Management

There are many management options available for urethral stricture disease: commencing with less invasive urethral dilatation, urethral stenting, urethrotomy and progressing to anastomotic and substitution urethroplasty. There are many techniques and procedures. Each patient must be treated based upon their individual circumstances and with due regard for consent. Below we discuss the evidence for the various options available.

Optical Urethrotomy/Dilatation

Data relating to the prevalence of urethral strictures is rather sparse, but a recent publication reported that in the USA, based on 10 public and private databases between the years 1992 and 2000, there were 5 million office visits per year and more than 5,000 inpatient admissions per year.7 It was estimated in the year 2000 that the total cost of urethral stricture disease in the USA was $2 million and that this increased healthcare expenditure by $6,000 per insured person.

This leads on to the question as to how anterior urethral strictures are managed. Out of a nationwide survey of 1,262 urologists polled by the American Urology Association, resulting in a response rate of 34%, and from a publication by Bullock et al., 63% of urologists treat between 6 and 20 strictures per year8 – the most common procedures being dilatation (92.8%), optical internal urethrotomy (85.6%), and endourethral stent insertion (23.4%). Universally, minimally invasive procedures were used much more commonly than urethroplasty, since 57.8% of urologists did not perform urethroplasty surgery. Only 4.2% of urologists performed buccal mucosal grafts and for a long bulbar urethral stricture or a short bulbar urethral stricture refractory to internal urethrotomy, between 20% and 29% of respondents referred to another urologist, while 31–33% continued to manage the stricture by minimally invasive means. It is of note that 74% of urologists believe that urethroplasty should only be performed after repeat failure of endoscopic methods.

It is clear that urethrotomy and dilation are standard procedures which are readily available and minimally invasive. By splitting the stricture via urethrotomy or dilatation, it is presumed healing will occur without re-stenosis.

This is dependent upon adequate vascularity within the underlying corpus spongiosum. There is no compelling evidence in the literature that any particular form of urethrotomy is more effective than another, whether using a cold knife or a laser. A randomized controlled trial reported by Steenkamp and colleagues in 1997 reviewed 210 men of whom 106 underwent dilatation and 104 urethrotomy under local anesthetic.9 At 1 year there was a success rate of 60% if the stricture was less than 2 cm, 50% if it was between 2 and 4 cm, and 20% if it was more than 4 cm in length. Across the board at 4 years follow-up, for strictures between 2 and 4 cm in length, the success rate of each procedure was 25%. The authors concluded that longer strictures could be appropriately managed in the first instance by urethroplasty, whereas optical urethrotomy or dilatation (both of which seem to be equally effective) were always appropriate for shorter strictures.

In a subsequent publication, Heyns, working on the same dataset, looked at whether repeated dilatation or urethrotomy was useful and noted that after a single treatment, looking at the population group as a whole, 70% would be stric- ture-free at 3 months, 35–40% would remain stricture free at 48 months, and a secondary procedure was of limited benefit at 24 months, but not at 48 months.10 A third treatment was of no benefit at all.

It is certainly a perception among urologists working in this area that subsequent urethroplasty is rendered more difficult and is more likely to require a substitution procedure due to lengthening of the stricture as a consequence of trauma due to repeated urethrotomy or dilatation, than if the procedure had been carried out at an earlier stage.The evidence for this is certainly compelling based on the recurrence rate of strictures where a redo procedure has proved to be necessary.11

Taking economic analysis into consideration, Greenwell et al. concluded that the use of urethroplasty after failure of initial urethrotomy or dilatation was likely to be the most cost-effective approach.12 In contrast to this,Rourke and Jordan suggested that treatment of short bulbar strictures by urethroplasty is more cost-effective than urethrotomy.13 A compromised suggestion from Wright and colleagues suggests that in their view initial urethrotomy followed by urethroplasty is the most cost-effective approach if there is recurrence of the stricture, unless the success rate of urethrotomy as treatment was less than 35%.14