In recent years, the surgical treatment of BPH has evolved considerably. Newer enucleation and vaporization techniques, improved energy platforms, and refined endoscopic instruments have changed the way we treat bladder outlet obstruction. However, technological progress has not eliminated the risk of urethral trauma. Prolonged operative time, repeated movement of the resectoscope, large-caliber sheaths, postoperative infection, catheterization, and local ischemic injury may all contribute to stricture development.
The aim of our systematic review was to summarize the available evidence on the treatment of iatrogenic urethral strictures after endoscopic BPH surgery, with a particular focus on contemporary endoscopic and open reconstructive approaches. Despite the clinical relevance of this topic, we found that the literature remains limited. Only eleven studies, including 610 patients, met the inclusion criteria. Most studies were retrospective, single-center series, and the reporting of stricture characteristics, previous treatments, follow-up, recurrence, and functional outcomes was heterogeneous; a meta-analysis was not appropriate.
Our research led to several considerations.
Firstly, both endoscopic treatment and open reconstruction showed acceptable outcomes in selected patients. Endoscopic management, mainly cold-knife urethrotomy with or without dilation, was associated with low reported morbidity and acceptable short-term success. However, these results must be interpreted cautiously because follow-up in the endoscopic series was generally shorter. In contrast, open reconstructive surgery provided more durable outcomes over longer follow-up, with success rates exceeding 80–90% in most contemporary series.
In clinical practice, endoscopic treatment may remain reasonable for short, non-obliterative strictures or those wishing to avoid more invasive surgery. Nevertheless, repeated endoscopic procedures should not delay definitive reconstruction in appropriate candidates.
Moreover, the location of the stricture plays a crucial role. Post-BPH strictures frequently involve the bulbo-membranous or sphincteric urethra, where surgery requires a careful balance between restoring patency and preserving continence. Our review confirms that urinary incontinence is the most relevant functional complication after open reconstruction, with rates varying according to technique and stricture location. This is particularly important because many of these patients may already have compromised bladder neck or internal sphincter function after previous prostate surgery.
One of the main messages from this review is that treatment should not be guided by a simple “endoscopic versus open” dichotomy. Instead, management should be individualized according to stricture length, location, degree of obliteration, previous interventions, patient comorbidities, continence status, expectations, and local surgical expertise.
This review also highlights what is still missing. Future studies should move beyond reporting only anatomical patency. Standardized definitions of success, longer follow-up, and systematic assessment of patient-reported outcomes are needed. Continence, sexual function, postoperative flow, quality of life, and patient satisfaction should all be incorporated into future datasets. Multicenter prospective registries would be particularly valuable, given the relative rarity and heterogeneity of these strictures.
Ultimately, iatrogenic urethral stricture after BPH surgery represents a reconstructive challenge that sits at the intersection of endourology and urethral surgery. Endoscopic treatment has a role, particularly in selected early or short strictures, but open reconstruction could offer the most durable solution for complex or recurrent disease. The best outcomes are likely achieved when patients are referred early to centers with expertise in both endoscopic BPH surgery and urethral reconstruction, allowing treatment to be tailored rather than repeated by default.
Written by: Mattia Lo Re,1,2 Anna Cadenar,1,2 Marta Pezzoli,1,2 Elettra Fuligni,1,2 Behzad Abbasi,3 Łukasz Białek,4 Francesco Chierigo,5 Mikołaj Frankiewicz,6 Leonidas Karapanos,7 Jakob Klemm,8 Guglielmo Mantica,9 Paul Neuville,10 Bruno Bucca,11 Maciej Oszczudłowski,4 Elaine Redmond,12,13 Jordán Scherñuk,14 Juan Diego Tinajero,15 Wesley Verla,16 Andrea Minervini,2 Malte W. Vetterlein,8 Andrea Cocci,2 on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
- Unit of Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy.
- Department of Urology, University of California, San Francisco, CA, USA.
- Department of Urology, Centre for Postgraduate Medical Education, Warsaw, Poland.
- Department of Urology, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy.
- Department of Urology, Medical University of Gdańsk, Gdańsk, Poland.
- Department of Urology, Klinikum Leverkusen, Leverkusen, Germany.
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genoa, Genoa, Italy.
- Department of Urology, Hospital Lyon Sud, Hospices Civils de Lyon, Lyon, France.
- Department of Urology, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy.
- Department of Urology, Cork University Hospital, Cork, Ireland.
- School of Medicine, University College Cork, Cork, Ireland.
- Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
- Chelsea Centre for Gender Surgery, Chelsea and Westminster Hospital, NHS Trust, London, UK.
- Department of Urology, AZ Maria Middelares, Ghent, Belgium.