Urethral stricture excision and primary end-to-end anastomosis: a single-tertiary center long-term experience
Duan Gao1,2,3,4#
, Xiaoyu Li1,2,3,4#, Wenyuan Leng1,2,3,4, Xing Ji1,2,3,4, Weimin Hu1,2,3,4, Zhenpeng Zhu1,2,3,4, Chunru Xu1,2,3,4, Jian Lin1,2,3,4
Contributions: (I) Conception and design: D Gao, X Li; (II) Administrative support: C Xu, J Lin; (III) Provision of study materials or patients: J Lin; (IV) Collection and assembly of data: D Gao, X Li, W Leng, X Ji, W Hu, Z Zhu; (V) Data analysis and interpretation: D Gao, X Li, W Leng, X Ji, W Hu, Z Zhu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
#These authors contributed equally to this work.
Background: Urethral stricture represents a prevalent clinical entity in urological practice, with urethroplasty currently serving as the primary therapeutic approach for complex cases. This study aimed to analyze the efficacy of urethral stricture resection and primary end-to-end anastomosis for treating male urethral strictures and identify potential risk factors for postoperative recurrence.
Methods: A retrospective analysis was conducted on 37 male patients who underwent this procedure at Peking University First Hospital between February 2018 and September 2024. Clinical data of the patients, including age, preoperative urinary tract infection, etiology of urethral stricture, location of urethral stricture, length of stricture segment, preoperative urethral surgery history, presence of bladder fistula, preoperative and postoperative quality of life (QoL) index, preoperative and postoperative International Prostate Symptom Scores (IPSS) score, postoperative regular dilation, and postoperative complications, were collected and analyzed using statistical methods.
Results: The median follow-up time for the patients was 57 [interquartile range (IQR), 39.5–66.5] months, and the stricture length was 20 (IQR, 10–30) mm. The rate of recurrent stricture was 40.54% (15/37), with a median time from surgery to recurrence of 3 (IQR, 1–6) months. The preoperative and postoperative QoL and IPSS scores showed significant differences (P<0.05). Sexual dysfunction and urinary tract infections were the most common postoperative complications. There was no statistically significant difference in efficacy between posterior and anterior urethral strictures.
Conclusions: We provided clinical information on stricture resection and end-to-end anastomosis in the treatment of male urethral strictures, providing a baseline reference for relevant research. Individualized assessment and management are crucial for improving surgical success rates and patient QoL.
Keywords: Urethral stricture; end-to-end anastomosis; urethroplasty
Submitted Mar 03, 2025. Accepted for publication May 01, 2025. Published online Jun 26, 2025.
doi: 10.21037/tau-2025-175
Highlight box
Key findings
• This study evaluated the efficacy of urethral stricture excision and primary end-to-end anastomosis (EPA) in treating complex male urethral strictures. The median follow-up time for the patients was 57 [interquartile range (IQR), 39.5–66.5] months, and the stricture length was 20 (IQR, 10–30) mm. The recurrence rate was 40.54% (15/37), with a median time to recurrence of 3 (IQR, 1–6) months. Significant improvements were observed in quality of life (QoL) and International Prostate Symptom Scores (IPSS) postoperatively (P<0.05).
What is known and what is new?
• EPA is a well-established technique for short-segment bulbar urethral strictures (<2 cm), with success rates exceeding 90%. However, its application for urethral strictures is limited to specific cases.
• This study provides long-term outcomes for complex strictures, highlighting the recurrence rates and potential risk factors such as stricture location, prior urethral surgery, presence of bladder fistula, and etiology.
What is the implication, and what should change now?
• The high recurrence rate underscores the need for individualized patient assessment and management to improve surgical outcomes.
• Future research should focus on larger sample sizes and longer follow-up periods to further explore strategies for reducing recurrence rates. Additionally, meticulous surgical technique, including complete scar excision and tension-free anastomosis, is crucial for better outcomes.
Introduction
Urethral stricture is a relatively common benign disease in urology, with etiologies including trauma, infection, iatrogenic injury and idiopathic factors. The incidence of male urethral stricture is becoming higher in China, with trauma and iatrogenic injury being the main causes, often associated with complications such as urinary tract infections, urinary incontinence, and erectile dysfunction (1).
