Anterior urethral strictures: Etiology and characteristics

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Anterior urethral strictures: Etiology and characteristics
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   ANTERIOR URETHRAL STRICTURES: ETIOLOGY  AND CHARACTERISTICS ANN S. FENTON, ALLEN F. MOREY, RICARDO AVILES,  AND  CARLOS R. GARCIA  ABSTRACT Objectives.  To evaluate the etiology and characteristics of symptomatic anterior urethral strictures in alarge series of men presenting for urologic treatment in an effort to determine the common themes that mayinfluence possible prevention or treatment strategies. Many questions about the srcin and features of contemporary anterior urethral stricture disease remain unanswered. Methods.  The records of 175 men with symptomatic anterior urethral strictures were reviewed. Data wereenteredbothprospectivelybycarefulpatientquestioningandretrospectivelyfromdetailedchartreview.Thestricture length, location, and cause were recorded from urologic presentation, before definitive treatment.Posterior strictures from pelvic fracture urethral disruption defects were excluded from this review. Results.  A total of 194 strictures were identified in 175 men. Most strictures were idiopathic (65 of 194,34%) or iatrogenic (63 of 194, 32%); fewer were inflammatory (38 of 194, 20%) or traumatic (28 of 194,14%). Most involved the bulbar urethra (n  100, 52%). Pendulous strictures (mean 6.1 cm) were longer onaverage than those in the fossa navicularis (mean 2.6 cm) or bulb (mean 3.1 cm). Prolonged catheterization(n  26) and transurethral surgery (n  25) were common causes of iatrogenic strictures. Conclusions.  Ourresultsshowedthatidiopathicandiatrogenicstricturesaresurprisinglycommon.Externaltrauma was a relatively uncommon cause of anterior urethral stricture disease overall. Unnecessary urethralcatheterization and repeated urethral instrumentation should be avoided to prevent stricture formation orexacerbation. More study is necessary to determine the origin of anterior urethral stricturedisease.  UROLOGY  65:  1055–1058, 2005. Published by Elsevier Inc. S ince the development of effective antibiotictherapy, we have observed that few urethralstrictures occur in association with gonorrhea orother sexually transmitted diseases. Externaltraumaisnowgenerallyassumedtobethecauseof most anterior urethral strictures. 1 Little is knownabout the srcin of nontraumatic strictures. A re-viewofpublishedurologicstudiesfromthepast40years revealed a dearth of citations related specifi-callytoanteriorstrictureetiology,withmostinfor-mation reported only in conjunction with variousreconstructive techniques. 2–7 Many questions about anterior urethral stric-tures remain unanswered. How prevalent are idio-pathicstrictures?Howcanstricturesbeprevented?Do pendulous strictures differ from bulbar stric-tures in length, severity, or srcin? Does strictureetiologyorpriortreatmentinfluenceprocedurese-lection? What are the main causes of iatrogenicstrictures? We evaluated the causes and character-isticsofsymptomaticanteriorurethralstricturesina large series of men who presented for urologictreatmentinanefforttofurtherourunderstandingof contemporary urethral stricture disease. MATERIAL AND METHODS Under a Brooke Army Medical Center institutional reviewboard-approved protocol, a detailed chart review was con-ducted among men treated by a single surgeon (A.F.M.) forsymptomaticanteriorurethralstricturedisease.Between1997and 2002, 175 patients with complete records were identifiedfromtheUrologyServiceatBrookeArmyMedicalCenter(n  138) and the Hospital Escuela in Tegucigalpa, Honduras (n  37). The data collected included anatomic location within theanterior urethra, estimated stricture length, most probablecause, and management method. Posterior strictures were ex-cluded from this analysis. We classified the anterior stricture location into three ana-tomic categories: fossa navicularis, pendulous, and bulbar. From the Urology Services, Brooke Army Medical Center, San Antonio, Texas; and Hospital Escuela, Tegucigalpa, HondurasReprint requests: Allen F. Morey, M.D., Urology Services,Brooke Army Medical Center, 3851 Roger Brooke Drive, MCHE-SDU, Fort Sam Houston, TX 78234-6200. E-mail: allen.morey@ amedd.army.milSubmitted: August 5, 2004, accepted (with revisions): Decem-ber 3, 2004  ADULT UROLOGY  P UBLISHED BY  E LSEVIER   I NC . doi:10.1016/j.urology.2004.12.018  1055  The cause of stricture was determined to be inflammatory(lichensclerosisandsexuallytransmitteddisease),iatrogenic,traumatic,oridiopathic.Thestricturelengthineachanatomiclocation was compared by a nonparametric Kruskal-Wallistest of the harmonic mean of each group. RESULTS A total of 194 anterior urethral strictures wereidentified in the 175 patients. In 19 men (11%),synchronous or extensive strictures involved morethan one anatomic