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Felix Campos-Juanatey, Simon Bugeja, Stella L Ivaz, Anastasia Frost, Daniela E Andrich, Anthony R Mundy
REVIEW
1 March 24, 2016
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Management of penile urethral strictures: Challenges and
future directions
Felix Campos-Juanatey, Simon Bugeja, Stella L Ivaz, Anastasia
Frost, Daniela E Andrich, Anthony R Mundy, Institute of Urology,
University College London Hospitals, London NW1 2PG, United
Kingdom
Felix Campos-Juanatey, Marques de Valdecilla University
Hospital, Santander39008, Spain
Author con tr ibutions: Campos-Juanatey F and Bugeja S
reviewed the literature and drafted the manuscript; Ivaz SL and
Frost A contributed to review the literature; Andrich DE and
Mundy AR review the manuscript and made critical revision and
edition of the contents; all authors read and approved the final
version of the manuscript.
Conflict-of-interest statement: All authors declare no potential
conflicts of interest related with the contents of this manuscript.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Anthony R Mundy, PhD, MS, FRCS,
FRACS, Professor, Medical Director, Institute of Urology,
University College London Hospitals, ULCH Trust Headquarters,
2nd floor central, 250 Euston Road, London NW1 2PG,
United Kingdom. kelly.higgs@uclh.nhs.uk
Telephone: +44-20-34479099
Fax: +44-20-34479401
Received: September 21, 2015
Peer-review started: September 22, 2015
First decision: November 24, 2015
Revised: December 15, 2015
Accepted: February 23, 2016
Article in press: February 24, 2016
Published online: March 24, 2016
Abstract
The anatomy of the penile urethra presents additional
challenges when compared to other urethral segments
during open stricture surgery particularly because of its
unsuitability for excision and primary anastomosis and its
relatively deficient corpus spongiosum. Stricture aetiology,
location, length and previous surgical intervention remain
the primary factors influencing the choice of penile
urethroplasty technique. We have identified what we feel
are the most important challenges and controversies in
penile urethral stricture reconstruction, namely the use
of flaps
vs
grafts, use of skin or oral mucosal tissue for
augmentation/substitution and when a single or a staged
approach is indicated to give the best possible outcome.
The management of more complex cases such as pan-
urethral lichen-sclerosus strictures and hypospadias
“cripples” is outlined and potential developments for the
future are presented.
Key words: Reconstructive surgical procedures; Anterior
urethral stricture; Oral mucosa; Tissue transplants; Skin
grafting; Hypospadias; Lichen sclerosus
© The Author(s) 2016. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: The anatomy of the penile urethra presents
additional challenges when compared to other urethral
segments. Stricture aetiology, location, length and pre-
vious surgical intervention remain the primary factors
influencing the choice of penile urethroplasty technique.
We described the most important challenges and
controversies in penile urethral stricture reconstruction:
Use of flaps
vs
grafts, use of skin or oral mucosal tissue
for augmentation/substitution and when a single or a
staged approach is indicated to give the best possible
outcome. The management of more complex cases (pan-
urethral lichen-sclerosus strictures and hypospadias
“cripples”) is outlined and potential developments for the
World Journal of
Clinical Urology
W
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DOI: 10.5410/wjcu.v5.i1.1
World J Clin Urol 2016 March 24; 5(1): 1-10
ISSN 2219-2816 (online)
© 2016 Baishideng Publishing Group Inc. All rights reserved.
2 March 24, 2016
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Campos-Juanatey F
et al
. Challenges on penile urethral strictures management
future are presented.
