Urethral stricture depend on the site, length and recurrence rate, have different outcomes and treatments. Generally urethral strictures remained as a challenge in Urology. The high recurrence rate basically is due to the fragility of urethral mucosa and the fibrous element resulted from injury sequel. Theoretically complete excision of fibrous elements and tension free sutures results in satisfying outcomes. Recently application of autologous stem cell culture and grafting sounds to be the modern treatment for complicated cases. Moreover Buccal mucosal graft and inlay methods are also associated with acceptable outcomes.

Whether repeated endoscopic treatment ( urethrotomy/urethral dilation ) or definitive excision of the structure with reconstruction (urethroplasty) continues to be debated and is being addressed by the "open" clinical trial in the uk. A cochrane review has shown that very limited evidence exists and what there is shows no difference in outcome. There are no new treatments that I am aware of.

You have to read on Buccal mucosa grafting techniques

urethral stricture is due to encroachment on urethral lumen by spongiofibrosis this lead to narrowing of urethral lumen. urethral stricture may be due to urethral inflammation due to infection , post catheter, post endoscopy, post traumatic , idiopathic or rare to be congenital. for evaluation of urethral stricture either by ascending urethrogram if affecting the anterior urethral(fossa navicularis, pendulous urethra and bulbar urethra) and by Voiding urethrogram if stricture affecting the posterior urethra like post TURP. but urethrogram had may pitfalls as it only determine the diameter of stricture only and not the actual length of stricture and not the degree of surrounding spongiofibrosis, also it is personal dependent and should be done by the surgeon or trained radiologist (do not trust in radiologist in this investigation. Sonourethrogram has good benefit for determination of the degree of spongiofibrosis which is important for evaluation of stricture. determination of line of treatment depends on pt age, site of stricture, length of stricture, urethral lumen, degree of spongiofibrosis, associated complications like infection and fistula and patient general condition, previous prostatectomy specially in cases of posterior urethral stricture. if stricture at the fossa navicularis ttt by either transverse penile ventral skin flap, or buccal mucosa inlay graft to the dorsum. regarding the pendulous urethra tty by either the use of orandi flap, circular flap, zigzag penile skin flap or q shape flap all these flap are used as only either ventral or dorsal but if the lumen is less than 6f these flaps (circular, zigzag, q is configured as tube). the length of stricture is important, if short so short flap if long should long flap, penile skin graft or extragenital graft can be used only dorsal at the anterior urethral stricture as only to be supported by tunica albuginea. if the diameter in the anterior urethra is narrow than 6f total replacement of urethra using either flap as tube or graft in two stage. as regarding the bulbar urethral stricture the tty depends on length of stricture and diameter of lumen, if length less than 2.5cm tty by PEA, if more thanks 2.5cm tty by either only graft or flap either ventrally or dorsally (the best) or laterally, if lumen less than 6f and length of stricture of the bulbar urethra is more than 2.5cm should do either augmented anastomotic repair using either dorsal or ventral (using either graft or flap). recently nerve and muscle sparing of the bulbar urethra to preserve ejaculation and avid postmict. drippling , also transurethral inlay graft for bulbar urethra by Palminteri . lastly posterior urethral stricture in patient tty by TURP should only by endoscopic dilatation to avoid incontience.

dr tiki ramadani if you want more regarding urethral stricture let me know

Article Modified annular penile skin flap for repair of pan-anterior...

Thank for all your answers...it's very helpfull

Urethral strictures that follow pelvic fractures are now called PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS and are treated by initial endoscopic alignment followed by urethroplasty using a pull through technique.

Certain Questions and answer pattern in provided in my website link which I think will answer your questions.

http://www.nuhospitals.com/faq_details.html/856/Male-Urethral-Stricture-Disease/

http://www.nuhospitals.com/faq_details.html/857/Management-of-Stricture-Disease/

http://www.nuhospitals.com/faq_details.html/858/Post-Operative-Care-Following-BMG-Urethroplasty/

Urethral stricture management is controversial in many aspects and the voluminous literature available can be reviewed by those interested in the hundreds of websites/ URLs on www. Excellent illustration videos are available on youtube. I will therefore concentrate on urethral stricture management in adult, mostly circumcised males, and provide personal experience only,

 It is convenient to approach the problem by anatomical site of stricture, starting at the urethral meatus and going proximally.

