Vol.

42 (2): 351-355, March - April, 2016

ORIGINAL ARTICLE
doi: 10.1590/[Link].2015.0115

The long-term results of temporary urethral stent placement

for the treatment of recurrent bulbar urethral stricture
disease
_______________________________________________
Gokhan Temeltas 1, Oktay Ucer 1, Mehmet Bilgehan Yuksel 1, Bilal Gumus 1, Volkan Tatli 1, Talha
Muezzinoglu 1
1
Department of Urology, Faculty of Medicine - Celal Bayar University, Manisa, Turkey

ABSTRACT ARTICLE INFO

______________________________________________________________ ______________________
Aim: To evaluate the long term outcomes of temporary urethral stent placement for the Key words:
treatment of recurrent bulbar urethral stricture. Urethral Stricture; Stents;
Materials and Methods: Twenty-eight patients who underwent temporary polymer co- Disease; Therapeutics
ated urethral stent placement due to recurrent bulbar urethral stricture between 2010
and 2014 were enrolled in the study. The long term outcomes of the patients were Int Braz J Urol. 2016; 42: 351-55
analyzed.
Results: The mean age of the patients was 62.3±6.4 (44-81). The overall clinical suc- _____________________
cess was achieved in 18 (64.2%) of the 28 patients at a median (range) follow-up of
29 (7–46) months. No patient reported discomfort at the stent site. Stone formation Submitted for publication:
was observed at the urethral stent implantation area only in one patient. Stenosis oc- March 03, 2015
curred in the distal end of the stents in two patients and took place in bulbar urethra
_____________________
in seven patients after removed the stents. The mean maximum urine flow rates were
6.24±2.81mL/sec and 19.12±4.31mL/sec before and at 3 months after the procedure, Accepted after revision:
respectively. June 09, 2015
Conclusion: In this study, the success rate of temporary urethral stent placement has
remained at 64.2% at a median follow-up of 29 months. Therefore, our outcomes have
not achieved desired success rate for the standard treatment of recurrent bulbar ure-
thral stricture.

INTRODUCTION such as excision and primary anastomosis, penile

skin graft or buccal mucosa graft urethroplasty,
Urethral strictures are commonly managed which provide better long-term outcomes (3). Al-
initially by direct visual internal urethrotomy or though direct visual internal urethrotomy or dila-
dilatation. This can be curative in half of cases in tation is appealing both for urologists and patients
a suitably located short stricture (1). Nonetheless, as it is minimally invasive, urethroplasty is not a
these approaches are associated with high recur- minimal invasive approach. Therefore, as an alter-
rence rates and deficient long-term efficacy, espe- native treatment to traditional methods urethral
cially for strictures longer than 1cm (2). Therefo- stents have been used since 1985 in the treatment
re, many patients progress to open reconstruction of urethral strictures and successful results have

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 ibju | Long-term results of temporary urethral stent for recurrent bulbar urethral stricture

been reported by many centers (4). Temporary All patients were evaluated with uroflow-
urethral stent placement for recurrent bulbar ure- metry and post voiding residual urine measurement
thral strictures after direct visual internal urethro- in the postoperative third month. All stents were
tomy or dilatation may be considered as an option removed at 3 or 6 months after the procedure. All
before deciding urethroplasty. patients were followed at 3, 6 and 12 months after
The purpose of our study was to evalua- stent removal and then yearly. The success criteria
te the long term outcomes of temporary urethral after stent removal were no evidence of stricture on
stent placement for the treatment of recurrent bul- urethrogram or endoscopy, urinary peak flow gre-
bar urethral stricture. ater than 15mL/sec. and no recurrent urinary tract
infection.
MATERIALS AND METHODS A patient’s radiologic image before and af-
ter the urethral stent replacement and the views of
Participants the stent before the replacement and after removal
Twenty-eight patients who were treated of it are given in Figure-1.
with temporary polymer coated urethral stent
(Allium®, Allium LTD, Caesarea, Israel) due to re- Statistical analysis
current bulbar urethral stricture between 2010 and
2014 were included in the study. All patients had Statistical analysis was performed using
previously undergone many dilatations and/or di- SPSS version 13.0. The paired Student’s t-test was
rect visual internal urethrotomies. The inclusion used to analyze and compare Qmax and post voiding
criteria included: adult patients, recurrent bulbar residual urine preoperatively and at 3, 6 and 12
urethral strictures and at least two previous dila- months after stent removal. P<0.05 was considered
tations or direct visual internal urethrotomies. The to indicate statistical significance.
exclusion criteria consisted of: penile or posterior
urethral stricture, history of pelvic malignancy or
radiation, and previous hypospadias repair. Figure 1 - Radiologic images before and after the urethral
The patients were evaluated with retrogra- stent replacement and, the views of stent before the
de urethrogram and uroflowmetry. Residual urine replacement and after removal of it.
volume was estimated with ultrasonography. Pre-
operative demographics and clinical characteris-
tics were recorded including age, stricture etiolo-
gy, location, length, maximum urinary flow rate
(Qmax), number of previous direct visual internal
urethrotomies/dilatations and time to last stric-
ture recurrence. All patients provided informed
consent form and underwent urethral stent pla-
cement. The study protocol was approved by the
Local Ethics Committee.

