ICUD on Urethral Strictures SIU/ICUD Consultation on Urethral Strictures: Dilation, Internal Urethrotomy, and Stenting of Male Anterior Urethral Strictures Jill C. Buckley, Chris Heyns, Peter Gilling, and Jeff Carney Male urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. Our objective was to review all contemporary and historial articles on the topic of dilation, internal urethrotomy, and stenting of male anterior urethral strictures. An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Using criteria set forth by the ICUD, a committee of international experts in urethral stricture disease reviewed the literature and created a consensus statement incorporating levels of evidence and expert opinion in regard to dilation, internal urethrotomy, and stenting of male anterior urethral strictures. UROLOGY 83: S18eS22, 2014. 2014 Elsevier Inc.
M
ale urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. The oldest and simplest form of management is urethral dilation, which can be performed with a number of different devices and is generally considered a palliative maneuver. In 1974, Sachse1 introduced direct vision internal urethrotomy (DVIU) to treat urethral strictures by cold-knife incision. Optical urethrotomy by either incision or ablation has been considered standard therapy for anterior urethral strictures and is regarded, along with dilation, as the initial treatment of choice for most urethral strictures. In general, open urethral reconstruction is the most successful management option for urethral strictures, but it requires surgical expertise, adequate operating room facilities, and has a longer recovery period. A number of large series from the late 1990s have well characterized the success of incision or dilation of the urethra and delineated predictive factors of outcomes.2-4 Various modifications of the single cold-knife incision have been suggested, including a variety of different laser wavelengths and the introduction of anterior urethral stenting.5,6 However, there are no prospective, randomized studies to prove their claims of greater efficacy. The long-term success rate of urethrotomy has continued on a steady downward trend from the results of
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Lahey Clinic, Burlington, MA (J.C.B.); Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa (C.H.); Promed Urology, Tauranga, New Zealand (P.G.); and the Grady Memorial Hospital, Atlanta, GA (J.C.) Reprint requests: Jill C. Buckley, M.D., UCSD Health System, Department of Urology, 200 West Arbor Drive MC 8897, San Diego, CA 92103-8897. E-mail: [email protected] Submitted: May 30, 2013, accepted (with revisions): August 1, 2013
S18
ª 2014 Elsevier Inc. All Rights Reserved
20 years ago, which suggested a cure rate of over 90%.2,7-9 The reported success rates of urethral stricture treatment are critically dependent on the criteria used for stricture diagnosis before and after treatment, and on the definition of success (in some studies this includes eventual outcome, despite multiple treatments). Modalities used in determining the success of treatment include symptoms, uroflowmetry, urethral catheterization or calibration, urethrocystoscopy, urethrography (radiological or sonographic), post-void residual urine volume, absence of urinary tract infection, and requirement for subsequent treatment. Clearly, the success rates reported in various studies depend not only on the type of treatment given, but on the criteria used for stricture diagnosis before treatment, the type and duration of follow-up, and the modalities and criteria used to determine stricture recurrence and to define success.
METHODS An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Recommendations were graded according to the levels of evidence and agreement of expert opinion.
Incision/Dilation of Male Anterior Urethral Strictures A recent survey examining the practice patterns of boardcertified American urologists found that 92.8% and 85.6% use dilation and/or incision, respectively, to treat anterior urethral 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.08.075
strictures. Of the urologists that perform urethral reconstruction, only 0.7% perform >10 per year.10,11 The appeal of DVIU/ dilation is its relative ease of performance, minimal resource requirements, and simplicity in not requiring expertise in urethral reconstruction. The procedure can be performed in the office (with the patient under local anesthesia), requires minimal recovery time, and has a low cost burden to the patient in terms of disability precluding work.12-14 The goal of incision or dilation is to provide a minimally invasive treatment that achieves a patent urethra to allow unobstructed voiding with minimal side effects. For the urethra to remain patent, re-epithelialization must occur at a faster rate than wound contracture.15 For highly selected patients with optimal stricture characteristics (primary bulbar stricture, 2) DVIU/dilation for early stricture recurrence after previous DVIU/dilation is a palliative maneuver with expected recurrence.2,4,8,9,18 Thus, it is inappropriately and excessively used because of its convenience and familiarity when referral for urethral reconstruction could be curative. The literature consists largely of case series with diverse patient populations that are not matched for age, stricture etiology, length, location, or primary vs recurrent strictures. Techniques vary from blind urethral dilation and incision to direct visualization and incision urethrotomy with a cold knife, hot knife, or various types of lasers. The definition of success was vague and poorly defined in most series and limited to one of the following: lack of symptoms, “acceptable” flow rates, radiography, and (rarely) urethroscopy. Outcomes were largely based on short-term follow-up (35%-50%. Primary urethroplasty becomes more cost effective if a repeat urethrotomy is required. Wright et al28 found that the most cost-effective strategy for the management of short bulbar urethral strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails. For longer strictures, in which the success rate of DVIU is expected to be