Campos-Juanatey F, Bugeja S, Ivaz SL, Frost A, Andrich DE,
Mundy AR. Management of penile urethral strictures: Challenges
and future directions. World J Clin Urol
2016; 5(1): 1-10
Available from: URL: http://www.wjgnet.com/2219-2816/full/
v5/i1/1.htm DOI: http://dx.doi.org/10.5410/wjcu.v5.i1.1
INTRODUCTION
The treatment of penile urethral strictures is generally
more complex when compared with other segments
of the urethra by virtue of various anatomical conside-
rations. This is evidenced by the variety of techniques
with have been described for reconstruction in this
area[1]. Achieving a satisfactory and durable functional
outcome (i.e., unobstructed voiding) is the main goal
but the cosmetic appearance of the male genitalia also
deserves due consideration[2]. Penile shape and length
should be preserved and ultimately restored if damaged
by injury or scarring from previous surgery[3].
A further concern with penile urethroplasty is erec-
tile function, and in particular, penile shortening and
curvature. The risk of transient erectile dysfunction after
urethroplasty is clearly described[4]. Loss of penile length
and penile curvature are more common after penile
urethral surgery[5], particularly when local aps are used[6].
Mucosal and skin grafts, or local skin aps, may be
considered for penile urethral reconstruction. Conse-
quently the reconstructive surgeon should be skilled at
a broad range of techniques and be able to carefully
evaluate the benefits and adverse effects of each in
individual circumstances[1].
There is a paucity of sound scientific evidence in
this field of urology, most of the available literature
being based on descriptive case series (not always
with homogeneous cohorts of patients) and expert
opinions[1,7]. In this paper, we address current practice
and the challenges and controversies faced by the
reconstructive surgeon in the management of penile
urethral strictures. Future developments in this eld are
also explored.
ANATOMICAL CONSIDERATIONS
The penile (or pendulous) urethra is the distal part of the
male anterior urethra. It is about 15 cm in length and
extends from the external meatus, the narrowest part of
the urethra (21-27 F), to the penoscrotal junction where
the bulbar segment starts. The penile urethra presents
important anatomical differences compared with the
bulbar segment[8]. It is surrounded by the thinnest part
of the corpus spongiosum in the penile shaft, meaning
that it does not provide the best vascular support for a
graft. The glans penis, which is the expanded distal end
of the corpus spongiosum, surrounds the navicular fossa
and external meatus[9]. On the contrary, this rich glanular
blood supply provides an ideal vascular bed for successful
graft take.
The urethra and the spongiosum are covered by
the anterior extension of Buck¡’s fascia, and a layer of
dartos areolar tissue (continuation of Colles fascia) that
provides blood supply to the penile shaft skin[10]. This
dartos tissue is also very well vascularised, making it an
ideal graft bed or a pedicle for skin grafts.
Unlike the bulbar urethra, which can be mobilised
proximally and distally to allow excision of a stricture
and a tension-free primary anastomosis, this is not
possible in the penile urethra due to the risk of loss of
length and curvature during erection. This means that
reconstructive techniques in the penile urethra are limited
to augmentation or substitution using free grafts or aps
which in themselves may also result in chordee if used
incorrectly. Moreover, pendulous strictures usually tend to
be longer[11] (in some series nearly twice as long) than in
the bulbar urethra.
IMPORTANCE OF STRICTURE
AETIOLOGY
The commonest identifiable cause of penile strictures
in young and middle-aged adults is lichen sclerosus
(LS) or balanitis xerotica obliterans[12] (Figure 1). This
was recently evidenced in a large European cohort of
patients[13]. The proposed pathophysiology of penile
strictures secondary to LS is that the initial changes occur
at the urethral meatus when it becomes involved by the
scarring affecting the rest of the glans and prepuce[14].
This atrophic fibrosis can extend proximally, affecting
the fossa navicularis and penile urethra, which may be
associated with palpable thickening at the level of the
strictures. The progression of a distal stricture proximally
is related to metaplastic changes due to chronic dis-
tension and extravasation of urine with subsequent
inflammation of the peri-urethral glands as a result of
pressure during voiding. This may be reversible if the
obstruction is relieved early[12].
The penile urethra is also susceptible to strictures
resulting from infection and traumatic instrumentation
during catheterisation or transurethral procedures[15].