1- For fossa navicularis strictures( mainly due to Lichen sclerosus(BXO), I do a two stage surgery using free skin graft from the pre-auricular skin(hairless). First stage is to lay open the fossa and the whole glans, excise all scar tissue and onlay the graft. 3-6 months later do the tubularization. Gives good results long term

2- All anterior urethra to the bulb: I use single stage free buccal mucosal graft , usually dorsal in the pendulous part and ventral in the bulb. sometimes both dorsal and ventral in the bulb for v tight strictures. Excellent results

3- Pelvic fracture distraction injuries: Excision of all scar tissue meticulously and end to end mucosa to mucosa anastomosis. This is the most demanding surgery as there is no " pattern" for the injury. The use of supra pubic trocar and flexible scope in the prostatic urethra is invaluable.

4- Prostatic urethra/ Bladder neck contracture: usually post previous intervention( TURP and recently TUMT) Endoscopic resection/incision is the treatment but many times needs revision second  look.

Any place for Urethrotomy/ bouginage ?

 In my practice I do it : 1- ONCE for short (less than 5 mm) strictures and if it recurs - it mostly does- then straight to plasty.2- In high risk and poor general condition patients.3. if patients choose it at initial counseling

nothing really groundbreakingly new I am afraid.I do agree with most of the comments,however please note that the litterature (unfortunately retrospective) shows that

1- There is NO major difference in outcome between buccal mucosa and preputial skin except that the 1st is "sexy" but time consuming,not free of local complications,the latter is easy to harvest and,as long as you want it to be...

2- There is NO demonstrated difference in outcome between dorsal and ventral inlay :the dorsal is "sexier" but requires extensive mobilisation of the urethra and in proximal bulbar strictures securing the proximal healthy part of the urethra is not a "walk in the park".The ventral approach is easier,proper suture of the spongious albuginea will secure an excellent haemostasis and avoid secondary sacculation

Urethral strictures can also be managed with laser vaporization using low Wattage(7-10) in a contact mode with durable results.

Inder Perkash.MD

Stanford

probably an expensive way to perform a urethrotomy ...

Buccal mucosal grafts are widly used now a days. In experienced hands, the outcomes of both dorsal onlay grafts and ventral onlay grafts in bulbar urethroplasty are similar. The dorsal onlay technique is, however, possibly less dependent on surgical expertise and therefore more suitable for surgeons new to the practice of urethroplasty. The complications associated with ventral onlay techniques can be minimised by meticulous surgical technique, but in series with longer follow-up, complications still tend to be more prevalent. In penile urethroplasty, two-stage dorsal onlay of BM (after complete excision of the scarred urethra) still provides the best results, although in certain circumstances a one-stage dorsal onlay procedure is possible. In general, ventral onlay of BM and tube graft procedures in the management of penile strictures are associated with much higher rates of recurrence and should therefore be avoided.

Reference:

Patterson JM1, Chapple CR. Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol. 2008 Jun;53(6):1162-71

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With the available Holmium Laser, it takes about 20 to 30 minutes to vaporize with no down time and no bleeding. Can be repeated easily with almost return of normal urethra. Please see several of my publications...google.

The problem of stricture is spongiofibrosis, it is not a problem of mucosa, so you may need to replace the fibrous spongiosum by interpositioned tissue.

Spongiofibrosis with white fibrous tissue can be vaporized carefully with tip of Holmium fiber (8 to 10 Watts setting) without burning the tissue. Amazingly the urethra recovers with normal tissue.

I think it affecting Men there is a serious social dimension relating to patients willingness to present themselves to urological assessment

For excellent results with use of laser is vaporization of fibrous tissue. I have reviewed several papers, their technique is to just make an incision (urethrotomy) which is not what I have done and recommended in my publications. Using lower wavelengths about 10 0-12 Watts, white fibrous tissue can be easily vaporized. Most of my patients in few months had normal urethra. Higher wave length can burn the urethra and prevents regeneration.

Inder Perkash.MD. FACS .FRCS(Emeritus) Professor Urology. Stanford. Ca. 94305

Laser vaporization seems the way to go. Thanks prof. Only we are in Kenya and I doubt such expertise is available

The Optilume paclitaxel-coated balloon device has shown good results in the ROBUST trials.

You can find my way in prophylaxis of recurrent stricture in patients who have had urethral operations . I started to calibrate (not dilate) urethra with anti-scar gel with straight hegars and taught patients how to do it at home. Every 4 - 6 weeks of such treatment done - which is important - during early phase of wound healing increased the size of urethra as well as its elasticity. Patients helped themselves under my control. Among 36 of them no one had recurrency up till now.