Surgical technique
All patients used 2nd generation cephalos-
porins for prophylaxis. After induction of adequate
spinal or local anesthesia, the patient was placed in
the lithotomy position. Direct visual internal ure-
throtomy was performed at 12 o’clock direction and
then the urethral stent was placed in bulbar urethra A) The patient’s voiding cystourethrography before the operation; B) The patient’s
with 0 degree optical image. No Foley catheter was retrograde urethrography after direct visual urethrotomy and replacement of stent; C)
inserted after the urethral stent placement. The view of stent before the replacement; D) The view of stent after removal of it.

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 ibju | Long-term results of temporary urethral stent for recurrent bulbar urethral stricture

RESULTS a median (range) follow-up of 29 [7-46] months.

Three stents were removed at 3 months after the
The mean age of the patients was 62.3±6.4 operation because of stent migration. Urethral ste-
(44-81). The mean (range) stricture length was 1.9 nosis recurred in only one of these three patients.
(0.5–3.5)cm. The median (range) number of pre- Other stents were removed at 6 months after the
vious failed direct visual internal urethrotomy or procedure.
dilatation was 3 (2–11). The mean (range) time to The mean maximum urine flow rates were
stricture recurrence was 5 (1–60) months after the 6.24±2.81mL/sec and 19.12±4.31mL/sec before
most recent procedure. The etiologies of the stric- and at 3 months after the procedure, respective-
tures are summarized in Table-1. ly. Preoperative and postoperative Qmax and post
All stents were inserted successfully. The voiding residual urine values are given in Table-2.
operative time ranged between 15 to 35 minutes
(25±5.15) with no obvious intraoperative com- DISCUSSION
plications. Spontaneous voiding was achieved
in all patients immediately after stent insertion. Urethral strictures may be cured with en-
No patient reported discomfort at the stent site. doscopic technique alone. However, in longer
Stone formation was observed with infection at strictures with significant spongiofibrosis, the na-
the urethral stent implantation area only in one tural history is of stricture recurrence. Heyns et al.
patient two months after the operation. The stent (5) analyzed the role of repeated urethrotomies in
was removed and given medication for infection. patients who had a stricture recurrence after the
Stenosis occurred in the distal end of the stents first urethrotomy. They showed that after a single
in two patients and took place in bulbar urethra dilatation or a direct visual internal urethrotomy,
in seven patients after removal of the stents. The not followed by restricturing at 3 months, the
mean time from stent removal to restenosis was stricture recurrence rate was 55-60% at 24 months
4.2±1.5 (2-9) months. The overall clinical success and 50-60% at 48 months. After a second direct
was achieved in 18 (64.2%) of the 28 patients at visual internal urethrotomy for stricture recurren-
ce at 3 months, the stricture-free rate was 30-50%
Table 1 - The etiologies of the strictures. at 24 months and 0-40% at 48 months. After a
third dilatation or direct visual internal urethro-
Etiology Number of patients (%) tomy for stricture recurrence at 3 or 6 months, the
Iatrogenic 10 (36) stricture-free rate at 24 months was 0. Therefore,
Trauma 7 (25) for the treatment of recurrent urethral strictures
after many internal urethrotomies or dilatations
Idiopathic 7 (25)
it was recommended to perform urethroplasy. The
Post-infectious 4 (14) success rate of urethroplasty with buccal mucosa

Table 2 - The mean Q max and post voiding residual urine values in preoperative and postoperative follow-up.