These are most commonly located in the navicular fossa
and at the peno-scrotal junction[2].
The incidence of each causative factor remains
unclear, however in some series it is suggested that
fossa navicularis strictures are equally of iatrogenic,
idiopathic, and inflammatory origin (including LS) but
not the result of external trauma[11]. LS is the most
common cause of strictures affecting the entire penile
and bulbar urethral segments[16].
Another common occurrence is a recurrent penile
urethral stricture following previous failed urethroplasty,
particularly in hypospadias-related strictures (Figure 2).
Recurrence after hypospadias surgery is the most
frequent cause of complex anterior urethral strictures[17]
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and in some series from tertiary referral centers is the
most common indication for staged penile reconstruc-
tion[18]. Strictures following failed hypospadias surgery
usually occur as a result of early postoperative com-
plications such as infection and consequently become
apparent shortly after the surgery. They may however
also manifest themselves many years later due to failure
of the graft or ap[19].
Stricture aetiology is one of the most important
factors determining the choice of management strategy
of penile urethral strictures (and indeed all urethral
strictures) and particularly the choice of surgical recon-
structive procedure[1]. In LS-related strictures the use
of mucosal grafts (usually oral but bladder or rectal also
possible) is recommended since LS is a skin condition
and any skin used for reconstruction is either already,
or has the potential to become involved by the disease
process[20]. On the other hand, genital skin is suitable for
use as a flap or graft for reconstructing the urethra in
selected patients with previous hypospadias surgery or
instrumentation-related strictures[21].
DISCUSSION
Controversies
Flaps or grafts for penile urethroplasty: In 1968,
Orandi[22] rst reported on reconstruction of the anterior
urethra using a pedicled skin ap. The Orandi longitudinal
ap provides a long strip of penile skin with a consistent
blood supply, adequate to augment the urethral lumen.
This urethroplasty technique has proved to be useful for
non-obliterative strictures within the penile shaft that
are not secondary to LS[1]. Other skin flaps have been
described using preputial, penile and scrotal skin[23-25]
to treat strictures in any part of the penile urethra.
These flaps achieved satisfactory outcomes in selected
cases, mainly as an augmentation patch[26] after having
excluded LS as a causative factor[27]. It has been shown
that such skin flaps, when tubularised, are associated
with a higher failure rate; up to 58% in the intermediate-
term[26]. In addition, pedicled flaps are associated with
other problems. When penile shaft skin is used, patients
tend to report unacceptable scars at the donor site
incisions, as well as irregularity of the skin caused by
raising and rotating the dartos fascia as a pedicle.
Furthermore, a degree of penile torsion can occur as a
consequence of the pedicle[21]. In cases reconstructed
using a circumferential skin tube, “bow-stringing” of the
neo-urethra away from the corpora cavernosa can occur,
giving the appearance of ventral webbing of the penis[21].
Scrotal skin is associated with the added complication of
hair growth resulting in recurrent urethral obstruction by
hairballs and stones.
Traditionally penile aps were preferred to free grafts
for penile urethral reconstruction. This was related to the
perception of an initial high failure rate of grafts reported
in the penile urethra[8]. A graft is only as good as its bed,
and unfortunately, the anatomy of the penile spongiosum
means that this is not always guaranteed. The rich
glanular tissue on the other hand provides a healthy
scaffold for grafting, but adequate penile spongiosal
tissue and dartos fascia are not always available and thus
do not ensure sufcient support for a graft in all patients.
The use of skin grafts for hypospadias surgery has
long been described, as a single procedure[28], or as
a staged approach[29], when still present, the foreskin
has been the preferred graft source[30]. Since the
popularisation of oral tissue as a substitution graft for
urethroplasty in 1993[31], it has become the material of
choice due to certain characteristic properties[32]. Oral
mucosa is typically harvested from the cheek but can
also be taken from the tongue and inner lip, resulting in
a relatively concealed donor site scar and also providing
sufficient graft material for almost every length of
stricture[33]. A lack of oral tissue for grafting is usually
associated with previous failed procedures.
