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Asian Journal of Urology (2017) xx, 1e6

Available online at www.sciencedirect.com 61

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9 Review 71
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A brief review on anterior urethral strictures 73
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14 Q3 Li Cheng a,b,1, Sen Li c,1, Zicheng Wang a,b, Bingwei Huang d, 76
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16 Jian Lin a,b,* 77
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a 80
19 Department of Urology, Peking University First Hospital, Beijing 100034, China
b 81
20 Institute of Urology, Peking University, Beijing 100034, China
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21 Beijing Shunyi District Hospital, Beijing 101300, China
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22 First Affiliated Hospital of PLA General Hospital, Beijing 100048, China
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24 Received 29 December 2016; received in revised form 26 April 2017; accepted 23 July 2017
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KEYWORDS Abstract The treatment of urethral strictures remains a challenging field in urology even 90
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Anterior urethral though there are a variety of procedures to treat it at present, as no one approach is superior 91
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strictures; over another. This paper reviewed the surgical options for the management of different sites 92
31
Urethral and types of anterior urethral stricture, providing a brief discussion of the controversies 93
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reconstruction; regarding this issue and suggesting possible future advancements. Among the existing proced- 94
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Tissue engineering; ures, simple dilation and direct vision internal urethrotomy are more commonly used for short 95
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Review; urethral strictures (<1 cm, soft and no previous intervention). Currently, urethroplasty using 96
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Urethral strictures buccal mucosa or penile skin is the most widely adopted clinical techniques and have proved 97
36
successful. Nonetheless, complications such as donor site morbidity remain a problem. Tissue 98
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engineering techniques are considered as a promising solution for urethral reconstruction, but 99
38
require further investigation, as does stem cell therapy. 100
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ª 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This 101
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is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ 102
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licenses/by-nc-nd/4.0/). 103
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47 1. Introduction to treat this disease. However, the diversity of treatment
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48 modalities reflects the scarcity of an optimal technique [1].
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49 Urethral stricture is a common and challenging disease in The male urethra can be divided into two parts, the
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50 urology. Currently, there are numerous surgical procedures posterior urethra which consists of the membranous and
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53 * Corresponding author. Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, Beijing 100034,
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54 China. Fax: þ86 10 66551211.
E-mail addresses: chenglibjmu@163.com (L. Cheng), 569354461@qq.com (S. Li), wangzicheng310@163.com (Z. Wang), 116
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bingweiHUANG11@gmail.com (B. Huang), linjianbj@163.com (J. Lin). 117
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Peer review under responsibility of Second Military Medical University. 118
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Contributed equally. 119
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https://doi.org/10.1016/j.ajur.2017.12.005 121
60 2214-3882/ª 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This is an open access article under 122
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Cheng L, et al., A brief review on anterior urethral strictures, Asian Journal of Urology (2017), https://
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2 L. Cheng et al.

1 prostatic urethra, and the anterior urethra which includes 3. Diagnosis and preoperative assessment Q2 63
2 bulbar and the penile urethra. The bulbar urethra is 64
3 enclosed by the bulbospongiosus muscle and the penile Before clinical treatment, a precise diagnosis and preop- 65
4 urethra runs from the distal margin of the bulbospongiosus erative evaluation of anterior urethra stricture is neces- 66
5 to the fossa navicularis and external meatus. sary. While the American Urological Association symptom 67
6 Considering the variety of surgical treatment modalities, index captures the most common voiding complaints of men 68
7 urologists must be up-to-date with the use of different with urethral stricture, including lower urinary tract 69
8 surgical techniques to deal with various conditions. The symptoms (LUTS) or acute urinary retention (AUR), 22.3% of 70
9 purpose of this article is to overview the current manage- patients have different presenting complaints [8]. The most 71
10 ment of anterior urethral stricture, providing a brief dis- common symptoms include spraying of urinary stream, 72
11 cussion of the controversies regarding this issue and dysuria or no symptoms. For men with lichen sclerosus, 73
12 possible future advancements. obstructive symptoms are more common. Sexual dysfunc- 74
13 tion was also reported, most commonly in patients with 75
14 2. Etiology failed hypospadias repair and lichen sclerosus [9]. A vali- 76
15 dated, accurate methodology for diagnosis is needed to 77
16 fully capture the presenting comprehensive voiding symp- 78
Urethral stricture in developed countries mainly involves
17 toms and other complaints of men with urethral stricture 79
the anterior urethra, in particular the bulbar tract, which
18 disease. 80
accounts for 46.9% [2]. In addition, 30% occur in the penile
19 The current standard is to use combined ascending and 81
urethra, and the remainder in a combination of the two and
20 descending urethrograms to image the urethra, supple- 82
panurethra. The reasons for stricture also vary by site.
