Enzo Palminteri ^a,*, Mauro Cacci b, Elisa Berdondini a, Maurizio Poluzzi c, Giorgio Franco d, Vincenzo Gentile^d

Centre for Recanstrurtive Urethrai and Genitalia Surgery, Arezzo, Italy ^bDeparrment of Urology, Florence University, Florence, Italy

Department of Urology, Ospedale Sacro Cuore, Negrar, ltaly

1. Introduction

In 1988, Milroy et al introduced the use of stents in the treatment of urethral strictures [l ]. After initial enthusiasm and expanding indications for different I

Reoperation rates af failures after stent placement in anterior urethra range between 33% and 45% [2,4[, and their management usually results in a difficult therapeutic challenge. Stent failures are commonly treated by internai optical urethromy (IOU) and/or dilations, with poor outcome requiring subsequent complicated urethroplasty with mod­erate success [2,4-71.

We report our experience with the management of restenoses and complications after urethral stent insertion far recurrent anterior urethral strictures.

2. Methods

We retrospectively analysed the records of 13 men with anterior urethral stricture who experienceci restenosis and complications alter urethral stent insertion. All patients vere referred to ourcentre between 2000 and 2008 after implantation of urethral stent in other urology departments. For each patient. we determined the aetiology of primitive stricture, stent position, urethral procedures perforrned before (prestent) and after (poststent) stent placement, restenosis lacation, stent-related complica­tions. management of stent failures, and outcomes. Preoperative evalua­don included clinical history, physical examination, urine culture, uroflowmetry.retrograde-voiding cystourethrography,and urethroscopy.

Based on the above-mentioned parameters, we chose conservative (nonsurgical) or interventional (surgical) approaches. The rationale of our surgical procedure was to provide stent removal followed by urethro­plasty.lJrethral repairwas fashioned arcording to intraoperative findings.

Follow-up assessment included urofiosvrnetey and urine culture every 4 'no in the first year and annually thereafrer. Urethrography and urethroscopy were performed in case of newly developed obstructive symptams. Successful outcome was defined as standard voiding without need of any postoperative procedure, including dilation, and full recovely from complications.

3. Results

Mean ag^re at time af first treatment of early stenosis was 42.4 yr (range: 20-72), at time of stent insertion was 48.7 yr (range: 24-75), and at time of our office referral was 58 yr (range: 44-78). Mean time between first treatment of primitive stenosis and stent placement was 6.1 yr (range: 1-20) and between stent placement and our approaches was 7.7 yr (range: 1-14). Mean Cime between first treatment and our surgical approach was 13.3 yr (range: 3-26).

The aetiologies of early urethral strictures were un­known in four (30.7%) cases, were iatrogenic in six (46.1%) cases, were lichen sclerosus in one (7.7%) case, and were tram-natie in two (15.4%) cases (Table 1). Patients under­went a mean of 4.5 prestent treatments (range: 1-13) for anterior urethral stricture: Eight patients underwent IOUs,

two underwent 10Us and dilations, one underwent ure­throplasty, and twa underwent IOUs and dilations and urethroplasty.

Stent location was bulbar in 12 cases (bulbar proximal in 4 of the 12 cases) and peno-bulbar in 1 case. In all cases, the stent was a UroLume stent (American Medicai Systems, Minnetonl

All patients developed restenoses after stent placement, and nine underwent a mean of 1.5 poststent treatments (range: 1-3) before referral to us: IOU, dilations, or urethro­plasty failed to overcome the obstruction. At time of visit to our centre, 11 patients presented severe obstructive voiding symptams and two presented with urinaiy retention treated by suprapubic cystostomy.

Restenosis was located inside the stent in four cases (cases 6, 8, 11, and 13), inside the stent plus far from stent in one case (case 10), far from the stent in two cases (cases 4 and 12), far from and dose to the stent in two cases (cases 1 and 3), and dose to the stent in four cases (cases 2, 5, 7, 9) (Figs. 1--4).

The restenoses were 2.5-10 cm long (mean: 5 cm). Four patients reported stent-related complications such as recur­rent archiepididymitis and urinary infections, twa reported perineal pain, and two reported sexual discomfort or dysfunction (chordee, paio during erection).

