Long-segment urethral stricture or panurethral stricture disease, involving the different anatomic segments of anterior urethra, is a relatively less common lesion of the anterior urethra compared to bulbar stricture. However, it is a particularly difficult surgical challenge for the reconstructive urologist. The etiology varies according to age and geographic location, lichen sclerosus being the most prevalent in some regions of the globe. Other common and significant causes are previous endoscopic urethral manipulations (urethral catheterization, cystourethroscopy, and transurethral resection), previous urethral surgery, trauma, inflammation, and idiopathic. The iatrogenic causes are the most predominant in the Western or industrialized countries, and lichen sclerosus is the most common in India. Several surgical procedures and their modifications, including those performed in one or more stages and with the use of adjunct tissue transfer maneuvers, have been developed and used worldwide, with varying long-term success. A one-stage, minimally invasive technique approached through a single perineal incision has gained widespread popularity for its effectiveness and reproducibility. Nonetheless, for a successful result, the reconstructive urologist should be experienced and familiar with the different treatment modalities currently available and select the best procedure for the individual patient.

Penile urethral strictures are common and impact on quality of life and healthcare costs. Management of penile urethral strictures is complex and depends on the physical characteristics of the stricture. Contemporary studies show no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes. Overall, long-term success rates range from 20 to 30%. However, their recurrence rate is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures, which make them less cost-effective. Surgical urethroplasty is associated with higher long-term success rates, averaging from 85 to 90%, mostly in virgin or noncomplex cases. Historically, modern urethral reconstruction has evolved from 1950s with the revolutionary introduction of Johanson's technique for staged urethral reconstruction. Since then, many techniques have been developed and employed for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

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Purpose: To evaluate efficacy of urorectal fistula (URF) repair using different approaches and the clinical factor determinant of success, and also the morbidity associated to the procedure and health-related quality of life (HRQoL) in male survivors of pelvic malignancies. Material and Methods: Retrospective evaluation of 39 patients with URF primarily intervened in three institutions using different surgical approaches. Success was defined as effective fistula closure. Variables evaluated included demographics, previous treatments, surgical approach, ancillary surgeries, complications and HRQoL by using a standardized nonvalidated specific questionnaire. Median follow-up from surgery to interview was 55 months (interquartile range 49, range 4-112). Factors determinant of success were investigated using logistic regression. Safety of the procedure was evaluated by Clavien-Dindo scale. Deterioration of continence and erectile function and other HRQoL issues were evaluated. Results: Prostate cancer treatment was the predominant etiology. The success rate for fistula repair was 89.5%. The surgical approach was not related to failed repair (p=0.35) or complications (p=0.29). Factors associated with failure were complications (p=0.025), radiotherapy (p=0.03), fistula location (p=0.04) and fistula size (p=0.007). Multivariate analysis revealed fistula size was the only independent determinant of failure (OR 6.904, 1.01-47.75). Complications occurred in 46.2% and severe complications in 12.8%. The mortality related to the procedure was 2.6%. Urinary incontinence was present before repair in 26.3% and erectile dysfunction in 89.5%. Fistula repair caused de novo urinary incontinence in 7.9% and deterioration of erectile status in 44.7%. Globally 79% were satisfied after repair and only 7.9% rated HRQoL as unhappy. Trans-sphincteric approach was related to less deterioration of erectile function (p=0.003), and higher perceived satisfaction in QoL (p=0.04). Conclusions: The surgical approach elected to correct URF is not determinant of success nor of complications. Fistula size appears as independent determinant for failure. Transsphincteric approach could be advantageous over other procedures regarding HRQoL issues.

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