










































Key Words Competing Interests Article Information

Radiotherapy, urethral stricture, dilation, 
intermittent catheterization

None declared. Received on July 28, 2021 
Accepted on August 27, 2021 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(1):14–20

DOI: 10.48083/XFYL6260

14 SIUJ  •  Volume 3, Number 1  •  January 2022 SIUJ.ORG

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

ORIGINAL RESEARCH

The Efficacy and Safety of a Conservative 
Management Approach to Radiation-Induced  
Male Urethral Strictures in Elderly Patients  
With Comorbidities
Alexander T. Rozanski,1 Matthew J. Moynihan,1 Lawrence T. Zhang,1 Alexandra C. Muise,2  
Daniel D. Holst,2 Steven A. Copacino,1 Leonard N. Zinman,1 Jill C. Buckley,2 Alex J. Vanni1

1 Lahey Hospital and Medical Center, Burlington, United States 2 University of California San Diego School of Medicine, San Diego, United States

Abstract

Objectives To assess the outcomes of a conservative management approach to radiation-induced urethral stricture 
disease (R-USD) in an elderly population with comorbidities.

Methods Patients with R-USD managed with endoscopic procedures and/or clean intermittent catheterization 
(CIC) between 2007 and 2019 were included. Patients were excluded if they had an obliterative stricture, prior 
urethral reconstruction/urinary diversion surgery, or < 3 months follow-up. Primary outcome measures were 
urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, uroflowmetry/post-void residual, 
and urinary incontinence (UI). Failure was defined as progression to reconstructive surgery or permanent indwelling 
catheterization.

Results Ninety-one men were analyzed with a median follow-up of 15.0 months (IQR 8.9 to 37.9). Median age 
was 75.4 years (IQR 70.0 to 80.0), body mass index was 26.5 kg/m2 (IQR 24.8 to 30.3), and Charlson comorbidity 
index was 6 (IQR 5 to 8). Median stricture length was 2.0 cm (IQR 2.0 to 3.0). Stricture location was bulbar (12%), 
bulbomembranous (75%), and prostatic (13%). A total of 90% underwent dilation, and 44% underwent direct visual 
internal urethrotomy (DVIU). For those that underwent these procedures, median number of dilations and DVIUs 
per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), respectively. Forty percent used CIC. Thirty-four percent developed a 
UTI, and 15% had an AUR episode requiring urgent treatment. Creatinine values, uroflowmetry measurements, and 
UI rates remained stable. Eighty percent avoided reconstructive surgery or indwelling catheterization.

Conclusion Most elderly patients with comorbidities with R-USD appear to be effectively managed in the short-
term with conservative strategies. Close observation is warranted because of the risk of UTIs and AUR. The potential 
long-term consequences of repetitive conservative interventions must be considered.

Introduction

Radiotherapy is a commonly used modality for the treatment of pelvic malignancies, particularly prostate cancer 
and anorectal cancers. According to a large retrospective analysis of the Surveillance, Epidemiology, and End Results 
(SEER) Program from 2004 to 2013, 38% of patients with localized prostate cancer chose radiation as initial therapy[1]. 

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Although significant technical in recent years have 
allowed for more targeted therapy of the malignancy, 
ionizing radiation treatment can still result in ischemia 
and fibrosis of the surrounding tissues through direct 
and indirect damage to cellular deoxyribonucleic acid, 
with significant clinical consequences. Radiation-
induced urethral stricture disease (R-USD) is one of 
these consequences, with a reported incidence of 1.7% 
to 31.6% depending on the type of radiation used[2–4]. 
This subset of USD is of particular importance to the 
reconstructive urologist because of the risk of stricture 
recurrence and development or worsening of urinary 
incontinence (UI) after surgical treatment.

Strictures after pelvic radiotherapy most commonly 
affect the bulbomembranous urethra[5], although 
isolated bulbar strictures or prostatic stenoses can 
occur. Recurrence rates after urethroplasty for R-USD 
are reported to range from 10% to 27% in series with 
short median follow-up[5,6], in comparison with the 
15.6% recurrence rate reported in long-term follow-up of 
urethroplasties of any kind[7]. Reported UI rates range 
from 7% to 50% for those patients who have undergone 
urethroplasty for R-USD[5,6,8–11]. These patients may 
require subsequent artificial urinary sphincter (AUS) 
placement, and are subject to the increased risk of AUS 
erosion in a radiated field[12–14]. These well-docu-
mented risks in reconstructive surgery for R-USD lead 
some to instead consider endoscopic management with 
urethral balloon dilation, direct vision internal urethrot-
omy (DVIU), and/or clean intermittent catheterization 
(CIC) despite stricture recurrence rates reported in the 
range of 40% to 60%[15]. Additionally, many of these 
patients are elderly and have comorbidities resulting in 
suboptimal surgical candidacy.

