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Introduction: Distal anterior urethral strictures (DAUS) affect the meatus, navicular fossa (NF) and penile urethra (PU). The main causes are inflammatory (lichen sclerosous [LS]), traumatic iatrogenic, or idiopathic. Post-hypospadias stenosis is common and constitutes a separate entity, dealt with in a separate article., Method: A summary of North American, European and French recommendations was drawn up, supplemented by a literature search from December 2020 to December 2023, to provide a current overview of strategies adapted to DAUS., Results: Stricture limited to the meatus without LS can be dilated once. From the 1st recurrence or in the presence of LS, only a ventral or dorsal meatoplasty will be effective. In cases of Navicular involvement, an augmentation urethroplasty, respecting the glans penis (aesthetic preservation) will be preferred. Severe cases or recurrences may require replacement urethroplasty in two or more stages. PU stricture should not be treated by endoscopic urethrotomy but by urethroplasty in all cases. A one-stage augmentation technique will be discussed with a staged (2 stages most often) urethroplasty depending on the severity of the obstruction, stricture length, recurrent nature and the presence of LS. Buccal mucosa (jugal, lingual) is the most commonly used material in the form of a free graft. The most complex cases may require a perineal urethrostomy., Conclusion: DAUS present in a variety of ways. They are mainly managed surgically, in one or more stages. It is necessary to master several techniques to adapt to their heterogeneity., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Purpose: To determine the prevalence of concomitant squamous metaplasia (SM), the initial histological change from normal urethra to urethral stricture, in bulbar urethral strictures and to investigate the associated clinical factors., Methods: A retrospective review was conducted on 165 male patients with bulbar urethral strictures who underwent excision and primary anastomosis (EPA) between 2010 and 2020, for whom complete clinical data and excised urethral specimens were available. An experienced pathologist histologically evaluated concomitant SM in paraffin sections of the proximal end of the excised urethra blinded to the clinical data. Disease duration was calculated as the period from the initial diagnosis of urethral stricture to the date of EPA. The association between concomitant SM and clinical background was investigated., Results: SM was identified in 86 (52.1%) patients. The median disease duration in patients with SM (38 months) was significantly longer than that in patients without SM (9 months, p < 0.0001). In multivariate analysis, the longer disease duration, non-traumatic stricture etiology, and failure to maintain urethral rest with urinary diversion via a suprapubic tube for more than 90 days were independent factors predicting concomitant SM. No significant difference was observed in success rates of EPA between patients with SM (93.2%) and those without SM (97.5%, p = 0.18)., Conclusions: Reconstructive urologists need to be aware that concomitant SM is frequent in patients with bulbar urethral stricture, especially in those with long disease duration and those who were voiding volitionally during the period of urethral rest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs., Materials and Methods: A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses., Results: Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05)., Conclusions: One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Purpose: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty., Materials and Methods: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy., Results: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080)., Conclusions: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.

Purpose: Urethroplasty of lichen sclerosus strictures has a significantly higher failure rate than strictures due to other causes. We sought to determine predictors of urethroplasty failure in men with lichen sclerosus urethral stricture disease by evaluating protein expression profiles., Materials and Methods: Urethral tissue was excised from patients with lichen sclerosus who were undergoing urethroplasty of urethral stricture disease at a single institution. A tissue microarray was created with cores from each sample. Immunohistochemistry was performed to compare protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. Stricture recurrence was defined by the need for a subsequent unanticipated procedure for urethral stricture disease., Results: We evaluated 50 men with lichen sclerosus urethral stricture disease, including 31 with successful reconstruction and 19 with recurrent stricture. Recurrent strictures expressed lower levels of several inflammatory markers and had a lower Ki-67 mitotic index and significantly higher vascular endothelial growth factor levels than nonrecurrent strictures., Conclusions: To our knowledge this is the first study to use tissue protein expression to identify risk factors for urethroplasty failure among men with lichen sclerosus urethral stricture disease. Our findings suggest that recurrent lichen sclerosus strictures demonstrate a suppressed inflammatory response, a decreased cell turnover rate, and poor oxygenation and nutrient delivery. Prospective studies are needed to clarify the role of these pathways in the pathophysiology of lichen sclerosus urethral stricture disease, determine whether preoperative biopsy can predict urethroplasty success, help counsel patients and develop future treatments.

