Clinical challenge
An example of the most frequent aetiology of urethral strictures nowadays: iatrogenic strictures
Prof. Oliver Hakenberg Section editor Rostock (DE)
The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem. Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org
Comments by Prof. Luis Martínez-Piñeiro Madrid (ES)
with approximately 85-90% good long-term results [2]. The graft can be placed dorsally, dorsolaterally, or ventrally with similar results. The latter technique would not be adequate in case of strong spongiofibrosis and lack of spongy tissue. Most probably the very tight distal aspect of the stricture will require an augmented anastomotic reconstruction or a double graft (dorsal-Asopa + ventral). In case that the stricture appears shorter during surgery and with strong fibrosis, pseudodiverticula or epithelialized false passages, a resection and end to end anastomosis could be another alternative. References: 1. A drug-coated balloon treatment for urethral stricture disease: Three-year results from the ROBUST I Study. Virasoro R et al . Urology 2022;14:177–183 ; One-year results for the ROBUST III Randomised controlled trial evaluating the Optilume drug-coated balloon for anterior urethral strictures. Elliot S et al. J Urol April 2022;207(4):866-875 . 2. U rethral Strictures EAU Guidelines 2022. Lumen N et al .
Retrograde and voiding cystourethrographies show a stricture of the proximal bulbar urethra of approximately 3 cm. The stricture starts distally to the external urethral sphincter and has a very tight portion at its distal aspect. Spongiofibrosis and small pseudodiverticula can be seen at this proximal aspect, most probably related to the false passage reported during previous urethrotomy. Internal urethrotomy is not an option because the stricture is too long, and the patient was already treated with internal urethrotomy with bad results. The treatment that offers the best results is urethroplasty. Dilatation using the Optilume balloon is another alternative, although the length of the stricture is almost out of the manufacturer’s recommendation (< 3 cm). The results reported by the ROBUST studies [1] are less effective than the standard urethroplasty and taking into account the young age of the patient, I would offer the treatment with best long-term results.
Oliver.Hakenberg@ med.uni-rostock.de
Case study No. 75 A 28-year-old man complained of dysuria 3 weeks after a ureteroscopy with fragmentation of a ureteric stone. A urethrogram showed a bulbar stricture and direct vision internal urethrotomy was performed. Due to an intraoperative false passage, the indwelling urethral catheter was left in situ for one week. Three months later, the patient still has a weak urinary stream. The current urethrogram is attached.
Bulbar urethral augmentation with buccal mucosa graft or internal preputial mucosa is a technique
Fig. 1 Retrograde
Fig. 2 Antegrade
Case study No. 75 continued Iatrogenic strictures usually have superficial lesions, but due to the number of failed procedures in this gentleman, spongiofibrosis may be present. It has to be assessed intraoperatively since the distal part of the stricture is very tight and doesn’t allow endoscopic assessment. Palpation after perineal incision shows thick and soft spongiosum (Fig. 1) and a ventral urethral approach is performed. The dorsal aspect of the stricture is 13 mm long. It is excised superficially (Fig. 2) leaving a dorsal gap (Fig. 3). Mucosal anastomosis is performed (Fig. 4) which avoids dorsal grafting. Proximal to this suture, the lumen is now
Discussion point: • What treatment is advisable? Case provided by Dr. Amin Bouker Coral Médical, Tunis, Tunisia E-mail: aminbouker@gmail.com
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European Urology Today June/July 2023
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