What is the optimal surgical strategy for bulbous urethral stricture in boys?

PURPOSE

Optimal management for bulbous urethral stricture in children is poorly defined. We compared our long-term experience with direct vision internal urethrotomy and open repair to define the optimal surgical strategy.

MATERIALS AND METHODS

We reviewed the records of 63 patients who underwent direct vision internal urethrotomy or open repair. A total of 46 patients (73%) were treated with 1 or more urethrotomies. Of the patients 17 (27%) underwent urethroplasty, 13 underwent end-to-end repair and 4 received a patch graft or tube. Eight of 17 cases required urethroplasty only, whereas in 9 combined open repair and urethrotomy were done. Mean patient age was 14.1 years (range 5 months to 21 years). Followup included voiding cystourethrogram, retrograde urethrogram and/or cystoscopy, or flow rate. Mean followup was 30 months for urethrotomy and 16 months for open urethroplasty.

RESULTS

When direct vision internal urethrotomy was the initial approach, 1 procedure was successful in 28 of 53 cases (53%). Multiple urethrotomies increased the success rate to 59% (43 of 73 cases). The 53 patients with urethrotomy required a total of 84 procedures (mean 1.6 each). When open repair was the initial approach, 1 procedure was successful in 8 of 10 cases (80%). A total of 12 procedures (mean 1.2 each) were required in those 10 cases. A combined urethrotomy/open approach with 2 procedures was successful in 78% of cases (7 of 9).

CONCLUSIONS

Open reconstruction is more successful than direct vision internal urethrotomy as the initial approach to bulbous urethral strictures. Although aggressive, end-to-end repair usually provides a definitive solution. Initial direct vision internal urethrotomy is successful in half of the cases and repeat urethrotomy adds little to success. The success of the combined urethrotomy/open approach approximates that of initial open reconstruction. If initial direct vision internal urethrotomy is elected, we advocate only 1 attempt, followed by open end-to-end urethroplasty if necessary.