Objective: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends., Methods: The Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected., Results: The mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques., Conclusion: In this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To describe the feasibility of a novel cell-based endoscopic technique using buccal epithelium, expanded and encapsulated in a thermoreversible gelation polymer scaffold for the treatment of urethral stricture., Methods: Six male patients with bulbar urethral stricture ranging from 2.0 to 3.5 cm in length were included in this pilot study. Autologous buccal epithelial cells from a small buccal mucosal biopsy were isolated, cultured and encapsulated in thermoreversible gelation polymer scaffold, and were implanted at the stricture site after a wide endoscopic urethrotomy., Results: All the patients voided well, with a mean peak flow rate of 24 mL/s. Urethroscopy carried out at 6 months showed healthy mucosa at the urethrotomy site. However, two of the six patients had recurrence at 18 and 24 months, respectively., Conclusions: This endoscopic-based Buccal epithelium Expanded and Encapsulated in Scaffold-Hybrid Approach to Urethral Stricture (BEES-HAUS) technique is a promising alternative for the open substitution buccal graft urethroplasty. It is possible to achieve the benefits of open substitution buccal urethroplasty with this endoscopic technique., (© 2018 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association.)

Purpose: We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution., Materials and Methods: We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram., Results: We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A-short focal recurrence, which may be salvaged with an endoscopic procedure, and type B-the long graft length type, which is less likely to be salvaged with endoscopy., Conclusions: Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We compared the results of initial buccal mucosal graft urethroplasty to the results of repeat and secondary cases of previous urethroplasty done by any technique other than buccal mucosal graft urethroplasty., Materials and Methods: We performed a retrospective study of patients who underwent buccal mucosal graft urethroplasty between January 2009 and December 2016 at a high volume center. Patients were stratified according to surgical sequence and characteristics were compared. We plotted Kaplan-Meier curves to compare stricture recurrence-free survival according to the surgical sequence. Multivariable Cox regression analyses were performed to delineate the impact of the surgical sequence on recurrence-free survival after adjusting for known clinical and surgical confounders., Results: Of 534 men with a median followup of 33 months (IQR 17-52) 436 (81.6%), 64 (12.0%) and 34 (6.4%) underwent an initial, a repeat and a secondary procedure, respectively. Patient characteristics were comparable (each p ≥0.2). Patients with reoperative procedures had received more previous endoscopic interventions and were more often operated on by high volume surgeons (each p ≤0.021). Operative time, graft length, stricture location and surgical techniques were comparable (each p ≥0.1). The success rate of initial, repeat and secondary procedures was 87.4%, 87.5% and 70.6%, respectively. On survival analyses patients who underwent secondary procedures fared worse than those who underwent repeat or initial procedures (p = 0.010). Similarly a secondary procedure was an independent risk factor for recurrence (HR 2.42, 95% CI 1.03-5.68, p = 0.043)., Conclusions: We found excellent results for repeat anterior 1-stage buccal mucosal graft urethroplasty, comparable to those of initial procedures. Patients who underwent secondary procedures were at higher risk for recurrence. However, when performed at a specialized center, the success rate was still high., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To compare postoperative outcomes between the perineal inverted-U and the vertical midline incision approaches of the urethroplasty and clarify them via gross anatomy., Patients and Methods: A total of 461 male patients, from Jan. 2006 to Jun. 2014, who underwent the urethroplasty via perineal midline vertical or inverted-U incision approach were recruited retrospectively. By match pairing for etiology and stricture length, 410 patients from two groups (205 for each group) were selected. Anatomy experiments were also performed. Outcome measurements and statistical analysis: the Chi-square, Student's t and binary logistic regression analyses were performed to compare the operative and postoperative data on the two groups., Results: With regard to patients with bulbar urethral stricture, the rate of surgical site infection (SSI) in perineal inverted-U group was 18.6% while 1.9% in the midline vertical group (p < 0.001). As for patients with posterior urethral stricture, the rate of SSI in the perineal inverted-U group was 16.4% while 3.1% in the midline vertical group (p = 0.001). Mean hospital stay between both groups were 15.8 ± 9.0 vs. 12.7 ± 3.8 days (p < 0.001). Anatomy experiments showed the number of damaged vessels and nerves involved in the inverted-U incision were approximately 1.6 to 2.0 folds more than the vertical midline, but the visual operation fields are similar between two approaches., Conclusions: The perineal midline vertical incision is a safer approach with fewer SSI and shorter hospital stay than the perineal inverted-U incision for bulbar and posterior urethroplasty.

