Canadian Urological Association guideline on male urethral stricture

Abstract

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum which in turn causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors including the accuracy of cystoscopy as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient’s quality of life. Endoscopic treatment either as dilation or internal urethrotomy is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus) or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.

Diagnosis and treatment of anterior urethral strictures in China: an internet-based survey

“…Increasing evidence demonstrates that urethroplasty is the gold standard for treatment of urethral strictures [ 18 ]. However, our survey results showed that urethral dilation (92.3%) and IU (60.1%) were still the most commonly used procedures by Chinese urologists, which is consistent with all previous surveys.…”

The evolution of urethral stricture and urethroplasty practice over 15 years: A single-center, single-surgeon 1319 urethroplasty analysis

“…Broadly reported success rates for the index stricture patient undergoing standard buccal mucosa graft urethroplasty have been estimated across multiple series to be at least 80%. 8,9 In our centre, from the outset, this threshold has been exceeded across all urethroplasty subjects, increasing from 86.7% in the first five years to 93.4% in the most recent tertile. Urethroplasty competency has been estimated to occur at around 100 cases which seems plausible given that this threshold was surpassed in all five-year tertiles.…”

“…[6][7] Given the low rates of cure with repeat endoscopic treatment, multiple urological guidelines within the last 5-7 years have recommended urethroplasty after failure of endoscopic treatment or in patients at high risk of stricture recurrence. [8][9][10] These recommendations in theory should result in a reduction in the use of repeat endoscopic treatment. 4,5 In addition to advances in urethroplasty and guideline recommendations, urethroplasty practice can also be shaped by locoregional referral patterns.…”

A GRADE approach hits the mark in the new CUA male urethral stricture guideline

“…T he latest clinical practice guideline from the Canadian Urological Association (CUA), authored by a venerable cast of Canadian reconstructive urologists and guideline methodologists, is a guideline on male urethral stricture. 1 It is published in this month's edition of CUAJ and was constructed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) adolopment approach. 2 Central to the adolopment approach in GRADE guideline development is updating and improving existing guidelines in an attempt at reducing redundancy in a world of medical literature recapitulation.…”

“…Importantly, this suggestion should not be applied to those patients presenting with any degree of complexity, including penile urethral strictures and strictures >2 cm in length, among other complicating presentations. 1 The final formal suggestion from the authors suggests urethroplasty for a stricture having failed endoscopic management. The suggestion is based on 32 studies -21 newly added to the 11 from the AUA's guideline -and is a "conditional recommendation."…”