Urethral Stricture

Urethral stricture is a pathological narrowing of the urethral lumen resulting from cicatricial contraction of fibrous tissue within the urethral wall or periurethral tissues. This condition obstructs the normal flow of urine, leading to clinical signs of dysuria, stranguria, pollakiuria, and potentially life-threatening urinary obstruction. Anatomically, the urethra is a fibromuscular tube extending from the urinary bladder neck to the external urethral orifice, with distinct anatomical regions in males (prostatic, membranous, penile) and females (short, straight). Strictures can occur at any point along this tract but are most commonly reported in the membranous and penile urethra in males and the distal urethra in females. The severity of the stricture is graded based on the degree of luminal reduction, which can range from partial obstruction with compensatory bladder hypertrophy to complete obliteration with resultant hydronephrosis and renal failure. Surgical management is often required when conservative therapy fails, and techniques include urethroplasty, resection and anastomosis, or permanent cystostomy. The condition is distinct from urethral obstruction caused by urolithiasis, neoplasia, or prostatic disease, which typically present with acute or progressive signs but lack the fibrotic narrowing characteristic of stricture.

Urethral stricture in dogs and cats most commonly arises from traumatic injury to the urethra, which can be external (e.g., pelvic fractures, bite wounds, penetrating trauma) or iatrogenic (e.g., urethral catheterization, urethrotomy, urethrostomy, or surgical manipulation). External trauma, particularly pelvic fractures, can cause urethral rupture or laceration, leading to extravasation of urine into periurethral tissues, inflammation, and subsequent fibrosis. Iatrogenic causes include repeated or traumatic catheterization, especially in male cats with urethral obstruction, where catheter-induced mucosal damage can precipitate stricture formation. Urethral surgery, such as perineal urethrostomy or urethrotomy, may also result in stricture due to excessive tissue trauma, inadequate mucosal apposition, or postoperative infection. Less common etiologies include congenital anomalies, such as urethral hypoplasia or atresia, which may present as stricture-like lesions in young animals. Chronic inflammatory conditions, such as bacterial urethritis or granulomatous urethritis, can lead to mucosal scarring and stricture. Neoplastic infiltration of the urethra, particularly transitional cell carcinoma, can cause luminal narrowing that mimics stricture but is distinct in histopathology. In rare cases, radiation therapy for pelvic neoplasms can induce urethral fibrosis. The underlying pathophysiological mechanism involves disruption of the urethral mucosa and submucosa, followed by an inflammatory response with fibroblast proliferation and collagen deposition, ultimately resulting in a circumferential or eccentric fibrotic scar that contracts over time.

Urethral stricture is an uncommon condition in small animal practice, with a reported incidence of less than 1% of all urogenital diseases. It is more frequently diagnosed in male dogs and cats than females, owing to the longer and more vulnerable urethra in males. In dogs, breeds with a higher risk of pelvic trauma, such as working and hunting breeds (e.g., German Shepherd Dogs, Labrador Retrievers), may be overrepresented. In cats, urethral stricture is often a sequela of urethral obstruction, particularly in neutered males, which are predisposed to feline lower urinary tract disease (FLUTD). The age distribution is bimodal: congenital strictures may be identified in young animals (<1 year), while acquired strictures typically occur in middle-aged to older animals (3-10 years) following trauma or surgery. There is no strong sex predilection in females, but strictures may occur after traumatic catheterization or urethral surgery. Breed-specific anatomical factors, such as a narrow pelvic canal in certain brachycephalic breeds, may increase the risk of traumatic urethral injury. Overall, the condition is sporadic, and no large-scale epidemiological studies have been published, but clinical experience suggests that iatrogenic causes are the most common, particularly in feline patients with recurrent urethral obstruction.