Purpose: We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty., Materials and Methods: We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm 2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure., Results: Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted., Conclusions: Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To report our experience with anastomotic uretroplasty (AU) due to male urethral stricture disease (USD) and to identify factors affecting the results., Patients and Methods: We conducted a retrospective study over a period of 4 years and 6 months (July 2012 to December 2016). Any subsequent use of endoscopic urethrotomy or new urethroplasty was considered a failure., Results: Forty-eight cases were included. The mean age of patients was 53.5±17.3 years (23-87 years). Urinary retention was the reason for consultation in 42 cases (87.5%). The most common localization of USD was the bulbar urethra (n=45). The mean length of USD was 1.23±0.62cm (0.5-3cm) with a median length of 1cm. The etiology was post-infectious in 56.3% of cases. More than half (58.3%) of patients had already undergone at least one urethral manipulation. After an average follow-up of 21.1±12.6 months (1 to 52 months), the overall success rate was 77.1%. In univariate analysis, length, cause and location of the stricture, age of patient, the presenting symptoms of the stricture, previous urethral manipulation and surgeon experience did not significantly impact on the success rate of anastomotic urethroplasty at one and two years follow-up., Conclusion: The AU had provided good results in our practice. The infectious origin of the stricture and previous urethral manipulation did not significantly impact the result of this surgical technique., Level of Evidence: 4., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist., Materials and Methods: All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease., Results: There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007)., Conclusions: There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.

Introduction: Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results., Objective: We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies., Materials and Methods: We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success., Result: All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2 mL/s to 26 mL/s (p = 0.0002) and from 1.6 mL/s to 12.2 mL/s (p = 0.003), respectively. Median follow-up was 34 months (range 30-42 months)., Discussion: This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure., Conclusion: A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes., Materials and Methods: We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis., Results: A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2-10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self-dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24-month stricture-free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02)., Conclusions: Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the surgical outcome and predictors of failure of substitution urethroplasty using either dorsal onlay buccal mucosal (BM) graft or ventral onlay penile skin flap (PS) for anterior urethral stricture ≥ 8cm., Patients and Methods: Between March 2010 and January 2016, 50 patients with anterior urethral stricture ≥ 8 cm were treated at our hospital. The surgical outcome and success rate were assessed. The predictors of failure were analyzed using multivariate analysis. Failure was considered when subsequent urethrotomy or urethroplasty were needed., Results: Dorsal onlay BM graft was carried out in 24 patients, while PS urethroplasty in 26 patients. There was no significant difference between both groups regarding patients demographics, stricture characteristics or follow-up period. One case in the BM group was lost during follow- up. Stricture recurrence was detected in 7 (30.4%) patients out of BM group while in 6 (23.1%) patients out of PS group (p value= 0.5). No significant differences between both groups regarding overall early and late complications were observed. Occurrence of early complications and the stricture length were the only predictors of failure in univariate analysis, while in multivariate analysis the occurrence of early complications was only significant., Conclusion: On short-term follow-up, both dorsal onlay BM graft and ventral onlay PS flap urethroplasty have similar success rates. However, BM graft has a potential advantage to reduce operative time and is also technically easier. The surgeon should avoid early local complications as they represent a higher risk for failure., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objectives: To report our initial experience with urethra-sparing reconstruction combining dorsal preputial skin and ventral buccal mucosa grafts for tight bulbar urethral strictures., Methods: Between November 2006 and September 2012, 26 patients with tight bulbar strictures underwent urethroplasty. Using a ventral urethrotomy approach, the two-sided urethral reconstruction was carried out avoiding the transection of urethra and augmenting the preserved urethral plate by dorsal preputial skin plus ventral buccal mucosa grafts. The primary outcome was the objective urinary result, defined as the absence of stricture recurrence. The outcome was considered a failure when any postoperative instrumentation was required. Postoperative sexual dysfunctions were investigated using a validated questionnaire., Results: Mean follow up was 30.1 months (range 12-79 months). Mean stricture length was 3.3 cm (range 1.5-6 cm). Mean length for dorsal preputial skin and ventral buccal mucosa grafts was 3.2 cm (range 2-7 cm) and 4.9 cm (range 4-6 cm), respectively. Of 26 cases, 23 (88.5%) were successful and three (11.5%) were failures with stricture recurrence. Failures were treated with perineal urethrostomy in one case, ventral buccal graft urethroplasty in one case and internal urethrotomy in one case. Among 12 sexually active men preoperatively, none reported postoperative penile curvature/shortening, impaired erection or dissatisfaction regarding erection; sexual activity was unaltered pre- and post-surgery., Conclusions: In tight bulbar urethra strictures, the two-sided urethroplasty combining dorsal preputial skin and ventral buccal mucosa grafts provides a safe and effective semi-circumferential reconstruction by augmenting the preserved urethral plate, with no impact on sexual function., (© 2015 The Japanese Urological Association.)

