Classification systems for anterior urethral stricture disease in men: a systematic review.

OBJECTIVE: To identify and explore the various classification systems that have been proposed for anterior urethral stricture disease (AUSD) and to identify the advantages and disadvantages of each. METHODS: A comprehensive systematic review was conducted in MEDLINE, EMBASE, SCOPUS and COCHRANE databases with a search strategy created appropriately. Titles and abstracts of search results were screened by two authors and selected for full-text review. Studies exploring urethral stricture classification, clinical scoring or staging systems used in men over the age of 18 with benign anterior urethral stricture disease were included. RESULTS: The search identified 3113 articles, of which 10 were selected for inclusion after scrutiny. Four classification systems were identified. These include ULTRA score, urethral stricture score, cystoscopy-based staging system and Gombe Urethrographic score. These were based on various modalities, including cystoscopy, retrograde urethrogram (RUG) and sonourethrogram (SUG). From the scoring systems identified, the urethral stricture scoring system has multiple external validation studies and is predictive of operative complexity, operative time, recurrence and postoperative complications. CONCLUSIONS: Several classification systems have been proposed for AUSD. Each has its advantages and disadvantages. The urethral stricture score has been externally validated and shown to been predictive of surgical outcomes and recurrence. There are no scores that incorporate patient-related outcome measures (PROMs). Many classification systems have yet to provide sufficient external validation. Further external validation studies are needed before the general adoption of a particular system.

Development and Validation of A Male Anterior Urethral Stricture Classification System.

OBJECTIVE: To develop and validate a clinical classification system for urethral stricture disease (USD) based on the retrograde urethrogram (RUG), physical exam, and stricture-specific patient history. MATERIALS AND METHODS: Three elements were chosen to be included in the classification system: 1) Length of urethral stricture (L); 2) Stricture segment/location (S); 3) Stricture Etiology (E) (LSE classification system). Each element was divided into clinically relevant sub-categories. A three-step development and validation process then ensued, culminating in an in-person Trauma and Urologic Reconstruction Network of Surgeons (TURNS) meeting, at which the final classification system was unanimously agreed upon by attendees based on interrater reliability data obtained from the classifying of 22 clinical vignettes. A final validation step involved retrospectively classifying cases in the TURNS database to determine if classification influenced surgical technique and was associated with presumed stricture etiology. RESULTS: The final LSE classification system was found to have an interrater reliability of 0.79 (individual components 0.76, 0.70 and 0.93 respectfully). Retrospective classification of the 2162 TURNS strictures revealed the segment (S) to be strongly associated with urethroplasty type (p = 0.0005) and stricture etiology (E) (p = 0.0005). CONCLUSION: We developed and validated a novel, easy to use, urethral stricture classification system. The system's ability to aid in directing treatments, predict treatment outcomes, and facilitate collaborative research efforts will require further study.

Meatal Occlusive Disease in Adult Males: Are There Any Clinical Variations?

OBJECTIVE: The study aimed to document the types of meatal occlusive disease (MOD) in adult males in terms of its clinical presentation, management and prognosis. MATERIAL AND METHODS: Eighty-six adult males with MOD were assessed during the study period. The patients were divided into Group 1, having meatal opening that was occluded by flimsy adhesions (meatal synechia/adhesive type MOD), and Group 2 that included patients who had circumferential constriction of the meatus (meatal stenosis/constrictive type MOD). All patients underwent meatal dilatation up to 18 Fr followed by self-dilatation for 3 months with topical clobetasol for 4 weeks. Degree of discomfort during self-dilation, improvement in flow rate, International Prostate Symptom Score (IPSS score) and recurrences were recorded at pre-determined intervals. RESULTS: Twenty-eight patients had meatal synechia (Group 1) and 48 had meatal stenosis (Group 2). Discomfort during self-dilatation in Group 1 patients was significantly less; there was improvement in IPSS and peak flow rate (mean follow-up 26.8 months) as compared to Group 2. With dilation alone, no recurrence was noted in Group 1; however, Group 2 showed 62.8% recurrence indicating poor outcome in this subset of patients. CONCLUSION: MOD in adult males consists of 2 separate clinical entities with different therapeutic outcomes.

[Overview of urethral strictures: etiology, epidemiology, physiopathology and classification. General principles of urethral repair]. / Aspectos generales de la estenosis uretral: etiología, epidemiología, fisiopatología, clasificación. Principios generales de la reparación uretral.