There is a dearth of literature on the outcomes of 
conservative treatment strategies for R-USD with the 
goal of avoiding invasive surgery or permanent indwell-
ing catheterization; in particular, there is little on the 
safety, associated complications, and effect on quality of 
life of such an approach. The objective of this multi-in-
stitutional study was to evaluate the outcomes of conser-

vative management for R-USD in patients who were not 
optimal surgical candidates or who were unwilling to 
accept the risks associated with stricture recurrence and 
new or worsening UI following urethroplasty.

Methods
After obtaining institutional review board approval, we 
retrospectively identified patients with R-USD placed on 
a conservative treatment regimen by 3 fellowship-trained 
reconstructive urologists at 2 participating institutions 
between 2007 and 2019. The decision to manage R-USD 
with conservative techniques, urethral reconstruction, 
urinary diversion surgery, or permanent indwelling 
catheterization was based upon a patient-centered 
decision-making model including thorough counseling 
on the risks and benefits of all treatment options. 
Conservative management was defined as urethral 
balloon dilation, DVIU, or CIC. Patients were excluded 
from analysis if they had an obliterative stricture, 
separate stricture of the pendulous urethra or fossa 
navicularis/meatus, isolated bladder neck contracture, 
prior history of urethral reconstruction or urinary 
diversion surgery, or less than 3 months’ follow-up.

Patient demographics, pelvic radiation details, previ-
ous urologic interventions, and stricture-related urinary 
symptoms were evaluated. Stricture characteristics were 
assessed by retrograde urethrogram, voiding cysto-
urethrogram, and/or cystourethroscopy. The choice 
of diagnostic tool(s) was based on surgeon discretion, 
consistent with American Urological Association guide-
lines for male urethral stricture[16]. Treatment details 
were recorded, including the number of dilations and 
DVIUs per patient and CIC regimen details. Patients 
who underwent multiple different management tech-
niques were included to reflect real-life clinical practice.

During the study period, we evaluated several 
primary outcome measures. These included the inci-
dence of culture-proven urinary tract infections (UTI) 
requiring antibiotic therapy and acute urinary retention 
(AUR) episodes requiring urgent intervention such as 
complex urethral catheter placement or suprapubic tube 
placement. Objective outcomes including changes in 
serum creatinine levels, uroflowmetry values, and post-
void residual measurements over time were captured. 
The effect of conservative management strategies on 
urinary continence status and the need for incontinence 
treatment was also assessed. Conservative management 
failure was defined as progression to reconstructive 
surgery or permanent indwelling catheterization.

Categorical variables were compared with the McNe-
mar test, chi-square test, and Fisher exact test. Contin-
uous variables were compared with the Wilcoxon 
signed-rank test and the Wilcoxon rank-sum test. Statis-
tical significance was predefined at P < 0.05.

Abbreviations 
AUR acute urinary retention
AUS artificial urinary sphincter
CCI Charlson comorbidity index
CIC clean intermittent catheterization
DVIU direct visual internal urethrotomy
R-USD radiation-induced urethral stricture disease
UI urinary incontinence
UTI urinary tract infection

15SIUJ.ORG SIUJ  •  Volume 3, Number 1  •  January 2022

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Results
A total of 91 men were analyzed with a median follow-
up of 15.0 months (IQR 8.9 to 37.9). Median age was 
75.4 years (IQR 70.0 to 80.0), BMI was 26.5 kg/m2 (IQR 
24.8 to 30.3), and Charlson comorbidity index (CCI) 
was 6 (IQR 5 to 8). The indication for pelvic radiation 
was prostate cancer (97%) and anorectal cancer (3%). 
Two patients who received radiation for prostate cancer 
also received radiation for other pelvic malignancies 
(one for bladder cancer and one for testicular cancer). 
Radiation type included external beam radiation alone 
(63%), brachytherapy alone (26%), combination external 
beam radiation and brachytherapy (5%), and proton-
beam therapy (5%). Of those with prostate cancer, 81% 
received radiation as primary therapy, and 19% received 
adjuvant or salvage radiation. There were no salvage 
prostatectomies in this cohort.

