Pediatric urethral strictures and management strategies; an evolving and learning experience.

INTRODUCTION: Most of the surgical strategies for pediatric urethral strictures are derived from the adult experiences. Owing to this, we carried out this study to assess the management strategies for pediatric urethral strictures (PUS) in our institute.
METHODS: This prospective study included 28 patients with pediatric urethral strictures. Preoperatively, patients were assessed clinically and were subjected to VCUG and pre-procedure cystoscopy. Intraoperatively, urethroscopy, VCUG and retrograde urethrography were used to evaluate the length of the stricture.
Urethral dilatation (UD), direct visualization and internal urethrotomy (DVIU), excision and primary anastomosis (EPA) with or without pubectomy and dorsal onlay urethroplasty (DOU) were the procedures instituted to treat the strictures. After procedure, a silicone catheter was left in situ for 1-2 weeks in cases of DU and DVIU and 4-6 weeks in cases of EPA and DOU.
Postoperatively patients were assessed for symptoms and VCUG/cystoscopic evidence of reestablishment of urethral continuity. Average follow up 1.9 years. Long term results with regards to erectile dysfunction are yet awaited.

RESULTS: Three patients were successfully treated with single session urethral dilatation and another three with multiple sessions. Two UD patients required excision and primary anastomosis. Direct visualization and internal urethrotomy was performed in four patients which failed in one requiring EPA. EPA was carried out in fourteen patients with two requiring redo-EPA. Graft onlay urethroplasty was performed in five patients with satisfactory results.
DISCUSSION AND CONCLUSION: The procedure to address a stricture should be tailored to the individual urethral anatomy, stricture length and the surgeons’ experience. For smaller and partially obstructing strictures DVIU and DU can be tried but seem to be less effective than EPA, with high rates of secondary procedures. However, if not accompanied by complete excision of fibrosed spongiosum, EPA may be faced with recurrences. For longer bulbar strictures substitution urethroplasties are viable alternatives.