In this article we present the causes of urethral stenosis in the adult male and review data about incidence. Regarding disease physiopathology we emphasize the inflammatory causes and, more specifically lichen sclerosus, as the clinical scenario that presents the greater difficulty for the management of urethral stenosis since we do not know its natural evolution. Regarding treatment of urethral stenosis we discuss the various options from excision and terminal-terminal anastomosis to oral mucosal graft augmentation urethroplasty, passing by two-step operations in more severe cases. Looking forward to the future a real gate opens with the application of tissue engineering to obtain oral mucosa.

Aspectos generales de la estenosis uretral: etiología, epidemiología, fisiopatología, clasificación. Principios generales de la reparación uretral / Overview of urethral strictures: etiology, epidemiology, physiopathology and classification. General principles of urethral repair

En este artículo se exponen las causas de estenosis de uretra en el varón adulto y se revisan los datos de incidencia. En lo referente a la fisiopatología de esta enfermedad se pone especial énfasis en las causas inflamatorias y, más concretamente, en el liquen escleroso como escenario clínico que confiere mayor dificultad al manejo de la estenosis de uretra ya que no conocemos su evolución natural. En lo referente al tratamiento de la estenosis de uretra se discuten las diferentes opciones que van desde la excisión y anastomosis termino-terminal hasta la uretroplastia de aumento con injerto de mucosa bucal, pasando por la cirugía en dos tiempos en casos más severos. De cara al futuro se abre una puerta real mediante la aplicación de la ingenieria tisular para la obtención de mucosa bucal

In this article we present the causes of urethral stenosis in the adult male and review data about incidence. Regarding disease physiopathology we emphasize the inflammatory causes and, more specifically lichen sclerosus, as the clinical scenario that presents the greater difficulty for the management of urethral stenosis since we do not know its natural evolution. Regarding treatment of urethral stenosis we discuss the various options from excision and terminal-terminal anastomosis to oral mucosal graft augmentation urethroplasty, passing by two-step operations in more severe cases. Looking forward to the future a real gate opens with the application of tissue engineering to obtain oral mucosa

Estenosis de la anastomosis vesicouretral tras prostatectomía radical y radioterapia postoperatoria / Vesicourethral anastomotic stricture following radical prostatectomy with or without postoperative radiotherapy

Objetivo: conocer la incidencia de la estenosis de la anastomosis vesicouretral en pacientes con cáncer de próstata tratados con prostatectomía radical. El objetivo secundario fue analizar si la radioterapia postoperatoria incrementa el riesgo de presentar una estenosis de la anastomosis. Material y métodos: se revisaron retrospectivamente las historias de los pacientes sometidos a prostatectomía radical como tratamiento primario entre enero 2000 y diciembre del 2008, con un seguimiento clínico mínimo de 12 meses. Del total de pacientes 258 cumplían los requisitos anteriores. De ellos 25 (9,6%) recibieron radioterapia postoperatoria, 12 (48%) de forma adyuvante y 13 (52%) de rescate. La edad media de los pacientes irradiados fue 64 (46-77) años. La mediana del PSA pre-radioterapia fue 2,3 (0,04-26,1)ng/ ml. El tiempo medio entre la cirugía y la radioterapia fue 17,4 (3-72) meses. La dosis media administrada fue 68 (58-70) Gy. El seguimiento medio fue 50,5 (15-117) meses. Resultados: de 25 pacientes prostatectomizados que recibieron radioterapia 4 (16%) desarrollaron estenosis de la anastomosis vesicouretral. El tiempo medio desde la finalización de la radioterapia hasta la aparición de la estenosis fue de 4 meses (1-22). Por otro lado, 36 (15,4%) pacientes prostatectomizados que no recibieron radioterapia postoperatoria presentaron esta misma complicación. Comparativamente no se apreciaron diferencias significativas entre ambos grupos (p = 0,599).Conclusiones: en nuestra revisión retrospectiva, la radioterapia postoperatoria no incrementó de forma significativa la incidencia de estenosis de la anastomosis vesicouretral (AU)

