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      Evaluation and management of anterior urethral stricture disease

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          Abstract

          Urethral stricture disease affects many men worldwide. Traditionally, the investigation of choice has been urethrography and the management of choice has been urethrotomy/dilatation. In this review, we discuss the evidence behind the use of ultrasonography in stricture assessment. We also discuss the factors a surgeon should consider when deciding the management options with each individual patient. Not all strictures are identical and surgeons should appreciate the poor long-term results of urethrotomy/dilatation for strictures longer than 2 cm, strictures in the penile urethra, recurrent strictures, and strictures secondary to lichen sclerosus. These patients may benefit from primary urethroplasty if they have many adverse features or secondary urethroplasty after the first recurrence.

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          Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful?

          C F Heyns, J Steenkamp, M De Kock … (1998)
          We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures. Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments. Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001). Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.
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            Internal urethrotomy in the management of anterior urethral strictures: long-term followup.

            V Pansadoro, P Emiliozzi (1996)
            We evaluated the long-term results of internal urethrotomy for anterior urethral strictures. Between 1975 and 1990, 224 patients underwent internal urethrotomy for anterior urethral strictures. Median followup was 98 months (range 60 to 216). The recurrence rate after 1 urethrotomy was 68% overall, and 58% for bulbar, 84% for penile and 89% for penile bulbar urethral strictures. Repeated urethrotomies did not improve the success rate. Prognostic characteristics of bulbar urethral strictures associated with good results included single or primary strictures, length shorter than 10 mm. and caliber wider than 15F. Preoperative infection and etiology of the strictures did not correlate with results. Multiple urethrotomies achieve only temporary improvement and can be compared to repeated dilations. Alternative treatments should be considered for penile strictures and after failure of initial urethrotomy.
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              Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective.

              T.J. GREENWELL, C. Castle, D.E. Andrich … (2004)
              We developed an algorithm for the management of urethral stricture based on cost-effectiveness. United Kingdom medical and hospital costs associated with the current management of urethral stricture were calculated using private medical insurance schedules of reimbursement and clean intermittent self-catheterization supply costs. These costs were applied to 126 new patients treated endoscopically for urethral stricture in a general urological setting between January 1, 1991 and December 31, 1999. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention following initial intervention. Mean followup available was 25 months (range 1 to 132). The costs were urethrotomy/urethral dilation 2,250.00 pounds sterling (3,375.00 dollars, ratio 1.00), simple 1-stage urethroplasty 5,015.00 pounds sterling (7,522.50 dollars, ratio 2.23), complex 1-stage urethroplasty 5,335.00 pounds sterling (8,002.50 dollars, ratio 2.37) and 2-stage urethroplasty 10,370 pounds sterling (15,555.00 dollars, ratio 4.61). Of the 126 patients assessed 60 (47.6%) required more than 1 endoscopic retreatments (mean 3.13 each), 50 performed biweekly clean intermittent self-catheterization and 7 underwent urethroplasty during followup. The total cost per patient for all 126 patients for stricture treatment during followup was 6,113 pounds sterling (9,170 dollars). This cost was calculated by multiplying procedure cost by the number of procedures performed. A strategy of urethrotomy or urethral dilation as first line treatment, followed by urethroplasty for recurrence yielded a total cost per patient of 5,866 pounds sterling (8,799 dollars). A strategy of initial urethrotomy or urethral dilation followed by urethroplasty in patients with recurrent stricture proves to be the most cost-effective strategy. This financially based strategy concurs with evidence based best practice for urethral stricture management.
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                Author and article information

                Journal
                Journal ID (nlm-ta): F1000Res
                Journal ID (iso-abbrev): F1000Res
                Journal ID (pmc): F1000Research
                Title: F1000Research
                Publisher: F1000Research (London, UK )
                ISSN (Electronic): 2046-1402
                Publication date (Electronic): 9 February 2016
                Publication date Collection: 2016
                Volume: 5
                Electronic Location Identifier: F1000 Faculty Rev-153
                Affiliations
                [1 ]Department of Urology Research, Royal Hallamshire Hospital, Sheffield, UK
                Author notes

                Competing interests: The authors declare that they have no competing interests.

                Article
                DOI: 10.12688/f1000research.7121.1
                PMC ID: 4755397
                PubMed ID: 26918169
                SO-VID: 4ce630a1-27ab-4a75-92a8-a63e10e2c2a7
                Copyright © Copyright: © 2016 Mangera A et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : 8 February 2016
                Funding
                The author(s) declared that no grants were involved in supporting this work.
                Categories
                Subject: Review
                Subject: Articles
                Subject: Benign Bladder & Urethral Disorders

                Keywords: urethral stricture disease,urethrotomy,dilatation,urethrography
                Data availability:
                Keywords: urethral stricture disease, urethrotomy, dilatation, urethrography

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