21 mented by urethroscopy when necessary [10]. However, 83
Basically, the anterior urethral strictures are caused by the
22 one study suggested that independently reported retro- 84
following:
23 grade urethrograms (RUGs), which are not usually per- 85
24 formed by urologists, are not as accurate as reported by 86
(1) Iatrogenic injuries are the most common reason for
25 primary physicians. Consequently, such information 87
anterior urethral stricture [3]. In recent years, the
26 should be used with caution for preoperative planning 88
rapid development of diagnosis and clinical tech-
27 [11]. By contrast, urethroscopy allows urologists to 89
niques have resulted in more urological procedures
28 directly view the length and ischemic condition, which is 90
performed in the clinic, leading to an increase in the
29 favorable to the evaluation of urethral narrowing and 91
incidence of iatrogenic injuries. Among the iatrogenic
30 selection of treatment option. Ultrasonography of the 92
cases, catheterization appeared to be the most
31 anterior urethra is a reliable and valuable procedure to 93
frequent cause, followed by hypospadias repair and
32 help select the optimal anterior urethral reconstructive 94
transurethral surgery [2]. Mostly, stenotic segment
33 approach [12]. 95
caused by iatrogenic injury often involves the penile
34 96
urethra and meatus, which may occur as a result of
35 97
36
ischemia after urological endoscopic procedures, 4. Management of anterior urethral stricture 98
cardiovascular surgery or a long-term placement of
37 99
an indwelling catheter. The purpose of management of urethral stricture is to
38 100
(2) Idiopathic strictures occur more commonly in the restore the defect of the urethra continuity and to regain a
39 101
bulbar urethra and are more frequent in younger patent urethra. Treatment options include simple dilation,
40 102
versus older patients (48% vs 23%) [4]. For younger urethrotomy, and a variety of urethral reconstructive
41 103
patients, strictures may arise from unrecognized techniques such as tissue engineering techniques. The
42 104
childhood trauma or a congenital anomaly in urethral choice of the treatment option must take all factors into
43 105
development [5]. By contrast, decreased tissue blood consideration, such as the site, length, etiology of the
44 106
supply and ischemia have been proposed as a possible strictures as well as any previous surgery. In addition, it is
45 107
mechanism in the older patients [6]. widely acknowledged that there is no one appropriate
46 108
(3) Traumatic scarring after blunt straddle injury causes procedure for all stricture conditions [13].
47 109
urethral stricture in the bulbar tract involving the
48 110
spongiosum tissue. The blunt perineal trauma compress
49 5. Dilation 111
the urethra against the pubic symphysis [7], causing
50 112
urethral in continuity, local bleeding and urinary
51 As one of the most common modalities used in clinic, ure- 113
extravasation, giving rise to inflammation and scarring.
52 thral dilation is less invasive with minimal side effects, and 114
(4) Inflammatory stricture refers to a post infectious in-
53 appropriate for patients unwilling to undergo urethral sur- 115
flammatory reaction where the urethral lumen is
54 gery. A randomized study [14]compared dilation and direct 116
narrowed [3]. This etiology is more common in un-
55 vision internal urethrotomy (DVIU), showing no significance 117
developed countries. In developed countries, lichen
56 difference in the curative outcomes between the two mo- 118
sclerosus is a more frequent cause of inflammatory
57 dalities. However, due to the high recurrence rate of this 119
strictures and often involves panurethra.
58 procedure, urethral dilation is often performed as a palli- 120
59 ative maneuver and most patients will require a further 121
Other causes of anterior strictures such as infection,
60 urethral repairing surgery [13]. 122
tumor, and prostatectomy only account for minor proportion.
