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Guerra et al. Plast Aesthet Res 2022;9:42 https://dx.doi.org/10.20517/2347-9264.2021.136 Page 3 of 7

the necrotic tissue should be resected before a urethroplasty is attempted. In addition, cystoscopy is unable
to provide information regarding the surrounding spongiofibriosis. In some cases, urethroscopy alone is
considered deficient for a thorough diagnostic workup and more imaging exams are warranted. Endoscopic
management, such as dilation followed by direct visual internal urethrotomy of radiation-induced strictures
as the first-line treatment, has been proposed. However, these men have a high risk for recurrence, which
[18]
reportedly amounts to nearly 50% for patients who have undergone BT .
According to the European Association of Urology guidelines for urethral stricture diagnostics, the workup
should consist of medical history, physical examination, and laboratory, ultrasonography, and functional
studies . Currently, there is no single strict algorithm for US diagnosis; it depends on each patient’s age
[19]
and compliance, as well as the etiology.

TREATMENT
Radiotherapy-induced urethral strictures are a challenge, especially because of compromised vascular
supply, proximal location, and poor wound healing. Overall, the post-radiation anatomy and characteristics
[20]
of the patients must be considered when planning treatment . In this review, we focus on excision and
primary anastomosis (EPA), buccal mucosa graft (BMG) urethroplasty, and flaps. A comparison of success
rates for the different techniques is provided in Table 1 .
[21]

Excision and primary anastomosis
In urethral reconstruction with innovative fasciocutaneous flaps and a wide range of tissues for grafting,
stricture EPA remains the gold standard in reconstruction for properly selected patients. Patient selection is
limited by the length and location of the stricture, but the generally excellent long-term results with EPA
warrant its consideration in post-radiation urethral reconstruction.

The success of EPA relies on careful patient selection. From a strict anatomic perspective, only short
strictures (< 2 cm) located between the suspensory ligament and the membranous urethral area are
amenable to excision.

A suprapubic foley catheter to allow for tissue recovery is important for urethral rest, allowing the urethra to
rest for several weeks prior to urethroplasty. Urethral rest has numerous advantages as it allows for a precise
determination of the stricture area before urethroplasty. In addition, it allows for a decrease in the
periurethral inflammation, which might otherwise delay the wound healing process. Asymptomatic and
symptomatic bacteriuria are important to manage to avoid postoperative infection, including in the 24 h
before the procedure. The perineum must be adequately exposed for urethroplasty. A vertical midline
approach is made in the perineum; after dissection of the subcutaneous tissue and fascia of Colles, the
bulbospongiosus muscle is encountered and transected to expose the urethra. The proximal bulbar urethral
is exposed by a circumferential mobilization of the urethra from the penoscrotal junction using sharp
dissection. Intraoperative urethroscopy allows the stricture location to be determined. A urethral incision is
made at the level of the stricture and examined. Damaged urethral mucosa and spongiofibrosis are further
excised until healthy mucosa and corpus spongiosum are reached. It is important to remove this abnormal
urethral mucosa to avoid stricture recurrence. Subsequently, both ends of the urethra are widely spatulated
for approximately 1 cm and a foley catheter is placed (18 Fr catheter). Absorbable sutures are used to
approximate mucosa to mucosa. The anastomosis should be under control, avoiding excessive tension. If it
does occur, it demands additional mobilization of the urethra. The bulbospongiosus muscle and fascia of
Colles are closed with 3-0 Vicryl. The foley catheter is left in place for three weeks and prophylaxis is
continued for 24 h. The follow-up after surgery includes the determination of residual bladder volumes and,