Pre-op Post-op After stent removal p value

(n=28)
3 months 3 months 1 year 2 years 3 years
(n=25) (n=23) (n=15) (n=9) (n=4)

Qmax (mL/sec) 6.24* 19.12 19.01 18.40 18.56 17.26 <0.001

PVR (mL) 142.51* 40.12 44.14 46.85 41.56 48.89 <0.001

PVR = Post voiding residual urine;

* There were significantly differences between pre-op and post-op (both before and after stent removal)
Qmax and PVR values. There were no differences between post-op Qmax and PVR values.

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 ibju | Long-term results of temporary urethral stent for recurrent bulbar urethral stricture

was noticed to be 86% even if the length of stric- than direct visual internal urethrotomy in recur-
ture was long (mean 4.6cm) (6). In our country, rent urethral strictures, but also the complication
costs of urethroplasty with buccal mucosa, direct rate after placement of stent is very high. Stone
visual urethrotomy alone and placement of ure- formation of permanent stent has rarely been no-
thral stent with urethrotomy are approximate 400 ticed in literature (10). Karakose et al. (10) reported
USD, 200 USD and 1500 USD (stent: 1300 USD, the management of stone formation in the Memo-
procedure: 200 USD), respectively. Urethroplas- therm® urethral stent implantation area.
ty and direct visual urethrotomy are more cost- Yachia et al. (11) published their experien-
-effective than placement of stent in our country. ce of using a UroCoil™ temporary stent in 172 pa-
However, disadvantages of these two approaches tients with recurrent urethral strictures. The mean
in recurrent urethral strictures, the success rate of stent indwelling time was 12 months and their
direct visual urethrotomy is low and urethroplasty success rate was 83% at 24 months. In contrast
is not a minimal invasive approach. to this study, Choi et al. (12) noticed that the suc-
Being an alternative approach, temporary cess rate of covered nitinol stent in 33 patients
urethral stent is suggested for these patients who was 55% and they found that leaving the stent
have undergone many internal urethrotomies or for a minimum of 4 months resulted in less stric-
dilatations (1, 7). Wong et al. (1) hypothesized ture recurrence. Wong et al. (1) used Memokath®
that a temporary urethral stent might have a role stent in patients (n=22) with recurrent bulbar ure-
to play in the management of recurrent urethral thral stricture and the success rate was found to
strictures if deployed early during endoscopic be 78%. They removed the stents at three months
management. The temporary stent could act as a after the operations and the mean follow-up pe-
scaffold to splint against the mechanical forces of riod of their study was 23 months. Jordan et al.
scar contraction during the healing phase. This (13) placed a Memokath® 044TW stent into bulbar
may ultimately stabilize the stricture site during urethra in patients (n=63) with recurrent urethral
epithelization and thereby reduce the need for stricture and removed the stents at 12 months af-
further endoscopic or urethroplasty procedures. ter the operation. They compared between stent
Short-term stent placement also has the advan- and control groups. They reported that in stented
tage of fewer complications, e.g. migration, dis- patients patency was maintained significantly lon-
comfort, incontinence, infection and encrustation. ger than controls (median 292 versus 84 days). Ho-
Indeed, Atesci et al. (8) reported high complication wever, they did not test stent durability and did not
rate of permanent Memotherm® urethral stent in follow the patients after removal of the stents. The
recurrent bulbar urethral strictures (discomfort in reason for conflicting results of above studies may
implantation area: 40%, partial stent migration: be due to methodological diversity such as features
10%, stone formation in implantation area: 10% of stents and removal time of stent.
and dripping after micturition: 75%). They also The last study of the use of temporary ure-
found that the overall success rate of permanent thral stent in literature was reported by Culha et al.
urethral stents was 87.5% at the end of the ten- (7). Similar to our study, they used Allium® urethral
th year. Similar to our study, Sertcelik et al. (9) stent. However, they removed the stents 3 or 18
noticed long-term results of permanent urethral months after stent insertion. Our time for stent re-
stent (Memotherm®) in the management of recur- moval was 3 or 6 months. Their success rate was re-
rent bulbar urethral stenosis. They observed that ported 81.4% at a median follow-up of 10.6-month.
the success rate of stent was 78.7%, but also the In present study, the overall clinical success was
complications rate after the operation was high found to be 64.2% at a median follow-up of 29
(partial stent migration: 4.3%, hyperplastic re- months. Although number of patients in our study
action: 14.9%, discomfort in implantation area: was lower than their study, the mean follow-up pe-
42.6%, post-micturition dribbling: 68.1%, pain riod of our study was longer than their follow-up
during erection: 6.4%). These two studies show period. The low success rate of our study may due
that the success rate of permanent stent is higher to that the mean time of stent removal in our stu-