Objective: To know the incidence of vesicourethral anastomotic stricture in patients with prostate cancer treated with radical prostatectomy. Our secondary aim was to verify if postoperative radiotherapy increases the risk of presenting anastomotic stricture. Materials and methods: We retrospectively checked the clinical records of patients that had undergone radical prostatectomy as their primary treatment between January 2000 and December2008, with a minimum clinical follow-up of 12 months. Of the total patients, 258 met the foregoing requirements. Of them, 25 (9.6%) received postoperative radiotherapy, 12 (48%) received adjuvant radiotherapy and 13 (52%) received salvage radiotherapy. The mean age of the patients that received radiotherapy was 64 (46-77) years. The mean pre-radiotherapy PSA was 2.3 (0.04-26.1) ng/ ml. The mean time between surgery and radiotherapy was 17.4 (3-72) months. The mean dosage administered was 68 (58-70) Gy. The mean follow-up was 50.5(15-177) months. Results: Of 25 prostatectomized patients that received radiotherapy, four (16%) developed vesicourethral anastomotic stricture. The mean time from the completion of the radiotherapy until the appearance of the stricture was 4 months (1-22). On the other hand, 36 (15.4%) of the prostatectomized patients that did not receive postoperative radiotherapy presented the same complication. Comparatively, we did not note significant differences between both groups (p = 0.599). Conclusions: In our retrospective review, postoperative radiotherapy did not significantly increase the incidence of vesicourethral anastomotic stricture (AU)

The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system.

OBJECTIVE: • To characterize and categorize adults with hypospadias who presented to our clinic with urethral stricture and fistula to better clarify the presentation, history and intraoperative findings in this heterogeneous group and to better describe the natural history of this anomaly in adulthood. PATIENT AND METHODS: • A retrospective chart review was performed on adults with hypospadias who underwent urethroplasty for urethral stricture, urethrocutaneous fistula, and/or hypospadias repair at Cleveland Clinic between 1993 and 2009. All procedures were performed by a single staff surgeon (K.W.A.). • The charts were reviewed for site of hypospadias, presenting complaint, overall symptoms, history of repair and type of surgery performed. RESULTS: • Fifty-five adult patients were identified. Median age was 37 years (range: 18-72). About half of the patients had distal (glanular/subcoronal or pendulous) hypospadias (56.4%) and the others had more proximal (bulbar) hypospadias (43.6%). • Voiding symptoms (such as dysuria, weak stream, spraying, urgency, frequency) were the most common presenting complaint (50.9%) and overall symptom (81.8%). About half of patients underwent a two-stage urethroplasty (52.7%). • Based on their history of repair, patients were divided into three categories: I, patients who have undergone continuous multiple surgeries for repair with significant scarring and tissue loss; II, delayed complications after an initially successful childhood repair; and III, no previous repair. Most patients were category I (58.2%); however, seven patients (12.7%) were category III. Balanitis xerotica obliterans (BXO) was more common in this subgroup compared with other categories (42.9% vs 8.3%, respectively, P= 0.037). In two of the three patients in category III with BXO, the stricture length was longer than 7 cm. CONCLUSIONS: • Adults with hypospadias represent a heterogeneous group. More than half of adults with complications related to hypospadias have had multiple operations (category I) representing one of the most difficult challenges to the reconstructive urologist. • Roughly 30% of patients undergo an initially successful repair in childhood with recurrent problems in adulthood (category II), suggesting that the outcomes of repair may not be as durable as estimated by studies with shorter-term follow-up. • Finally, BXO is over-represented in men with hypospadias who have not previously undergone repair, which contradicts the previous suggestion that the risk of BXO is related to the use of skin grafts/flaps from previous repairs and suggests that there may be an increased risk of severe stricture disease in patients who have never undergone corrective surgery for this anomaly.

[Meatal stenosis. Mundane problem or surgical challenge?]. / Die Meatusstenose: Banales Problem oder operative Herausforderung?

There is no common pathology in strictures of the external urinary meatus in men and women. These strictures have to be considered in their complexity and history with influential factors like additional diseases and previous surgical interventions. It is necessary to distinguish a simple situation from extensive findings. Successful therapy depends on the exact evaluation and classification of the stricture.