location. Open urethroplastywas performed in 146 cases, endoscopic urethrot-omy in 10, and dilation in 3; 16 men were awaitingtreatment. S TRICTURE  L ENGTH AND  L OCATION  The average stricture length overall was 4.1 cm.Bulbar strictures were more prevalent (n    100,52%)thanthoseofthependulousurethra(n  59,30%) or fossa navicularis (n  35, 18%). Pendu-lous strictures (mean 6.1 cm) were longer on aver-age than those in the fossa navicularis (mean 2.6cm) or bulb (mean 3.1 cm), a difference that ap-proached,butdidnotattain,statisticalsignificance( P    0.091), likely because of the variability indistribution and the relatively small sample size. E TIOLOGY  Idiopathic(65of194,34%)andiatrogenic(63of 194, 32%) strictures were the most common. Sur-prisingly,traumawastheleastcommonetiologyof stricture disease in this population. Distal stric-tures were more often related to inflammatory dis-orders (Table I) than were bulbar strictures, in which trauma was more prevalent (Table I). Trau-matic strictures (mean 3.1 cm) tended to be muchshorter than inflammatory (mean 5.4 cm,  P  0.05).Of the 56 iatrogenic strictures, most occurred inthe bulbar urethra (n    29, 52%). Transurethralsurgery accounted for most iatrogenic strictures(Table II), but traumatic catheterization or pro-longed catheterization after burns or injuries wasalso frequently related to stricture formation. Cys-toscopy and open prostate surgery were uncom-mon causes of stricture formation (n  6, 3%). COMMENT  What is the most common cause of contempo-rary anterior urethral stricture disease? Although Jordan and Schlossberg 1 have suggested that mostresult from external trauma, recent data have indi-cated that idiopathic and iatrogenic strictures aremore common (Table III). Traumatic strictures tend to be short and occuralmost exclusively in the bulbar urethra; most arerelated to straddle injury. Santucci  et al. 5 foundthatmostshortstricturesamenabletotreatmentbyexcisionwithprimaryanastomosisareoftraumaticorigin;however,idiopathicstricturesweresurpris-ingly common (38%). Idiopathic bulbar stricturesmay often be the delayed manifestation of unrec-ognized childhood trauma, a theory supported bythe relatively high number of idiopathic stricturesdetected in the bulb in our series (35%). Baskinand McAninch 8 noted that adult strictures maypresent as long as 18 years after perineal trauma.  TABLE I.  Etiology of urethral strictures CauseIdiopathic Iatrogenic Inflammatory Traumatic Distal anterior (n  94)Fossa navicularis 12 (12.8) 11 (11.7) 12 (12.8) 0Pendulous urethra 18 (19.1) 19 (20.2) 13 (13.8) 9 (9.6)Total 30 (31.9) 30 (31.9) 25 (26.6) 9 (9.6)Bulbar (n  100) 35 (35) 33 (33) 13 (13) 19 (19) Data presented as number of strictures, with percentages in parentheses.  TABLE II.  Etiology of iatrogenic urethral strictures (n    63) LocationProcedure TUR Cystoscopy ProlongedCatheterizationHypospadiasRepair Prostatectomy  FN 5 (7.9) 0 2 (3.2) 0 1 (1.6)PU 7 (11.1) 2 (3.2) 9 (14.3) 3 (4.8) 0B 14 (22.2) 3 (4.8) 12 (19) 1 (1.6) 1 (1.6)Total 26 (41) 8 (12.7) 23 (36.5) 4 (6.3) 2 (3.2) K EY  : TUR  transurethral resection; FN    fossa navicularis; PU    pendulous urethra; B  bulb.Data presented as number of strictures, with percentages in parentheses. 1056  UROLOGY 65 (6), 2005  The distal urethra is prone to iatrogenic injurybut has also been linked with histologic features of lichen sclerosis on the glans or prepuce. 9 Armena-kas etal. 10 foundthat47%offossanavicularisstric-tures resulted from lichen sclerosis and iatrogenicinjurywasimplicatedin37%.The35fossanavicu-laris strictures in our series were equally of iatro-genic, idiopathic, and inflammatory srcin—notthe result of external trauma.The reconstructive urologist must consider theetiology and prior attempted treatments whenplanning whether to excise or graft the stenoticurethral segment. Iatrogenic strictures tend to bemore complex than traumatic strictures, fre-quently requiring elaborate reconstruction proce-dures. 3 Repeated urethral dilation procedures ex-acerbate short strictures and may make themlonger. 11,12  Wehavepreviouslyobservedthatshorttraumatic strictures may be converted to interme-diate length strictures after repeated instrumenta-tion, thus complicating the reconstructive ap-proach.The finding that pendulous strictures averagedmore than 6 cm in this series (nearly twice thelength of the bulbar strictures [3.3 cm]) under-scoresthecustomaryneedforurethralsubstitutionwith tissue transfer techniques in this area. Webelieve the length difference noted between thependulousandbulbarstricturesisclinicallysignif-icant and would have attained statistical signifi-canceinalargersamplesize.Itislikelythatelderlymen with a history of prior instrumentation havelonger strictures than younger men who havenever undergone instrumentation. Accordingly,more than one half of men older than 65 yearsundergoing urethroplasty were noted to requiretissue transfer in one recent series. 