Urethroplasty for bulbomembranous strictures after benign prostatic hyperplasia surgery: systematic review and meta-analysis

To systematically evaluate surgical outcomes of urethroplasty for bulbomembranous urethral strictures developing after endoscopic surgery for benign prostatic hyperplasia (BPH), focusing on patency, urinary continence, and erectile function.

A pre-registered systematic review (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD420261374244) was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. PubMed and the Excerpta Medica database (EMBASE) were searched for observational studies reporting urethroplasty outcomes in ≥10 patients with post-BPH bulbomembranous, membranous, or proximal bulbar strictures. Risk of bias was assessed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I). Random-effects meta-analysis with logit back-transformation and Hartung-Knapp-Sidik-Jonkman correction pooled proportions of patency and urinary incontinence (UI), stratified by technique.

A total of 11 studies comprising 669 patients were identified, of which nine (417 patients) were included in the primary quantitative analysis. All studies were retrospective or prospective observational cohorts with moderate-to-serious risk of bias. Definitions of patency and continence were heterogeneous across studies. The overall pooled patency rate, predominantly defined as freedom from re-intervention rather than objectively confirmed anatomical patency, was 90% (95% confidence interval [CI] 85-93%), with moderate heterogeneity (Q = 11.22). Subgroup analysis by technique yielded patency rates of 87% (95% CI 76-93%) for ventral onlay buccal mucosal graft (BMG) (four studies), 94% (95% CI: 87-97%) for anastomotic urethroplasty (three studies), and 91% (95% CI 83-95%) for dorsal onlay BMG (one study). The pooled UI rate was 5% (95% CI 3-10%), with moderate heterogeneity (Q = 11.38). Sensitivity analysis excluding studies incorporating simple prostatectomy cases (two studies) yielded consistent results. Erectile function data were insufficient for pooled analysis; the two studies reporting Sexual Health Inventory for Men scores documented no significant deterioration.

Urethroplasty for bulbomembranous strictures following BPH surgery achieves high, heterogeneously defined patency-predominantly freedom from re-intervention-with low de novo UI in experienced centres. The heterogeneous, non-comparative evidence precludes technique-specific recommendations; prospective, standardised studies are needed to refine patient selection.