Regardless of their previous treatment, all patients should undergo similar preoperative evaluation. Initial evaluation consists of a complete history and physical exam with emphasis on previous surgical history, GU instrumentation and any significant history that might represent a contraindication for buccal graft harvest for example head and neck radiation for malignancy. We generally diagnose recurrent stricture with a combination of obstructive symptoms, high post void residual, low peak urine flow rates, and a flattened uroflow pattern consistent with obstruction. Stricture is confirmed by cystoscopy, RUG or even by failure to pass an 18 F catheter to the bladder.

Once the suspected diagnosis of recurrent is established, we perform a retrograde urethrogram to establish the anatomy, determine if the recurrent stricture represents failure or a new stricture at a different location. Also all patients will provide a urine sample to evaluate the presence of asymptomatic bacteriuria to guide preoperative antibiotics and identify/treat an active urinary tract infection prior to intervention. In patients with a previous urethroplasty, our initial re-treatment is almost always a urethrotomy. We take advantage of this opportunity to thoroughly familiarize ourselves with the urethral anatomy during the urethrotomy procedure, in order to plan the subsequent redo urethroplasty.

Recurrence after endoscopic treatment may be related to incorrect initial treatment of a long stricture or a location not amenable for endoscopic treatment such as penile strictures. Recurrence may also be due to poor success rate of direct vision internal urethrotomy (DVIU) in general. Series confirmed over 92 % failure rate of initial DVIU and several series report 100 % failure for two or more DVIU [2, 3, 6]. One paper that famously reported 50 % overall success rate of initial DVIU, had no success in strictures longer than 1.5 cm [2]. In that series, also, dilation was shown to have a much higher failure rate than urethrotomy.

In patients who are fit for surgery, we plan urethroplasty in patients with even a single failure of previous urethrotomy. In patients that are not good surgical candidates for formal urethroplasty, then we may perform palliative DVIU with the expectations of recurrence.

It is said that recurrence after EPA might be related to lack of a tension-free anastomosis at the time repair. It is important to mention there is always a subgroup of patients who will develop a new stricture distal/proximal to the initial repair, therefore recurrent stricture might not represent primary surgical failure but new disease at a different location within the urethra. Failure after excision and primary anastomosis represents a unique problem when compared to other surgical techniques since the recurrent stricture may obliterate the urethral lumen more often than other techniques. Also, patients who have failed a previous EPA are unlikely to be able to have a second EPA since the urethral length has already been compromised by the previous surgery. Assuming the initial surgery was for a 2 cm bulbar stricture, and the patient has a recurrent stricture of at least 2 cm, the total urethral excised at the time of redo excision and primary anastomosis will not be less than 4 cm. Primary anastomosis of a 4 cm gap is technically challenging and prone to failure and can create a significant chordee on patients with preserved erectile function.

Urethral obliteration, if present, may represent a challenge at the time of revision surgery. In our hands, we almost always perform a ventral buccal urethroplasty for bulbar recurrences after EPA (Fig. 18.1), and a dorsal buccal urethroplasty for penile recurrences after EPA (Fig. 18.2). If at the time of surgery the recurrent stricture after EPA does not completely obliterate the lumen, we tend to use a standard ventral onlay substitution buccal urethroplasty (Fig. 18.1). In patients where there is significant lumen obliteration, we will perform a “modified roof strip” urethroplasty with ventral placement of a buccal graft. This technique consists of performing a ventral urethrotomy at the stricture and evaluating the residual urethral plate dorsally. If urethral plate dorsally is nearly not existent, we will excise just the urethra plate without transecting the corpora spongiosum. Once this is achieved, the ends of the dorsal urethral plate will be sutured together or a second buccal graft will be placed dorsally if the gap is more than about 1.5 cm. In only rare selected cases, where there is SHORT complete obliteration of the urethral lumen and the stricture location is within the proximal bulb we will perform a redo excision and primary anastomosis.