The field of reconstructive urology has undergone significant growth as a result of the burden of disease and the unmet need for urethral stricture care. In 2016, the AUA created guidelines based on literature searches from 1990 to 2015 and included 250 articles as the evidence base.¹ The 2023 urethral stricture guideline amendment contains 33 statements and underwent rigorous peer review, panel response, and approval by the AUA Practice Guidelines Committee, the Science and Quality Council, and the Board of Directors.² Based on updated evidence reports, the amendment includes new statements supporting urethral dilation for recurrent stricture, perineal urethrostomy, oral mucosa graft choice, and female urethral stricture reconstruction, as well as new supporting text on urethral rest, urethrotomy and urethroplasty, and robotic surgery. These concepts were presented at the 2023 AUA Annual Meeting plenary session on reconstruction as “Urethral Stricture Guidelines: Case-Based Presentations.”

Initial Evaluation

The guideline statements on initial evaluation and management of urethral stricture, established in 2016, were reaffirmed and broadened to include male and female urethral stricture. One notable amendment based on stronger evidence supports the concept of “urethral rest.” Patients with urethral stricture who have had recent urethral instrumentation or are dependent upon an indwelling urethral catheter or intermittent catheterization should be catheter- and instrumentation-free for a period of 4 to 6 weeks. This period of rest allows for maturation of the stricture and overall tissue recovery, which leads to more accurate stricture staging prior to intervention.^3,4 Management of patients at risk for urinary retention during their urethral rest is most effective with suprapubic cystostomy. If they can void, no intervention is necessary prior to staging.

Endoscopic Management of Bulbar Urethral Stricture Comes of Age

The 2016 AUA urethral stricture guideline recommended urethroplasty for recurrent, short (≤2 cm) bulbar strictures rather than repeat general endoscopic interventions (Figure 1). This is because repeat endoscopic interventions result in limited success and increasing stricture complexity.^4-6 Conversely, the updated guideline includes an additional treatment option in this scenario: “11b. Surgeons may perform urethral dilation, or direct visual internal urethrotomy combined with drug-coated balloons, for recurrent bulbar urethral strictures <3 cm in length. (Conditional Recommendation; Evidence Level: Grade B).” This guideline statement reflects the findings of 2 recent randomized control trials (RCTs).

Figure 1. Retrograde urethrogram demonstrating short (<2 cm) recurrent bulbar urethral stricture. Image courtesy of Dr Katherine T. Anderson.

ROBUST III was an RCT that compared urethral dilation with a drug-coated balloon (DCB; Optilume) vs standard endoscopic intervention (ie, direct vision internal urethrotomy [DVIU] or dilation) in patients with recurrent bulbar strictures.⁷ In this study, treatment with a DCB resulted in significantly better urethral patency after 6 months (75% DCB vs 27% control, P < .001) and significantly fewer patients needing repeat stricture surgery after 1 year (17% DCB vs 78% control, P < .0001; Figure 2). This solidified the role of a DCB in the treatment of recurrent bulbar stricture disease. Of note, due to insufficient evidence, the panel did not recommend the use of the DCB in penile urethral stricture, first-time stricture treatment, or retreatment after prior DCB.

Figure 2. ROBUST III Trial Kaplan-Meier curve of freedom from repeat intervention through 1 year after control and drug-coated balloon arms. Adapted with permission from Elliott et al, J Urol. 2022;207(4):866-875.⁷

The OPEN trial was the second RCT comparing standard DVIU to urethroplasty in recurrent bulbar strictures.⁸ Patients undergoing urethroplasty had significantly better clinical outcomes such as improved uroflow rates as well as a 48% reduced risk of needing repeat surgical intervention. Despite this, patients in the 2 groups had equivalent satisfaction scores 2 years after surgery. Since urethral stricture disease is largely a quality-of-life condition, the guideline now states that we should not dismiss the role of DVIU if it results in equivalent patient satisfaction. As more treatment options become available for urethral stricture disease, we should engage in shared decision-making with our patients to help guide intervention.