Trauma (51.76%) and iatrogenic injury (34.49%) are the leading causes of urethral stricture in China, with pelvic fractures and transurethral surgeries being the most common contributors (2). Historically, iatrogenic injuries (especially transurethral procedures) increased from 11.5% to 18.7% (1), while radiation- and infection-related strictures declined. From 2005 to 2010, endoscopic procedures (e.g., urethral dilation) decreased from 54% to 32.75%, whereas open urethroplasty increased significantly. Despite this shift, urethral dilation (92.3%) and endoscopic incision (60.1%) remain dominant in current practice, reflecting regional disparities in the adoption of advanced techniques (3). Urethroplasty, though increasingly accepted (45.2% end-to-end anastomosis), is limited by technical expertise, with only 8.9% of surgeons performing >10 cases annually.
The recurrence rate of urethral stricture is high, and surgical intervention is usually required. Current surgical treatment methods include endoscopic minimally invasive treatments such as urethral dilation and internal urethrotomy, as well as open urethroplasty. Urethral stricture excision and primary anastomosis (EPA) is suitable for bulbar urethral strictures of less than 2–3 cm, as well as the standard method for treating traumatic posterior urethral strictures as the first approach or after failure of primary endoluminal treatment (4). Despite the high success rate of EPA, it faces challenges such as technical complexity, the risk of complications such as recurrence, the potential for erectile dysfunction, and sometimes a prolonged recovery period (5-8).
We detail our single-center clinical experience on urethral stricture excision and primary end-to-end anastomosis, and we also discuss the factors affecting the recurrence of urethral stricture after surgery. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-175/rc).
Methods
General information
This retrospective study included 37 male patients with complex urethral strictures who underwent urethral stricture resection and end-to-end anastomosis at Peking University First Hospital between February 2018 and September 2024. The inclusion criteria were: (I) male patients aged ≥18 years; (II) clinical diagnosis of urethral stricture confirmed by cystoscopy, urethrography, and uroflowmetry; (III) no serious heart, lung, or other organ diseases; (IV) complete surgical records; (V) informed consent signed. The exclusion criteria were: (I) presence of urethral cancer or other malignant tumors; (II) loss to follow-up or incomplete data; (III) inability to cooperate with the study. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Ethics Committee of Peking University First Hospital (No. 2022 467-002). Because of the retrospective nature of the study, the requirement for informed consent was waived.
Surgical procedure
All patients underwent urethrography before surgery and received routine preoperative preparation. Those with urinary tract infections received antimicrobial treatment. The surgery involved a lithotomy position, perineal disinfection, and a midline incision to adequately expose the bulbocavernous uretha. After identifying the site of the stricture using urethral probes, the scar tissue was completely removed. The urethra was then anastomosed using absorbable sutures, and a silicone catheter was inserted. For posterior urethral strictures, interrupted sutures should be utilized to achieve a tension-free anastomosis between the bulbar urethra and prostatic urethral mucosa, with 4-0 or 5-0 absorbable sutures recommended. In anterior urethral stricture repair, short-segment strictures are managed with interrupted sutures, while long-segment strictures require a combined technique: initial interrupted sutures are placed to anchor the edges, followed by continuous mucosal suturing at a spacing of approximately 3 mm, all performed with 5-0 absorbable sutures. Postoperative care included antimicrobial treatment, monitoring for complications, and early ambulation. The catheter is usually retained for 3 months after surgery. During the 3-month period after surgery, the catheter should be replaced with a new one each month.
Observation indicators
Endpoints were defined as the need for surgical intervention due to recurrence of stricture, and surgical intervention included endourethral therapy and open urethroplasty. Information was collected from electronic medical records, outpatient clinics, and phone follow-up, including age, preoperative urinary tract infection, etiology of urethral stricture, location of urethral stricture, length of stricture segment, preoperative urethral surgery history, presence of bladder fistula, preoperative and postoperative quality of life (QoL) index, preoperative and postoperative IPSS scores, postoperative regular dilation, and postoperative complications.
