Hypothesis / aims of study
Urethral strictures are a difficult urological condition. Recently, earlier urethroplasty has been encouraged by updated guidelines and evidence to optimize patient outcomes (1,2). Our aim was to review the trends of management for urethral strictures at our tertiary center.
Study design, materials and methods
This is a retrospective cohort study involving patients with recurrent urethral strictures managed at our institute from June 2012 to March 2020. Patient records were reviewed for demographics, stricture characteristics and location, specific management and follow up. Institutional ethics for the study was obtained.
Results
From our centre, we found 185 male patients that received surgical management for urethral strictures, with a median age of 66 years (20-90 years). Mean follow up was 50 months (5-120 months) At first presentation, lower urinary tract symptoms was the most common cause for investigation and intervention 148/185 (80%), while 37/185 strictures were found incidentally.
Penile strictures were the most common documented in 135 patients (73%), bulbar in 32 (17%), panurethral in 4 (2%) and unclassified in 14 patients (8%). However, retrograde urethrograms were only performed in 20 patients.
116 (63%) required two or more procedures, and 45/185 (24%) patients had ≥3 procedures. An additional 397 total procedures were performed among these 116. An average intervention time between endoscopic procedures was 10 months (1-83 months). Interestingly, in those with a high recurrence rate of stricture disease, a documented discussion of intermittent self dilation (ISD) only occurred in 20/45 patients (45%). Of those advised to do ISD, a majority stopped early. There were 17 failures of ISD, with 3 patients having a subsequent urethroplasty, and 14 required regular endoscopic management, of which only 5 patients were
categorized as poor surgical candidates. Merely 3 patients continued long term ISD without further intervention.
28 patients (15%) underwent urethroplasty with median age of 39 (19-78). These patients had a mean of 3 dilations (1-7) prior to urethroplasty. Recurrence of stricture post urethroplasty was 2/28 (7%). One patient underwent a redo urethroplasty and one patient required one dilation with good success. Recently the rates of urethroplasty increased with 16/28 (57%) occurring in last 2 years (see Figure 1).
Interpretation of results
The management of urethral stricture is not easily standardized. It appears comprehensive discussion of urethral stricture options is not well communicated and adopted within our recurrent stricture population. Endoscopic management still appears to be the most commonly performed procedure in these patients. However, for recurrent stricture this offers only temporary relief, and most patients have poor adherence and success with ISD. There was a high failure rate with ISD and many of these patients could be managed with urethroplasty.