Early reports suggested that outcomes with oral
mucosal grafts were better when used as a patch because
the failure rates when used as a tubed substitution were
high, similar to the previous experience with tubularised
flaps. The management of penile urethral strictures
changed dramatically with the description of the dorsal
free oral mucosal graft technique[34]. Those patients
previously treated using a circumferential substitution
in one stage with a tubularised local flap began to
be managed in a staged fashion using buccal grafts
Figure 1 Typical appearance of lichen sclerosus with scarring on the
glans, loss of the normal contour of the glans and coronal sulcus, meatal
regression and stenosis.
Figure 2 Urethral stricture after failed mid-penile hypospadias reconstruction.
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instead[21] (Figure 3).
In summary, the answer to the question “graft vs
flap?” needs to be answered on the operating table,
each case taken on its own merit, after a careful intrao-
perative evaluation based on the above-mentioned
factors. However as a general rule, one would use a local
pedicled ap with its own blood supply preferentially to
a free graft in situations where the graft bed is poor, as
with severe scarring or following radiotherapy[1].
Skin or oral mucosal grafts for augmentation or
substitution: Oral mucosa has become the most widely
utilised free graft for urethral reconstruction[35]. The
advantages of a concealed donor site and availability
have already been alluded to. Harvesting the graft is
relatively easy and associated with low morbidity[32,36]
(Figure 4). Biological and clinical characteristics explain
the consistently good results associated with its use
since it was rst described[37-39]. Oral mucosa is resistant
to infection. It usually hosts a variety of microorganisms
hence its minimal inammatory response to organisms[38].
LS does not tend to recur in oral mucosa as it does in
skin[20]. Further anatomical advantages are related to a
thick elastin-rich epithelium and a highly resilient lamina
propria-oral epithelium interface, making it easy to
manipulate. A thin and highly vascular lamina propria
facilitates inosculation and imbibition, hence improving
graft take. These structural features are retained once
transplanted to the genital area with histological studies
demonstrating that once in the urethra, buccal graft is
often indistinguishable from host tissues[40].
The commonest site for free skin grafts is the
prepuce[28] (Figure 5), due to its relative ease of harvest-
ing, it being hairless as well as the satisfactory cosmetic
appearance of the circumcising incision. Other non-
hairy skin donor sites have been suggested such as
the medial aspect of the upper arm and the posterior
auricular area[28]. Postauricular skin, when used as a
full-thickness free graft (Wolfe graft), is associated with
a very satisfactory outcome which may be comparable
to that obtained using oral mucosa[21]. Facial skin has a
particularly dense subdermal plexus, which allows for
better graft take and prevents contraction when used as
a full-thickness graft. Full thickness skin grafts generally
do not take as well as split-skin grafts, but when they
do they tend to contract far less (around 20%)[41].
Some authors suggest that the choice of substitution
material (oral mucosa vs preputial skin) should be based
primarily on surgeon preference and experience[42].
However, several factors need to be taken into con-
sideration including aetiology (skin contraindicated
in LS), availability of oral mucosa (such as in revision
procedures) and the consequence of any degree of
contraction of the grafts particularly chordee, which
suggests that split-skin grafts are not suitable for use in
the penile urethra.
Single stage or multi-staged penile urethroplasty:
When the residual urethral plate is of adequate calibre
and the corpus spongiosum, dartos fascia and penile skin
are preserved, single stage reconstruction is possible and
preferable[18]. Besides avoiding a proximal urethrostomy
and its negative impact on quality of life[3,43] for 3-6 mo, the
main advantage of a single stage approach is the fewer
number of procedures. The staged approach for penile
urethral reconstruction is associated with a reported rst
stage revision rate for graft contracture of between 20%
and 31%[18,21,44] ultimately resulting in a three- or more
staged procedure.