Urethral strictures and anomalies remain a challenging urological problem. Reconstructive plastic surgery has been shown to be the most effective way to treat them. There are two main types of urethroplasty: anastomosis (anastomotic urethroplasty) and expansion of the urethral lumen using of flaps and grafts (substitution urethroplasty). Currently the ideal material for substitution urethroplasty does not exist. Tissue engineering of the urethra seems to be one of the most promising approaches to address this problem. Various tissues-engineering techniques were proposed for substitution urethroplasty. In this study, tissue-engineering design was based on the decellularized cadaveric arterial wall. The study results demonstrated the feasibility of creating stable tissue-engineered structures with autologous cultured epithelial cells of the buccal mucosa and decellularized matrix from human cadaveric arterial wall (DMCAW). There was a complete engraftment of tissue-engineering design based on DMCAW and buccal mucosa cells, used for substitution urethroplasty in a patient with the bulbar urethral stricture. Postoperatively (within 4 months after surgery) no complications and/or adverse events were observed. However, in the late postoperative period (12 months) there was recurrence of urethral stricture in the middle of the tissue-engineering design and the native urethra that warranted another surgery. Tissue-engineering design based on DMCAW and autologous buccal mucosa is safe as a material for substitution urethroplasty. Further research is required to ascertain the effectiveness of the method.

Background: There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken., Objective: We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes., Design, Setting, and Participants: A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons., Surgical Procedure: Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy., Outcome Measures and Statistical Analysis: Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed., Results and Limitations: A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence., Conclusions: Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex., Patient Summary: We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture., (Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The article presents a comprehensive study of 121 patients with stricture disease of the male urethra. Diagnosis and staging of the disease were made on the basis of medical imaging, namely retrograde urethrography, voiding cystourethrography and magnetic resonance imaging with complex pulse sequences developed by the authors. The results were compared with surgical findings and morphological study of surgical specimens. Detailed semiotics of magnetic resonance imaging of stricture disease, differences in the visualization of traumatic and inflammatory strictures of various locations, as well as features of primary and recurrent lesions are described. Detailed analysis of the data shows significant advantages of MRI in identifying stricture disease of the male urethra over traditional methods of endoscopic visualization. It makes possible to increase the diagnostic accuracy for detection of the disease and better surgical planning strategy.

