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Page 2 of 7 Guerra et al. Plast Aesthet Res 2022;9:42 https://dx.doi.org/10.20517/2347-9264.2021.136

[1]
with cancer are treated with RT . However, this treatment is not without side effects and urethral strictures
[2]
are among the possible complications. Urethral strictures are reported for nearly 32% of patients . The
[3]
damage to this tissue involves multiple factors, both directly and indirectly linked to RT . This pathology is
[4]
uncommon and, in many cases, not reported as important, despite being associated with high morbidity .
In addition, the reconstructive urologist must be trained to understand and manage post-irradiation
urethral pathologies due to their complexity and the need for numerous operative techniques.

EPIDEMIOLOGY, INCIDENCE, AND ETIOLOGY
Post-RT pelvic complications are often moderate to severe, usually occurring following treatment for
malignant pelvic tumors . Recent reports list a 2% incidence rate and a risk of urethral narrowing for
[5,6]
approximately 25 years following RT. The most common type of RT leading to urethral stricture (US) is
prostate cancer brachytherapy (BT) . Recent studies report a bulbomembranous stricture rate following BT
[7]
of 8% versus 4% for external beam radiation therapy (EBRT) . Health-related studies have reported on the
[8]
relevance of functional morbidity resulting from cancer treatments. A long-term functional decline over a
period of 15 years has been found in primary treatments, such as radical prostatectomy or RT . Although
[9]
bulbomembranous stenosis accounts for 100% of post-radiation strictures, a narrowing can theoretically
form at any location of the urethra. The type of radiation and the radiation dosage used also have an impact
on the overall incidence of urethral stricture . Merrick et al. described that the behavior between radiation
[10]
and doses (expressed as the dose delivered 20 mm from the prostatic apex) and the time of hormonal
[11]
manipulation were predictive of urethral damage after RT .
RT damages living cells both directly by inducing cellular apoptosis and DNA mutation and indirectly
[12]
through the action of hydroxide free radicals . Ballek et al. studied the correlation between radiation and
urethral strictures, inadequate perfusion, and poor wound healing due to vascular compromise . Due to
[13]
the effects of radiation on the epithelium, fibroblasts are not able to provide sufficient collagen to meet the
demands of healing. Tightening of fibroblasts and scar formation due to collagen maturation are also
endangered . Over time, the metaplasia induces fibrotic changes in the corpus spongiosum, resulting in a
[14]
[15]
narrower urethral lumen .

For the genitourinary reconstructive surgeon, it is of utmost importance to assess the quality of tissue. It will
allow for a highly successful surgery.

DIAGNOSTICS
The diagnostic workup is important and can be designed on a case per case basis. Patients with urethral
stricture mostly complain of obstructive voiding symptoms. They more often present with storage lower
[16]
urinary tract symptoms. The most evident symptom is weakening of the urinary flow . It can be valuable
to evaluate preoperative bladder function by performing a urodynamic study. Uroflowmetry will be
adequate in a variety of cases . Uroflowmetry gives us valuable information on bladder function as well as
[15]
capacity, being a predictor of damage caused by chronic obstruction of urethral stricture. Radiographic
examination of the length and location of the stricture is essential. When the retrograde urethrogram is
[17]
deficient, a voiding urethrocytogram (VCUG) can be performed to evaluate the bladder neck . The VCUG
provides information on the length, location, severity, and number of US. In addition, it provides
information on fistulas, urethral duplication, false pathway, and the status of the bladder neck. Cystoscopy
is a fast and relatively easy way to identify a urethral stricture. This procedure provides evidence about the
location and remaining caliber of the damaged urethra. Anterograde cystoscopy with a flexible device can
be performed when the patient has had a cystostomy to visualize the proximal urethra and the bladder neck,
as well as the presence and extent of radiation necrosis of the prostate, which is important to recognize as