61 123
62 124

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Anterior urethral strictures 3

1 6. Direct vision internal urethrotomy analyzed the results in 10 consecutive patients with a 63
2 pan-anterior urethral stricture who underwent Monsieur’s 64
3 Direct vision internal urethrotomy (DVIU) using a cold knife urethroplasty, demonstrating that Monsieur’s tunica albu- 65
4 or laser remains the first-line therapy for short bulbar ginea urethroplasty (TAU) is an effective technique for the 66
5 urethral stricture [15] (<1 cm, soft and no previous inter- treatment of anterior urethral stricture, in particular, in 67
6 vention). Although it is much less efficacious than ure- those cases with unavailable buccal mucosa. 68
7 throplasty, this modality can be justified by its simplicity of 69
8 surgical procedure and relatively low morbidity. Some 9. Substitution urethroplasty 70
9 studies using optical internal urethrotomy (OIU) with a laser 71
10 have reported good results, and additional intralesional 72
Substitution urethroplasty is commonly performed to deal
11 injection of triamcinolone, hyaluronidase and mitomycin 73
with long or complex strictures. In carrying out this pro-
12 may be favorable to avoid the reoccurrence of stricture 74
cedure, the substitution tissue must possess a thick
13 [16,17]. Various new articles on intralesional treatment of 75
epithelial layer, minimal donor site morbidities and be easy
14 these strictures have shown good results. 76
to procure [25]. Currently, alternative replacement tissues
15 Moreover, there is consensus that repeated DVIU for 77
include scrotal skin [26], penile skin [27], bladder epithe-
16 early recurrence has a far less curative effect than ex- 78
lium [28], colonic mucosa [29], and buccal and lingual
17 pected [18], thus, for patients with early stricture recur- 79
mucosa [30]. Among all these tissues, genital skin and
18 rence, reconstructive urethroplasty is likely to be a more 80
buccal mucosa are now most commonly used in the clinic
19 appropriate choice rather than repeated DVIU. 81
and have met with success to some extent. Sharma et al.
20 82
[31] compared lingual and buccal mucosa graft ure-
21 83
7. End-to-end anastomotic repair throplasty for anterior urethral stricture with respect to
22 84
intraoperative, postoperative parameters and ure-
23 85
In the bulbar urethra, the choice of surgical techniques throplasty outcome. They showed that lingual mucosa
24 86
depends on the stricture length. Stricture excision and graft urethroplasty provides outcomes equivalent to those
25 87
primary re-anastomosis is considered an appropriate pro- of buccal mucosa graft urethroplasty, but postoperative
26 88
cedure for short strictures within 2 cm. For strictures morbidity and long-term change in speech make lingual
27 89
3e5 cm or longer, augmented roof-strip anastomosis and mucosa a second choice for strictures >7 cm, and only for
28 90
substitution urethroplasty are recommended, respectively cases where a buccal mucosa graft is unavailable. In
29 91
[19]. Eltahawy et al. [20] reported, with a mean follow-up addition, there are some issues with substitution ure-
30 92
of 50.2 months, a high success rate of up to 95% of primary throplasty surgery which will be discussed later.
31 93
end-to-end anastomosis in 168 patients with stricture
32 94
33
length ranging from 0.5 to 4.5 cm (mean, 1.9 cm). However, 10. Flap vs graft 95
some researchers suggested that this surgical procedure
34 96
should be limited to strictures within 1 cm [21]as excision of This area is very controversial. In 2008, Barbagli et al. [32]
35 97
a 1-cm urethral segment with opposing 1-cm proximal and reported their results of 375 patients who underwent one-
36 98
distal spatulations results in a 2-cm urethral shortening, staged bulbar urethroplasty using penile skin flap or oral
37 99
and excision of a longer urethral segment risks penile mucosa graft,showing that the oral mucosa graft is supe-
38 100
shortening or chordee. rior to penile skin flap with a higher overall success rate
39 101
In recent years, a novel approach without transecting (82.8% vs 59.6%). However, another prospective random-
40 102
the urethra was developed. Transecting the urethra allows ized study compared the outcomes of buccal mucosa graft
41 103
complete removal of scarred tissue. In strictures after blunt dorsal onlay and penile skin flap dorsal onlay urethroplasty,
42 104
perineal trauma and bulbar urethral injury, removal of the and revealed no significant difference between the success
43 105
traumatic scarred tissues is mandatory, as not removing this rate of the two modalities (89.9% vs 85.6%) [33]. Conse-
44 106
tissue may lead to stricture recurrence over time [19]. quently, it remains uncertain if buccal mucosa graft is
45 107
However, this procedure may also cause vascular and superior to skin flap in curative outcomes, and the choice
46 108
neuronal damage to the urethra, thus leading to possible of substitution material is primarily based on the surgeon’s
47 109
urinary and sexual dysfunction [22]. Andrich and Mundy [23] preference and patients’ conditions. Technically, the flap
48 110
applied the non-transecting technique in 22 patients (mean procedure is more complex. By contrast, substitution
49 111
age, 34 years). The range of follow-up was 6e21 months, urethroplasty with buccal mucosa requires less extensive
50 112
and 16 of the patients had been followed up for at least 1 training and is associated with less morbidity [33].