The article introduces the clinical and statistical analysis of 113 patients treated for urethral strictures (US) in the urological clinic of the Rostov State Medical University in 2011. 58% of patients experienced a recurrent course of the disease. Radical curative surgery was possible in 93 (82.3%) patients. In other cases, non-invasive strategy was indicated (13.3%) or surgery for urethral stricture was impossible due to comorbidities (4.4%). Resection with urethral end-to-end anastomosis, which is the most effective approach to the treatment of patients with US, was possible in only half of the patients (51.8%). In the rest of the patients, one-, two- or more stage urethroplasty substitution was carried out. By the end of 2013, treatment of 84 (90.3%) patients was completed with a total of 110 operations. 9 (9.7%) patients were scheduled for operation in 2014.

Objective: To describe the anatomical characteristics and vascularization of the biaxial hair free scrotal flap (BAES-flap) and to detail its surgical application to reconstruction of the more complex urethral strictures., Methods: We performed macro and micro anatomical dissections of the scrotum in 15 cryopreserved cadavers for the study of the arterial microvascularization of the BAES flap, and this anatomical knowledge has been implemented with the aim to improve the anterior and posterior urethra reconstructive surgical technique. For scrotal skin conditioning we performed definitive hair removal with the alexandrite laser., Results: The BAES flap, thanks to its rich biaxial vascularization, its anatomical disposition over the urethral axis, and the suitable characteristics of hair free scrotal skin, has allowed us to perform successful one-step urethral reconstruction in complex cases such as panurethral disease, multioperated hypospadias, failed urethroplasties and obliterative stenosis., Conclusions: Detailed study of scrotal skin arterial vascularization is essential to design reliable and versatile genital skin flaps that result appropriate for the most complex reconstructive urethral surgery. The BAES scrotal flap complies with these requirements offering the patient a one step reconstructive option with a very satisfactory surgical experience over more than 20 years.

Patients with panurethral and complex urethral strictures after failed urethral reconstruction due to strictures and hypospadias repair is a rare but challenging condition. Contemporary surgical techniques include one and two staged urethroplasties using different graft substitutes (i.e., buccal mucosa) or full thickness skin grafts (i.e., from the inner thigh(, thereby providing satisfactory results with reducing the re-stricture rate in these patients. However, all current techniques do so at the expense of higher revision rates and thus requiring multiple procedures. Studies investigating the outcomes of reconstruction in panurethral and complex urethral strictures often have heterogeneous patient cohorts including children and adults, different underlying causes, and different techniques, thus allowing only limited interpretation of the published data. In the field of urethral reconstruction, where personal experience and expertise presents an accepted necessity, however, leading to rather small single center studies,only well-designed randomized clinical trials can truly answer the question of which technique will be advantageous in these patients.

Objective: To evaluate the results of a dorsal onlay augmented anastomosis using buccal mucosa to reconstruct long segment bulbar urethral strictures. The ideal treatment of long segment bulbar urethral strictures remains controversial. Urethroplasty with tissue transfer is typically required, but the optimal technique is unknown., Materials and Methods: A prospective cohort of 163 patients with complete follow-up data underwent dorsal onlay augmented anastomosis using buccal mucosa for long segment bulbar urethral strictures from November 2003 to March 2011. All patients underwent preoperative urethrography and cystoscopy. The follow-up protocol consisted of cystoscopy and subjective symptom assessment at 6 months and symptom assessment at 12 months, with repeat cystoscopy, if indicated. Annual symptom assessments were performed thereafter as required. Stricture recurrence was defined as a segment <16F on cystoscopy or the presence of intractable voiding symptoms. The secondary outcome measure was the incidence of postoperative complications using a nonvalidated questionnaire. Fisher's exact test was used to evaluate the patency and complication rates between patient age and stricture length., Results: The median follow-up period was 31.0 months (range 6-91). Of the 163 patients, 157 (96.9%) had no evidence of stricture recurrence. Postoperative complications included postvoid dribbling (41.7%; 68 of 163), urinary tract infection (3.7%; 6 of 163), erectile dysfunction (3.1%; 5 of 163), orchalgia (10.4%; 17 of 163), and donor site morbidity (4.3%; 7 of 163). Age was not associated with recurrence, but stricture length ≥5 cm was associated with a lower patency rate (P = .010)., Conclusion: Dorsal onlay augmented anastomosis using buccal mucosa demonstrated a 96.9% patency rate in our single-center prospective study and should be considered for reconstruction of long segment bulbar urethral strictures, especially with a focal segment of obliteration. Strictures ≥5 cm are prone to recurrence but are still amenable to dorsal onlay augmented anastomosis using buccal mucosa., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Graft urethroplasty using free transplants has become a standard procedure in the therapy of complicated urethral strictures. Various types of tissues can be used as graft material and different criteria are important for the suitability of tissues for urethroplasty. It was recognized early on that the prepuce was an easy to harvest tissue with low morbidity and excellent functional results. In this article the suitability of this tissue for functional results will be discussed within the context of the biology of free transplants and the available literature.

