Vol. 156, 78-79, J d y 1996 Printed in U S A

EDITORIAL: TREATMENT OF RECURRENT URETHRAL STRICTURES Treatment of strictures of the bulbo-membranous and pe-

nile urethra continues to be a fertile source of urological argument and debate. A reason for this difficulty is that there is a natural tendency for the patient and urologist to decide on a simpler and less invasive treatment, such as urethral dilation or urethrotomy for most strictures. The fact that these can be repeated easily and frequently gives a false sense of security that the stricture is under control. This policy also avoids newer and less well established treat- ments, such as urethral stents, and avoids what may seem to many urologists and certainly most patients to be the inva- sive, although frequently successful, urethroplasty proce- dures. Another difficulty in deciding on stricture manage- ment is that the history of this condition is beset with many new procedures, techniques and operations that have pro- duced excellent short-term results. Far more disappointing results emerge when long-term followup is assessed, which of course applies to all medical innovations. However, as is well known to every urologist, urethral strictures are remarkable for their unpredictability in recurring even after long periods of apparent subjective and objective relief of obstruction. Therefore, long-term followup of any new treatment is essen- tial. A 5-year period of review should be the minimum re- quirement but late stricture recurrence after 10 or even 20 years is not uncommon.

Many have described the results of optical urethrotomy but few have studied as many patients for as long as Pansadoro and Emiliozzi (page 73), who followed 224 patients for 5 to 18 years (median 8) with an overall stricture recurrence rate of 68%. A standard single urethrotomy at the 12 o'clock position was performed, leaving an indwelling urethral catheter for 24 to 36 hours. All types of stricture were treated within the bulb-membranous and penile urethra. The recurrence rate was similar regardless of the cause of the stricture, although urethrotomy was less successful for traumatic strictures. Bulbar strictures shorter than 1 cm. had a 71% success rate compared to 18% for longer strictures. Better results were also obtained with single rather than multiple strictures, and when the original caliber was larger than 16F. Although these differences were not found in the smaller group of penile strictures, the findings confirm the importance of the degree and extent of scar tissue within the urethral epithe- lium, surrounding bulbospongiosus and adjacent tissues. The more severe this fibrosis the less likely these simple endo- scopic techniques will succeed. Although 56% of recurrences were within 12 months after urethrotomy, the longer the patients were followed the more strictures recurred, with 10 of 153 (6%) recurring after more than 5 years. Of the 153 patients with a recurrent anterior urethral stricture 34 un- derwent a second urethrotomy with success noted in only 2, and a third urethrotomy failed in all patients. Occasion- ally it has been stated that urethrotomy is always worth attempting since little harm will be done. However, this article demonstrates that, although this procedure may suc- ceed for the simple, short, mild urethral stricture, success is less likely with the more complex multiple stricture, which involves extensive urethral and periurethral fibrosis, and with traumatic urethral strictures, which are treated much better by anastomotic urethroplasty. Even more significant is the important message that repeated urethrotomy is a waste of time and, even worse, with each procedure the amount of periurethral fibrosis will increase, making any subsequent urethral reconstruction more difficult and less likely to succeed.

Barbagli et al (page 76) present their results with surgical repair of 20 urethral strictures in the penile and bulbar urethra, which had recurred after previous urethroplasty. The failures followed a variety of surgical techniques, includ- ing anastomotic repair in 6 cases, pedicle patch urethroplasty in 6 and 2-stage inlay repairs in 8. Interestingly, 7 of these 20 patients had undergone 1 to 14 unsuccessful urethrotomies after failure of the initial urethroplasty. The authors do not attempt to discuss recurrence rates after urethroplasty but emphasize the importance of long-term followup. The stric- tures in these 20 patients recurred 4 months to 15 years after the first operation. The authors briefly describe the range of techniques necessary for this operation to succeed. Each case must be considered individually and those who perform re- peat reconstructions must have at their command the full range of surgical procedures as well as considerable surgical experience. The authors are to be congratulated on achieving satisfactory or excellent results in all 20 patients, with a mean followup of 20 months. Even if some of these satisfac- tory results show urethral narrowing in the future, the au- thors demonstrate that further operative attempts by expe- rienced surgeons at specialist centers are worthwhile in patients whose initial urethroplasty failed.

How then are we to treat recurrent urethral strictures? Pansadoro and Emiliozzi convincingly demonstrated that al- though there may be a reasonable chance for success when treating a short, uncomplicated urethral stricture with a single urethrotomy, except perhaps strictures following trau- matic urethral rupture, there is no point whatsoever in re- peating the procedure in the hope of achieving cure by ure- throtomy alone. Repeated conservative treatments, such as urethrotomy, self-catheterization or self-dilation,l certainly have a role in the treatment of recurrent urethral strictures but they should be restricted to patients too old, unfit or unwilling to undergo potentially curative techniques. Care- fully selected patients with recurrent strictures may benefit from a urethral stent. The 5-year results of some permanent stents are now being reported2 but, as stated previously, followup for 15 to 20 years is necessary before the true role of any new treatment can be determined. This certainly applies to temporary metallic3 and biodegradable stents,4 for which few long-term results are available. Barbagli et a1 and others demonstrated that careful surgical technique in the hands of experienced reconstructive urologists can retrieve the situa- tion in many of these unfortunate patients and restore the urethra to a normal caliber. However, it is important to emphasize that the longer patients who have had any form of substitution urethroplasty are followed the higher the failure rate5 This fact applies not only to scrotal and perineal skin, which produce the worst results, but also to penile and pre- putial skim6 Promising early results with free bladder and buccal epithelial grafts must be tempered by the possibility that future late results may be more disappointing. Finally, it can be stated that the forlorn hope of many that a cure will eventually be achieved if they perform enough urethrotomies on a recurrent stricture is incorrect, and also that many difficult recurrent strictures will respond to surgical repair in the hands of an experienced urologist.

Euan Milroy Institute of Urology The Middlesex Hospital London

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TREATMENT OF RECURRENT URETHRAL STRICTURES 79 REFERENCES

1. Harriss, D. R., Beckingham, I. J., Lemberger, R. J. and Lawrence, W. T.: Long-term results of intermittent low- friction self-catheterization in patients with recurrent ure- thral strictures. Brit. J. Urol., 74 790, 1994.

2. Milroy, E. and Allen, A.: Long-term results of UroLume urethral stent for recurrent urethral strictures. J. Urol., 155: 904,1996.

3. Yachia, D. and Beyar, M.: Temporarily implanted urethral coil stent for the treatment of recurrent urethral strictures: a preliminary report. J. Urol., 146 1001, 1991.

4. Talja, M., Tammela, T., Petas, A., Valimaa, T., Taari, K., Viherkoski, E. and Tormda, P.: Biodegradable self-reinforced polyglycolic acid spiral stent in prevention of postoperative urinary retention after visual laser ablation of the prostate- laser prostatectomy. J. Urol., 164 2089, 1995.

5. Rosen, M. A., Nash, P. A,, Bruce, J. E. and McAninch, J. W.: The actuarial success rate of surgical treatment of urethral stric- tures. J. Urol., part 2, 151: 360A, abstract 529, 1994.

6. Mundy, A. R.: The long-term results of skin inlay urethroplasty. Brit. J. Urol., 75: 59, 1995.