Four of the 13 patients did not undergo surgery and the stent was left in situ; in ali cases the stent was in the proximal bulbar urethra. Two patients refused open surgery due to high risi< of postoperative incontinente because the stent was adjacent to the residual sphincter after transure­thral resection of the prostate (TURF') (cases 11 and 13) (Fig. 5). One patient was not suitable for surgery due to severe cardiovascular comorbidities (case 10). One patient refused any further procedure (case 12). Of these four conservatively treated patients, two required permanent suprapubic cystostomy.

Overall, 9 of 13 patients underwent surgical stent removal and salvage urethroplasty. Mean follow-up for these patients was 40.3 ma (range: 12-105). An inverted Y-shaped perineoscrotal incision or a midline penile incisian was made for a bulbar or a pende stent removal, respectively. A signiftcant amount of fibrosis surrounding the corpus spongiosum was found. In two patients, the stent was strongly embedded inside a fibrotic urethra and it was removed en bloc with the whole urethral segment. In seven patients, the stent was removed wire by wire and the urethral plate was preserved. The removal of the individuai wires was outlined by a ventral-sagittal urethrotomy and stent section in four cases or by double-ventral plus dorsal-sagittal urethrotomy and stent section after urethral mobilisation from the corpora cavernosa in three cases (Fig, 6).

Following stage 1, three patients are waiting for further reconstructive steps. Pive elected the urethrostomy as permanent diversion and declined further surgery, and one patient completed the reconstruction in two steps by tabularisation ofthe urethral plate with buccal mucosa graft (BMG) at stage 2 (case 9).

After surgery, seven of the nine patients (77.8%) were stricture free without the need for any additional procedures. Two (22.2%) patients had restenosis: One underwent three 10Us (case 9) and one is now on intermittent self-dilatation (ISD) (case 7). No patients became incontinent. All patients overcame the complications, and they were satisfied with their recovered sexual life. Qualiry of fife was improved in all cases.

4. Discussion

The first urethral stent placements showed good short-terra outcomes, and the procedure was welcomed as an effettive minimally invasive therapy [2,8-10]. After that first enthusi­asm and following expanding indications in severa] urethral segments, the stents have been shown to fai] in most posterior strictures [4,11]. Stents have not been promoted in penile strictures, particularly in the anterior urethra, and long-terra results in the bulbar tract showed progressive deterioration with only a 13-45% success rate reported [2,3].

Some reports have been published on the supposed safety. efficacy, and reversibility of this device [2,8-10]. However. clinica] practice has shown many complications following

stent insertion. hyperplastic overgrowth with restenosis inside or adjacent to the prosthesis. Regarding the presumed safety of stent complete placement, severe side-effects, such as perineal pain, sexual discomfort, erectile disorders, stent encrustations, stones, recurrent urinary tract infections (UTI), dysuria, postvoiding dribbling, and urinary incontinence, affect quality of )ife [2,8,12,13]. Hussain et al reported stent-related complica­tions in 55% of patients; the majority of these were restenoses, but others were postmicturition dribbie (32%), recurrent urinary tract infection (UTI) (27%), and perineal pain and dysuria. In total, 45% of their patients suffered more than one complication; operative intervention was required in 45% oftheir patients, and open stent removal was required in 8.3% [2].

was performed in one (7.7%) patient, and he is awaiting stage 2; in 12 (92.3%) patients, a one-stage penile tabularised flap was used to bridge the urethral defect with a 91% success rate but with a short-terra follow-up [5]. Eisenberg et a] reported that of nine patients with stents located in the anterior urethra, eight (89%) underwent prosthesis excision and urethroplasty: stage 1 urethroplasty in was performed in Tour (end-to-end anastomosis in one and dorsal BMG urethro­plasty in three) and stage 2 urethroplasty with dorsal SMG was performed in fourpatients. With a short-terra follow-up of only few months in most cases, they had a 62.5% success rate [6].