The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy (DVUI) method according to Sachse. It is an effective short-term treatment, but the long-term success rate is low. A number of factors influence the outcome of DVUI including stricture location, spongiofibrosis and previous endoscopic stricture treatment. Multiple urethrotomy has a negative impact on the success rate of subsequent urethroplasty. A thorough preoperative diagnostic work-up including combined retrograde urethrogram/voiding cystourethrogram (RUG/VCUG) and urethrocystoscopy is, therefore, mandatory to allow for patient counselling regarding the risk of stricture recurrence and other treatment options. After a failed primary DVUI, subsequent urethrotomy cannot be expected to be curative.

The use of oral mucosa for urethral stricture repair has become the standard approach in reconstructive urethral surgery. Compared to other tissues oral mucosa shows several advantages, such as simple harvesting, good urine tolerance and low harvesting morbidity. For defects of the male bulbar urethra measuring 2 cm or longer, urethral reconstruction with oral mucosa is the procedure of choice. The oral mucosa graft can be used as an inlay or as an onlay graft. Most repairs can be completed in one stage but for complex strictures two stages are needed.

What's known on the subject? and What does the study add? Urethral strictures are common and increasingly common in an ageing population. The treatment is controversial and particularly the relative roles of urethrotomy or urethral dilatation on the one hand and urethroplasty on the other. This review aims to provide a comprehensive overview of the subject including less commonly discussed issues such as the history and pathology of stricture disease. We would hope that a comprehensive overview of the subject will give a sharper perspective to aid the investigation and management of patients with urethral strictures., (© 2010 BJU INTERNATIONAL. NO CLAIM TO ORIGINAL US GOVERNMENT WORKS.)

The management of patients with urethral stricture can be a complex process. However, with the appropriate tools, the urologist experienced in urethral surgery can manage most cases without too much difficulty. Here, we describe three surgical techniques--anastomotic urethroplasty, buccal mucosal graft-onlay urethroplasty and the two-staged Johanson urethroplasty--that, in our experience, can accommodate the majority of patients with urethral stricture and provide excellent long-term results. Diagnosis and evaluation of candidacy for each of the surgical techniques are important aspects of treatment planning, and are also described. The aim of the article is to increase the awareness of the technique and application of these three urethroplasty procedures, which can be implemented by all urologists who actively care for and surgically treat patients with urethral stricture disease.