Several techniques are available for single stage
penile urethroplasty. Local skin aps such as the McAninch
preputial ap[24] have been described if the urethral plate
can be preserved and no features of LS are evident. The
Orandi procedure[22] is recommended by some authors
as the best choice for penile urethral augmentation in
selected mid-penile short strictures which are not related
to LS[1]. Barbagli et al[34] described the dorsal free graft
oral mucosal graft technique to augment strictures in the
penile urethra in a single stage in addition to the well-
known dorsal approach to bulbar urethroplasty.
Another technique for the treatment of distal penile
strictures using grafts has been suggested as an
evolution of the Snodgrass longitudinal incision of the
urethral plate in which an oral mucosal graft is placed as
an inlay into the incised urethral plate[45]. Based on the
same principle of preserving the native urethral plate
when available, Asopa et al[46] described the technique
of dorsal augmentation with skin or oral mucosa as a
dorsal inlay via a ventral urethrotomy. This procedure
is not recommended in cases when the urethral plate
is severely scarred, brotic or narrowed, but is suitable
for less complicated strictures, with the advantage
of a less invasive approach through a circumcision
incision. Placement of the oral mucosal graft ventrally
has also been described in the penile urethra, however
due to the lack of adequate spongiosal support, a
pseudospongioplasty with dartos tissues is necessary
and is not recommended as standard treatment[47].
A significant development in the single stage
reconstruction of long penile urethral strictures with a
Figure 3 Operative image showing a complete first stage full-length
penile urethroplasty using bilateral buccal mucosal grafts quilted dorsally
to create a neo-urethral plate of adequate calibre to be retubularised in
the second stage.
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salvageable urethral plate is dorso-lateral augmentation
using oral mucosal graft via a transperineal approach
with invagination of the penis as described by Kulkarni
et al[48] (Figure 6). This technique is associated with
excellent success rates of up to 92% in the short term
(12 mo)[48] and 83.7% in the intermediate term (5
years)[49].
Circumferential reconstruction in a single stage
using a tubularised local skin ap is associated with an
unacceptably high failure rate[24]. A tubularised repair
using oral mucosal grafts in one stage has also been
described in the penile urethra but the reported outcomes
were similar to previous reports using tubularised skin
flaps and are therefore not usually recommended[39].
Consequently those patients in whom complete urethral
substitution is necessary due to an unsalvageable
urethral plate are preferentially managed via a staged
approach using oral mucosal grafts[21]. A stricturotomy
is performed and the diseased segment excised. A roof
strip is reconstructed using graft during the rst stage to
produce a neo-urethral plate of adequate width which is
then rolled back into a tube in the second stage 3-6 mo
later. The success rate of this staged approach is up to
96% in tertiary referral centers[18]. However, complication
rates of up to 35% are reported in some series[50].
We have recently shown that in selected cases it
is possible to excise the spongiobrosis, create a neo-
urethral plate using oral mucosa and tubularise it, all
in a single stage (Figure 7). We refer to this as a “two-
in-one” stage urethroplasty and is dependent on glans
size, spongiosal thickness and adequate dartos to
provide support for the graft and allow enough tissue
mobility for tension-free retubularisation. Previously
unoperated, LS-related navicular fossa and distal penile
urethral strictures are most suitable for this technique
which is associated with a success rate of 90% at a
mean follow-up of 16.2 mo[51].
In some cases, such as following failed hypospadias
surgery, absence of an adequate spongiosum or lack
of dartos and/or penile skin, a staged approach is
recommended[52] for the reasons described above.
However, as with all urethroplasties, but particularly in
the penile urethra, it is not always possible to predict
the quality of the local tissues or the residual urethral
plate available for reconstruction prior to the surgery.
Consequently, in our practice, patients undergoing penile
urethroplasty are consented for either approach. The
decision as to whether or not a single staged approach
should be avoided in favour of a staged procedure is
always based on a thorough intraoperative evaluation
by an experienced reconstructive surgeon who is able
to predict the likelihood of success and complications of
either approach[21].
