Presentation, treatment and outcomes of pediatric anterior urethral strictures: 28 years' experience from a referral center

Background Pediatric urethral strictures are an uncommon entity, with the anterior urethra being the most common affected location, similar to adults. The, literature on outcomes in these strictures is limited, especially in the non-traumatic group, as most of the studies have included hypospadias related "neourethral" strictures and posterior strictures, thereby making interpretation difficult. It is for these reasons we decided to search our database to identify the different surgical procedures used and analyze the outcomes of interventions in these children and adolescents with anterior urethral strictures. Objective To report the treatment strategies and outcomes in a series of 119 pediatric anterior urethral strictures, identified in a 28-year period in a high-volume tertiary center. Materials and methods A retrospective case-note review of all cases of pediatric anterior urethral strictures was done. Data on the clinical presentation including age at presentation, characteristics of strictures identified, primary intervention and additional secondary procedures and outcomes were collected. Results We identified 119 boys with anterior urethral strictures with commonest location being the bulbar urethra (60.5%). Sixty patients (50.4%) in this cohort underwent minimally invasive intervention in the form of dilatation or direct visual internal urethrotomy (DVIU) with the rest undergoing open intervention. The primary success rate was 87.1% (101/116) at a median follow-up of 29 (IQR 21-38) months. Idiopathic urethral stricture and iatrogenic strictures had better success rate of 92.5% and 82.1% than traumatic strictures (78.9%) and it was lowest for those traumatic strictures that were treated with DVIU (66.7%). Multifocal strictures had comparatively poorer outcomes (62.5%) compared with penile or bulbar strictures, with worst outcomes (44.4%) in those treated with substitution urethroplasty. Length >1 cm, multifocality and treatment with substitution urethroplasty were significantly associated with recurrence. Three boys with strictures associated with anorectal malformations were a particularly difficult group and needed multiple intervention and had poor outcomes. Conclusion Based on our study, we recommend a minimally invasive approach for short segment, bulbar strictures, especially of idiopathic etiology. For other locations and longer strictures, we recommend urethroplasty. Caution must be exercised to avoid underestimation of the actual pathology of the stricture. Caretakers of children with complete bulbar level blockage associated with anorectal malformations undergoing urethroplasty should be explained about the need for multiple interventions and possibility of poor voiding outcomes.