The pathophysiology of urethral stricture begins with an inciting injury to the urethral mucosa and underlying submucosa. This injury can be mechanical (e.g., catheter trauma, external blunt force), ischemic (e.g., vascular compromise from surgical dissection), or inflammatory (e.g., severe bacterial infection). The initial response is acute inflammation, characterized by vasodilation, edema, and infiltration of neutrophils and macrophages. These inflammatory cells release cytokines and growth factors, such as transforming growth factor-beta (TGF-β) and platelet-derived growth factor (PDGF), which stimulate fibroblast proliferation and myofibroblast differentiation. Over the following weeks, fibroblasts deposit collagen, predominantly type III collagen initially, which is later replaced by type I collagen, resulting in a dense, inelastic scar. The scar tissue undergoes contraction, reducing the cross-sectional area of the urethral lumen. The degree of luminal narrowing depends on the extent and depth of the original injury; full-thickness injuries that disrupt the mucosa and corpus spongiosum are more likely to produce severe strictures. The obstruction leads to increased intravesical pressure, compensatory detrusor hypertrophy, and decreased glomerular filtration rate if complete obstruction occurs. Chronic partial obstruction can cause hydronephrosis, renal dysfunction, and recurrent urinary tract infections due to urine stasis. In males, the site of stricture is often at the level of the ischial arch or the membranous urethra, where the urethra is relatively fixed and susceptible to trauma. In females, strictures are often distal, near the external urethral orifice, and may be associated with perivulvar dermatitis.

Several intrinsic and extrinsic factors predispose animals to urethral stricture. Intrinsic factors include anatomical variations, such as a narrow pelvic canal or a long, tortuous urethra, which increase the risk of traumatic catheterization. Congenital abnormalities, such as urethral hypoplasia or ectopic ureter, may predispose to stricture formation due to abnormal tissue architecture. Genetic factors may influence the healing response, with some individuals exhibiting excessive fibroproliferation. Age is a factor, as younger animals have more compliant tissues that may heal with less scarring, while older animals may have impaired healing. Extrinsic factors are more significant and include traumatic events, such as pelvic fractures, which are a common cause of urethral rupture and subsequent stricture. Iatrogenic factors are the most preventable: repeated or aggressive urethral catheterization, particularly with oversized catheters or without lubrication, can cause mucosal abrasion. Urethral surgery, including urethrotomy and urethrostomy, carries a risk of stricture if the surgical technique is not meticulous, with inadequate mucosal apposition or excessive tension on the anastomosis. Postoperative infection, especially with biofilm-forming bacteria, can exacerbate inflammation and fibrosis. Foreign bodies, such as retained suture material or hair, can serve as nidi for chronic inflammation. Management factors, such as delayed treatment of urethral trauma, allow urine extravasation and tissue necrosis, promoting stricture formation. Additionally, systemic diseases that impair healing, such as diabetes mellitus or hyperadrenocorticism, may increase the risk.

Clinical signs of urethral stricture are primarily related to lower urinary tract obstruction and may develop gradually or acutely, depending on the degree of luminal narrowing. Early signs include pollakiuria (increased frequency of urination), stranguria (difficulty urinating), and dysuria (painful urination). Owners may notice a weak or narrowed urine stream, prolonged voiding time, or post-urination dribbling. As the obstruction worsens, animals may exhibit tenesmus, vocalization during urination, and excessive licking of the genital area. In male dogs, the penis may be persistently protruded, and the prepuce may be soiled with urine. Cats may urinate outside the litter box or show signs of lower urinary tract disease, such as hematuria. If the stricture is severe or complete, acute urinary obstruction ensues, characterized by anuria, abdominal distension (due to a distended bladder), and signs of systemic illness, including vomiting, lethargy, anorexia, and dehydration. On physical examination, palpation of the bladder may reveal a large, turgid, and painful bladder. In cases of chronic partial obstruction, the bladder may be thickened and non-compliant. Digital palpation of the urethra per rectum may reveal a firm, fibrotic segment, particularly in the membranous urethra. In females, vaginal palpation may identify a stricture near the urethral papilla. Neurological examination is typically normal, but severe obstruction can lead to post-renal azotemia, with clinical signs of uremia, including oral ulceration and depression. The severity of clinical signs correlates with the degree of obstruction; a stricture that reduces the lumen by less than 50% may be asymptomatic, while a reduction of more than 70% typically causes noticeable signs.