Median stricture length was 2.0 cm (IQR 2.0 to 3.0). 
The majority of patients (75%) had a bulbomembranous 
stricture location with or without more proximal pros-
tatic involvement. Isolated bulbar strictures and pros-
tatic stenoses were seen in 12% and 13%, respectively. 
The most common urinary symptoms were slow f low 
(59%), urgency/frequency (52%), and nocturia (45%). UI 
was reported in 59% of patients at initial evaluation (42% 
stress UI, 34% urgency UI, 24% mixed UI). A total of 82 
patients (90%) underwent urethral balloon dilation, and 
40 patients (44%) underwent DVIU. For those that under-
went these procedures, median number of dilations and 
DVIUs per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), 
respectively. CIC was used in 40% of patients.

Treatment Outcomes
Median serum creatinine, urof lowmetry values, and 
post-void residual measurements remained stable 
between first and last visits (Table 1). Fourteen patients 
(15%) had an AUR episode requiring urgent treatment, 
with a median of 1 episode per patient (IQR 1 to 2). 
Median time to first AUR episode after initiation of 
conservative management was 14.4 months (IQR 1.7 
to 48.6). Thirty-one patients (34%) developed a UTI 
requiring antibiotic therapy, with a median of 2 UTIs 
per patient (IQR 1 to 3). Median time to first UTI after 
initiation of conservative management was 14.3 months 
(IQR 4.5 to 39.4). Two patients developed urosepsis 
requiring hospitalization, 1 episode per patient. No 
patient developed severe or end-stage chronic kidney 
disease secondary to their stricture disease. UI rates 
remained stable over the study period (59% to 56%, 
P = 0.47). For those patients who used incontinence 
products, median number of pads per day (2.0 versus 
1.5, P = 0.47) and median number of diapers per day (1.0 
versus 1.0, P > 0.90) remained stable. Four patients (4%), 
none of whom progressed to urethral reconstruction, 

under went subsequent AUS placement w it h no 
postoperative complications to date.

Treatment Failures
Eighteen patients (20%) started and subsequently 
failed conservative management strategies (Figure 1). 
Three patients (17%) pursued urethral reconstruction 
and 1 (6%) opted for ileal conduit diversion. Definitive 
indwelling urethral catheterization and suprapubic 
catheterization was pursued in 4 patients (22%) and 10 
patients (56%), respectively. Failure rate stratified by 
radiation type was external beam radiation alone (19%), 
brachytherapy alone (13%), combination external beam 
radiation and brachytherapy (60%), and proton-beam 
therapy (20%). In the 55 of 91 patients (60%) with at least 
1-year follow-up, failure rate was 22%.

The incidence of UTI episodes was significantly 
higher in those who failed conservative management 
(P = 0.03) (Table 2). Median CCI was also statistically 
significantly higher in the failure group (P = 0.003). 
The success group and failure group were comparable 
with respect to which conservative interventions were 
performed and median follow-up.

Discussion
To our knowledge, this is the largest multi-institu-

tional study to date focusing on conservative manage-
ment outcomes for R-USD. The majority of patients 
(80%) who were placed on a conservative management 
regimen over a median follow-up of 15.0 months were 
able to avoid invasive surgery or permanent indwell-
ing catheterization with stable serum creatinine levels, 
uroflowmetry values, and post-void residual measure-
ments. UI rates were not affected by conservative strate-
gies, and this is an important reason why many patients 
elect to pursue conservative treatment rather than 

16 SIUJ  •  Volume 3, Number 1  •  January 2022 SIUJ.ORG

 ORIGINAL RESEARCH

TABLE 1. 