Management of complex cases: Penile urethral
strictures range from short strictures (Figure 8) in which
the urethral plate is preserved and which are relatively
easily treated by augmentation techniques, to complete
obliteration of the entire length of the penile urethra due
to severe LS or failed hypospadias surgery (Figure 9).
Management of the latter, especially those after previous
failed attempts at reconstruction, presents additional
challenges. The literature relating to these complex cases
is sparse and does not provide reliable guidelines[42],
particularly because of the heterogeneity of this group of
patients. Treatment of such complex strictures commonly
involves excision of the original obliterated skin tube
and substitution of the entire diseased segment. These
cases are often complicated further by urethrocutaneous
AB
Figure 4 Operative image showing (A) harvesting of a sublingual graft and (B) bilateral sublingual graft donor sites closed primarily.
Figure 5 Operative image showing a preputial skin free graft being
harvested.
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stulae (Figure 10), penile curvature and loss of penile
length. In fact, in some series of penile urethroplasty[17],
the reconstruction was restricted solely to the urethra
in only 25.5% of the cases, with the rest requiring
additional procedures such as correction of chordee or
penile lengthening. A staged approach is preferable in
these cases[29].
Such surgery, involving reconstruction of the urethra
and the corpora cavernosa, should be performed by
experienced surgeons in high volume, tertiary referral
centres to ensure the best cosmetic and functional
outcome for these patients[53]. The best outcome in these
patients is achievable during the first reconstructive
procedure, with salvage surgery becoming increasingly
complex and associated with an increased failure rate.
Not all complex penile urethral strictures are am-
enable to reconstruction[54] and indeed some patients
may not be keen on having further surgical intervention
or may not be medically t for major surgery. In these
patients a regime of interval urethral dilatation may be
feasible to preserve urethral voiding and adjunctive self-
dilatation may prolong the interval between recurrence[55].
Many find this unsustainable due to pain, bleeding and
recurrent infections and is generally associated with
a poor quality of life[56]. Perineal urethrostomy, though
not immediately acceptable to many, does present a
feasible salvage treatment option in these patients with
a reasonably good functional outcome and minimal
AB
Figure 6 Kulkarni technique for long penile strictures via a transperineal approach with (A) invagination of the penis and (B) dorsolateral placement of the
sublingual graft.
ABC
DFE
Figure 7 “Two-in-one” stage approach for a distal penile urethral stricture using oral mucosal graft. A: Ventral stricturotomy; B: Glans cleft deepened; C:
Spongiobrosis excised; D: Neo-urethral plate created using oral mucosa; E and F: Retubularised in layers in one stage.
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complications[57].
Future directions: Penile urethroplasty has evolved
since first attempts at reconstruction using foreskin
tubes[28] or a staged approach using penile skin[58]. An
increased understanding of the pathophysiology of LS
together with the high recurrence rate if skin was used
for reconstruction led to the recommended use of oral
mucosal grafts in LS strictures[20]. However, to date,
very little benefit has been achieved with non-surgical
treatment options[59]. Further research in this eld may
lead to the development of ways and means of stabilis-
ing or even inducing remission in this recalcitrant skin
pathology.
The main limitations of current penile urethroplasty
techniques are the frequent requirement of a staged
procedure with its associated patient inconvenience
and 20%-31% incidence of graft failure following the
first stage requiring further revision surgery prior to
retubularisation. Lack of available oral mucosa in full-
length penile strictures, particularly in revision cases,
presents additional problems. The inability to simply
excise obliterative strictures and perform an end-to-
end anastomosis means that substitution techniques
become necessary however tubularised substitution is
inherently associated with a high failure rate.
Extensive research has been carried out in the
elds of biomaterials, regenerative medicine and tissue
engineering in order to try and overcome some of the
limitations related to current penile urethral stricture
management outlined above. The primary aim has been
to generate a graft with properties similar to oral mucosa
but which is readily available “off the shelf”, in unlimited
quantities and with no morbidity associated with graft
harvesting. Despite significant advances, the ideal bio-
material or composite graft has not yet been identied
for use in routine clinical practice[60].