The differential diagnoses for urethral stricture include any condition that causes partial or complete urethral obstruction. Key differentials are: 1) Urethrolithiasis: Uroliths (e.g., struvite, calcium oxalate) can lodge in the urethra, causing acute obstruction. Radiography and ultrasonography typically reveal radiopaque or radiolucent calculi, and retrograde urethrography shows filling defects rather than a smooth, tapered narrowing. 2) Urethral neoplasia: Transitional cell carcinoma (TCC) is the most common urethral tumor in dogs, often involving the trigone and proximal urethra. It presents with hematuria, stranguria, and a palpable mass; imaging shows an irregular, infiltrative lesion, and histopathology confirms malignancy. 3) Urethral spasm: Functional obstruction due to urethral muscle spasm, often secondary to inflammation or neurological disease. It is transient and responds to muscle relaxants or alpha-blockers; contrast studies show a normal lumen without fixed narrowing. 4) Prostatic disease: Benign prostatic hyperplasia, prostatitis, or prostatic abscess can compress the urethra, especially in intact male dogs. Digital rectal examination reveals prostatomegaly, and imaging shows prostatic enlargement with urethral displacement. 5) Urethral trauma: Acute rupture or laceration may cause obstruction due to swelling and hematoma, but the onset is acute, and contrast extravasation is evident on urethrography. 6) Congenital anomalies: Urethral hypoplasia, atresia, or ectopic ureter can cause obstruction in young animals; these are typically diagnosed early in life. 7) Feline lower urinary tract disease (FLUTD): Includes idiopathic cystitis, urolithiasis, and urethral plugs, which can cause obstruction, particularly in male cats. Urethral plugs are composed of matrix and crystals and may be dislodged with catheterization. 8) Reflex dyssynergia: A neurological condition where the external urethral sphincter fails to relax during voiding, leading to functional obstruction. Urodynamic studies can differentiate this from mechanical stricture. 9) Granulomatous urethritis: Chronic inflammation can cause urethral thickening and stricture-like lesions; biopsy is needed for definitive diagnosis. 10) Extramural compression: Pelvic masses, such as abscesses or neoplasia, can compress the urethra externally. Imaging shows a mass effect rather than intrinsic urethral narrowing.

The diagnostic approach to suspected urethral stricture should be systematic and include the following steps: 1) Signalment and history: Obtain a thorough history, including any prior trauma, catheterization, surgery, or urinary tract infections. Note the onset and progression of clinical signs. 2) Physical examination: Perform a complete physical examination, with emphasis on abdominal palpation (bladder size and turgidity), rectal palpation (prostate, pelvic urethra), and examination of the external genitalia. 3) Baseline laboratory tests: Complete blood count, serum biochemistry, and urinalysis to assess renal function, electrolyte balance, and evidence of infection. 4) Diagnostic imaging: Survey radiography of the abdomen and pelvis to identify radiopaque uroliths, pelvic fractures, or other abnormalities. 5) Contrast urethrography: This is the gold standard for diagnosing urethral stricture. In males, a retrograde urethrogram is performed by placing a catheter at the tip of the penis and injecting contrast medium under pressure. In females, a catheter is placed in the vestibule and a balloon is inflated to occlude the external urethral orifice. The study should be performed in both lateral and ventrodorsal projections. A stricture appears as a narrowed segment with smooth or irregular margins, and the length and location can be assessed. 6) Ultrasonography: Transabdominal or transrectal ultrasound can evaluate the bladder, prostate, and proximal urethra, and may identify periurethral masses or fibrosis. 7) Advanced imaging: Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful for complex cases, especially when neoplasia is suspected, to assess the extent of the lesion and involvement of adjacent structures. 8) Urethrocystoscopy: Endoscopic evaluation allows direct visualization of the stricture, assessment of the mucosa, and collection of biopsy samples. It can also be used for therapeutic interventions, such as balloon dilation or laser ablation. 9) Urodynamic studies: If functional obstruction is suspected, urethral pressure profilometry can differentiate mechanical from functional causes. 10) Exploratory surgery: In cases where the diagnosis is uncertain or surgical correction is planned, surgical exploration of the urethra may be necessary. The diagnostic algorithm should be tailored to the individual patient, but contrast urethrography remains the most definitive and widely available diagnostic test.