Objective urinary outcomes 

Median (IQR) N

Creatinine (mg/dL)(first visit) 1.0 (0.9 to 1.2) 72

Creatinine (mg/dL)(last visit) 1.1 (0.9 to 1.2) 53

Qmax (mL/sec)(first visit) 8.0 (4.8 to 10.0) 29

Qmax (mL/sec)(last visit) 10.0 (8.5 to 14.0) 19

Post-void residual (mL)(first visit) 31.0 (15.0 to 100.5) 68

Post-void residual (mL)(last visit) 24.0 (4.0 to 156.0) 45

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urethroplasty, which leads to new or worsening UI in 
7% to 50% of patients[5,6,8–11]. Given that 34% of this 
population developed a UTI and 15% developed an AUR 
episode requiring urgent intervention, it is important to 
counsel patients on these risks when discussing stricture 
management options. There were few other serious stric-
ture-related complications, including hospitalizations 
for urosepsis and development of severe or end-stage 
chronic kidney disease. Notably, the incidence of UTIs 
was significantly higher in the failure group (P = 0.03), 

and thus patients who develop UTIs should be moni-
tored more carefully.

Our observational retrospective cohort is consis-
tent with other studies on R-USD in that a majority of 
patients (97%) underwent radiotherapy for treatment 
of prostate cancer[17], and a majority of strictures were 
bulbomembranous (75%)[9,18]. Median stricture length 
was 2.0 cm, which is important to consider because the 
American Urological Association guidelines for male 
urethral stricture recommend initially offering urethro-
plasty for bulbar urethral strictures ≥ 2 cm[16]. However, 
our cohort had a median age of 75.4 years and a median 
CCI of 6 (corresponding to a predicted 10-year survival 
rate of approximately 2.25%), highlighting the fact that 
this patient population is often elderly with significant 
comorbidities, which can negatively impact their candi-
dacy for urethral reconstructive surgery[19]. Addition-
ally, a majority of our patients already presented with UI 
before stricture management. One of the key challeng-
ing decisions that patients and physicians must make in 
this scenario is whether to proceed with urethroplasty 
with the potential need for subsequent AUS. There is 
an inherent increased risk of AUS erosion in the setting 
of prior radiation, and an even higher risk of erosion in 
patients who have had both prior radiation and urethro-
plasty[12–14].

In a 2009 study by Sullivan et al., 38 patients who 
developed R-USD after high-dose brachytherapy were 
followed to determine the need for intervention based 
on their stricture disease and symptoms[20]. All patients 
were initially treated with dilation or DVIU, with 49% 
requiring further endoscopic management or intermittent 
catheterization and only 1 patient proceeding to urethro-
plasty. Our study included multiple forms of radiotherapy 
and demonstrated similar results with respect to the need 
for repeat intervention, suggesting that although the risk 
of development of R-USD may differ between radiation 
modalities, the progression and outcomes may be similar 
once the stricture has developed.

The genesis for this study was patient-driven, as with 
many clinical studies. Not surprisingly, many patients 
hope to avoid invasive reconstructive surgery if possi-
ble and desire information on the efficacy and safety 
of pursuing more conservative approaches. There is a 
paucity of recent literature on conservative management 
specifically for R-USD and the unique characteristics 
of these strictures. This disease process is challenging 
to manage surgically, even in expert hands, and carries 
a well-documented risk of stricture recurrence and 
either new or worsening postoperative UI. Additionally, 
patients undergoing urethroplasty complicated by both-
ersome UI need to wait an additional 6 months before 
pursuing AUS placement. As seen in our cohort, R-USD 
also commonly occurs in elderly patients with multiple 

17SIUJ.ORG SIUJ  •  Volume 3, Number 1  •  January 2022

The Efficacy and Safety of a Conservative Management Approach to Radiation-Induced Male Urethral Strictures

TABLE 2.

Conservative management successes versus failures 

Successes  
(n = 73)

Failures  
(n = 18)

P-value*

Age (years)
[median(IQR)]

73.8 
(69.9 to 79.7)

78.0 
(71.0 to 84.0)

0.16

BMI (kg/m2)
[median(IQR)]

26.5 
(24.8 to 30.6)

27.6  
(25.1 to 28.9)

> 0.90

CCI 
[median(IQR)]

6 
(5 to 6)

7 (6 to 9) 0.003

History of UTI 
(%)

21 
(29%)

10 (56%) 0.03

No. of UTIs 
[median(IQR)]

1 
(1 to 3)

2 (1 to 3) > 0.90

History of AUR 
(%)

10 
(14%)

4 (22%) 0.46

No. of AUR 
[median(IQR)]

1 
(1 to 2)

1 (1 to 1.5) 0.79

History of 
urosepsis (%)

1 
(1%)

1 (6%) 0.46

Stricture length 
(cm) [median(IQR)]

