Urethroplasty rarely offered for anterior urethral stricture

Irvine, CA-Most men with anterior urethral strictures are treated without imaging, and 90% are not being offered urethroplasty.

Video: Excision and primary anastomosis anterior urethroplasty

This despite the recommendation by the Société Internationale d’Urologie (SIU)/International Consultation on Urological Diseases (ICUD) that urethral reconstruction be considered a primary management option for men with bulbar urethral strictures, and also for strictures that are recurrent or refractory to a second internal urethrotomy (IU)/dilation.

The findings come from Joel Gelman, MD, director of the Center for Reconstructive Urology at the University of California, Irvine. The prospective data collection of men who were previously evaluated and/or treated for anterior urethral stricture were presented by Justin J. De Grado, MD, MS, fellow in male reconstructive urology at UC Irvine, at the 2015 AUA annual meeting in New Orleans.

With success rates up to 98% reported for urethroplasty in men with anterior urethral strictures, “it’s surprising that 90% of men are never offered urethroplasty to begin with,” Dr. De Grado said.

Data collected on 103 adult men who were seen between April 2011 and January 2014 were analyzed for the study. Disease-related information, outside imaging, treatments, and whether the patient was imaged and/or offered urethroplasty prior to treatment were evaluated. If the men could not recall whether they had been offered urethroplasty, but their records documented that they were offered it, they were counted as having been offered it as a treatment option.

Watch: Bulbospongiosus sparing dorsal onlay bulbar urethroplasty

Seventy-four of the 103 men were 31 to 70 years of age. More than half (55) had bulbar urethral strictures, 17 had panurethral strictures, and 20 had strictures in multiple locations.

Of the 103 men, 91 had prior treatment.

Next: Urethroplasty offered to 9 patients

Urethroplasty offered to nine patients

“Only nine were offered urethroplasty, seven of which elected to undergo other treatments for personal choice, but 82 out of the 91 were never offered urethroplasty prior to being treated,” said Dr. De Grado.

Seventy-six of the 91 patients (84%) did not have urethral imaging before being treated. Of the 76 who did not have imaging performed, 51 had an IU, with 43 of them undergoing multiple procedures, and only 10 of the 43 underwent subsequent imaging after one or more failures.

Of the 25 who had dilation performed, 15 had multiple procedures, and only three of the 15 had subsequent imaging after one or more failures.

When combined, “that’s only 22% of men who underwent subsequent imaging after one or more failures,” he said.

“This is a problem,” Dr. De Grado said. “The reason this is a problem is because there’s a disconnect between the literature and practice patterns that we’re seeing in our general urology colleagues.”

Video: Perineal urethrostomy for severe urethral strictures

SIU/ICUD contends that IU and dilation have equal efficacy, and may be offered as a reasonable first option for single, short bulbar strictures as they are outpatient procedures with minimal recovery time, despite a much lower long-term success rate. A repeat procedure can be indicated “as long as the recurrence happens late,” he said. A third IU/dilation is generally not recommended.

These recommendations are based on findings that IU has a higher stricture-free rate when strictures are short (<1 cm), when it’s a first attempt, when performed on a single stricture rather than multiple strictures, and when the stricture is located in the bulbar urethra.

However, more recent data from Santucci and Eisenberg show a much lower success rate of IU on a first attempt, “and it rapidly approaches 0% on multiple attempts,” Dr. De Grado said.

Next: "The majority of men are never being imaged"

“The majority of men are never being imaged and they’re being diagnosed only with cystoscopy, which can really only give you the appearance of the urethra distal to the stricture, the caliber of the distal aspect, and the approximate location,” said Dr. De Grado. “We really need to know the length, the number of the strictures, and we need to know the exact location, which only urethral imaging can provide. Urethral imaging should absolutely be performed if we’re to adequately counsel our patients on their best options.”

Watch: Posterior urethroplasty for pelvic fracture urethral injury

Further, urethroplasty should always be offered, even as a primary treatment option, given its high success rate, and should definitely be offered with prior failure of IU.

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