CUA 2020 Urethral Stricture

Question 1

what is a urethral stricture?

Answer 1

fibrosis of urethral epithelial tissue and corpus spongiosum which causes narrowing of the urethral lumen

Question 2

What is the difference bw urethral stricture and stenosis

Answer 2

stricture: anterior urethra
Stenosis: posterior urethra

Question 3

Increased likelihood of stricture with increasing age and decreases socioeconomic status

Answer 3

TRUE

Question 4

Is urethral stricture a risk factor for fournier’s gangrene?

Answer 4

Yes

Question 5

Should men with suspected urethral stricture undergo cystoscopy?

Answer 5

Yes
also suggest performing retrograde urethrography to further stage urethral stricture or refer to recon when recurrent stricture is suspected, recommend against use of MRI in routine initial diagnosis of suspected stricture.

Question 6

What work up should be done in initial assessment of stricture?

Answer 6

H&P, physical exam, Cr, UA, IPSS, uroflow, US and PVR

Question 7

In what situations may MRI be helpful in work up of urethral strictures?

Answer 7

Complex trauma, suspected urethral malignancy, RT induced stenosis or rectourethral fistula

Question 8

Is DIVU superior to urethral dilatation

Answer 8

No evidence, No

Question 9

who is a well selected patient for urethral dilatation/ DIVU?

Answer 9

(<1cm bulbar strictures with minimal spongiofibrosis and ≤2 prior dilations/incisions).

Question 10

What situation is anastomotic urethroplasty good for?

Answer 10

anterior strictures, <2cm, in bulbar urethra.

Question 11

do oral mucosal grafts and genital fasciocutaneous graft have similar success rates?

Answer 11

Yes, ( most urologists use oral mucosal as the primary source)

Question 12

allograft, xenograft, synthetic material should not be used to perform urethroplasty

Answer 12

Correct

Question 13

Should endoscopic management (dilation or direct vision internal
urethrotomy) compared to urethroplasty be used for men with the initial diagnosis of urethral stricture?

Answer 13

We suggest endoscopic management as the initial treatment of the
symptomatic undifferentiated stricture

Question 14

Should urethroplasty compared to endoscopic treatment (either
dilation or dviu) be used for men with recurrent urethral stricture?

Answer 14

In the setting of men with recurrent urethral stricture failing prior endoscopic
treatment, we suggest performing urethroplasty rather than repeat endoscopic management
(DVIU or dilation)

Question 15

In what patients should you not really attempt endoscopic management of urethral stricture?

Answer 15

strictures from failed hypospadias repairs, penile
urethral strictures, lichen sclerosis related strictures, trauma related urethral strictures, strictures
longer than 2 cm, and those with a completely obliterated lumen

Question 16

How should trauma stenosis be managed

Answer 16

delayed urethroplasty at 3 to 6 months, very high success rates

Question 17

How should patients with straddle urethral injury be treated

Answer 17

endoscopic realignment or SP– followed by urethroplasty

These are often transmural injury to Corpora spongiosa

Question 18

what are the 4 classes of urethral strictures in patients with hypospadias?

Answer 18

1- long “pan-penile” stricture involving the majority of the penile urethra in the setting of
previous (and often multiple) hypospadias surgery
2- “junctional
stricture” which is a stricture of variable length at the junction of previous hypospadias repair
and native urethra
3- isolated bulbar urethral stricture after
hypospadias repair
4-urethral stricture developing in the setting of
previously untreated hypospadias

Question 19

What are treatment options for hypospadias associated Urethral strictures?

Answer 19

urethroplasty, perineal urethrostomy,

Endoscopic management is not a great option

Question 20

What are risk factors for developing bladder neck contracture?

Answer 20

low adenoma weight, unmanaged preoperative infections, long resection time, extensive resection of bladder neck, diabetes, smoking, cardiovascular disease.

Question 21

What are treatment options for bladder neck contracture?

Answer 21

Urethral dilatation( first line), BNI+/- CIC to stabilize bladder neck, , permanent SP catheter, Open recon using Y-V plasty techniques

Question 22

what is bladder neck contracture?

Answer 22

narrowing of the bladder neck following surgical

treatment of bladder outlet obstruction

Question 23

What is Vesicourethral anastomotic stenosis

Answer 23

narrowing of the anastomosis after radical prostatectomy

Question 24

What is a rare but serious complication of treating VUAS and how is it treated?

Answer 24

fistulation to the pubic symphysis
-This almost uniformly occurs in patients
with a history of radiation therapy, and in many cases, develops after endoscopic procedures to
treat VUAS. A patient will have severe pelvic pain, and an MRI of the pelvis should be done to
confirm the diagnosis. Treatment of this complication usually requires a urinary diversion

Question 25

How is VUAS treated?

Answer 25

Observation,

If symptomatic and less than 14-F then dilatation –> laser/coldknife/hot knife incision of stricture

Question 26

Radiation associated stenoses are usually refractory

to endoscopic techniques

Answer 26

correct,
urethroplasty in reasonably selected patients seems to be a good option.
but given advanced patient age some may prefer endoscopic treatment over surgery.

Question 27

in case of radiation induced strictures in patients with patients with extensive prostate necrosis, cavitation,
prostatosymphyseal fistula, osteomyelitis or a small functional bladder capacity are best served by ….what?

Answer 27

by urinary diversion in lieu of urethral reconstruction

Question 28

what is another name for Lichen sclerosis and what causes it

Answer 28

balanitis xerotica obliterans(no longer the accepted term). caused by lymphocyte mediated skin disease.

Question 29

why is surveillance recommended in patients with lichen sclerosis

Answer 29

association with the development of squamous cell carcinoma which can occur in 2– 8% of men with lichen sclerosus

Question 30

How is cutaneous LS treated

Answer 30

topical steroid cream for 8-12 weeks, dorsal slit or circ may be needed as well.

Question 31

(True or False) Urethral strictures with LS are sporadic and self resolving.

Answer 31

Wrong. They are often progressive

Question 32

what are some treatment options for LS associated isolated meatal stenosis

Answer 32

dilatation w or w/o intra-urethral steroid administration

Question 33

how is Ls with longer urethral stricture treated?

Answer 33

Urethroplasty often requiring tissue transfer. Dont use genital skin as LS can reccur in it, oral mucosal graft is gold standard