51 113
year. They achieved a 100% success rate, concluding that Furthermore, due to the scarcity of clinical evidence of a
52 114
their non-transecting anastomotic bulbar urethroplasty large series of patients and adequate follow-up data, it is
53 115
technique was as good as the traditional anastomotic ure- also questionable if the vascularized pedicled flap will
54 116
throplasty with less surgical trauma. perform better therapeutically.
55 117
56 In addition, for patients with lichen sclerosus, the use of 118
57 8. Tunic albuginea urethroplasty oral mucosa is mandatory since lichen sclerosus is a skin 119
58 disease and any skin that would be used for the repair is 120
59 For patients with unavailable autologous substitution tissue already or may become diseased [19]. 121
60 such as buccal mucosa, albuginea urethroplasty is also In the case of crippled urethral stricture, techniques 122
61 considered as a promising option or even as a primary used include circumferential advancement of penile skin, 123
62 approach with equivalent results. Sharma et al. [24] dorsal transposition flap of preputial skin, distally based 124

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4 L. Cheng et al.

1 transposition flap of penile skin, and full-thickness skin endoscopic therapy are considered to be predictive factors 63
2 graft [34]. of a failed urethroplasty [45]. Thus, in these patients, the 64
3 one-staged technique may not be the most appropriate 65
4 11. Tubular graft vs patch option due to the possible high risk of failure [46]. 66
5 For cases with adverse local conditions, such as exten- 67
6 sive scarring, fistula, infection and cancer, both Palminteri 68
Considering the tridimensional structure of the urethra,
7 et al. [42]and Andrich et al. [47]recommended a two-stage 69
tubular graft was once regarded as a better choice for
8 approach owing to its lower re-stricture rate than the one- 70
substitution urethra. Numerous studies were conducted
9 stage urethroplasty in the penile urethra, despite the 71
with this technique [35e37]. Venn and Mundy [36] per-
10 expense of a significantly higher revision rate. Further- 72
formed one-stage urethroplasty using buccal mucosa for 39
11 more, when the penile shaft is on the whole normal and the 73
patients (aged 23e59 years), 28 with a patch and 11 with
12 urethral plate, corpus spongiosum and dartos fascia are 74
tube grafts, and after a follow-up for 2e5 years, recurrent
13 suitable for single-stage reconstruction, a single-stage 75
stricture (3%) occurred in only one patient in the group with
14 procedure should be performed whenever possible to 76
a patch urethroplasty; however, five of the 11 patients in
15 avoid patient discomfort and disability [43]. On the other 77
the tubular graft group (45.5%) had a recurrent stricture.
16 hand, for strictures after hypospadias repair or where the 78
Moreover, Andrich and Mundy [37] reviewed the results of
17 penile skin, urethral plate and dartos fascia are not suitable 79
urethroplasty using buccal mucosal graft in 128 patients
18 for single-stage reconstruction, a two-stage urethroplasty is 80
and found the re-stricture rate was 11% for patch grafts and
19 recommended [48,49]. 81
45% for tube grafts. Generally, most of the studies revealed
20 82
that tubular graft is not as good in curative outcomes as
21 14. Sexual morbidity after surgery 83
expected.
