Principles of urethral stricture repair

This manuscript outlines the important points in the evaluation and treatment of urethral stricture disease. The algorithms described within are not presented as strict guidelines but rather are intended to give a logical thought progression which incorporates the basic principles of urethral reconstruction. It is important to determine the therapeutic goal before applying these principles. There are basically two arms of consideration, the first is to attempt to cure the patient of urethral stricture disease and the second is to simply manage the patient's urethral stricture disease without intent of cure. Applying the current knowledge of anatomy with modern tissue transfer techniques will achieve a highly successful, single stage reconstruction in most patients. Although approaching urethral stricture disease with the intent to cure is preferred, management may not be unreasonable in certain cases. Some patients have entensive co-morbidities or may prefer a trial of conservative measures before definitive treatment is undertaken. If the goal established is urethral reconstruction, the gold standard is to perform a single stage pocedure that is highly successful and durable. Excision of the urethral stricture with primary anastomosis (EPA) represents this gold standard. However, ist application is limited by stricture location or length. An accurate evaluation of the stricture location, length, and associated spongiofibrosis is mandatory in forming viable options for repair. By exploiting the advantages of differing techniques, the proper course of action can be chosen which generally will solve even the most complex problem in one stage. The reconstructive surgeon come to the operative suite armed with the full knowledge and understanding of the principals and techniques which will result in a favorable outcome. It is not uncommon for intra-operative findings to guide the decision for the best alternative for urethral reconstruction. We also offer some helpful hints regarding positioning, sutures, exposure, and retractors.