Cirugía de la estenosis de uretra. Actualización / Surgical treatment of urethral stenosis: update

Objetivo: Llevar a cabo una recopilación de los principales métodos de tratamiento quirúrgico de la estenosis de uretra peneana y bulbar. Métodos: Revisamos la bibliografía más actualizada, centrándonos en autores con gran experiencia en el tratamiento de la estenosis uretral, y utilizamos nuestra experiencia para contrastar o reafirmar alguna de las técnicas. Resultados/Conclusiones: La base del tratamiento de la estenosis uretral radica en la propia estenosis, es decir, localización, etiología y longitud, así como en las características del paciente (edad, historia clínica). Entre las uretroplastias disponemos de técnicas en un tiempo, como la excisión y anastomosis, y el uso de injertos libres o colgajos pediculados. Las técnicas en dos tiempos como la de Johanson o la perineostomía son de gran utilidad en determinados casos de estenosis complejas. Debemos permanecer atentos al desarrollo de nuevas técnicas y al empleo de nuevos materiales que ayudaran, una vez consolidados a obtener mejores resultados (AU

Objectives: To compile the main methods of surgical treatment of penile and bulbar urethral stenosis. Methods: We review the most updated bibliography, focusing on authors with large experience in the treatment of urethral stenosis, and we use our own experience to contrast or reaffirm some of the techniques. Results/Conclusions: The base of the treatment of urethral stenosis remains in the stenosis itself (localization, etiology and length) and also in patient’s characteristics (age, past medical history). Among the techniques of urethroplasty we have techniques in one step, as the technique of excision and anastomosis, and the use of free grafts or vascularized flaps. The techniques in two steps like Johannson's or perineostomy are very useful in certain cases of complex stenosis. We should keep an eye on the development of new techniques and the use of new materials that will help, once consolidated, to improve results (AU)

[Value of perineal sonography for diagnosing anterior urethral stenosis]. / Valeur de l'échographie de surface par voie périnéale dans le diagnostic des sténoses de l'urètre antérieur.

OBJECTIVES: To determine the value of perineal sonography in the diagnosis of urethral stenosis and evaluation of surrounding fibrosis. Materials and methods. Fifty-eight healthy subjects underwent urethral sonography. Thirty-two patients with suspected urethral stenosis underwent sonography after retrograde distension of the urethra using normal saline and retrograde urethrogram and voiding cystourethrogram. RESULTS: The mean diameters of the healthy urethra varied from 11 to 15 mm. The mean thickness of normal periurethral tIssue was between 2 and 4mm. Sonography detected 34 stenoses (97.4%). The length of the stenosis was significantly longer at sonography compared to retrograde urethrogram and voiding cystourethrogram. No significant difference was found between both techniques when measuring urethral diameter. In all cases, the thickness of periurethral tIssues was greater at the stenotic level than at a normal level, irrespective of the involved segment. There was no correlation between the thickness of periurethral tIssues and the degree of stenosis. CONCLUSION: Urethral sonography is a method that permits diagnosis of urethral stenosis and evaluation of periurethral fibrosis. It may replace retrograde urethrogram and voiding cystourethrogram in the diagnosis of post infectious stenosis.

Urethral reconstruction of strictures resulting from treatment of benign prostatic hypertrophy and prostate cancer.

Urethral strictures commonly result from treatments for prostate disease, such as transurethral resection, radical prostatectomy, and radiotherapy. Treating these strictures can be difficult: it may be complicated by previous irradiation, and endoscopy often fails. We review the risk factors for development of strictures resulting from the treatment of prostate disease and discuss the success rates of both endoscopic and open therapies.

Iatrogenic prostatic urethral strictures: classification and endoscopic treatment.

OBJECTIVES: The treatment of posterior urethral strictures is a controversial subject. For proper treatment, it is important to differentiate between iatrogenic prostatic urethral strictures and post-traumatic membranous urethral strictures. METHODS: Iatrogenic strictures of the prostatic urethra have been classified according to location and etiology into three categories: type I, located exclusively at the bladder neck; type II, located in the midportion of the prostatic fossa; and type III, when the whole prostatic fossa is replaced by stricture. From 1970 to 1996, 163 patients with postoperative strictures of the prostatic urethra were treated endoscopically. RESULTS: The results obtained in 122 patients are reported; 41 patients are not evaluable. The median follow-up was 63 months (range 12 to 239). Seven patients required a second endoscopic procedure to attain cure. Good results were achieved in 54 (91%) of 59 patients with type I strictures, in 45 (98%) of 46 patients with type II strictures, and in 13 (76%) of 17 patients with type III strictures. The overall success rate was 92% (112 of 122). Complications occurred in 21 patients (17%), including postoperative urinary tract infection (11%), incontinence (4%), stress incontinence (1%), and severe bleeding (1%). CONCLUSIONS: Postoperative strictures of the prostatic urethra must be recognized and can be easily treated with endoscopic therapy.