Statistical analysis
SPSS 26.0 software was used for statistical analysis. Data were presented as mean ± standard deviation for normally distributed data and median [interquartile range (IQR)] for non-normally distributed data. Count data were presented as frequency (percentage) [n (%)]. Kaplan-Meier survival analysis with the log-rank test was used for univariate analysis, and the Cox proportional hazards regression model was used for multivariate analysis. P<0.05 was considered statistically significant.
Results
The general information of the patients is shown in Table 1. The average age of the patients was 48.7±2.14 years. Most patients had a hospital stay of 5 to 7 days. The median stricture length was 20 (IQR, 10–30) mm. The median operation time was 93 minutes, and the longest operation time was over 2 hours. The blood loss was relatively small, mostly 20 mL or less. Most patients (64.86%) were from rural areas. In this case series, posterior urethral stricture is more common (59.46%). Eighty-six-point-four-nine percent of the patients had undergone bladder fistulation before surgery. Trauma was the most common cause (78.38%), followed by balanitis (5 cases, 13.51%), iatrogenic injury (2 cases, 5.41%), and infection (1 case, 2.70%).
Table 1
| Item | Open surgery (n=37) |
|---|---|
| Age (years) | 48.7±2.14 |
| Length of hospital stay (days) | 5 [5–7] |
| Stricture length (mm) | 20 [10–30] |
| Operation time (hours) | 1.33 [1.24–1.45] |
| Blood loss during operation (mL) | 20 [0–50] |
| Postoperative catheterization time (months) | 3 [3–3] |
| Region | |
| Urban | 13 (35.14) |
| Rural | 24 (64.86) |
| Stricture location | |
| Anterior urethra | 15 (40.54) |
| Posterior urethra | 22 (59.46) |
| Preoperative urethral surgery history | |
| Yes | 9 (24.32) |
| No | 28 (75.68) |
| Preoperative bladder catheterization | |
| Yes | 32 (86.49) |
| No | 5 (13.51) |
| Etiology | |
| Trauma | 29 (78.38) |
| Balanitis | 5 (13.51) |
| Iatrogenic injury | 2 (5.41) |
| Infection | 1 (2.70) |
Data are presented as mean ± standard deviation, median [interquartile range], or n (%).
The postoperative restenosis analysis curve is presented in Figure 1. The median follow-up time for the patients was 57 (IQR, 39.5–66.5) months. The recurrence rate of urethral stricture was 40.54% (15/37), with a median time to recurrence of 3 (IQR, 1–6) months. Significant improvements were observed in both QoL scores and International Prostate Symptom Scores (IPSS) after surgery (P<0.05). Regarding postoperative complications, 5 patients had sexual dysfunction and 5 patients had postoperative infections. No other postoperative complications were observed during follow-up.
We categorized the patients into a non-recurrence group and a recurrence group based on whether they had recurrence after surgery, and their clinical characteristics are shown in Tables S1,S2. Due to the small sample size, we did not find statistically significant differences in the clinical characteristics of the two groups.
We divided the patients into an anterior urethral group and a posterior urethral group based on the location of their urethral stricture. The analysis compared anterior urethral stricture (n=15) and posterior urethral stricture (n=22) groups in Table 2. The median follow-up time for the anterior urethral group was 56 (IQR, 46–65) months, while for the posterior urethral group, it was 61 (IQR, 38–66) months. The recurrence rate of the anterior urethral group was 53.3%, while the recurrence rate of the posterior urethral group was 31.8%, with no significant statistical difference (P=0.31). The posterior group had longer hospital stays (median 5.5 vs. 5 days, P=0.049) and surgery duration (median 1.35 vs. 1.28 hours, P=0.03). All posterior strictures were trauma-related (100%), while anterior strictures had more varied etiologies (53.5% non-traumatic).
