Urethroplasty in a post irradiation urethral stricture - a review

Abstract

Radiotherapy-induced urethral strictures (RIUS) decrease quality of life and present a great challenge for surgical reconstruction, especially due to proximal location, compromised vascular supply, and poor wound healing. It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation. We review the pathophysiology, diagnostic workup, and disease-specific aspects of RIUS. Furthermore, we discuss several management alternatives such as excision and primary anastomosis, as well as techniques for open reconstruction with flaps. The most extensive techniques in the treatment of strictures include, for example, those using gracilis muscle flaps, as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing. In brief, RIUS represent a significant challenge. In carefully chosen patients, urethroplasty should be considered as a feasible and durable treatment. However, medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.

Keywords

Urethra / stricture / radiotherapy / urethroplasty / buccal mucosa graft / gracilis muscle flap / stricture

References

[1] Carlos-Reyes A,Romero-Garcia S,Hernández-de la Cruz ON.Biological adaptations of tumor cells to radiation therapy.Front Oncol2021;11:718636 PMCID:PMC8652287

[2] Hoeh B,Kluth LA.Management of medium and long term complications following prostate cancer treatment resulting in urinary diversion - a narrative review.Front Surg2021;8:688394 PMCID:PMC8381645

[3] McBride WH.Radiation-induced tissue damage and response.J Pathol2020;250:647-55 PMCID:PMC7216989

[4] Martins FE,Lumen N.Devastated bladder outlet in pelvic cancer survivors: issues on surgical reconstruction and quality of life.J Clin Med2021;10:4920 PMCID:PMC8584541

[5] Elliott SP.Long-term urinary adverse effects of pelvic radiotherapy.World J Urol2011;29:35-41 PMCID:PMC3075494

[6] Pascoe C,Lamb BW.Current management of radiation cystitis: a review and practical guide to clinical management.BJU Int2019;123:585-94

[7] Toia B,Ecclestone H.Outcomes of reconstructive urinary tract surgery after pelvic radiotherapy.Scand J Urol2019;53:156-60

[8] Srikanth P,Tijerina AN.Narrative review of the current management of radiation-induced ureteral strictures of the pelvis.AME Med J2021;

[9] Chorbińska J,Zdrojowy R.Urological complications after radiation therapy - nothing ventured, nothing gained: a narrative review.Transl Cancer Res2021;10:1096-118 PMCID:PMC8798528

[10] Resnick MJ,Fan KH.Long-term functional outcomes after treatment for localized prostate cancer.N Engl J Med2013;368:436-45 PMCID:PMC3742365

[11] Merrick GS,Tollenaar BG,Lief JH.The dosimetry of prostate brachytherapy-induced urethral strictures. I.nt J Radiat Oncol Biol Phys2002;52:461-8

[12] Khourdaji I,Chennamsetty A.Treatment of urethral strictures from irradiation and other nonsurgical forms of pelvic cancer treatment.Adv Urol2015;2015:476390 PMCID:PMC4606407

[13] Ballek NK.Reconstruction of radiation-induced injuries of the lower urinary tract.Urol Clin North Am2013;40:407-19

[14] Hughes M,Li G,Blakley S.Histologic characterization of the post-radiation urethral stenosis in men treated for prostate cancer.World J Urol2020;38:2269-77

[15] Waterloos M,Verla W,Lumen N.Current management of membranous urethral strictures due to radiation.Front Surg2021;8:635060 PMCID:PMC7969877

[16] Verla W,Spinoit AF.A comprehensive review emphasizing anatomy, etiology, diagnosis, and treatment of male urethral stricture disease.Biomed Res Int2019;2019:9046430 PMCID:PMC6500724

[17] Browne BM.Management of urethral stricture and bladder neck contracture following primary and salvage treatment of prostate cancer.Curr Urol Rep2017;18:76

[18] Abu Nasra W, Abu Ahmed M, Visoky A, Huckim M, Elias I, Katz R. The importance of cystoscopy in diagnosis and treatment of urethral stricture following transurethral prostatectomy.Isr Med Assoc J2020;22:241-3

[19] Campos-Juanatey F,Greenwell T.European association of urology guidelines on urethral stricture disease (part 2): diagnosis, perioperative management, and follow-up in males.Eur Urol2021;80:201-12

[20] Hofer MD,Morey AF.Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease.J Urol2014;191:1307-12

[21] Hofer MD.Management of radiation-induced urethral strictures.Transl Androl Urol2015;4:66-71 PMCID:PMC4708282

[22] Rourke K,Zorn J.Observations and outcomes of urethroplasty for bulbomembranous stenosis after radiation therapy for prostate cancer.World J Urol2016;34:377-82

[23] Ahyai SA,Kuhl M.Outcomes of ventral onlay buccal mucosa graft urethroplasty in patients after radiotherapy.J Urol2015;194:441-6

[24] Zinman L.Muscular, myocutaneous, and fasciocutaneous flaps in complex urethral reconstruction.Urol Clin North Am2002;29:443-66

[25] Oyelowo N,Tolani MA.Analysis of the determinants, characteristics and management of recurrent urethral strictures.Niger J Surg2020;26:130-4 PMCID:PMC7659749

[26] Meeks JJ,Granieri MA.Stricture recurrence after urethroplasty: a systematic review.J Urol2009;182:1266-70.

[27] Palmer DA,Zinman LN.Urethroplasty for high risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap.J Urol2015;193:902-5

[28] Markiewicz MR,Margarone JE 3rd,Chuang SK.Morbidity associated with oral mucosa harvest for urological reconstruction: an overview.J Oral Maxillofac Surg2008;66:739-44