22 84
23 85
24
12. Ventral vs lateral vs dorsal onlay Among the side effects of urethral surgeries, sexual func-
86
tion, which consist of sexual drive, erectile function and
25 87
As one-stage oral mucosa represents the most widespread ejaculatory function, is much concerned in patients’
26 88
method for the repair of bulbar urethral strictures due to its satisfaction [50], while few studies systemically intro-
27 89
highly vascular spongiosum tissue, the location of the free duced. Using the O’Leary’s Brief Male Sexual Function In-
28 90
graft on the dorsal or ventral or lateral urethral surface has ventory (BMSFI), Erickson et al. [51] evaluated the sexual
29 91
become a contentious issue [19]. From 1997 to 2002, Bar- function of 52 men (aged 18e79 years) who underwent
30 92
bagli et al. [38] repaired 50 bulbar urethral strictures using urethral reconstructive procedures for anterior urethral
31 93
buccal mucosa grafts, with the graft placed on the ventral, stricture disease before and after surgery. They reported
32 94
dorsal and lateral bulbar urethral surface in 17, 27 and 6 that in general, sexual drive and erectile function did not
33 95
cases, respectively. The mean follow-up was 42 months show a decline after surgery. However, when the patients
34 96
(range 12e76), and their results revealed that the place- were further divided by age, the results revealed that the
35 97
ment of buccal mucosa grafts into the ventral, dorsal or older men (>50 years old) might have a higher incidence of
36 98
lateral surface of the bulbar urethra showed the same erectile dysfunction post-operation, but this morbidity
37 99
success rates (83%e85%) and the outcome was not affected might recover with time. Besides, for younger men (<40
38 100
by the surgical technique. Furthermore, the curative out- years old), the ejaculatory function might improve
39 101
comes are similar among these three procedures, the significantly.
40 102
ventral graft placement is considered technically easier, In addition, some factors, such as the size and location
41 103
since it requires less urethral dissection and mobilization of the stricture, operation modalities and prior in-
42 104
[39]. It is also suggested that the ventral graft is appro- terventions may also influence patients’ sexual function
43 105
priate for non-traumatic urethral strictures located in the after surgery. Sharma et al. [52] argues that patients
44 106
proximal bulbar urethra and the dorsal graft is preferred in without prior interventions might have a better prognosis in
45 107
patients with non-traumatic urethral strictures located in ejaculation function and overall satisfaction. However,
46 108
the distal bulbar urethra [40,41]. there is still some controversy regarding whether the size
47 109
and location of the stricture and operation modalities
48 110
13. One-staged vs staged urethroplasty impact on sexual morbidity [51e53].
49 111
50 112
51 One-staged urethroplasty using a buccal mucosa graft has 15. Tissue-engineering urethroplasty 113
52 been reported to achieve a high success rate. Nonetheless, 114
53 when dealing with a more complex stricture or cases with Despite the significant progress made by the current pro- 115
54 adverse local conditions, a staged procedure is more cedures, there are still major challenges in urethral 116
55 commonly recommended [42]. Complex anterior urethral reconstruction. The scarcity of sufficient substitution ma- 117
56 strictures include strictures simultaneously involving the terials, donor morbidity and time-consuming harvesting has 118
57 penile and bulbar urethra (pan-urethral stricture) yet to be resolved. However, the advent of tissue engi- 119
58 commonly caused by lichen sclerosus [43], and strictures in neering techniques may provide potential solutions. 120
59 patients who had undergone repeated prior failed ure- Through regenerative medicine, a tissue-engineered ure- 121
60 throplasties, frequently referred to as a failed hypospadias thra can be constructed with a limited amount of material 122
61 repair [44]. Furthermore, the length of the urethral stric- without harvesting a mass of autologous healthy tissue. 123
62 ture (greater than 4 cm), prior urethroplasty and failed Recent clinical trials conducted on animals have achieved 124

Please cite this article in press as: Cheng L, et al., A brief review on anterior urethral strictures, Asian Journal of Urology (2017), https://
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Anterior urethral strictures 5

1 satisfactory outcomes, but few human clinical trials have [6] Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011;107: 63
2 been performed. 6e26. 64
3 The choice of scaffold plays a crucial role in tissue en- [7] Park S, McAninch JW. Straddle injuries to the bulbar urethra: 65
gineering. To date, acellular matrix such as acellular management and outcomes in 78 patients. J Urol 2004;171:
4 66
722e5.
