Paris — The management of urethral stenosis has progressed significantly in recent years. Urethral reconstruction (urethroplasty) has notably become the standard treatment, thanks to the use of the oral mucosa. L’French Association of Urology (AFU) devoted its latest annual report to this pathology, in which the main surgical approaches are described in detail, depending on the location of the stenosis.
The report was presented during the 118th AFU Congress [1]. It aims in particular to “encourage urologists to invest in reconstruction surgery”, which has gained importance in recent years, underlined the Dr Nicolas Morel-Journel (Lyon University Hospital), co-author of the report, during a press conference.
Current research also suggests new therapeutic options, underlined the urologist. Trials are currently being conducted to evaluate the use of stem cells, as well as the use of chemotherapy-coated dilation balloons to prevent the proliferation of fibroblasts and thus reduce the risk of recurrence.
Recommendations less than ten years old
Evidence of recent developments in the management of urethral stenosis: the first international recommendations on urethral stenosis in men were issued in 2016 by theAmerican Urological Association (AUA). They were followed in 2021 by those of theEuropean Association Urologie (EAU), then those of the AFU, which focus on stenosis of the anterior urethra.
Stenoses of the anterior urethra must today be treated as first intention by urethroplasty in a very large number of cases, which requires a significant change in paradigm and practice.
The seven chapters which make up the report distinguish the treatment in men of stenosis of the anterior urethra (bulbar, penile or meatal), located after the urethral sphincter, from that of the posterior urethra, at the level of the prostate. A chapter is also devoted specifically to female urethral stenosis.
Given that 90% of stenoses in men affect the anterior urethra, half of which at the bulbar level, the first recommendations of the AFU focused on the management of this stenosis, underlined during his presentation the Dr François-Xavier Madec (Foch Hospital, Suresnes), co-author of the report.
Urethral stenosis refers to a narrowing of the urethra due to a process of fibrosis and scarring of the mucosa. The prevalence is estimated at nearly 1%. The main causes of stenosis are idiopathic, iatrogenic, traumatic, inflammatory and infectious. Urethral catheterization for bladder catheterization is, for example, a risk factor for iatrogenic stenosis.
An x-ray assessment
The diagnosis of urethral strictures is based on fibroscopy, recalled Dr Morel-Journel during his presentation. The evaluation of the stenosis requires urethral rest of two to three months, which implies not intervening in particular by self-catheterization. A suprapubic catheter can then be placed to facilitate emptying of the bladder.
The evaluation (degree of obstruction, location, length, number of stenosis) is done by urethrography (UCRM). The examination, considered unprofitable and time-consuming by radiologists, is difficult to access, but essential to characterize the stenosis and define the treatment, said the urologist. “We will have to insist to radiologists on the necessity of this examination.”
Regarding treatment, dilation has long been the only option available. The first reference to this treatment dates back to antiquity. Until the advent of endoscopy in the 1970s and 1980s, dilations were performed blindly, using, in more contemporary times, metal or plastic candles.
The arrival of endoscopy made it possible to carry out sections of stenosis (urethrotomy), but this more targeted approach did not significantly improve the results, compared to dilation. One of the reasons is the formation of fibrosis after treatment, especially when interventions are repeated.
Only 5% urethroplasty
Another technique then developed in the 2000s: urethral reconstruction or urethroplasty, which was shown to be superior to dilation and urethroplasty. Over the past ten years, with the emergence of reconstructive surgery of the genitourinary organs, the management of urethral strictures has considerably improved.
Initially carried out with a skin graft, urethroplasty has become more reliable with the oral mucosa graft. “Today we obtain up to 90% success,” said Dr Morel-Journel. Unlike the skin, the oral mucosa has the advantage of being well resistant to the acidity of urine, of having a high rate of grafting and low retraction.
In France, with nearly 1,600 procedures carried out per year, urethroplasties are on the rise. However, despite its interest, this treatment is rarely practiced. “Only 5% of procedures for urethral strictures are urethroplasties,” underlined Dr Madec, who hopes to see urologists take greater ownership of this approach.
According to the AFU recommendations, “stenoses of the anterior urethra must today be treated as first intention by urethroplasty in a very large number of cases, which requires a significant change in paradigm and practice”. Training in these reconstruction techniques is therefore strongly encouraged.
Testing placlitaxel dilation
“The continued improvement of surgical techniques and increased training of French urologists in this area should make it possible to better meet the needs of patients suffering from urethral strictures,” commented the AFU in a press release.
Currently, the main treatment applied is that using endoscopy to cut the stenosis (urethrotomy), despite a success rate close to 40%, explained Dr Madec during the press conference. “Endoscopic treatment has the advantage of being minimally invasive. It can be carried out in a consultation office or on an outpatient basis.
Reconstruction surgery by urethroplasty with oral mucosa graft is generally offered as a second line in the event of recurrence of stenosis. “A second endoscopic treatment can be considered if the patient is reluctant to be treated by surgery,” but the risk of further recurrence is high.
Other therapeutic options are currently under evaluation. Dilation is once again being considered with the development of dilation balloons coated with a cytotoxic agent (paclitaxel) to prevent the proliferation of fibroblasts, major players in recurrence after dilation.
The first results at 3 and 5 years are “quite promising”, even if the success rates are lower than urethroplasty, commented Dr Morel-Journel.
Focus on female urethral stenosis
Another promising technique being tested: cell therapy. Stem cells are injected at the incision site after urethrotomy, in order to promote the reconstitution of the urethral mucosa and prevent the development of fibrosis in reaction to the passage of urine through the cut tissues.
Rarer, but probably underdiagnosed, female urethral stenosis was the subject of a separate chapter. Although there is not yet a validated diagnostic or therapeutic algorithm in this indication, the latest European recommendations suggest performing dilation as first intention, before considering urethroplasty.
“Urethroplasties in this indication are so rare that they are the responsibility of expert centers,” indicated the Pr Gilles Karsenty (Hôpital de la Conception, Marseille), also co-author, during a final presentation dedicated to the AFU report.
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