Table 2
| Item | Anterior urethra (n=15) | Posterior urethra (n=22) | P value |
|---|---|---|---|
| Postoperative recurrence status | 0.31 | ||
| Recurrence | 8 (53.3) | 7 (31.8) | |
| No recurrence | 7 (46.7) | 15 (68.2) | |
| Age (years) | 51 [40–57] | 54 [38.5–56.25] | 0.89 |
| Length of hospital stay (days) | 5 [2–6] | 5.5 [5–8] | 0.049 |
| Stricture length (mm) | 10 [10–30] | 22.50 [10.00–26.25] | 0.33 |
| Operation time (hours) | 1.28 [0.49–1.40] | 1.35 [1.27–1.52] | 0.03 |
| Blood loss during operation (mL) | 0 [0–50] | 30 [0–50] | 0.23 |
| Postoperative catheterization time (months) | 3 [3–3] | 3 [3–4.75] | 0.12 |
| Region | 0.30 | ||
| Urban | 7 (46.7) | 6 (27.3) | |
| Rural | 8 (53.3) | 16 (72.7) | |
| Preoperative urethral surgery history | 0.71 | ||
| Yes | 3 (20.0) | 6 (27.3) | |
| No | 12 (80.0) | 16 (72.7) | |
| Preoperative bladder catheterization | 0.007 | ||
| Yes | 10 (66.7) | 22 (100.0) | |
| No | 5 (33.3) | 0 | |
| Etiology | <0.001 | ||
| Trauma | 7 (46.7) | 22 (100.0) | |
| Others (balanitis, iatrogenic, infection) | 8 (53.3) | 0 |
Data are presented as median [interquartile range] or n (%).
Discussion
This study evaluated the effectiveness of EPA for treating male urethral strictures at a large tertiary referral center in China. EPA is still the preferred option for short segment bulbar urethral strictures, while longer strictures (>2–3 cm) usually require substitution techniques, such as the implantation of buccal mucosa grafts (9). The mobility of the bulbous urethra is relatively high, and the tension after anastomosis is low. However, EPA is not recommended for penile urethral strictures. The mobility of the urethra in the penile region is limited, making it prone to angulation or rupture after anastomosis. Moreover, the surgical injury also tends to cause cavernous fibrosis and sexual dysfunction. In cases of traumatic stricture of the posterior urethra, scarring after injury may lead to difficulties in manipulation. In our study, posterior urethral strictures undergoing EPA were all traumatic urethral strictures and all the patients had cystostomy. They had more complex disease conditions, with longer hospital stays and longer operation time than patients undergoing EPA for anterior urethral strictures. Nevertheless, our experience shows that EPA still has promising effects on posterior urethral stricture. Posterior and anterior urethral strictures had comparable efficacy among patients who received EPA, with no statistically significant difference in recurrence rates. Scar tissue from traumatic urethral stricture may be more localized and simpler than strictures caused by other factors, creating the possibility for complete excision.
The key to the successful EPA lies in the complete removal of local scar tissue, ensuring that the anastomosis is tension-free and has a sufficient blood supply. During the procedure, it is important to fully expose the bulbous urethra. If necessary, a portion of the penile suspensory ligament can be divided to increase the mobility of the urethra. When performing anastomosis of the two urethral ends under tension, the following techniques can be applied to reduce the distance between the ends: extensive mobilization of the distal urethra, incising the septum between the corpora cavernosa, and wedge resection of the inferior pubic symphysis. To prevent postoperative painful erections, the urethral mobilization should not exceed the suspensory ligament of the penis in principle. By adhering to this principle, the natural elasticity of the urethra can be utilized to achieve an anterior urethral elongation of approximately 3 cm. For patients with insufficient mobility even after mobilizing the distal urethra to the level of the suspensory ligament, further release of the suspensory ligament should be considered (10). When performing a free urethral cavernous body procedure, it is important to preserve the bilateral cavernous arteries to avoid postoperative cavernous fibrosis (11,12). At the same time, it is necessary to perform complete excision of the fibrotic segment down to the normal urethral mucosa, and the cut ends can be trimmed obliquely to increase the diameter of the anastomosis and reduce the risk of postoperative circumferential stricture. Current research has found no significant differences in success or complications between continuous and interrupted suturing methods, but continuous suturing may have the advantage of allowing for earlier and safer removal of the urinary catheter, in addition to reducing surgical time (13).
In our study, erectile dysfunction is the most common postoperative complication. During the EPA procedure, there may be damage to the neurovascular bundle when operating near the membranous urethra. Additionally, posterior urethral surgery may injure the external sphincter, increasing the risk of temporary urinary incontinence after surgery. The selection of appropriate cases is crucial, as excessive length can lead to anastomotic rupture or restenosis. For experienced surgeons, the length limit can be appropriately adjusted, such as in the case of managing proximal stenosis with combined resection of the inferior pubic ramus.