5 dermal matrix grafts (ADMG) and acellular porcine small 67
[8] Rourke K, Hickle J. The clinical spectrum of the presenting signs
6 intestinal submucosa (SIS) have been applied clinically due and symptoms of anterior urethral stricture: detailed analysis 68
7 to their appropriate biomechanical properties [54,55]. De of a single institutional cohort. Urology 2012;79:1163e7. 69
8 Filippo et al. [56] compared the acellular and cell-seeded [9] Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM. Pre- 70
9 scaffold, and argued that the cell-seeded scaffold is a su- senting symptoms of anterior urethral stricture disease: a 71
10 perior option in urethral reconstruction. In 2011, a major disease specific, patient reported questionnaire to measure 72
11 breakthrough was made when an observational clinical outcomes. J Urol 2012;187:559e62. 73
12 study reported that satisfactory therapeutic results were [10] Chapple C, Andrich D, Atala A, Barbagli G, Cavalcanti A, 74
13 achieved in five patients (aged 10e14 years) using an Kulkarni S, et al. SIU/ICUD consultation on urethral strictures: 75
urothelium-seeded scaffold. The median follow-up was 71 the management of anterior urethral stricture disease using
14 76
substitution urethroplasty. Urology 2014;83(Suppl. 3):S31e47.
15 months (range 36e76 months) and no re-stricture occurred. 77
[11] Bach P, Rourke K. Independently interpreted retrograde ure-
16 Currently, stem cell therapy has been applied in urethral thrography does not accurately diagnose and stage anterior 78
17 reconstruction [57,58], but more clinical data are required urethral stricture: the importance of urologist-performed 79
18 to fully evaluate its effects and potential hazards. More- urethrography. Urology 2014;83:1190e3. 80
19 over, the mechanism of differentiation from stem cells to [12] Buckley JC, Wu AK, McAninch JW. Impact of urethral ultra- 81
20 urothelium has not been fully elucidated. sonography on decision-making in anterior urethroplasty. BJU 82
21 Int 2012;109:438e42. 83
22 [13] Peterson AC, Webster GD. Management of urethral stricture 84
16. Conclusion disease: developing options for surgical intervention. BJU Int
23 85
2004;94:971e6.
24 86
During the last few decades, reconstructive surgeries of the [14] Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy
25 87
anterior urethral stricture have been successful and are versus dilation as treatment for male urethral strictures: a
26 88
continually evolving. However, as yet, there is no one prospective, randomized comparison. J Urol 1997;157:
27 98e101. 89
approach for urethral stricture that can be considered su-
28 [15] Pansadoro V, Emiliozzi P. Internal urethrotomy in the man- 90
perior. Tissue engineering techniques may provide a
29 agement of anterior urethral strictures: long-term followup. J 91
promising solution for urethral reconstruction, but further
30 Urol 1996;156:73e5. 92
investigation is required. Likewise, stem cell therapy may
31 [16] Kumar S, Kishore L, Sharma AP, Garg N, Singh SK. Efficacy of 93
also be an option in the future. holmium laser urethrotomy and intralesional injection of
32 94
33 Santosh PGI tetra-inject (Triamcinolone, Mitomycin C, Hyal- 95
uronidase and N-acetyl cysteine) on the outcome of urethral
34 Conflicts of interest 96
strictures. Cent Eur J Urol 2015;68:462e5.
35 97
[17] Yildirim ME, Kaynar M, Ozyuvali E, Badem H, Cakmak M,
36 The authors declare no conflict of interest. Kosem B, et al. The effectiveness of local steroid injection 98
37 after internal urethrotomy to avoid recurrence. Arch Ital Urol 99
38 Androl 2016;87:295e8. 100
39 Acknowledgments [18] Wright JL, Wessells H, Nathens AB, Hollingworth W. What is 101
40 the most cost-effective treatment for 1 to 2-cm bulbar ure- 102
41 thral strictures: societal approach using decision analysis. 103
This work was supported by the Natural Science Foundation
42 Urology 2006;67(5):889e93. 104
of China (grant no. 81670617). We are very grateful to the [19] Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M.
43 CureEdit Company for providing language editing 105
Current controversies in reconstructive surgery of the anterior
44 assistance. 106
urethra: a clinical overview. Int Braz J Urol 2012;38:307e16.
45 107
[20] Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA,
46 Jordan GH. Long-term followup for excision and primary 108
47 References anastomosis for anterior urethral strictures. J Urol 2007;177: 109
48 1803e6. 110
49 [1] Andrich DE, Mundy AR. What is the best technique for ure- [21] Guralnick ML, Webster GD. The augmented anastomotic ure- 111
50 throplasty? Eur Urol 2008;54:1031e41. throplasty: indications and outcome in 29 patients. J Urol 112
51 [2] Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, 2001;165:1496e501. 113
52 Carmignani L. Contemporary urethral stricture characteristics [22] Barbagli G, Sansalone S, Romano G, Lazzeri M. Bulbar ure- 114
53 in the developed world. Urology 2013;81:191e6. throplasty: transecting vs. nontransecting techniques. Curr 115
[3] Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral Opin Urol 2012;22:474e7.
