A urethral stricture is a medical condition defined by the abnormal narrowing of the urethra, the tube responsible for carrying urine out of the body. This narrowing is primarily caused by scar tissue, which can develop anywhere along the length of the urethra. The resulting obstruction can lead to a variety of frustrating symptoms, including a weakened or spraying urinary stream, the need to strain to empty the bladder, a feeling of incomplete emptying, and pain during urination. Left untreated, this restriction can cause serious complications like chronic urinary tract infections, bladder stones, and damage to the kidneys. Fixing a urethral stricture requires surgical intervention to restore the natural flow of urine, with treatment selection depending heavily on the stricture’s length, location, and severity.
Endoscopic Treatments
Endoscopic treatments are minimally invasive procedures often considered the first-line approach for short or less severe strictures. These techniques aim to widen the narrowed channel without requiring a major open incision, offering the benefit of a short recovery time. However, their primary limitation is the high probability of the stricture returning, as they do not remove the underlying scar tissue.
Urethral dilation is one such method, involving the gradual stretching of the strictured segment using specialized instruments called dilators or a balloon device. This process forcibly expands the scar tissue to increase the urethral diameter, allowing for better urine flow. While dilation is a simple procedure, it carries a high recurrence rate, with success rates falling significantly after the first attempt.
A second endoscopic option is Direct Visual Internal Urethrotomy (DVIU), where a small scope is inserted into the urethra to visualize the stricture directly. A tiny blade or laser is then used to cut longitudinally through the scar tissue, opening the channel. The long-term success rate for a single DVIU procedure typically ranges between 20% and 60%, with recurrence being more likely for strictures longer than one centimeter or those located in the penile urethra.
Both dilation and DVIU are considered temporizing measures because the act of stretching or cutting the scar tissue can sometimes lead to the formation of denser, longer scar tissue, a process known as spongiofibrosis. If a stricture recurs after one or two endoscopic attempts, specialists generally recommend moving to a more definitive, open surgical repair to prevent further damage.
Urethroplasty: The Definitive Surgical Repair
Urethroplasty is the open reconstructive surgery considered the gold standard for achieving a durable, long-term correction of a urethral stricture. This procedure involves excising the scarred segment or augmenting the narrow area with healthy tissue, resulting in success rates significantly higher than endoscopic treatments, often exceeding 80% to 90%. The specific technique chosen depends entirely on the stricture’s characteristics, particularly its length and location within the urethra.
Excision and Primary Anastomosis (EPA)
The most successful form of urethroplasty for short segments, typically less than two centimeters, is Excision and Primary Anastomosis (EPA). This procedure involves surgically removing the entire scarred portion of the urethra and then meticulously sewing the two healthy ends back together in a tension-free connection. EPA is most commonly performed for strictures in the bulbar urethra, the segment located under the scrotum, and boasts long-term success rates reliably above 90%.
Substitution Urethroplasty
For longer strictures or those that cannot be safely excised and reconnected without excessive tension, a Substitution Urethroplasty is required. This technique uses a graft or flap of healthy tissue to widen the narrowed urethra, effectively patching or replacing the affected area. The most common and preferred material for this reconstruction is Buccal Mucosal Graft (BMG), which is tissue harvested from the inside of the cheek or lip.
Buccal mucosa is an ideal graft material because it is accustomed to a moist environment and is naturally durable, offering excellent vascularity for successful integration. The BMG is typically harvested and then sewn into place, either on the top (dorsal), bottom (ventral), or both sides of the opened urethra, to create a wider channel. Success rates for BMG urethroplasty remain very high, ranging from 73% to 90%, making it the preferred method for complex or lengthy strictures.
Managing Recovery and Preventing Recurrence
Recovery after urethral stricture repair varies significantly depending on whether an endoscopic or open procedure was performed. Following a minimally invasive DVIU, a temporary catheter may be left in place for only a few days, and patients can often resume normal activities within a week. The faster recovery time is a major reason these methods are commonly attempted first, despite their high recurrence risk.
Recovery from a urethroplasty is longer, reflecting the reconstructive nature of the surgery. Patients typically remain hospitalized for one to two days, and a urinary catheter is left in place for two to four weeks to allow the surgical site to heal completely. During this time, physical activity is restricted, with patients advised to avoid heavy lifting and anything that puts pressure on the perineum, such as cycling or prolonged sitting.
Long-term follow-up is a critical component of successful stricture management, regardless of the initial repair technique. Regular monitoring is necessary because most recurrences occur within the first one to two years after surgery. This follow-up includes non-invasive tests, such as uroflowmetry, which measures the speed and strength of the urinary stream, and symptom questionnaires to detect any subtle signs of re-narrowing.
For some patients, a physician may recommend intermittent self-catheterization (ISC) as a long-term preventive measure, particularly after an endoscopic treatment or for complex strictures. ISC involves the patient briefly passing a small, lubricated catheter into the urethra on a schedule to maintain patency and prevent scar tissue from reforming. Adherence to the prescribed follow-up schedule is essential to ensure the long-term success of the procedure.