Objectives: To evaluate the outcome of different techniques of urethroplasty and to assess the quality of an in-home algorithm., Methods: Two hundred fifty-two male patients underwent urethroplasty. Mean patient's age was 48 years (range 1-85 years). Data were analyzed for the failure rate of the different techniques of urethroplasty. An additional analysis was done based on an in-home algorithm., Results: Median follow up was 37 months (range: 6-92 months). Global failure rate was 14.9%, with an individual failure rate of 11.7%, 16.0%, 20.7% and 20.8% for anastomotic repair, free graft urethroplasty, pedicled flap urethroplasty and combined urethroplasty, respectively. In free graft urethroplasty, results were significantly worse when extrapreputial skin was used. Anastomotic repair was the principle technique for short strictures (83.3%), at the bulbar and posterior urethra (respectively 50.8 and 100%). Free graft urethroplasty was mainly used for 3-10 cm strictures (58.6%). Anastomotic repair and free graft urethroplasty were more used in case of no previous interventions or after urethrotomy/dilation. Pedicled flap urethroplasty was the main technique at the penile urethra (40.7%). Combined urethroplasty was necessary in 41 and 47.1% in the treatment of, respectively, >10 cm or panurethral/multifocal anterior urethral strictures and was the most important technique in these circumstances. Two-stage urethroplasty or perineostomy were only used in 2% as first-line treatment but were already used in 14.9% after failed urethroplasty., Conclusion: Urethroplasty has good results at intermediate follow up. Different types of techniques must be used for different types of strictures.

Purpose: We report a comprehensive review of our experience with labial mucosa graft urethroplasty to evaluate the indications for this kind of substitution urethroplasty, and the possible complications and risk factors for an untoward recipient site outcome both in children and adults., Materials and Methods: Complications were retrospectively assessed by chart review. Patients with and without complications were compared with respect to age at surgery, indication for surgery (epispadias vs. hypospadias vs. urethral stricture), graft length and configuration (tube vs. patch). Moreover, in cases with urethral stricture a comparison was made according to the level of the stricture (penile vs. bulbar)., Results: After a median follow-up of 36 (6–90) months, the overall success rate was 66%. Complications were observed in 39 (34%) patients, of whom 18 (16%) required additional surgical procedures. Complications appeared to be unrelated to patient age at surgery, indication for surgery, graft length, and the urethral level of the stricture. Use of the graft as a tube was the single factor significantly more frequent in patients experiencing complications, particularly in the urethral defects associated with hypospadias where use of a tube corresponded to an odd ratio of 5.86 (95% CI 1.5–23.4)., Conclusions: Oral grafts harvested from the lower lip are a versatile tissue for the repair of urethral defects associated with either urethral malformations or strictures, both in children and adults. Use of the graft as an on-lay seems preferable particularly in hypospadias repairs.

Objectives: To review the results of utilizing different grafts for substitution urethroplasty for anterior urethral stricture caused by balanitis xerotica obliterans (BXO)., Methods: 153 patients who underwent substitution urethroplasty for anterior urethral strictures were included in this study. The stricture length varied from 3.8 to 16.4 cm (mean 10.2 cm). In 32% of the patients (49), local genital, penile (18), perineal (16) and scrotal (15) skin grafts were used. Over the 3 years our standard treatment policy has been to utilize a free mucosal graft from a non-genital area. Buccal mucosa was the most preferred, utilized in 74 (48.3%) patients and bladder mucosa in 12 (7.8%). Recently we have used lingual mucosal grafts in 18 (11.7%) patients for substitution urethroplasty., Results: The overall success rate for non-genital mucosal graft was 92.2%. The remaining 8 patients required more than one supplementary procedure postoperatively but none required a second urethroplasty. Of 49 patients who underwent substitution urethroplasty utilizing genital skin, the success rate was only 4%. 16.3% required one and 14.3% required multiple auxiliary procedures postoperatively. 34 patients (69.4%) required subsequent urethral reconstruction., Conclusions: A free graft urethroplasty using non-genital skin is recommended for anterior urethral stricture related to BXO., (2008 S. Karger AG, Basel)

Purpose: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success., Materials and Methods: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications., Results: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee., Conclusions: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.