M
ale urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. The oldest and simplest form of management is urethral dilation, which can be performed with a number of different devices and is generally considered a palliative maneuver. In 1974, Sachse1 introduced direct vision internal urethrotomy (DVIU) to treat urethral strictures by cold-knife incision. Optical urethrotomy by either incision or ablation has been considered standard therapy for anterior urethral strictures and is regarded, along with dilation, as the initial treatment of choice for most urethral strictures. In general, open urethral reconstruction is the most successful management option for urethral strictures, but it requires surgical expertise, adequate operating room facilities, and has a longer recovery period. A number of large series from the late 1990s have well characterized the success of incision or dilation of the urethra and delineated predictive factors of outcomes.2-4 Various modifications of the single cold-knife incision have been suggested, including a variety of different laser wavelengths and the introduction of anterior urethral stenting.5,6 However, there are no prospective, randomized studies to prove their claims of greater efficacy. The long-term success rate of urethrotomy has continued on a steady downward trend from the results of
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Lahey Clinic, Burlington, MA (J.C.B.); Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa (C.H.); Promed Urology, Tauranga, New Zealand (P.G.); and the Grady Memorial Hospital, Atlanta, GA (J.C.) Reprint requests: Jill C. Buckley, M.D., UCSD Health System, Department of Urology, 200 West Arbor Drive MC 8897, San Diego, CA 92103-8897. E-mail: [email protected] Submitted: May 30, 2013, accepted (with revisions): August 1, 2013
S18
ª 2014 Elsevier Inc. All Rights Reserved
20 years ago, which suggested a cure rate of over 90%.2,7-9 The reported success rates of urethral stricture treatment are critically dependent on the criteria used for stricture diagnosis before and after treatment, and on the definition of success (in some studies this includes eventual outcome, despite multiple treatments). Modalities used in determining the success of treatment include symptoms, uroflowmetry, urethral catheterization or calibration, urethrocystoscopy, urethrography (radiological or sonographic), post-void residual urine volume, absence of urinary tract infection, and requirement for subsequent treatment. Clearly, the success rates reported in various studies depend not only on the type of treatment given, but on the criteria used for stricture diagnosis before treatment, the type and duration of follow-up, and the modalities and criteria used to determine stricture recurrence and to define success.
METHODS An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Recommendations were graded according to the levels of evidence and agreement of expert opinion.
Incision/Dilation of Male Anterior Urethral Strictures A recent survey examining the practice patterns of boardcertified American urologists found that 92.8% and 85.6% use dilation and/or incision, respectively, to treat anterior urethral 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.08.075
strictures. Of the urologists that perform urethral reconstruction, only 0.7% perform >10 per year.10,11 The appeal of DVIU/ dilation is its relative ease of performance, minimal resource requirements, and simplicity in not requiring expertise in urethral reconstruction. The procedure can be performed in the office (with the patient under local anesthesia), requires minimal recovery time, and has a low cost burden to the patient in terms of disability precluding work.12-14 The goal of incision or dilation is to provide a minimally invasive treatment that achieves a patent urethra to allow unobstructed voiding with minimal side effects. For the urethra to remain patent, re-epithelialization must occur at a faster rate than wound contracture.15 For highly selected patients with optimal stricture characteristics (primary bulbar stricture, 2) DVIU/dilation for early stricture recurrence after previous DVIU/dilation is a palliative maneuver with expected recurrence.2,4,8,9,18 Thus, it is inappropriately and excessively used because of its convenience and familiarity when referral for urethral reconstruction could be curative. The literature consists largely of case series with diverse patient populations that are not matched for age, stricture etiology, length, location, or primary vs recurrent strictures. Techniques vary from blind urethral dilation and incision to direct visualization and incision urethrotomy with a cold knife, hot knife, or various types of lasers. The definition of success was vague and poorly defined in most series and limited to one of the following: lack of symptoms, “acceptable” flow rates, radiography, and (rarely) urethroscopy. Outcomes were largely based on short-term follow-up (35%-50%. Primary urethroplasty becomes more cost effective if a repeat urethrotomy is required. Wright et al28 found that the most cost-effective strategy for the management of short bulbar urethral strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails. For longer strictures, in which the success rate of DVIU is expected to be