2.0 
(2.0 to 3.0)

2.0 
(1.5 to 3.0)

0.55

History of dilation 
(%)

66
(90%)

16 
(89%)

> 0.90

No. of Dilations 
[median(IQR)]

2 
(1 to 5)

2 
(1 to 3.5)

0.18

History of  
DVIU (%)

33 
(45%)

7 
(39%)

0.63

No. of DVIU 
[median(IQR)]

2 
(1 to 3)

1 
(1 to 2)

0.25

History of  
CIC (%)

29 
(40%)

7 
(39%)

> 0.90

Follow-up (months)
[median(IQR)]

15.0 (8.8 to 
37.0)

18.0 (9.1 to 
50.7)

0.47

* Continuous variables: Wilcoxon rank-sum test; Categorical variables: 
Fisher exact test or chi-square test

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comorbidities at baseline. For all these reasons, we felt 
it was important to further evaluate less invasive treat-
ment strategies for R-USD at our reconstructive centers.

Our study has several limitations, including its retro-
spective nature. A prospective study with direct random-
ization to a conservative management arm and a urethral 
reconstruction arm would allow for better comparison 
of efficacy and safety. Furthermore, separately analyzing 
and comparing each conservative management technique 
may also be helpful but would not adequately reflect real-
life clinical practice. For example, some patients may not 
be able to continue to effectively perform CIC over time 
or may be unable to tolerate CIC because of radiation-in-
duced lower urinary tract sensitivity/cystitis-like symp-
toms and thus require endoscopic interventions instead. 
Selection bias is present, as this cohort focuses on those 
patients who specifically pursued conservative strategies 
after thorough patient-centered counseling on all avail-
able treatment options. Nevertheless, we strongly believe 
there is utility in assessing the efficacy of such strategies 
in this patient population. Further analysis of this popu-
lation over longer follow-up with robust patient-reported 

outcome data should be pursued to assess how many 
patients will be successfully managed with conserva-
tive techniques indefinitely. The potential long-term 
consequences of repetitive conservative interventions in 
worsening the USD must be considered when using this 
treatment approach[21]. This study is not advocating for 
conservative management over surgical reconstruction 
for all patients with R-USD, as many patients do benefit 
from both anastomotic and substitution urethroplasty 
techniques[10,22,23]. However, the management of USD 
at its core is a quality-of-life issue with often more than 
one lower urinary tract symptom involved. Patients 
should be counseled on all available treatment options for 
this disease process to make a well-informed decision that 
meets their goals of care. This study provides important 
data for all urology providers, and specifically reconstruc-
tive urologists, to improve patient counseling, refine clin-
ical decision-making, and assess which patients should be 
followed more closely. Regardless of treatment approach, 
we strongly advocate for fellowship-trained reconstruc-
tive urologists to manage this complex and challenging 
disease process to optimize outcomes.

 

91 Total Patients
on Conservative 
Management for 

R-USD

73/91 (80%)
Avoided

Reconstructive
Surgery or 
Permanent

Catheterization

18/91 (20%)
Failed Conservative

Management

 
3/18 (17%)
Urethral

Reconstruction

 1/18 (6%)
Ileal Conduit

Diversion
 

 
4/18 (22%)

Permanent Urethral
Catheter

 
 

10/18 (56%)
Permanent

Suprapubic Tube
 

 

FIGURE 1. 

Treatment failures 

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Conclusion
In short-term follow-up, conservative management 
strategies for R-USD, such as endoscopic techniques 
and CIC, appear to be effective for most elderly patients 
with comorbidities. This is important to consider 
in these patients, who may not be optimal surgical 
candidates and in patients who strongly desire to avoid 
invasive surgery, the risk of worsening UI, or permanent 
indwelling cat heterization. Close obser vation is 
warranted because of the risk of UTIs and AUR. 

The potential long-term consequences of repetitive 
conservative interventions must be considered as well. 
Ultimately, management decisions should focus on 
achieving patient-specific goals of care.

Acknowledgements
The Biostatistics, Epidemiology, and Research Design 
(BERD) Center of Tufts Clinical and Translational 
Science Institute (CTSI) provided assistance with 
statistical analysis.

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20 SIUJ  •  Volume 3, Number 1  •  January 2022 SIUJ.ORG

 ORIGINAL RESEARCH

http://SIUJ.org