54 116
strictures: etiology and characteristics. Urology 2005;65: [23] Andrich DE, Mundy AR. Non-transecting anastomotic bulbar
55 117
1055e8. urethroplasty: a preliminary report. BJU Int 2012;109:1090e4.
56 [24] Sharma AK, Ratkal CS, Shivlingaiah M, Girish GN, Sanjay RP, 118
[4] Smith 3rd TG. Current management of urethral stricture dis-
57 Venkatesh GK. Analysis of short-term results of monsieur’s 119
ease. Indian J Urol 2016;32:27e33.
58 [5] Latini JM, McAninch JW, Brandes SB, Chung JY, Rosenstein D. tunica albuginea urethroplasty as a definitive procedure for 120
59 SIU/ICUD consultation on urethral strictures: epidemiology, pan-anterior urethral stricture. Urol Ann 2013;5:228e31. 121
60 etiology, anatomy, and nomenclature of urethral stenoses, [25] Wessells H, McAninch JW. Current controversies in anterior 122
61 strictures, and pelvic fracture urethral disruption injuries. urethral stricture repair: free-graft versus pedicled skin-flap 123
62 Urology 2014;83(Suppl. 3):S1e7. reconstruction. World J Urol 1998;16:175e80. 124

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1 [26] Jordan GH. Scrotal and perineal flaps for anterior urethral male patients with genital lichen sclerosus: a preliminary 55
2 reconstruction. Urol Clin North Am 2002;29:411e6. report. J Urol 2011;185:2171e6. 56
3 [27] Vyas PR, Roth DR, Perlmutter AD. Experience with free grafts [44] Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. 57
in urethral reconstruction. J Urol 1987;137:471e4. Retrospective descriptive analysis of 1176 patients with failed
4 58
[28] Kinkead TM, Borzi PA, Duffy PG, Ransley PG. Long-term fol- hypospadias repair. J Urol 2010;183:207e11.
5 59
lowup of bladder mucosa graft for male urethral reconstruc- [45] Breyer BN, McAninch JW, Whitson JM, Eisenberg ML,
6 tion. J Urol 1994;151:1056e8. Mehdizadeh JF, Myers JB, et al. Multivariate analysis of risk 60
7 [29] Xu YM, Qiao Y, Sa YL, Zhang J, Fu Q, Song LJ. Urethral factors for long-term urethroplasty outcome. J Urol 2010;183: 61
8 reconstruction using colonic mucosa graft for complex stric- 613e7. 62
9 tures. J Urol 2009;182:1040e3. [46] Peterson AC, Palminteri E, Lazzeri M, Guanzoni G, Barbagli G, 63
10 [30] Bhargava S, Patterson JM, Inman RD, MacNeil S, Chapple CR. Webster GD. Heroic measures may not always be justified in 64
11 Tissue-engineered buccal mucosa urethroplasty-clinical out- extensive urethral stricture due to lichen sclerosus (balanitis 65
12 comes. Eur Urol 2008;53:1263e9. xerotica obliterans). Urology 2004;64:565e8. 66
13 [31] Sharma AK, Chandrashekar R, Keshavamurthy R, Nelvigi GG, [47] Andrich DE, Greenwell TJ, Mundy AR. The problems of penile 67
Kamath AJ, Sharma S, et al. Lingual versus buccal mucosa urethroplasty with particular reference to 2-stage re-
14 68
graft urethroplasty for anterior urethral stricture: a prospec- constructions. J Urol 2003;170:87e9.