Objective: The purpose of this study is to evaluate the effect of intraurethral captopril gel as an antifibrotic agent on patients with urethral stricture., Materials and Methods: In the first phase of clinical trial, 13 rabbits were included and local side-effects of captopril gel were evaluated. In the second phase, 56 patients were enrolled from April 2004 to January 2006. After internal urethrotomy the patients were classified into three patient groups: (i) received placebo gel (group I); (ii) received 0.1% captopril gel (group II); and (iii) instilled 0.5% captopril gel intraurethrally (group III)., Results: In phase I, no significant local side-effects were seen in the urethra of rabbits. In phase II, the mean age of the patients was 39.5 and the mean follow-up duration was 16 months. The most common etiology of the urethral stricture in the patients was iatrogenic (35.7%), most of their strictures had a depth of 0.5 cm or less (67.8%), and the length of most strictures was between 1 and 2 cm (41.1%). The patients' maximum urine flow increased more in groups II and III, than in group I (P < 0.04, P < 0.05, respectively). The recurrence rate was less in groups II and III than in group I (P < 0.05). In terms of the maximal urine flow and recurrence rate, no significant difference was seen between group II and group III (P = 0.13, P = 0.21, respectively)., Conclusion: Captopril gel is a safe, effective and non-toxic agent for decreasing the recurrence rate of the urethral stricture after internal urethrotomy. However, more studies, including more cases and a longer follow up, are needed to prove the effect of captopril gel on patients' urethra.

Purpose: We reviewed the results of direct vision urethrotomy for short (less than 1 cm) penile urethral strictures following hypospadias surgery., Materials and Methods: Patients with less than 1 cm anterior penile urethral strictures located proximal to the meatus underwent direct vision urethrotomy. Based on the type of initial urethroplasty patients were randomly divided into treatment with direct vision urethrotomy vs direct vision urethrotomy plus clean intermittent catheterization for 3 months. Success was defined as absent obstructive voiding symptoms and a normal urine flow 2 years following the last patient instrumentation., Results: Of patients with urethral strictures following hypospadias repair 44% (32) had previously undergone tubularized graft urethroplasty and 56% (40) had previously undergone flap urethroplasty, including a tubularized island flap in 18, an onlay flap in 11 and urethral plate urethroplasty in 11. Direct vision urethrotomy alone was performed in 51% of patients (37), and direct vision urethrotomy and clean intermittent catheterization were performed in 49% (35). Success with the 2 methods was similar, that is 24% (9 of 37 patients) vs 22% (8 of 35). Following direct vision urethrotomy all patients with tubularized graft urethroplasty showed failure (0 of 32). Success was noted in 11% of patients (2 of 18) with tubularized island flap urethroplasty compared to 72% (8 of 11) with onlay urethroplasty and 63% (7 of 11) with urethral plate urethroplasty (each p <0.05)., Conclusions: The addition of clean intermittent catheterization to direct vision urethrotomy does not improve the likelihood of success. Direct vision urethrotomy for short (less than 1 cm) urethral stricture usually fails following any type of tubularized graft or flap urethroplasty but it had moderate success following onlay flap and urethral plate urethroplasties.

Objective: To evaluate the selection of different procedures and the feasibility for the treatment of long segment urethral stricture., Methods: Seventy-six patients with complex urethral stricture greater than 8 cm long underwent different procedures of urethroplasty. Of them various mucosa grafts urethral reconstruction were adopted in 42 cases (colonic mucosal graft, n = 26; buccal mucosal graft, n = 10; bladder mucosal graft, n = 6); One-stage pedicle flaps urethroplasty in 20; two-stage urethroplasty of Johanson procedure in 12; and penile urethra-prostatic urethra anastomosis, three-stage urethroplasty in 2., Results: In early followed up (within 6 months postoperatively), 67 patients (88%) voided well and complications developed in 10. Among the 70 patients who lasted more than 1 year after operation, 51 cases were followed up. Forty-four patients voided well, and complications developed in 8. Of the 8 cases urethral restructure developed in 2 (18%) for pedicle flaps urethroplasty, 2 for colonic mucosal urethroplasty (9%), 1 for buccal mucosal graft (1/7), 1 for bladder mucosal graft (1/3); penile chordee in 2 (2/5), and one of them was accompanied by hair bearing neourethra for two-stage urethroplasty of Johanson procedure., Conclusions: Colonic mucosal and buccal mucosal grafts urethroplasty are feasible procedures for the treatment of long segment urethral stricture, and Colonic mucosal graft urethroplasty may be considered when more conventional procedures fail or complicated urethral strictures greater than 10 cm long.