Surgical Reconstruction

A significant update on the management of nonobliterative bulbar urethral strictures included data on the impact of transecting (excision and primary anastomosis) vs nontransecting (utilizing oral mucosal graft) urethroplasty on sexual function. Though there are numerous studies suggesting an association between transecting approaches and sexual dysfunction, these studies have generally been limited by the use of retrospective case series, nonvalidated questionnaires, and lack of power. A recent randomized control trial by Nilsen et al⁹ found a significant negative impact of transection on glans rigidity, sensation, and perceived penile curvature/foreshortening.

Further, although oral mucosa remains the recommended first choice graft selection for urethroplasty, whether to close or not to close the graft harvest site remains at the surgeon’s discretion based on a recent meta-analysis by Hwang et al,¹⁰ including 5 RCTs showing no difference in outcomes such as oral pain, numbness, salivary problems, impaired mouth opening, or cosmesis between the 2 techniques. An amendment expanding upon oral mucosa as the graft of choice for substitution urethroplasty states that surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. This new guidance stems from a meta-analysis of 12 different studies (Evidence Strength Grade A).¹¹

Figure 3. Retrograde urethrogram demonstrating long penile urethral stricture and patent, capacious proximal bulbar urethra suitable for perineal urethrostomy. Image courtesy of Dr Christopher Gonzalez.

Figure 4. Examples of posterior urethral stenoses and radiographic appearance on urethrography. Image courtesy of Dr Dmitriy Nikolavsky. BT indicates brachytherapy; EBRT, external beam radiation therapy; RP, radical prostatectomy; TURP, transurethral resection of prostate.

Perineal urethrostomy provides patients with a high quality of life postoperatively and noninferior long-term patency rates as compared to urethroplasty.^12,13 Secondary to these data, amendment 18A now states that surgeons may offer perineal urethrostomy to select patients (see Table and Figure 3) as a long-term treatment option and alternative to urethroplasty (Evidence Level: Grade C). Similarly, statement 18B emphasizes that perineal urethrostomy should be offered to patients with a high risk of treatment failure following urethroplasty.

Advances in Posterior Urethral Reconstruction

The final discussion of this plenary panel was centered on vesicourethral anastomotic stenosis (VUAS) and bladder neck contractures. As an illustration, the panelists discussed a 72-year-old patient with refractory vesicourethral anastomotic stenosis after radiation and salvage prostatectomy. The amended guideline states: “Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis” (Conditional Recommendation; Evidence Level: Grade C). The change was the addition of a robotic approach as an option for the reconstruction of posterior stenosis, and was based on several retrospective studies demonstrating that the robotic approach results in acceptable patency and preserves urinary continence.^14,15 Additionally, this approach avoids bulbar dissection, preserves perineum for future artificial urinary sphincter if needed, and preserves bulbar arteries.

In cases of bladder neck stenosis after an anti-benign prostatic hyperplasia procedure (ie, transurethral resection of the prostate), the prostate is in situ and stenosis is proximal to the prostate, and reconstruction through abdominal approach, robotic or open, provides the most direct access. On the other hand, patients with bulbomembranous/sphincteric urethral stenosis after radiotherapy or anti-benign prostatic hyperplasia procedures have stenosis distal to the prostate, and the perineal approach provides the most direct access. In contrast, a patient with VUAS has no prostate, and any of the above approaches and techniques could be used in reconstruction. These 3 scenarios are summarized in Figure 4. Ultimately, our 72-year-old patient with VUAS after salvage prostatectomy underwent dorsal onlay buccal mucosal graft urethroplasty through a perineal incision and had an AUS placement 6 months later.

Perspectives

New high-level evidence has allowed important amendments to the original AUA Guideline on Urethral Stricture. Further advances to improve the efficacy of endoscopic treatments in appropriate candidates, while at the same time identifying individuals best suited for urethral reconstruction, will usher in future precision approaches to the treatment of urethral stricture in men and women.