In their study with longer follow-up, Chapple et al reported the difficult surgical management of 10 patients with obstructed stents located in the anterior urethra. The stent was removed (en bloc or wire by wire) in nine cases and left in situ in one. All of the urethroplasties were performed in one stage: anastomotic urethroplasty in two patients and patch graft urethroplasty in eight (using BMG in three and penile skin grafi in five). Chapple's group had five (50%) successes and five failures. They eletteti one­stage procedures but avoided tube reconstruction. They stated, however, that if the one-stage approach had not been possible, then a two-stage procedure would be the preferred option [7]. Hussain et al conflrmed that severe stent-related problems are manager.] most effectively by staged urethroplasty. in their series, three patients requireci open stent excision and perineal urethrostomy, and one opted for a suprapubic catheter [2).

In our experience, stent extraction has been shown to be a complex surgical step. After stent removal, the residual urethral plate was not retrievabie and not suitable for a refined one-stage urethral reconstruction. [n two cases, the resection of the whole compromised urethral segment was necessary, resulting in an extensive urethra] defect. Our operative findings were targeted ori a salvage staged surgery-less refined but more realistic in these complex cases. As a matter of fact, seven (77.8%) of nine patients who underwent surgery were considered successful cases because now, even if by an urethrostomy, they void well without the need for any additional procedure and they have overcome any other stent­related complications.

Nevertheless, considering that of 13 patients, 5 (38.5%) were chosen for a definitive urethrostomy, 3 (23.1%) are waiting for final reconstruction, and 4 (30.7%) refused surgery, we can state that the management of urethral stricture disease complicateti by permanent stent is a therapeutic challenge. The only patient who completed the reconstruction (case 9) reported a clinical failure.

In the management of failed stents, the philosophy of many surgeons is to avoid the staged procedure if possible. in our experience, adverse [oca] tissue conditions bave forced us to a salvage staged solution. We otherwise avoid one-stage reconstructions because they carry a high failure rate that is generally unacceptable to men with a long history of stricture disease. Furthermore, the sclerotic disease frequently involves the urethra extensively and not only in the tract where the stent is located (Figs. 2-4).

We have found that patients accept this safer, staged surgical strategy and often elect urethrostomy as a definitive solution, improving their quality of life overall.

Bu]lock et al ascertained that the urethral stent is one of the most common procedures (23.4%) used for anterior urethral strictures in the United States [15]. Despite predictable failure, 33% of urologists continue to manage recurrent strictures by using the stent, which is erroneously believed to be a minimally invasive method. Unfamiliarity with the literature and inexperience with open urethral surgery have led to the erroneous concept that there is a reconstructive surgical ladder in which urethroplasty is only performed after repeated endoscopie attempts [15]. lndeed, our series of patients had to wait a mean of 13.3 yr between the first treatment of the early stenosis and our surgical approach.

Considering the risk of irreversible urethral damage, the use of stents remains a questionable choice, especially in young patients who could overcome the urethral stricture by a successful primary urethroplasty. After bis first enthusiastic reports, Milroy advised against the implant in short virgin strictures or in urethras with extensive fibrosis. His only recommendation was for recurrent bulbo­membranous strictures with a moderate fibrosis and a short history [I6]. Actually, this risks converting a simple stricture that is curable with a primary urethroplasty into a complex stricture with a stent trapped in a badly scarred urethral wall. Furthermore, the removal of a stent placed in the proximal bulbar urethra risks damage to the adjacent distai sphincter, and this could compromise the continente of patients after TURP. Recently, Chapple and Bhargava stated that stents should be avoided for recurrent strictures with extensive spongiofibrosis, such as those after trauma or a failed urethroplasty [7]. However, this assertion could lead some to think that other indications remain for the use of stents in urethral stricture diseases. Our opinion is that, today, there are no more indications far stents in any kincl of anterior urethral strictures [17].

5. Conclusions

Stents represent the dream of resolving urethral strictures with ari easy and noninvasive method. Unfortunately, stents have not only failed to show gocci resu]ts but also risi( converting a simple stricture into a complex stricture that is difficu]t to manage with a one-stage surgical solution, thus often requiring a two-stage option, a definitive perineostomy, or a suprapubic diversion. Urologists who implant a "permanent" stent should consider that it could permanently damage the patient's quality of life.

Author contribntions: Enzo Palminteri had full access to ali the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Palminteri.

Acquisition of dota: Berdondini.