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.