Urethral stricture excision and primary end-to-end anastomosis is an effective treatment for short-segment urethral strictures in men. However, the risk of recurrence remains significant, emphasizing the importance of individualized patient assessment and management to improve success rates and QoL. Even in the case of posterior urethral strictures, especially traumatic strictures, meticulous free technique and tension-free anastomosis can achieve promising clinical outcomes. Further research with larger sample sizes and longer follow-up periods is needed to confirm these findings and explore strategies for reducing recurrence.
Compared to the conventional 2- to 4-week indwelling time of urinary catheters after EPA, a prolonged indwelling time of up to 3 months may allow mucosal cells to fully cover the entire urethra, which is helpful in reducing the risk of recurrence.
Based on clinical case reports documented at our institution between 2003 and 2004, two individuals diagnosed with urethral strictures were treated with tissue-engineered urethral reconstruction (14). Histological examination at the 3-month postoperative follow-up demonstrated complete urothelial regeneration across the acellular dermal matrix graft (ADMG) implantation site.
The two patients with recurrent urethral strictures following multiple failed surgical interventions underwent tissue-engineered urethral reconstruction. Preoperative evaluations revealed stricture lengths of 5 and 3 cm, correlating to maximal urinary flow rates of 2.1 and 4.3 mL/s. The protocol commenced with partial cystectomy to harvest 3–5 cm of bladder mucosa, which was aseptically processed into 3 mm3 explants and cultured in keratinocyte serum-free medium (K-SFM) for primary urothelial cell expansion. After a 7-day incubation period, confluent urothelial cells were combined with an ADMG scaffold to generate bioengineered grafts.
Electron microscopy and hematoxylin-eosin staining confirmed successful epithelial stratification and integration at the cell-scaffold interface. Following 28 days of in vitro maturation, urethroplasty was performed via ventral urethrotomy to expose the fibrotic mucosa, followed by graft implantation. Postoperative urinary diversion was maintained via catheterization for 3 months prior to systematic evaluation.
Histopathological analysis at 3 months demonstrated complete re-epithelialization and anatomical restoration of the urethral lumen. Urodynamic studies revealed normalized maximal flow rates (>15 mL/s). Long-term follow-up at 36 months confirmed functional recovery of micturition and penile morphology. Remarkably, serial retrograde urethrography and urethroscopy over 96 months postoperatively showed sustained urethral patency without recurrence of strictures or fibrotic changes, underscoring the durability of this regenerative approach.
In rabbit models, complete epithelialization and functional recovery were observed within 3 months using urinary stem cells or decellularized amniotic scaffolds. In dogs, good recovery was observed after 3 months with stem cell-based repairs. Studies with poly(lactic-co-glycolic acid) (PLGA) scaffolds and autologous cells reported normal urethral structure after 3 months, with no complications over 72 months. However, whether the urinary catheter needs to be kept in place for as long as 3 months after EPA surgery requires further clinical research in the future.
Conclusions
End-to-end anastomotic urethroplasty demonstrates efficacy for short-segment urethral strictures, particularly traumatic posterior cases, with comparable recurrence rates between the anterior (53.3%) and posterior (31.8%) groups despite longer operative durations in the latter. Key technical determinants include complete excision of scar tissue, tension-free anastomosis, and preservation of vascular integrity. Postoperative complications, notably erectile dysfunction (13.5%), highlight the need for refined neurovascular bundle preservation techniques. These findings underscore the importance of surgeon expertise and individualized approaches in optimizing functional outcomes in urethral reconstruction.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-175/rc
Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-175/dss
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-175/prf
Funding: This work was supported by grants from
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-175/coif). All authors report that this study received funding from the National Natural Science Foundation of China (No. 82270708) and National High Level Hospital Clinical Research Funding (Scientific Research Seed Fund of Peking University First Hospital) (No. 2025SF037). The funders had no role in study design, data collection/analysis, or manuscript preparation. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Ethics Committee of Peking University First Hospital (No. 2022 467-002). Because of the retrospective nature of the study, the requirement for informed consent was waived.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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