[Urethral stenosis. Conceptual review and classification]. / Estenosis uretral. Revisión conceptual y clasificación.

In an extensive review focused on male urethral stenosis, where more than 1,200 publications relative to this problem were evaluated, we found a lack of conceptual precision when it comes to qualify the varied terminology used to define concepts such as normal urethra, urethral stenosis, relapsing urethral stenosis, spongiofibrosis and urethral callus. The lack of precision may be due to the fact that we surgeons are more interested in reporting our surgical successes than in semantic appraisals. No publications have either been commented with a global approach to the problem of the various and potential classifications of urethral stenosis in the various etiological, clinical, radiological, endoscopic, ultrasonic or therapeutic aspects. The current paper is an update of this old urological problem. The guidelines outlined below are neither entirely original, nor the only or even the most correct approach of all those that can be used to address this issue. They are simply the result of the cumulative surgical and medical experience as well as of the enthusiasm we feel toward this part of urology.

[The pathogenesis, classification and treatment of acute and recurrent traumatic stricture of the urethra]. / Patogenez, klassifikatsiia, lechenie oslozhnennoi i retsidivnoi travmaticheskoi striktury mocheispuskatel'nogo kanala.

The influence of uresis disorders, injuries of pelvic neural plexuses, anatomic pathways between urethra and spermiducts on the disease course and prognosis was studied in 128 patients with complicated and recurrent urethral stricture. Data concerning mechanism of pathologic process spread are adduced, classification of complicated and recurrent traumatic urethral stricture is proposed. Indications for urethral stricture resection with prostatectomy and prostatovesiculectomy, anastomosis between urethra and neck of the urinary bladder for urea passage disorders by upper and lower urinary tracts.

[Significance and consequences of mild fetal kidney pelvis dilatation]. / Bedeutung und Konsequenzen milder fetaler Pyelondilatationen.

Even mild fetal pyelectasia is a subject to post-partal control. As fetal kidneys can easily be examined by ultrasound, different degrees of dilatation are found, but the discrimination between normal and pathological has not yet been defined. We considered any dilatation of less than 7 mm als normal. 52 fetuses were found to have a dilatation of 7 mm and more. 8 of them required post partum surgery: 2/15 classified as Grignon grade I, 3/14 as Grignon II, and 3/3 as Grignon III. Further malformations in addition to pyelectasia require a prenatal caryotyping procedure.

[Calibrated cicatrization of internal urethrotomies over spiral metal endoprosthesis. Preliminary study]. / Cicatrisation calibrée des uréthrotomies internes sur endoprothèse métallique spiralée. Etude préliminaire.

The authors have developed a new model of flewible metal prosthesis to maintain the urethral calibre throughout the period of healing and epithelial restoration following internal urethrotomy. It consists of a large intravesical spiral, a shaft within the prostatic and sphincteric urethra and a spiral in the bulbar and anterior urethra. This prosthesis, implanted in 7 patients for periods ranging from 2 to 5 months, provides additional calibration following internal urethrotomy, but a longer follow-up is necessary to assess its real efficacy.

[The treatment of urethral strictures]. / Lechenie striktur uretry.

Analysis of the results of many-year treatment of 788 patients with traumatic urethral strictures indicated that it was advisable to perform Khol'tsov's operation without leaving a catheter in the urethra in short strictures of the anterior urethral segment, Solovov's operation was indicated for occlusive strictures of the posterior urethral portion, whereas endourethral interventions (urethrotomy, resection) were beneficial in short patent strictures. Vesicourethral strictures required transurethral electroresection. Stenotic urethral changes were seen at different levels in 3.7% of postoperative patients. Some recommendations were proposed by the authors for prevention of the changes. A classification of urethral strictures was also presented.

[The treatment of closed injuries and posttraumatic strictures of the urethra]. / Lechenie zakrytykh povrezhdenii i posttravmaticheskikh striktur uretry.

Immediate and long-term results of treatment were evaluated for 211 males who had pelvic and urethral injuries. Most common were the methods: primary epicystostomy followed by urethroplasty, healing on a permanent catheter from the bladder, the primary suture. The material of 12 autopsies was investigated to characterize morphohistological features of pelvic and urethral traumas with consequent pathomorphological substantiation of the ways to recover urethral patency. It is revealed that urethral injuries especially in hip bone fractures should be considered as severe. An individual surgical approach in the condition is to allow for its severity, presence of combined injuries, diagnostic evidence on urethral involvement.