Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). Like all surgical procedures, TURP may have complications. The incidence rate of urethral stricture after TURP is 2.2% to 9.8%, and it is considered a major cause of stenosis in older patients.¹

Urethral stricture after TURP is a bothersome complication, as patients tend to re-experience the same obstructive symptoms that they had before surgery.

Usually, the size of urethral meatus caliber is 25Fr, penile urethra 26Fr and bulbar portion of the urethra 30Fr.² The use of 26/28Fr resectoscope may traumatize the urethral mucosa and cause a stricture. Other factors contributing to urethral strictures may be resecting time, catheter type, duration of catheterization and urinary tract infection.

Urethral strictures after TURP may affect the anterior urethra at any anatomic site, even the posterior urethra. For the purpose of this article we will not discuss bladder neck contracture.

Strictures of the meatus and fossa navicularis are well managed with sporadic dilations whenever possible. For those refractory cases, surgery is mandatory. The objectives of these surgeries are not only to reestablish urethral patency, but also to achieve good cosmetic results.

Advanced meatoplasty is an excellent cosmetic and functional option when only the meatus is involved. When the fossa is also involved, meatoplasty is not an option. Virasoro et al described in 2007 the ventral transverse penile skin island flap.³ This is an effective, reliable and reproducible technique that has good functional and aesthetic results in all fossa navicularis strictures with the exception of those strictures resulting from lichen sclerosus. More recently, Daneshvar et al described the urethroplasty technique using transurethral inlay oral graft.⁴ In a multi-institutional study, this technique achieved a success rate of 95%.

When the stricture affects the urethra more proximally, we prefer a subcoronal approach and repair the distal urethra and fossa with a dorsal oral graft with glans preservation.⁵ In our experience, this technique provides excellent functional long-term outcomes, with minimal complication rates and substantial cosmetic results (fig. 1).

Penile and penobulbar strictures are managed with dorsal oral grafts with excellent success rates.² It is important to note that iatrogenic strictures can be longer than what is seen on urethrography, so it is advisable to dissect well into healthy urethra to prevent restenosis. Proximal bulbar stricture after BPH surgery poses a reconstructive challenge due to the proximity of the rhabdosphincter and cavernous nerves.

Figure 1. Dorsal oral graft with glans preservation.

Various terms have been used to describe more precisely the strictures after BPH surgery: sphincter strictures, proximal bulbar strictures and bulbomembranous urethral strictures (BMS), the term we will use in this article.

Male continence mechanism consists of 2 components: 1) proximal smooth muscle from condensating proximal detrusor fibers and 2) distal rhabdosphincter originated from longitudinal fibers from the bladder neck and prostate forming an omega-shaped structure around the urethra.⁶

After surgical treatment of BPH, the bladder neck is compromised and urinary continence depends solely on the external sphincter. Several techniques have been proposed in order to treat these strictures while preserving urinary continence.

Barbagli et al described a modified ventral onlay technique, hypothesizing that a dorsal approach could injure the sphincter.⁷ The authors approached these cases by opening along the ventral aspect of bulbar urethra, avoiding its circumferential dissection. With this technique, postoperative urinary incontinence (UI) was avoided in 95.6% of patients, as well as achieving a 79.6% stricture-free rate.

Angulo et al described in 2016 a dissection through the intracrural space and placement of a dorsal onlay buccal graft.⁸ This technique, which avoids circumferential dissection and transection, had little effect on erectile function. Results of a multi-institutional study reported 91% recurrence-free rate at 5 years, and 87.9% were continent.⁸ The authors concluded that dissecting near and even resecting a small portion of the external sphincter did not impact urinary continence.

Figure 2. Bulbomembranous urethra is dissected preserving the corpus spongiosum irrigation.

Figure 3. Bulbomembranous urethra was transected.

Gómez et al described in 2020 a circumferential mobilization of membranous urethra and dissection of the urethra off the external sphincter along a plane by gentle blunt dissection.⁶ With a mean followup of 34 months, free of stricture recurrence rate was 100%, and 83% of the patients were completely dry or required only 1 security pad.

In our experience, we approach these patients by a dissection of the bulbomembranous urethra, which is circumferentially isolated as it exits the urethral bulb and enters in the perineal membrane (fig. 2). The bulbomembranous urethra is transected, preserving bulbar blood supply, and a careful dissection of surrounding sphincter is performed, avoiding urethral lateral margin and therefore decreasing damage risk (fig. 3). The vessel preservation technique described by Jordan et al⁹ is our procedure of choice for proximal bulbar stricture as from the beginning of 2015. This technique has the advantage of preserving corpus-spongiosum irrigation and, therefore, increasing the protection of the urethra in patients who might require artificial urinary sphincter placement after urethroplasty as well as better erectile function outcomes.

Figure 4. BMS preoperative and postoperative cystourethrography.

In our series, with a median followup of 53 months, the urethral patency was 96.1% and postoperative urinary continence was 92.2%, in line with previous publications (fig. 4). We provide evidence that open simple prostatectomy was associated with postoperative UI more frequently than other endoscopic treatment modalities.¹⁰

Urethral stricture, although an uncommon complication, should be discussed with all patients who are about to undergo an endoscopic procedure for BPH. Urethral stricture before BPH surgery should be diagnosed to thus avoid the forced introduction of the resectoscope with the consequent damage to the urethral mucosa.

Although urethral stenosis after BPH surgery can occur at any site, special attention should be paid to fossa navicularis strictures and bulbomembranous urethral strictures for their cosmetic and functional consequences. Even though several approaches have been described for BMS, most techniques share similar stricture-free and UI rates.