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Advantages and disadvantages of different treatment methods

Advantages and disadvantages of different treatment methods

In the following, the advantages and disadvantages of the described methods are explained and compared..

Bougienage

Bougienage is a fairly simple, inexpensive procedure that can be performed on an outpatient basis.1 Due to the microlesions created during dilation, this procedure results in increased scarring and additional narrowing of the urethral lumen (see the chapter on bougienage). Thus, because of the short duration of success of the intervention and the high probability of recurrence, this method is not an alternative for long-term treatment of urethral stricture.

Urethrotomy

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Urethrotomy also offers a simple and rapid treatment option.2 Immediately after treatment, the patient experiences improvement. However, as described in chapter Urethrotomy, there is a prolongation of recurrence with each new procedure. With costs of EUR 1,505.75 for inpatient treatment and EUR 286.21 for outpatient treatment, urethrotomy is a relatively inexpensive form of therapy. The problem, however, is the very high, almost one hundred percent, probability of recurrence.3 Therefore, definitive treatment of urethral stricture on the basis of urethrotomies is very rarely successful. Performing multiple urethrotomies also worsens the efficacy of subsequent treatments and thus the long-term chances of cure.4.
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Stricture resection with end-to-end anastomosis

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Stricture resection with end-to-end anastomosis is also a treatment option only for short strictures. Furthermore, the results of this surgical technique depend on the number of previous endoscopic operations, which is why the indication should be given even in cases of first-diagnosed HRS. If end-to-end anastomosis is not possible due to the length of the HRS, open reconstruction of the HR by tissue transfer must be performed. The risks of the procedure are suture dehiscence, recurrence, and penile shortening and curvature.5.
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Reconstruction of the urethra using pedicled flap

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Reconstruction of the urethra using pedicled flaps is associated with relatively few early postoperative complications. However, problems often become apparent in the long-term course, for example, due to the continuous expansion of the thin foreskin, which is exposed to constant moisture. Because of the resulting recurrence, this technique is used increasingly infrequently.6,7
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Urethroplasty with native oral mucosa

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In urethroplasty with native oral mucosa, a piece of oral mucosa is first removed and used for reconstruction before transplantation.8 This procedure can lead to complications in the form of secondary damage after removal of the oral skin flap. Because of the lack of alternatives for the procedure to date, since at the current time the data are based only on expert reports and opinions, the side effects have been little studied. Urethroplasty with oral mucosa seems to be an effective procedure, but its evidence is currently not scientifically proven. However, the treatment of long-standing strictures presents a particular challenge because of the limited availability of oral mucosa and the associated increased risk of complications.9,10.

Transplantation of oral mucosa using MukoCell®

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Since 2013, transplantation of oral mucosa using MukoCell® has made it possible to treat long-standing strictures of the urethra as gently and effectively as possible. The characteristics of oral mucosa and its associated suitability for reconstruction of the urethra are used as the basis of the procedure. The biotechnologically grown tissue graft allows to use the advantages of oral mucosa without causing long-term damage to healthy organs. Accepting the injury of a healthy organ for the treatment of the stricture as well as the risk of side effects, although an advanced alternative procedure is available with MukoCell®, contradicts the principles of ethical action in medicine. Moreover, the injury to the oral mucosa not only tolerates consequential damage such as numbness, pain and impairment of facial expression, but also significantly increases the risk of developing oral cancer.

1 Kassenärztliche Bundesvereinigung KdöR. Berlin, Stand 2017/1, erstellt am 23.01.2017, abrufbar unter http://www.kbv.de/html/online-ebm.php, letzter Zugriff am 03.02.2017
2 Tritschler et al. Harnröhrenstrikturen – Ursachen, Diagnose und Therapien. Deutsche Ärzteblatt International. 2013; 110(13):220-226.
3 Santucci and Eisenberg. Urethrotomy has a much lower success rate than previously reported. The Journal of urology. 2010; 185(5):1859-1862.
4 Kessler et al. Long-term results of surgery for urethral stricture: a statistical analysis. J Urol. 2003 Sep;170(3):840-4.
5 Klevecka et al. Harnröhrenstriktur: Ursachen, Klassifikation, Diagnostik und Behandlung. Journal für Urologie und Urogynäkologie. 2010; 17(4):16-24
6 Knispel HH. Harnröhrenstrikturen. In: Jocham D u. Miller, K. Praxis der Urologie. In zwei Bändern. Band II. 3,. überarbeit. und erw. Auflage. Georg Thieme Verlag. Stuttgart. 2007.
7 Fiala R, Vidlar A, Vrtal R, Belej K,Student V. Porcine small intestinal submucosa graft for repair of anterior urethral strictures. Eur Urol 2007; 51: 702–8.
8 Ebd.
9 Palminterie et al. Urethral reconstruction in lichen sclerosus. Curr Opin Urol. 2012 Nov;22(6):478-83.
10 Engel et al. Harnröhrenrekonstruktion unter Verwendung von Mundschleimhauttransplantaten. Urologe A. 2013 May;52(5):650-656.