What Is Panurethral Stricture and How Is Its Treatment Planned?

A Stricture Affecting the Entire Urethra

The urethra is a tube-shaped structure that allows urine stored in the bladder to be expelled from the body. Panurethral stricture is one of the most complex and difficult-to-treat types of stricture in reconstructive urology. It involves a large part or the entire length of this channel, usually referring to strictures longer than 10 cm.

Although it is less common than localized strictures, it can seriously impair the patient’s quality of life. Patients usually visit our clinic with the following complaints:

Difficulty urinating with a very thin stream, dribbling, or straining

Frequently recurring urinary tract infections that are resistant to antibiotic treatment

The need for emergency placement of a catheter directly into the bladder through the lower abdomen, called cystostomy, due to complete blockage of the urethra

The aim of this article is to clearly explain the anatomical structure, accurate diagnostic methods, and treatment planning of this special type of stricture, which can be a challenging process for both the patient and the physician, in light of current guidelines.

How Does Panurethral Stricture Develop?

The inner structure of a healthy urethra is flexible. However, various traumas or diseases can damage this flexible tissue and replace it with scar tissue. The most common causes of panurethral stricture include:

Complications of Hypospadias Repair:Long-term consequences of multiple and unsuccessful surgeries performed in childhood due to the urinary opening being located lower than the tip of the penis.

Lichen Sclerosus, BXO:This is a chronic and progressive skin disease that affects the penile skin and the urethra. Lichen sclerosus-related urethral stricture is the most common dermatological cause of panurethral strictures. This disease narrows the urethra starting from the outer opening and progressing inward.

Other Causes:Severe trauma to the pelvic region, radiotherapy for prostate or bladder cancer, and previous severe urethral infections.

Why Are Closed Methods, Such as Internal Urethrotomy, Insufficient in This Group?

In a stricture longer than 10 cm that involves the entire canal, performing a closed surgery, meaning endoscopic cutting of the stricture or urethrotomy, does not provide benefit. On the contrary, it can deepen the existing scar tissue and make the disease even more difficult to treat. In such long strictures, the chance of success with a closed method is almost zero, and it is definitely not recommended.

Diagnosis: How Is the Full Map of the Stricture Created?

For a successful reconstructive surgery, it is necessary to know precisely where the stricture begins, where it ends, and how much damage it has caused to the surrounding tissues.

Retrograde Urethrogram, Contrast Urethral X-Ray:“What is a urethrogram?” is a question frequently asked by our patients. It is an X-ray performed by injecting a special contrast agent into the urethra through its external opening. It is considered the gold standard method that clearly shows the length of the stricture and the anatomical map of the canal.

MRI Urethrogram, Urethral MRI:Especially in very long and complex strictures, this advanced soft tissue imaging method is used not only to evaluate the inside of the canal but also to see how much the surrounding spongy tissue, called the corpus spongiosum, has hardened, a condition known as spongiofibrosis.

Cystoscopy:This is the visual confirmation of the stricture by entering the urethra with very thin, flexible camera-equipped instruments. When necessary, especially if lichen sclerosus is suspected, a tissue sample, or biopsy, may be taken during this procedure for a definitive diagnosis.

Uroflowmetry and Post-Void Residual Urine Measurement:This involves measuring the urine flow rate on a computer while the patient urinates into a special device, followed by an ultrasound check to determine how much urine remains in the bladder. It provides a functional evaluation.

How Is Treatment Planned?

Urethroplasty

The only definitive solution recommended by guidelines for panurethral strictures is urethroplasty, or open urethral reconstruction surgery. Since the stricture is very long, the narrowed segment cannot be removed and reconnected end to end. Instead, a substitution repair must be performed.

In this procedure, the most commonly preferred tissue, considered the gold standard, is the patient’s own oral mucosa, called buccal mucosa. The graft taken from inside the mouth is placed onto the diseased area of the urethra to widen the canal.

Especially in patients with lichen sclerosus, genital skin should definitely not be used in the reconstruction because the skin in the genital area is affected by the disease. Instead, an oral mucosa graft should be preferred.

Depending on the patient’s condition, the severity of tissue damage, and previous surgeries, this reconstruction procedure may be performed in a single session, or in some difficult cases, it may be planned as a two-stage urethroplasty with an interval of 6 months.

Note: These types of surgeries require a high level of surgical experience and should definitely be planned in centers specialized in reconstructive urology.

Frequently Asked Questions About Panurethral Stricture

Can panurethral stricture be treated with a single surgery?

This depends on the cause of the stricture, the severity of involvement along the urethra, and the extent of tissue damage. In many cases, it is possible to reconstruct the urethra in a single session using oral mucosa, or buccal mucosa, in a procedure called single-stage urethroplasty.

However, especially in patients who have previously undergone multiple unsuccessful closed surgeries, or urethrotomies, or in patients whose tissue integrity around the urethra has been severely damaged, planning the treatment as a two-stage, staged urethroplasty with an interval of 6 months may be necessary for a lasting and safe result.

Can surgery be performed before lichen sclerosus is treated?

Lichen sclerosus, or BXO, is a chronic skin disease. It is not possible to wait for the disease to completely disappear before relieving the severe obstruction in the urinary tract, and doing so may harm the patient.

The critical point here is the surgical method to be used. Since this disease disrupts the structure of the skin tissue in the genital area, skin tissue should definitely not be used in urethral reconstruction. Instead, oral tissue, or buccal mucosa, which is not affected by the disease, is taken and grafted onto the urethra, creating a durable channel independent of the diseased area.

Can every urology center perform this surgery?

Repair of panurethral strictures is quite different from standard urological surgeries and is one of the most challenging procedures in reconstructive urology. Reconstructing the entire urethra requires specific microsurgical experience and grafting skills.

To achieve long-term success and prevent recurrence of the stricture, these surgeries must be performed in centers with extensive case experience in reconstructive urology.

Approximately 40 years of academic and surgical expertise, experience with more than 500 urethroplasty procedures, and processes carried out within the infrastructure of a well-equipped university clinic provide the safest outcomes in these complex and long strictures.