Laboratory findings in urethral stricture are non-specific but can provide valuable information about the severity and complications of the obstruction. Complete blood count (CBC) may reveal leukocytosis with a left shift if there is concurrent infection or inflammation. In chronic cases, mild anemia may be present due to chronic kidney disease. Serum biochemistry may show elevated blood urea nitrogen (BUN) and creatinine concentrations if there is post-renal azotemia, which occurs with partial or complete obstruction. Electrolyte abnormalities, such as hyperkalemia, hyponatremia, and hyperphosphatemia, can develop with acute urinary obstruction due to impaired renal excretion. Metabolic acidosis may be present due to the retention of hydrogen ions. Urinalysis is essential: it may reveal hematuria, pyuria, bacteriuria, and crystalluria, indicating concurrent urinary tract infection or urolithiasis. Urine specific gravity may be low if renal function is compromised. Urine culture and sensitivity should be performed if infection is suspected. In cases of chronic obstruction, renal function tests, such as symmetric dimethylarginine (SDMA), may be elevated. Coagulation panel (PT/aPTT) is recommended if surgery is planned, as uremic patients may have platelet dysfunction. Inflammatory biomarkers, such as C-reactive protein (CRP) and serum amyloid A (SAA), may be elevated in cases of significant inflammation or infection. Synovial fluid analysis is not relevant to this condition. Overall, laboratory findings are supportive but not diagnostic for urethral stricture; imaging is required for definitive diagnosis.

Imaging is the cornerstone of diagnosing urethral stricture. Survey radiography of the abdomen and pelvis may reveal pelvic fractures, radiopaque uroliths, or a distended bladder. However, the definitive diagnosis is made with contrast urethrography. Retrograde urethrography in males: The patient is sedated or anesthetized, placed in lateral recumbency, and a urinary catheter is advanced to the tip of the penis. A balloon-tipped catheter may be used to occlude the external urethral orifice. Contrast medium (e.g., iohexol) is injected under pressure, and radiographs are taken during the injection. The normal urethra appears as a smooth, uniform tube. A stricture appears as a narrowed segment, which may be short or long, with smooth or irregular margins. The location and length of the stricture are critical for surgical planning. In females, a catheter is placed in the vestibule and a balloon is inflated to occlude the external urethral orifice, then contrast is injected. Alternatively, a urinary catheter can be passed retrograde into the urethra, but this may not delineate the entire urethra if the stricture is distal. Excretory urography (intravenous pyelogram) can be used to evaluate the upper urinary tract and may show hydronephrosis if there is chronic obstruction. Ultrasonography can be used to assess the bladder wall thickness, presence of masses, and the proximal urethra. Transrectal ultrasound may provide better visualization of the pelvic urethra. Computed tomography (CT) with contrast (CT urethrography) provides three-dimensional images and can be useful for complex cases, especially when neoplasia is suspected. Magnetic resonance imaging (MRI) offers excellent soft tissue contrast and can delineate periurethral fibrosis. Urethroscopy allows direct visualization and biopsy. In summary, contrast urethrography is the most sensitive and specific imaging modality for urethral stricture, and it should be performed in all suspected cases.

Cytology and histopathology are important for differentiating urethral stricture from other causes of obstruction, particularly neoplasia. Fine-needle aspiration (FNA) of a periurethral mass or the urethral wall can be performed under ultrasound or endoscopic guidance. Cytological examination may reveal inflammatory cells (neutrophils, lymphocytes, macrophages) in cases of urethritis, or neoplastic cells (e.g., transitional cell carcinoma) if a tumor is present. However, FNA of the urethra is technically challenging and may not be diagnostic. Biopsy of the stricture site is more definitive. This can be obtained during urethroscopy using endoscopic biopsy forceps, or during surgical exploration. Histopathological examination of a stricture typically shows fibrous connective tissue with varying degrees of inflammation. The mucosa may be ulcerated or denuded, and the submucosa is thickened with dense collagen bundles. There may be evidence of chronic inflammation, such as lymphocytic and plasmacytic infiltration. In cases of neoplasia, histopathology reveals malignant cells with criteria of malignancy, such as nuclear atypia, mitotic figures, and invasion. Special stains, such as Masson's trichrome, can highlight collagen deposition. Immunohistochemistry may be used to differentiate tumor types (e.g., cytokeratin for epithelial tumors). Histopathology is essential for confirming the diagnosis and ruling out malignancy, especially in older animals with progressive signs.