Numerous animal models and clinical studies have
tested a variety of engineered urethral substitutes
over the past 30 years. Both natural and synthetic
matrices, biodegradeable and non-absorbable, seeded
and unseeded, have been studied. Unseeded, “off the
shelf” tubularised grafts have only been successful in
replacing urethral defects less than 0.5 cm in length
due to failure of epithelialisation of longer grafts from
healthy surrounding tissues[61]. Unseeded grafts used
as a patch in an onlay or inlay fashion have shown
better results in clinical trials[62,63]. Unfortunately this has
not been replicated in longer strictures. One hundred
percent failure rates were reported in strictures longer
than 4 cm[64]. Suboptimal results were demonstrated in
patients who have had previous failed urethroplasties
or those with an unhealthy vascular bed[65], two patient
populations in whom alternatives to conventional
substitution materials are generally sought.
In order to treat longer strictures cellularised scaf-
folds seem to be necessary since graft survival would
be independent of epithelial cell ingrowth. Tubularised
seeded grafts have shown positive results in a canine
model[66] and in the only clinical trial to date[67] albeit
both in the bulbar or posterior urethra. A recent review
on tissue engineered oral mucosa[68] has shown this
to be a “promising alternative” but requires long-term
large cohort clinical trials before being advocated for
widespread use. Moreover, cellularised grafts require a
source of cells for seeding, are laborious, time-consuming
and expensive to manufacture[69] which defeat the
purpose of having a readily available off the shelf tissue
substitute.
Even though the ideal tissue engineered urethral sub-
Figure 9 Entire penile and distal bulbar urethra affected by a Lichen
Sclerosus-related stricture.
Figure 10 Multiple urethrocutaneous fistulae after failed hypospadias
repair.
Figure 8 Ascending urethrogram showing a short penile urethral stricture
limited to the fossa navicularis.
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stitute may be several years away, what can and should
certainly be addressed right away is the awareness
amongst urological surgeons that urethral reconstruction
is a highly specialised discipline and should only be
undertaken by experienced surgeons in high volume
tertiary units in order to ensure the best possible out-
come for patients[70] particularly given the fact that the
rst procedure is usually the one with the best results.
CONCLUSION
Penile urethral strictures present a therapeutic challenge
to the reconstructive urologist and are also associated
with a signicant negative impact on patient quality of
life, many of them starting off with problems in infancy
or adolescence and progressing into adult life, often
requiring multiple surgical interventions in the process.
Short, primary strictures are usually relatively easily
reconstructable using oral mucosal grafts or skin aps
in a single or multi-staged approach with high rates of
success. The major challenges lie with those patients
having extensive LS-related strictures or “hypospadias
cripples” for whom current urethroplasty techniques are
not always possible or feasible. These commonly end up
being managed by repeated endoscopic intervention,
self-dilatation or a perineal urethrostomy, often after
having undergone multiple failed attempts at urethral
reconstruction.
An abundance of penile urethroplasty techniques
have been described over the years bearing witness
to the difficulty in dealing with this condition. All are
however based on stricture aetiology, length, location
and previous surgical intervention. It is up to the
reconstructive surgeon to carefully evaluate the anatomy
of the stricture and supporting tissues intraoperatively
and only then decide which technique would give the
greatest likelihood of success in any given circumstance.
Hence the importance of centralisation of urethroplasty
services to high volume units with expertise in a braod
range of techniques.
One hopes that ongoing research will give rise to
therapeutic modalities which can alter the underlying
pathological processes in LS and that advances in
restorative medicine would lead to the generation of
novel, biocompatible and commercially viable urethral
substitutes.
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P- Reviewer: Kilinc M, Naselli A
S- Editor: Qi Y L- Editor: A E- Editor: Li D
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