Introduction

Management of male urethral stricture disease involves a wide range of treatment options. Current knowledge is well summarized in the AUA and European Association of Urology guidelines. Unfortunately, many of the recommendations are weak and based on low level of evidence or expert opinion. In the area of open surgery for bulbar strictures, there are several controversies and there is a need for good clinical studies, preferably multicenter randomized controlled trials (RCTs). The good news is that there are some well-designed studies to guide us. A PubMed search for the Medical Subject Headings (MeSH) term “anterior urethral strictures” with the filters “randomized controlled trial” and publication date within the last 10 years yields 49 results. We present the most relevant studies concerning male urethral strictures and urethroplasty techniques.

Does type of graft or flap matter?

Augmentation urethroplasty can be done with skin flaps, skin grafts, and mucosal grafts.

In 1 study, 37 long segment bulbo-penile strictures were operated on with either ventral onlay penile skin graft or a penile skin flap. In this high recurrence risk population, the recurrence rate was 28% after penile skin graft and 21% after penile skin flap (not significant) after a mean follow-up of 3 years.¹

The “Pee”BuSt trial compared penile skin graft to buccal mucosa graft (BMG) in 100 patients with 18 months of follow-up.² It showed no difference between the 2 groups in surgical outcome or sexual dysfunction.

A study with 30 patients compared lingual mucosa graft vs BMG. The short-term surgical outcomes were similar after a mean follow-up of 14.5 months, but more long-term speech morbidity was seen after long lingual grafts (>7 cm).³ Hence, lingual grafts are a second choice only for cases where BMG is unavailable.

Does graft placement matter?

For augmentation techniques with BMG, placement of the graft ventrally or dorsally, and as inlay or onlay, is still debated.

BMG placements were compared in a study of 47 patients with long strictures (26 penile, 17 bulbar, 4 panurethral) where the graft was placed with dorsal onlay or inlay fashion. The authors found no difference in success rates concerning surgical failure (redo operations) between the groups after mean follow-up of 22 and 24 months, respectively. However, the authors regarded the dorsal inlay technique as easier, with shorter operation time and less blood loss.⁴ An Egyptian study with 37 patients and follow-up of 6 months showed similar results.⁵

A study of 80 patients with bulbar stricture length more than 2 cm compared dorsal and ventral placement of BMG. The success rate, complication rate, and recurrence rate were similar in both groups after 12-month follow-up.⁶

Close or not close buccal mucosal graft bed?

As buccal mucosal grafting is common in several urethroplasty techniques, it is also relevant to consider the harvesting method. Another source of debate is whether closing the wound after BMG harvesting is necessary. One study with 34 participants showed less short-term pain after wound closure, but there was no long-term difference (from 3 weeks to 1 year of follow-up).⁷

Another study with 135 patients showed noninferiority for nonclosure vs closure in intensity for oral pain at any time after urethroplasty (6-month follow-up). However, the length of the graft had a significant effect on oral pain.⁸

Effect of tissue-sparing techniques

In the last decade, there has been more focus on tissue-sparing techniques in many surgical fields, including urethroplasty. A study exploring the effect of sparing the bulbospongiosus muscle showed improved Male Sexual Health Questionnaire Ejaculatory Dysfunction Short-Form scores and less post-void dribbling.⁹

Another study compared dorsal onlay with circumferential dissection of corpus spongiosum to dorsolateral onlay with dissection on only 1 side. The study included 136 patients and had a mean follow-up of 28 months. It found less erectile dysfunction measured by Brief Male Sexual Function Inventory after dorsolateral onlay.¹⁰

Our own study, the Scandinavian Urethroplasty Study, compared transecting excision and primary anastomosis to BMG procedure in short bulbar strictures with regard to sexual dysfunction, and found more penile complications after the transecting procedure.¹¹

Studies in the pipeline

Lastly, 2 ongoing RCTs still recruiting patients are worth mentioning. VeSpAR compares vessel-sparing anastomotic repair vs transecting anastomotic repair.¹² Another interesting trial is the DoVe trial, which compares dorsal to ventral onlay buccal mucosa in bulbar strictures.¹³ We hope the results of these studies can further guide us to improve urethroplasty techniques.

Discussion

Many RCTs in the field of urethral stricture management have not been able to show significant differences in success rates or complication rates. This may be due to inadequately powered studies with small study populations or limited follow-up. The levels of complications and reinterventions are relatively low for current urethral stricture treatment methods, hence larger RCTs with adequate follow-up time are still needed. Initiating and conducting clinical RCTs may seem like an impossible task. It is time-consuming and involves a lot of work, while pressure to publish favors retrospective studies or prospective studies with shorter follow-up. Inclusion can be difficult to achieve within an acceptable time frame, rendering results obsolete. Data from randomized studies should be reported in a standardized fashion to facilitate pooling of data. Unfortunately, patient-reported outcome measures encompassing all aspects of outcomes after urethral surgery are not available.

Conclusion

Several studies of good quality answer some questions regarding management of urethral strictures. However, large clinical RCTs within the field are still needed to develop the art of urethroplasty. Thus, cooperation between institutions may be necessary to facilitate high-quality research within the field.