Figure. Voiding cystourethrogram of a patient with a past history of prostate cancer treated by brachytherapy. There is a visible transurethral defect (arrow) in addition to a bulbomembranous urethral stricture. Prior to his prostate cancer diagnosis, he underwent prostate Rezūm treatment. On antegrade cystoscopy, he was noted to have dystrophic calcification. Definitive open urethral reconstruction would be high risk for this patient.

Urethral stenosis after radiotherapy is a complex entity with a broad scope of associated symptoms including high rates of incontinence, lower urinary tract symptoms, sexual dysfunction, subjective pain, and bowel dysfunction. This multifocal nature creates a uniquely challenging condition to treat. Compared to nonradiated posterior urethral injuries, presurgical assessment of men with postradiation urethral stenosis necessitates a more thorough evaluation. Limited bladder capacity secondary to radiation, radiation cystitis, concomitant stress urinary incontinence (SUI), and/or dystrophic calcification of the prostate fossa can negatively impact surgical candidacy. Radiated urethral stenosis can present many years after initial radiation therapy with a significant number of men at a more advanced age with potentially complex medical issues that can also hinder definitive management. Careful preoperative evaluation is paramount, as the aim is to improve quality of life following potential surgical reconstruction.

My preoperative evaluation of men with radiated urethral stenosis includes a retrograde urethrogram and voiding cystourethrogram. The retrograde urethrogram will reveal stricture length and location. The voiding cystourethrogram can be helpful to provide a basic understanding of bladder neck integrity and bladder volume/health. The bulbomembranous urethra is the most common location of stenosis following radiation therapy. A transurethral resection defect at the bladder neck and/or limited bladder capacity should prompt additional preoperative counseling to explain appropriate expectations and possibly alternative treatment options (see Figure). A detailed history and exam should focus on past urological procedures, possible prostate cancer recurrence, and patient goals for potential treatment. If the patient is an acceptable candidate, I recommend a suprapubic catheter with antegrade cystoscopy before tentative surgery. If the patient already has a suprapubic catheter, I will attempt cystoscopy via the suprapubic tract in the office. Bladder capacity, bladder tissue health, and the prostate fossa are examined. Bladder capacity <200 mL, hemorrhagic cystitis, and prostate dystrophic calcification are absolute contraindications in my experience.

Bladder capacity between 200 and 300 mL in the presence of stress incontinence is a relative contraindication in my practice, as these patients will require an artificial urinary sphincter after potentially successful urethral reconstruction. Reduced bladder compliance secondary to radiation-induced bladder fibrosis can result in reduced quality of life secondary to subjectively bothersome frequency/urgency and/or persistent stress incontinence post-artificial urinary sphincter. In my experience, adjuvant treatments to improve bladder compliance such as bladder botulinum toxin are less durable among these radiated patients. As such, I will generally recommend urinary diversion in lieu of definitive urethral reconstruction in these patients.

Postoperative stress incontinence is presumed to be secondary to radiotherapy-associated internal sphincter deficiency. We have previously published data regarding the incidence of stress incontinence among patients without preoperative stress incontinence or an endoscopic prostate procedure.¹ The incidence of de novo stress incontinence following posterior urethroplasty was 33%; however, 75% of these men with de novo SUI had extension of the radiated bulbomembranous urethral stricture into the prostate apex. The degree of stress incontinence was subjectively minimal, though, as only 17% of the affected men (5% of the total cohort) with de novo SUI required an artificial urinary sphincter. I typically wait 6 months after urethral reconstruction with confirmation of a stable urethral repair on 2 successive endoscopic procedures. Transcorporal urinary sphincter cuff placement is commonly employed to maximize success.

While endoscopic treatment is a treatment option for radiated urethral stenosis, long-term success rates of endoscopic treatments are dismal.² As such, urethral reconstruction via posterior anastomotic urethroplasty is preferred for definitive management. Analysis of reconstruction outcomes can be challenging because historically they are smaller series from single centers of excellence. TURNS (Trauma and Urologic Reconstructive Network of Surgeons) is a multicenter network of reconstructive surgeons across multiple academic and nonacademic centers with an effort to provide more generalizable outcomes in the field of urological reconstruction (TURNSResearch.org). We have previously published our outcomes among 137 patients with radiated urethral stenosis from 10 TURNS centers.³ Single and dual radiation patients were included in the analysis. Overall success was 86.9%, with increasing patient age and stenosis length noted to be risk factors for recurrence on multivariate analysis. Placement of a gracilis interposition muscle flap in the surgical field was at the discretion of the physician based on operative findings (ie, large wound defect following excision of radiated urethral stricture, history of dual radiation, need for partial pubectomy during reconstruction, etc). Artificial urinary sphincter was performed in 30 subsequent men with 5 subsequent urethral erosions (16.7%). A transcorporal approach during the urinary sphincter surgery was frequently utilized (83%).

While posterior anastomotic urethroplasty via a transperineal incision is the most common surgical approach, other surgical options are also possible in select patients. Robotic transabdominal surgery combined with a possible transperineal approach is an emerging procedure for men with radiated urethral stenosis proximal to the genitourinary diaphragm.⁴ The surgery begins via a robot-assisted transabdominal dissection. Transecting posterior urethroplasty is performed with concomitant prostatectomy if the prostate is present. For stenosis cephalad to a viable external sphincter, a solely robotic transabdominal approach can spare iatrogenic stress incontinence (and subsequent artificial urinary sphincter) which is expected following a sole transperineal approach that violates the external sphincter to achieve potential surgical success. A combined open transperineal approach can be utilized if a gap persists following excision of radiated tissue between the bladder neck and distal urethra. In men with radiated urethral stenosis in the absence of complete urethral obstruction, a ventral buccal graft supported by a gracilis interposition muscle flap is another surgical option. This approach is useful if the radiated stricture is long, precluding traditional excision and anastomosis of the impacted urethral segment. The gracilis interposition muscle flap is fixed to the ventral buccal graft and necessary to aid graft success in the radiated field.⁵

Urological complications following radiation therapy will continue to be an issue faced by urologists; however, there are viable reconstruction options with notable success in appropriately screened patients. Referral to experienced reconstructive urologists is recommended among these complex patients.