A surgical procedure to permanently repair a urethral stricture (narrowing of the urethral canal). Thanks to technological advancements, it now has a high long-term success rate.
Urethral strictures are very common processes that develop as a result of trauma (introduction of instruments or foreign bodies into the urethra, external forces, urethral piercing, etc.) or infections (urethritis). They primarily affect men due to their urethral length and involve narrowing of the urethral lumen, secondary to a scarring process of the corpus spongiosum (spongiofibrosis), of variable length and depth; they can be single or multiple and affect any urethral segment.
The logical consequence of urethral strictures is obstruction of urination; therefore, they usually present with the following symptoms:
- decreased force of the urinary stream or inability to urinate
- frequent need to urinate
- Urinary infections
- inflammations and infections of the prostate (prostatitis)
- drooling ejaculation
Long-term obstruction can lead to reversible or irreversible impairment of kidney function.
The choice of initial treatment is crucial, as the first opportunity is the best. The treatment decision must be based on a proper diagnostic evaluation.
Many years ago, the treatment of urethral strictures was carried out according to a "treatment ladder" in which all strictures were treated the same way, regardless of their location or length.
First, dilation was performed. When the stricture recurred, it was dilated again or treated with one or more internal urethrotomies. These two procedures were often performed in conjunction with intermittent catheterization to try to "stabilize" the urethra. Frequently, these treatments were carried out without a proper prior diagnostic workup. Only when the stricture did not respond after multiple dilations and urethrotomies (a very common outcome with this treatment) was open reconstruction recommended. This progression, from dilation to urethrotomy and from urethrotomy to open surgery, was known as the "treatment ladder," which is now completely discarded.
We have observed that many of our patients have undergone dilations and urethrotomies without prior diagnostic imaging studies. Furthermore, many have suffered up to 30 dilations and/or multiple urethrotomies without being offered open reconstruction. This cannot be considered acceptable today.
The modern approach to urethral strictures requires a complete prior evaluation and a treatment decision based on the location and length of the stricture.
Dilation or urethrotomy can be a valid treatment option in specific cases or to achieve temporary improvement with the least invasive approach. In many other cases, these procedures are not suitable options. This is especially true when strictures are not short, as in these cases the failure rates of dilation or urethrotomy are close to 100 percent. Furthermore, the trauma involved in dilation or urethrotomy can worsen the condition.
Open urethral reconstructive surgery, performed by experienced surgeons, may be the best initial treatment option in most cases. Excision and anastomosis provides a definitive cure in 98% of cases, meaning that catheterization or dilation to maintain urethral caliber is no longer necessary. When pedicled or free grafts are required, the success rate is slightly lower, but it typically cures 80–90% of patients.
Modern surgical techniques performed by a specialist in urethral reconstruction using the appropriate instruments and equipment are associated with high cure rates and few complications. However, the treatment should be chosen based on a thorough diagnostic evaluation and tailored to each individual patient.
