tubular graft to replace a segment of the urethra for 11 patients and for 2 extreme cases, to replace practically the entire urethra. Follow-up for half of the cases operated extended up to 2 years, the longest being up to 5 years, showed that 96% of the patients were satisfied. The criteria used for judging the quality of the results were clinical, radiographic and endoscopic.(ABSTRACT TRUNCATED AT 250 WORDS)

An urethral model was designed to assess the hydrodynamic consequences of stenosis of the bulbar urethra. This model was based on the geometric and hydrodynamic analysis of micturing urethrograms in a patient whose maximum flow rate was 24 ml/s for a bladder pressure of 40 cm of water. It corresponds to the conditions of flow observed wit maximum bladder pressure and flow rate. During this short period, the shape of the urethra is regarded as stable. Calculation took account of the characteristics of a turbulent flow of urine, of the head loss due to friction of the urine on the walls and of the head loss caused by the geometrical changes of the urethra from the neck of the bladder to the meatus. In these conditions, applying Bernouilli's equation allowed plotting of bladder pressure for various levels of urethral resistance. If there is no stenosis, the theoretical maximum flow rate of the model with a bladder pressure of 40 to 80 cm of water should be 19 to 26 ml/s. Calculation showed that a sudden reduction of the diameter to less than 2.5 mm occurring in a segment of the urethra with a diameter of 4 mm accounts for a flox rate lower than 15 ml/s, except when bladder pressure can exceed 100 cm of water. The decrease in the maximum flow rate caused by urethral stenosis is all the greater as bladder pressure remains low or normal, with other causes of head loss or with associated upstream dilatation. Lastly, progressive narrowing leads to a smaller head loss and will therefore be better tolerated than sudden narrowing to the same caliber. Inversely, a long stenosis will be less well tolerated as the head loss due to friction in a long and narrow passage is increased. The diameter of a stenosis accounting for a maximum flow rate of less than 15 ml/s cannot be determined in the absolute. Analyzing the hydrodynamic consequences of stenosis also requires knowing the associated urodynamic and geometric parameters.

The authors analyze the results obtained in a homogenous series of 49 patients with urethral stenosis treated by segmental resection of the urethra and end-to-end urethro-urethral suture, with the following conclusions:--Segmental urethrectomy is indicated only for short lengths of stenosis, which do not require the sacrifice of more than 4 cm.--Excellent results were obtained in 41 out of 49 cases (84%).--Good results remain stable, as they were still present in 33 of these 41 successful cases after periods varying from 14 months to 7 years (average: 3 years and 2 months).--Good results have a good chance of remaining as out of the 8 failures only 2 were due to secondary deterioration after a satisfactory initial result. Traumatic and congenital stenoses give the best results as suture of the two healthy sections of the urethra can be performed. Nine successful results were obtained in 10 cases of iatrogenic stenosis after in-dwelling urethral sounds or endoscopic procedures. Twelve cases were successful out of 16 traumatic stenoses of the membranous urethra following pelvic fractures. Two cases of traumatic stenosis of the perineal urethra were both treated with success, as were fourteen out of 15 so-called "congenital" urethral stenoses in which there was no history of trauma or infection. As far as the procedure used is concerned, a successful outcome depends upon the degree of mobilization of the urethral ends, which should be large in order to be able to suture without tension.--The factors causing failure include: absence of excision of post-traumatic callus, insufficient hemostasis, insufficiently prolonged modelling of the suture, favourable for the formation of synechia and, more particularly, a poor condition of the urethra: sclerosed inflammatory stenoses and untreated associated prostatitis.--Sexual impotence is found, temporarily, in all patients operated upon for urethral stenosis, but virility returns in all cases within variable periods of up to two years.

Urethral dilatation, internal urethrotomy both blind and endoscopical for treatment of strictured male anterior urethra are neither always successful nor without complications. Free full thickness patch grafts of skin and island grafts described for one-stage urethroplasty have their specific indications and are not devoid of complications. Monseur in 1968 described his technique of one-stage urethroplasty which was used in this work in 22 cases. Their age ranged between 18-60 years. None of them was complicated by fistulae, and their follow-up for 36 months excluded recurrence of the stricture.

In eleven patients with impassable urethral stenoses, we attempted retrograde catheterisation with an angiographic guide under fluoroscopic control. The stenosis was able to be negotiated with the guide in 10 cases (91% success). After dilatation by dilators (coaxial or rigid) or by Olbert's angioplasty balloon, we were able to introduce a Foley catheter into the bladder. The only failure was caused by a very marked separation of the two ends of the urethra due to trauma. This simple and effective method constitutes an alternative to immediate surgical treatment of endoscopically impassable urethral stenoses.

Dysuria is a relatively frequent complication after prostatic adenomectomy. The authors review 107 patients with this complication and demonstrate that radiological investigation, including a micturition study, preferably after IVU, shows the presence of an obstructive cause for the dysuria in the vast majority of cases (92.5%). There are two main types of obstructive lesion: - parietal stenosing lesions, - compression lesions. - The most frequent parietal stenosing lesions, apart from those of the bladder neck, are urethral stenoses. - Stenoses with total compression of the capsule are often the cause of severe dysuria. - Localized compression of the capsule and urethral stenosis usually cause only moderate dysuria. - An irregular lacunar image should suggest cancer of the prostate.

This article reports a case of urethral meatal stenosis and acute urinary retention in an adult male with no previous urological case history. Intravenous pyelography showed a full bladder and dilatation of the urethra. An emergency meatotomy was required, and intermittent dilatation will no doubt be necessary.