Reconstructive Urology and Urethral Stricture Disease
Core concepts
Reconstructive urology requires understanding stricture etiology, evaluation, and choice of repair. Anterior strictures are commonly traumatic, inflammatory, or iatrogenic; bulbar strictures may follow instrumentation or catheterization. Evaluate with retrograde urethrography and voiding cystourethrography to define length and location; adjunctive imaging helps complex cases. Short bulbar strictures may be treated with dilation or internal urethrotomy, but recurrence is common and repeated endoscopic treatment is discouraged for long or recurrent strictures. Buccal mucosal graft urethroplasty is the standard for longer or recurrent anterior strictures. Posterior urethral stenosis after pelvic fracture is managed with delayed anastomotic repair. Understand principles of ureteral reconstruction (primary repair, Boari flap, ileal ureter) and bladder reconstruction (augmentation, neobladder). Graft principles: well-vascularized bed, tension-free anastomosis, and appropriate graft material.
Traps
Questions test when to abandon repeated dilation/urethrotomy in favor of urethroplasty. Do not perform urethroplasty in the setting of active infection. Recognize that pelvic fracture urethral injury is managed initially with suprapubic drainage and delayed repair, not immediate anastomosis.
Worked example / rule of thumb
A man with a recurrent bulbar stricture after multiple urethrotomies: the answer is buccal mucosal graft urethroplasty, not another urethrotomy. Rule of thumb: repeat the endoscopic treatment only while it is working; escalate to reconstruction for recurrence or long strictures.