Urethral stricture recurrence after urethral reconstruction is one of the most challenging problems in urology. With the increase in endoscopic surgery over the last three decades the incidence of urethral strictures has increased, with iatrogenic manipulation the leading aetiology in the developed world. Treatment options for urethral strictures include dilation, urethrotomy, stent, and reconstructive techniques. A sizeable proportion of patients who receive urethral stricture treatments will eventually recur, often with more complicated length and severity of disease. This thorough review of the published literature focuses on the prevention of stricture recurrence following endoscopic surgery. Disappointingly the highest level of evidence for such strategies is limited to level three (non-experimental studies, correlation studies, case reports) and level four (committee reports, expert opinion) studies. The evidence for post-endoscopic management catheterisation, repeated urethral dilatation, endo-urethral brachytherapy, intra-urethral use of steroids, Halofuginone (an antifibrotic agent), use of antibiotics, topical administration of Mitomycin C, hyaluronic acid instillation and other agents and techniques are presented.
The authors’ recommendations include three-day urethral silicone catheterisation post-urethrotomy, avoiding catheters larger than 22F to prevent fossa strictures in TURP patients and repeated urethral dilation for selected patients. There was inadequate evidence on the use of endourethral brachytherapy following urethrotomy. Intraurethral use of steroid is effortless, low in complications and adjuvant treatment after endoscopic management should be considered. Halofuginone demonstrated efficacy on animals with limited study sizes. Efficacy and safety of other agents are preliminary and undefined, thus they should not be routinely prescribed. The key to optimising patient’s therapy is to develop a better understanding of the healing process following urethral reconstruction.