Effectiveness of contemporary treatments for iatrogenic urethral strictures following endoscopic management of benign prostatic hyperplasia: a comprehensive review

PURPOSE: Iatrogenic urethral strictures represent a relevant complication following endoscopic surgical treatment for benign prostatic hyperplasia, potentially leading to significant morbidity and impaired quality of life. Despite advances in endoscopic technologies, urethral trauma related to prolonged operative time and large-caliber instruments remains a concern. The optimal management of urethral strictures secondary to surgery is still debated, and high-quality evidence comparing endoscopic and open reconstructive approaches is lacking. This systematic review aimed to evaluate the efficacy and safety of contemporary treatments for iatrogenic urethral strictures following endoscopic management of benign prostatic hyperplasia. MATERIALS AND METHODS: A systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42024604611). MEDLINE, Embase, and the Cochrane Library were searched from 2000 to June 2025. Studies reporting outcomes of endoscopic or open surgical treatments for urethral strictures following benign prostatic hyperplasia surgery were included. Data extraction focused on patient characteristics, stricture features, treatment modality, success rates, complications, and follow-up. Due to substantial heterogeneity, a meta-analysis was not performed. RESULTS: Eleven studies comprising a total of 610 patients were included. Of these, 443 (73%) patients underwent primary treatment for urethral stricture, while 167 (27%) were treated for recurrent disease. The bulbar and membranous urethra were the most commonly involved sites. Overall, 58 patients (9%) underwent endoscopic management, whereas 552 patients (91%) were treated with open reconstructive surgery. The overall recurrence rate was 8 and 10% for both endoscopic and open approaches. However, follow-up duration differed substantially between groups, ranging from 12 to 24 months in endoscopic series and extending up to 54 months in open reconstructive cohorts. Complication rates were generally low. No perioperative or functional complications were reported following endoscopic treatments. Among open procedures, urinary incontinence was the most frequent complication, with rates varying from 4% after ventral onlay graft urethroplasty to 15% following intrasphincteric bulbo-prostatic anastomosis. Flap-related complications were rare. CONCLUSION: Management of urethral strictures following endoscopic prostatic surgery remains challenging. While endoscopic treatments offer acceptable short-term outcomes with minimal morbidity, open reconstructive surgery provides more durable long-term results at the cost of a higher, yet acceptable, risk of functional complications. Treatment choice should be individualized based on stricture characteristics, patient factors, and surgical expertise. Prospective, multicenter studies with standardized outcome reporting and longer follow-up are warranted to optimize treatment algorithms for this complex condition.