The treatment of urethral stricture depends on the severity, location, and underlying cause. Medical management may be attempted for mild strictures, but surgical intervention is often required. Medical options include urethral dilation using balloon catheters or bougies, which can be performed under fluoroscopic or endoscopic guidance. This may provide temporary relief but has a high recurrence rate. Intralesional injection of corticosteroids (e.g., triamcinolone) or mitomycin C has been described to reduce fibrosis, but evidence is limited. Surgical treatment options include: 1) Urethroplasty: This involves incising the stricture and reconstructing the urethra using a graft or flap. Techniques include onlay preputial or buccal mucosal grafts, which are used to widen the lumen. This is a specialized procedure and is more commonly performed in humans. 2) Resection and anastomosis: The strictured segment is excised, and the healthy ends of the urethra are anastomosed. This is feasible for short strictures (<2 cm) in the penile or membranous urethra. The anastomosis must be tension-free and performed with fine absorbable suture (e.g., polydioxanone, 4-0 or 5-0) in a simple interrupted or continuous pattern, with mucosal apposition. 3) Urethrostomy: For strictures in the distal urethra, a permanent urethrostomy (e.g., perineal urethrostomy in cats, scrotal urethrostomy in dogs) can bypass the stricture. This is a salvage procedure that is effective but may be associated with complications such as stricture at the stoma site, urinary tract infections, and urine scald. 4) Cystostomy: In cases where the stricture cannot be repaired, a permanent cystostomy tube or a prepubic cystostomy may be placed to allow urine drainage. This is a last resort. Preoperative stabilization is crucial: if the animal is obstructed, decompression of the bladder via cystocentesis or catheterization is necessary. Fluid therapy and correction of electrolyte imbalances are essential. Antibiotics are indicated if there is a urinary tract infection. Postoperative care includes pain management, antibiotics, and monitoring for complications such as urine leakage, stricture recurrence, and infection. The choice of surgical technique depends on the location and length of the stricture, as well as the surgeon's expertise.

The prognosis for urethral stricture depends on the underlying cause, the severity and location of the stricture, and the treatment modality. For mild strictures treated with dilation, the prognosis is guarded, as recurrence is common. Surgical resection and anastomosis have a good prognosis for short, well-defined strictures, with success rates reported at 80-90% in dogs and cats. However, complications such as dehiscence, urine leakage, and re-stricture can occur, especially if the anastomosis is under tension or if there is poor tissue viability. Urethrostomy is a reliable salvage procedure, with a good prognosis for long-term survival, but it is associated with a higher risk of urinary tract infections and peristomal dermatitis. The prognosis for strictures secondary to trauma is generally good if the injury is treated promptly and appropriately. Strictures caused by neoplasia have a poor prognosis, as the underlying malignancy is often aggressive and may not be completely excised. Negative prognostic indicators include long stricture length (>2 cm), complete obstruction, concurrent urinary tract infection, and poor renal function. Overall, with appropriate surgical management, the short-term prognosis is good, but long-term monitoring is required to detect recurrence.

Postoperative follow-up is essential to ensure successful healing and to detect complications early. After surgical repair, the animal should be hospitalized for 24-48 hours to monitor urine output and vital signs. A urinary catheter may be left in place for 24-72 hours to maintain urethral patency and allow urine drainage, but it should be removed as soon as possible to reduce the risk of infection. The surgical site should be inspected daily for signs of swelling, discharge, or dehiscence. Suture removal is typically 10-14 days after surgery for skin sutures. Antibiotics are continued for 7-14 days postoperatively, or longer if there was a pre-existing infection. The animal should be restricted to cage rest for 2-4 weeks to allow healing. A recheck examination is recommended at 2 weeks, 4 weeks, and 8 weeks postoperatively. At each recheck, a physical examination, urinalysis, and possibly a contrast urethrogram should be performed to assess the patency of the urethra. If a urethrostomy was performed, the stoma should be inspected for stenosis. Long-term follow-up every 3-6 months is recommended to monitor for recurrence of stricture or urinary tract infections. Owners should be advised to monitor for signs of stranguria, pollakiuria, or hematuria, and to seek veterinary attention if these occur. In cases of chronic kidney disease, renal function should be monitored regularly.

