Comparison of Treatment Methods for Urethral Stricture

Which Parts Make Up the Urethra?

In clinical practice, the urethra is divided into two main groups. The penile and bulbar urethra are referred to as the anterior urethra, while the prostatic and membranous urethra are referred to as the posterior urethra. This distinction forms the basis of treatment planning.

How Is Treatment Determined in Urethral Stricture?

Treatment of urethral stricture is planned individually for each patient. The location and length of the stricture, any previous interventions, and the quality of the surrounding tissue are all evaluated together. In particular, inappropriate or repeated interventions may impair tissue quality and make treatment more difficult. For this reason, choosing the right method at the right time is of great importance.

How Are Anterior Urethral Strictures Treated?

Anterior urethral strictures are the most common type of stricture, and several treatment options are available for this region. However, not every option is suitable for every patient.

Minimally invasive treatment (urethral dilation / internal urethrotomy)

This method involves widening the narrowed segment or opening it endoscopically by making an incision. It may be suitable especially for short, first-time bulbar strictures. However, repeated procedures reduce the success rate and are generally not recommended more than twice. This method is insufficient for penile urethral strictures and long-segment strictures.

Drug-coated balloon treatment

Drug-coated balloon treatment is a method developed in recent years. In this technique, while the narrowed segment is dilated with a balloon, a drug aimed at reducing scar formation is applied at the same time.

This method may be used in selected patients, particularly those with short, recurrent bulbar strictures. However, its success rate is around 60%, and it is not as durable as open surgery. In addition, since it is not covered by the Social Security Institution, it may be disadvantageous in terms of cost.

Open surgery (urethroplasty)

The most durable solution for urethral stricture is open surgery. International guidelines especially recommend open surgery for recurrent, long, and complex strictures.

Why is anastomotic urethroplasty preferred in bulbar strictures?

Anastomotic urethroplasty is based on the principle of completely removing the stricture segment and reconnecting the two healthy ends. This method is particularly preferred in short-segment bulbar urethral strictures that develop after perineal trauma.

The fact that the bulbar urethra is more flexible and mobile allows the two ends to be joined without tension, which explains its high success rates.

Why is it not preferred in penile urethral strictures?

The penile urethra is more fixed and less flexible. Therefore, tension may occur during end-to-end repair. This may result in:

• Penile curvature

• Functional problems

• Lower success rates

For this reason, graft-based repair is preferred in penile urethral strictures.

BMG (buccal mucosal graft) urethroplasty

BMG urethroplasty is currently one of the most important reconstructive surgical techniques used in the treatment of a large proportion of anterior urethral strictures. It is a standard method used in both penile and bulbar strictures.

How is BMG surgery performed?

The aim of this surgery is not to completely cut out and remove the narrowed urinary channel, but to enlarge and reconstruct it.

For this purpose:

• The narrowed urethral segment is surgically opened

• The narrowed area is widened

• A thin and healthy tissue graft taken from the inside of the mouth is placed in this area like a patch

In this way, the narrowed channel is reconstructed into a wider and healthier passage.

Where is the graft placed?

The placement of the graft depends on the type of stricture:

• On the lower part of the urethra (ventral)

• On the upper part of the urethra (dorsal)

• Sometimes on both sides

The surgeon chooses the most appropriate technique according to the structure of the stricture.

Why is BMG so successful?

Buccal mucosa (the tissue from the inner cheek):

• Naturally exists in a constantly moist environment

• Is flexible and adapts easily

• Is not damaged by contact with urine

• Is resistant to infection

• Has a strong blood supply

Thanks to these properties, it can function smoothly inside the urethra for many years.

Is taking tissue from the mouth difficult for the patient?

Usually not.

• The inside of the mouth heals quickly

• It typically returns to normal within 3–5 days

• Permanent damage is very rare

Patients usually tolerate this part much more easily than they expect.

Posterior urethral strictures (after pelvic fracture)

Posterior strictures are the most complex urethral strictures and usually occur after high-energy trauma. The most common cause is pelvic fractures related to traffic accidents.

In such trauma, the urethra may rupture or be severely damaged.

What should the emergency approach be?

The most critical mistake in these patients is blind catheterization.

If there is suspicion:

• Imaging should be performed first

• The urethra should be protected

If the injury is confirmed, a suprapubic catheter is inserted directly into the bladder through the lower abdominal wall. In most cases, approximately 3 months are allowed for bone and tissue healing before definitive treatment is planned.

Definitive treatment

After healing is complete following the trauma, posterior urethroplasty is performed.

In this surgery:

• Scar tissue is removed

• The healthy ends are reconnected

• This is called posterior anastomotic urethroplasty
  

Postoperative outcomes

Problems such as erectile dysfunction and urinary incontinence are mostly related to the trauma itself, and sometimes to the surgery. This is a difficult operation that requires significant experience and should be performed in experienced centers.

General Evaluation

The choice of treatment in urethral stricture should be individualized. While minimally invasive methods and balloon treatment may be used in certain situations, open surgery (urethroplasty) offers the most durable solution, especially in long and recurrent strictures. Today, BMG urethroplasty is one of the most important and most successful reconstructive methods for both bulbar and penile urethral strictures.

The emergency approach to posterior urethral strictures (after pelvic fracture) is quite different. These patients are generally managed with suprapubic diversion for about 3 months to allow healing. The surgery is technically demanding and requires substantial experience. It should be performed in experienced centers.

If your urinary flow has weakened, you should not delay seeking evaluation. With the right treatment, a permanent solution is possible.

Frequently Asked Questions

What is the most durable treatment method?

The most durable and successful treatment option for urethral stricture, in appropriate patients, is urethroplasty, which is an open surgical method.

Does balloon treatment provide a permanent solution?

No. Balloon treatment may provide temporary or medium-term benefit in selected patient groups. However, it is not considered a permanent treatment. In addition, it is not covered by the Social Security Institution reimbursement system.

Is the surgery difficult?

Urethroplasty is a surgical procedure that requires experience and technical expertise. For this reason, it is important that it is performed by experienced physicians in appropriately equipped centers.