Paradigm change in stricture Tx favors urethroplasty

New Orleans-Although endoscopic management of male stricture is more commonly performed than urethroplasty, the ratio of these procedures is decreasing over time, particularly among newly certifying urologists. According to a study presented at the AUA annual meeting, urologists in 2012 were 3.4 times more likely to choose urethroplasty than in 2004.

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“A changing paradigm in urethral stricture management favoring urethroplasty is evident over the last decade in the United States, both among urologists with more recent training as well as over time,” said lead study author Joceline S. Liu, MD, a urologist at Feinberg School of Medicine, Northwestern University, Chicago. “Academic affiliation and proximity to a reconstructive fellowship program were also associated with performing urethroplasty.”

While endoscopic management of adult male urethral stricture has been widely utilized since its induction, according to Dr. Liu, recent data reflect poor long-term success rates for urethrotomy (25%) and dilation (60%) compared to open urethroplasty (over 90%). However, despite increasing evidence supporting urethroplasty, endoscopic treatment remains more common.

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Changing practice patterns

Using case log data of certifying and recertifying urologists (2003 to 2013) from the American Board of Urology, Dr. Liu, working with Christopher M. Gonzalez, MD, MBA, and colleagues, pulled only those cases specifying urethral dilation, direct vision internal urethrotomy (DVIU), or urethroplasty and graft harvest in males ≥18 years.

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Among 6,320 urologists logging at least one reconstructive urology procedure, researchers identified 95,747 urethral dilations (86.2%), 10,986 DVIU (10.0%), and 4,349 urethroplasties (3.9%).

The researchers then looked for surgeon characteristics and surgeon-specific variables associated with different practice patterns.

“Over time,” said Dr. Liu, “we saw a significant change in practice patterns. According to the dataset, urologists were 2.5 times more likely to do a urethroplasty in 2013 than in 2003.”

Breaking the data down by certification stage, researchers found that new certification correlated with a decrease in ratio of dilation/DVIU to urethroplasty (p<.001). The ratio of dilation/DVIU to urethroplasty for new certification was much lower (7.9 to 1) compared to first (24.4 to 1), second (63.3 to 1), and third recertification cycles (99.5 to 1), wherein urethroplasty was increasingly rare (p<.001). Overall, newly certifying urologists performed urethroplasty 4.5 times more often than those recertifying.

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“The ‘young bucks’ are doing urethroplasties far more often than those who are 40 years into practice,” said Dr. Liu. “Even though their volume might not be the same as the older [doctors], the proportions of urethroplasties to DVIU are extremely different. I thought there might be a trend, but I did not expect to see it to that degree.”

NEXT: Academic urologists eight times more likely to perform urethroplasty

Urologists with academic affiliation were eight times more likely to perform urethroplasty (p<.001) than non-academically affiliated urologists. The data also showed geographic discrepancies: all states with a genitourinary reconstructive surgery fellowship maintained a ratio of 10.5 to 1 or less.

According to Dr. Liu, the majority of urethroplasty cases are performed by a small number of urologists with high volume, academic affiliation, recent residency graduation, and residence in a state with a reconstructive urology fellowship.

Although Dr. Liu would not pinpoint a single cause for the change in practice, she suggested that contemporary training and familiarity with urethroplasty may be contributing to this paradigm shift.

“It’d be really nice to take the concepts of this study and include multi-institutional groups to look at true data,” Dr. Liu concluded, “looking at practice patterns but also looking retrospectively at all of their patient demographics. The problem is that at an academic institution it’s really hard to capture what community urologists are doing. I think that’s something we still need to figure out.”

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