13 Iatrogenic strictures stem from ischemic insultduring traumatic passage of large instruments intothe urethral lumen during transurethral surgery orfrom prolonged catheterization. Our finding that36.5% of iatrogenic strictures were associated withprolonged catheterization suggests that when ure-thral catheterization is required, such as in treat-ment of burn or polytrauma patients, a small cath-eter such as 16F should be used for the shortestduration possible. Early suprapubic tube place-ment should be strongly encouraged whenever ex-tended catheterization is likely.The stricture risk after transurethral surgery hasbeen reported to be about 6%, although the dura-tion of resection and amount of tissue resectedwere notassociatedwith the likelihoodofstrictureformation. A trend toward stricture formation hasbeen noted with a larger urethral catheter size. 14 Routine preliminary urethrotomy has been shownto be effective for stricture prophylaxis duringtransurethralresectionoftheprostate. 15,16 Ourim-pression has been that urethrotomy is not rou-tinely indicated before transurethral resection of the prostate but does seem justified to prevent mu-cosal ischemia when resectoscope passage is ham-pered by a tight urethral lumen. CONCLUSIONS The bulbar urethra is the most common locationof anterior urethral strictures; many are traumaticin srcin and thus short and amenable to excisionwith primary repair. Distal strictures tend to belonger and therefore more frequently require sub-stitutionurethroplasty.Theriskofstrictureforma-tion after urethral instrumentation is concerningand warrants additional investigation. Unneces-sary urethral catheterization and repeated instru-mentation should be avoided whenever possible toprevent subsequent stricture formation or exacer-bation. REFERENCES1. Jordan GH, and Schlossberg SM: Surgery of the penisand urethra, in Walsh PC, Retik AB, Vaughan ED Jr , et al (Eds): Campbell’sUrology, 8thed.Philadelphia,WBSaunders,2002, pp 3886–3952.2. Wessells H, and McAninch JW: Use of free grafts inurethral stricture reconstruction. J Urol  155:  1912–1915,1996.  TABLE III.  Meta-analysis of anterior urethral stricture etiology Investigator Stricture(n)Cause (n)Idiopathic Iatrogenic Inflammatory Traumatic Wessells and McAninch 2 40 5 12 13 10Wessells  et al. 3 25 0 11 9 5 Andrich and Mundy 4 83 35 38 7 1Santucci  et al. 5 * 168 64 24 12 68Elliott  et al. 6 60 37 9 7 7 Andrich  et al. 7 162 38 84 23 17Present study 194 65 63 38 28Total (%) 732 244 (33) 241 (33) 109 (15) 136 (19) *  Included only bulbar strictures. UROLOGY  65  (6), 2005  1057  3. Wessells H, Morey AF, and McAninch JW: Single stagereconstruction of complex anterior urethral strictures: com-bined tissue transfer techniques. J Urol  157:  1271–1274,1997.4. Andrich DE, and Mundy AR: Substitution urethro-plasty with buccal mucosa-free grafts. J Urol  165:  1131–1133,2001.5. Santucci RA, Mario LA, and McAninch JW: Anasto-motic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol  167:  1715–1719, 2002.6. Elliott SP, Metro MJ, and McAninch JW: Long-termfollowup of the ventrally placed buccal mucosa onlay graft inbulbar urethral reconstruction. J Urol  169:  1754–1757, 2003.7. Andrich DE, Greenwell TJ, and Mundy AR: The prob-lems of penile urethroplasty with particular reference to2-stage reconstructions. J Urol  170:  87–89, 2003.8. Baskin LS, and McAninch JW: Childhood urethral in- juries: perspectives on outcome and treatment. Br J Urol  72: 241–246, 1993.9. Staff WG: Urethral involvement in balanitis xeroticaobliterans. Br J Urol  47:  234–239, 1970.10. Armenakas NA, Morey AF, and McAninch JW: Recon-struction of resistant strictures of the fossa navicularis andmeatus. J Urol  160:  359–363, 1998.11. Andrich DA, Danglison N, Greenwell TJ,  et al:  Thelong-term results of urethroplasty. J Urol  170:  90–92, 2003.12. Park SP, and McAninch JW: Straddle injuries to thebulbar urethra: management and outcomes in 78 patients. J Urol  171:  722–725, 2004.13. Santucci RA, McAninch JW, Mario LA,  et al:  Urethro-plasty in patients older than 65 years: indications, results,outcomes and suggested treatment modifications. J Urol  172: 201–203, 2004.14. Lentz HC, Mebust WK, Foret JD,  et al:  Urethral stric-tures following transurethral prostatectomy: review of 2,223resections. J Urol  117:  194–196, 1977.15. Emmet JL, Rous SN, Greene LF,  et al:  Preliminary in-ternal urethrotomy in 1036 cases to prevent urethral stricturefollowingtransurethralresection:caliberofnormaladultmaleurethra. J Urol  89:  829–832, 1963.16. Bailey MJ, and Shearer RJ: The role of internal ureth-rotomy in the prevention of urethral stricture following trans-urethral resection of prostate. Br J Urol  51:  28–31, 1979. 1058  UROLOGY 65 (6), 2005
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