15 69
tive comparative analysis. Int J Urol 2013;20:1199e203. [48] Barbagli G, De Angelis M, Palminteri E, Lazzeri M. Failed
16 [32] Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar ure- hypospadias repair presenting in adults. Eur Urol 2006;49: 70
17 throplasty: retrospective analysis of the results in 375 pa- 887e95. 71
18 tients. Eur Urol 2008;53:828e33. [49] Barbagli G, Lazzeri M. Surgical treatment of anterior urethral 72
19 [33] Dubey D, Vijjan V, Kapoor R, Srivastava A, Mandhani A, stricture diseases: brief overview. Int Braz J Urol 2007;33: 73
20 Kumar A, et al. Dorsal onlay buccal mucosa versus penile skin 461e9. 74
21 flap urethroplasty for anterior urethral strictures: results from [50] Kessler TM, Fisch M, Heitz M, Olianas R, Schreiter F. Patient 75
22 a randomized prospective trial. J Urol 2007;178:2466e9. satisfaction with the outcome of surgery for urethral stric- 76
23 [34] van der Werff JF, van der Meulen JC. Treatment modalities for ture. J Urol 2002;167:2507e11. 77
hypospadias cripples. Plast Reconstr Surg 2000;105:600e8. [51] Erickson BA, Wysock JS, McVary KT, Gonzalez CM. Erectile
24 78
[35] Castagnetti M, Rigamonti W. Aptness and complications of function, sexual drive, and ejaculatory function after recon-
25 79
labial mucosa grafts for the repair of anterior urethral defects structive surgery for anterior urethral stricture disease. BJU
26 in children and adults: single centre experience with 115 Int 2007;99:607e11. 80
27 cases. World J Urol 2009;27:799e803. [52] Sharma V, Kumar S, Mandal AK, Singh SK. A study on sexual 81
28 [36] Venn SN, Mundy AR. Early experience with the use of buccal function of men with anterior urethral stricture before and 82
29 mucosa for substitution urethroplasty. Br J Urol 1998;81: after treatment. Urol Int 2011;87:341e5. 83
30 738e40. [53] Feng C, Xu YM, Barbagli G, Lazzeri M, Tang CY, Fu Q, et al. The 84
31 [37] Andrich DE, Mundy AR. Substitution urethroplasty with buccal relationship between erectile dysfunction and open ure- 85
32 mucosal-free grafts. J Urol 2001;165:1131e4. throplasty: a systematic review and meta-analysis. J Sex Med 86
33 [38] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, 2013;10:2060e8. 87
Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts [54] Lin J, Hao JR, Jin J, Deng SM, Hu J, Na YQ. Homologous dermal
34 88
placed on the ventral, dorsal or lateral surface of the urethra: acellular matrix graft for urethral reconstruction in man
35 89
are results affected by the surgical technique? J Urol 2005; (report of 16 cases). Zhonghua yi xue za zhi 2005;85:1057e9.
36 174:955e8. [55] Fiala R, Vidlar A, Vrtal R, Belej K, Student V. Porcine small 90
37 [39] Wessells H. Ventral onlay graft techniques for urethroplasty. intestinal submucosa graft for repair of anterior urethral 91
38 Urol Clin North Am 2002;29:381e7. vii. strictures. Eur Urol 2007;51:1702e8. 92
39 [40] Barbagli G, Sansalone S, Romano G, Lazzeri M. Ventral onlay [56] De Filippo RE, Yoo JJ, Atala A. Urethral replacement using cell 93
40 oral mucosal graft bulbar urethroplasty. BJU Int 2011;108: seeded tubularized collagen matrices. J Urol 2002;168: 94
41 1218e31. 1789e93. 95
42 [41] Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided [57] Sun D, Yang Y, Wei Z, Xu Y, Zhang X, Hong B. Engineering of 96
43 anterior urethroplasty: a new dorsal onlay graft technique. pre-vascularized urethral patch with muscle flaps and 97
BJU Int 2009;104:1150e5. hypoxia-activated hUCMSCs improves its therapeutic
44 98
[42] Palminteri E, Lazzeri M, Guazzoni G, Turini D, Barbagli G. New outcome. J Cell Mol Med 2014;18:434e43.
45 99
2-stage buccal mucosal graft urethroplasty. J Urol 2002;167: [58] Wu S, Liu Y, Bharadwaj S, Atala A, Zhang Y. Human urine-
46 130e2. derived stem cells seeded in a modified 3D porous small in- 100
47 [43] Barbagli G, Mirri F, Gallucci M, Sansalone S, Romano G, testinal submucosa scaffold for urethral tissue engineering. 101
48 Lazzeri M. Histological evidence of urethral involvement in Biomaterials 2011;32:1317e26. 102
49 103
50 104
51 105
52 106
53 107
54 108

Please cite this article in press as: Cheng L, et al., A brief review on anterior urethral strictures, Asian Journal of Urology (2017), https://
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