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 ibju | Long-term results of temporary urethral stent for recurrent bulbar urethral stricture

dy was lower than their study. They reported that 3. Bullock TL, Brandes SB. Adult anterior urethral strictures: a
longer indwelling time was statistically related to national practice patterns survey of board certified urologists
higher clinical success compared to shorter period. in the United States. J Urol. 2007;177:685-90.
However, we think that prolonged stenting may in- 4. Braf Z, Chen J, Sofer M, Matzkin H. Intraprostatic metal
stents (Prostakath and Urospiral): more than 6 years’ clinical
crease the number of complications similar to the
experience with 110 patients. J Endourol. 1996;10:555-8.
complication rates of permanent stents. In our stu-
5. Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment
dy, the most serious complication was stone forma- of male urethral strictures: is repeated dilation or internal
tion with infection on the stent and it was obser- urethrotomy useful? J Urol. 1998;160:356-8.
ved only in a patient. This patient had undergone 6. Lumen N, Oosterlinck W, Hoebeke P. Urethral reconstruction
direct visual internal urethrotomies 11 times. This using buccal mucosa or penile skin grafts: systematic review
complication may due to many previous urethroto- and meta-analysis. Urol Int. 2012;89:387-94.
mies. Further randomized studies should compare 7. Culha M, Ozkuvanci U, Ciftci S, Saribacak A, Ustuner M,
the complications and success rates between short- Yavuz U, et al. Management of recurrent bulbar urethral
-term and prolonged stenting. stricture-a 54 patients study with Allium bulbar urethral
stent (BUS). Int J Clin Exp Med. 2014;7:3415-9.
CONCLUSIONS 8. Atesci YZ, Karakose A, Aydogdu O. Long-term results of
permanent memotherm urethral stent in the treatment
of recurrent bulbar urethral strictures. Int Braz J Urol.
In our study, the success rate of temporary
2014;40:80-6.
urethral stent placement has remained at 64.2% at 9. Sertcelik MN, Bozkurt IH, Yalcinkaya F, Zengin K. Long-term
a median follow-up of 29 months. Therefore, our results of permanent urethral stent Memotherm implantation
outcomes have not achieved the desired success in the management of recurrent bulbar urethral stenosis.
rate for the standard treatment of recurrent bulbar BJU Int. 2011;108:1839-42.
urethral stricture. The overall success rate of our 10. Karakose A, Atesci YZ, Aydogdu O. The stone formation in
study was lower than other studies. This may due the Memotherm urethral stent implantation area: Is it a rare
to that the stent removal time of our study was complication? Can Urol Assoc J. 2014;8:E213-4.
lower than the others. We suggest that further stu- 11. Yachia D, Markovic Z, Markovic B, Stojanovic V. Endourethral
dies should investigate the best time of stent remo- prostheses for urethral stricture. Acta Chir Iugosl.
val in temporary stents for treatment of recurrent 2007;54:105-14.
12. Choi EK, Song HY, Shin JH, Lim JO, Park H, Kim CS.
urethral stents. We could not compare between the
Management of recurrent urethral strictures with covered
success rate of temporary stent in our study and
retrievable expandable nitinol stents: long-term results. AJR
success rate of urethroplasty, because the num- Am J Roentgenol. 2007;189:1517-22.
ber of patients in our study was too small for this 13. Jordan GH, Wessells H, Secrest C, Squadrito JF Jr,
comparison. Therefore, we also suggest that large McAninch JW, Levine L, et al. Effect of a temporary thermo-
population studies should compare between suc- expandable stent on urethral patency after dilation or internal
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from a 1-year randomized trial. J Urol. 2013;190:130-6.
Conflict of Interest

None declared.

REFERENCES _______________________
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Fax: +90 236 233-8040
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