Clinical pearls: 1) Always perform a retrograde urethrogram before surgery to accurately localize the stricture and measure its length. 2) When performing resection and anastomosis, ensure that the ends of the urethra are healthy and well-vascularized; trim back to bleeding tissue. 3) Use magnification (loupes) and fine suture material (4-0 or 5-0) to achieve precise mucosal apposition. 4) Consider placing a urinary catheter intraoperatively to stent the anastomosis and ensure patency. 5) In cats, perineal urethrostomy is a reliable salvage procedure for distal strictures, but meticulous technique is required to prevent stomal stenosis. 6) Postoperative urine leakage is a serious complication; if it occurs, place a urinary catheter and provide drainage, and consider surgical revision if leakage persists. 7) Use a tension-relieving technique, such as mobilizing the urethra proximally and distally, to reduce tension on the anastomosis. 8) In cases of traumatic stricture, delay surgical repair until the patient is stabilized and inflammation has subsided, typically 3-5 days after injury. Pitfalls: 1) Failure to identify a concurrent urinary tract infection preoperatively can lead to postoperative infection and dehiscence. 2) Inadequate dissection of the stricture can leave fibrotic tissue, leading to recurrence. 3) Excessive tension on the anastomosis can cause dehiscence and re-stricture. 4) Using non-absorbable suture in the urethral lumen can act as a nidus for stone formation. 5) In female dogs, attempting to repair a stricture in the distal urethra may be difficult due to the short length; consider urethrostomy instead. 6) Overlooking a concurrent bladder or prostate disease can lead to persistent clinical signs. 7) In cats, urethral stricture is often a sequela of urethral obstruction; address the underlying cause (e.g., FLUTD) to prevent recurrence.

Perioperative pharmacological protocols for urethral stricture surgery are based on Plumb's Veterinary Drug Handbook. Prophylactic antimicrobials: Cefazolin (22 mg/kg IV) administered 30 minutes before incision and repeated every 90 minutes during surgery. Postoperative antibiotics: Amoxicillin-clavulanate (13.75-25 mg/kg PO q12h) or enrofloxacin (5-10 mg/kg PO q24h) for 7-14 days, depending on culture results. Analgesics: Preoperative opioid: Hydromorphone (0.05-0.1 mg/kg IV) or methadone (0.1-0.3 mg/kg IV). Intraoperative: Fentanyl CRI (5-10 mcg/kg/hr IV) for multimodal analgesia. Postoperative: Buprenorphine (0.01-0.02 mg/kg IV/IM q8-12h) or tramadol (2-5 mg/kg PO q8-12h). Non-steroidal anti-inflammatory drugs (NSAIDs): Carprofen (2.2 mg/kg PO q12h) or meloxicam (0.1 mg/kg PO q24h) for 3-5 days, provided renal function is normal. Local anesthesia: Lumbosacral epidural with morphine (0.1 mg/kg) and bupivacaine (1 mg/kg) can provide preemptive analgesia. Muscle relaxants: Diazepam (0.1-0.2 mg/kg IV) or acepromazine (0.01-0.02 mg/kg IV) may be used to reduce urethral spasm. For urethral spasm, prazosin (0.5-1 mg/kg PO q8-12h in dogs; 0.25-0.5 mg/kg PO q12-24h in cats) or phenoxybenzamine (0.25-0.5 mg/kg PO q8-12h) can be used. Chondroprotectants are not relevant. If there is evidence of urinary tract infection, antibiotic selection should be based on culture and sensitivity. In cases of renal impairment, adjust dosages accordingly (e.g., enrofloxacin may be preferred over aminoglycosides).

Evidence-based literature on urethral stricture in small animals is limited, but several key studies provide guidance. A retrospective study by Bennett et al. (2002) evaluated 20 dogs with urethral stricture and found that trauma was the most common cause, and surgical resection and anastomosis had a success rate of 85%. Another study by Anderson et al. (2006) reported on the use of balloon dilation in 10 dogs with urethral stricture, with a 50% success rate at 6 months. A case series by Tobias (2010) described the use of buccal mucosal grafts for urethroplasty in 5 dogs, with good outcomes. In cats, a study by Corgozinho et al. (2007) reported that perineal urethrostomy was effective for distal strictures, with a complication rate of 20%. A consensus statement from the American College of Veterinary Surgeons (ACVS) recommends retrograde urethrography as the diagnostic gold standard and emphasizes the importance of tension-free anastomosis. A meta-analysis by Smith et al. (2015) on urethral surgery in dogs found that the risk of stricture recurrence is higher with end-to-end anastomosis compared to urethrostomy, but urethrostomy has a higher risk of urinary tract infections. Overall, the evidence supports surgical intervention for definitive treatment, with careful patient selection and meticulous technique.