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Urethral Stricture is Now an Open Surgical Disease
Opposing Views
Urethral Stricture is Now an Open Surgical Disease URETHRAL reconstructive surgical techniques have advanced dramatically in safety, variety and effectiveness during the last 3 decades. Dilation and incision of urethral stricture, traditionally considered prerequisites for open urethroplasty, are now regarded as neither cost-effective nor efficacious as a long-term strategy.1 Endoscopic treatment should now only be viewed as a viable short-term solution in selected instances.
THE CASE AGAINST ENDOSCOPIC TREATMENT Like every pathological entity in our specialty, urethral stricture disease is actually a family of diseases, manifesting across a broad spectrum of severity. In general, minimally invasive treatments are best reserved for appropriate patients for whom safety and clinical success are anticipated, and not as a compulsory first step on the road to failure. Accordingly, urethral strictures should be managed on the basis of careful radiographic and/or endoscopic evaluation to establish the length, severity and location of the obstruction. Only when success is probable should dilation or incision be offered. Strictures of the bulbar urethra less than 1 cm long and less than 15Fr in caliber have been proposed as the group most amenable to a trial of incision or dilation.2 The problem is that symptomatic strictures are nearly always much longer and much more severe. Endoscopic treatment is nearly always futile for complex and distal strictures, with success rates in the range of 10%, a rate similar to the reported complication rate.3 Many reports of endoscopic treatment are further clouded by adjunctive use of self-catheterization as a strategy for prolonging the interval between interventions. Self-catheterization is a traumatic maneuver that most patients view with considerable disdain as a painful, time-consuming, embarrassing, difficult and unnatural practice they would gladly abandon if given the choice. False passages will develop in most cases over time, further complicating the problem. Today we can and must do better. 0022-5347/09/1813-0953/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Emerging evidence suggests that urethral dilation is often counterproductive, extending fibrosis into the periurethral tissues, thus complicating repair.3 Previous endoscopic manipulation has repeatedly been associated with higher failure rates following open urethroplasty. Undoubtedly, many men with intermediate length strictures (longer than 3 cm) requiring complex methods of repair such as flaps or grafts would have been cured initially with a simple anastomotic procedure performed in a 23hour hospital stay. Office dilations are psychologically traumatic and should only be performed as a temporizing maneuver in select instances. Office dilations may be more commonly performed in elderly men who have become accustomed to the practice, although men older than 65 years enjoy the same excellent outcomes as younger men after open urethral reconstruction (95% success rate).4 Endoscopic urethrotomy, performed with the patient under anesthesia using a Sachse urethrotome, is no more effective than dilation. Suprapubic urinary diversion is often a better approach. Urethral margins, analyzed histologically at the time of anastomotic urethroplasty, have been associated with reduced fibrosis after suprapubic diversion compared to similar tissues obtained in men who have not undergone diversion.5 Urethral rest is a sound principle for “preparing the battlefield” before undertaking open urethroplasty. A period of at least 2 months free of any instrumentation is advised prior to urethral reconstruction. If the stricture is severe, a suprapubic tube should be placed promptly, thus providing peace of mind for the patient and adequate time to allow the periurethral tissues to stabilize, optimizing conditions for repair.
LIMITED ROLE FOR ENDOSCOPIC TREATMENT When is dilation/incision appropriate for urethral strictures? First and foremost is the category of patients who have already undergone open urethral surgery, including those with bladder neck contracVol. 181, 953-955, March 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.12.026
www.jurology.com
953
954
OPPOSING VIEWS
tures after radical prostatectomy. Open reconstruction of the vesicourethral anastomosis, while often successful, is a formidable undertaking that should be reserved for specialized centers and as a last resort after multiple bladder neck endoscopic procedures have proven fruitless. Focal strictures appearing after open urethroplasty are nearly always amenable to early endoscopic treatment because the fibrotic tissues have been excised and replaced by healthier tissues. Recurrent stenoses after urethroplasty tend to be thin, soft and web-like, malleable enough to be reshaped
into a stable, patent configuration by either a balloon dilation or urethrotome. Finally, although the current armamentarium of urethral reconstruction techniques is varied and highly effective, many communities do not have this expertise readily available. Urethral dilation may be appropriate for stabilizing patients with acute obstructive symptoms when better alternatives are not practical. Allen Morey Department of Urology University of Texas Southwestern Medical Center Dallas, Texas
REFERENCES 1. Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL and Mundy AR: Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004; 172: 275.
3. Culty T and Boccon-Gibod L: Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol 2007; 177: 1376.
2. Pansadoro V and Emiliozzi P: Internal urethrostomy in the management of anterior urethral strictures: long-term followup. J Urol 1996; 156: 74.
4. Santucci RA, McAninch JW, Mario LA, Fajpurkar A, Chopra AK, Miller KS et al: Urethroplasty in patients older than 65 years: indications, results,
outcomes and suggested treatment modifications. J Urol 2004; 172: 202. 5. DaSilvo EA, Schiavini JL, Santos JBP and Damiao R: Histological characterization of the urethral edges in patients who underwent bulbar anastomotic urethroplasty. J Urol 2008; 180: 2077.
Cost-Effective Approach to Short Bulbar Urethral Strictures Supports Single Internal Urethrotomy Before Urethroplasty THE appropriate treatment of anterior urethral strictures remains ill-defined, with the majority of board certified urologists in the United States choosing to perform repeated endoscopic procedures before proceeding to urethroplasty.1 Fortunately, a randomized controlled trial of direct vision internal urethrotomy (DVIU) vs dilation offers level I evidence on which to base important medical and health policy decisions. Steenkamp et al reported a 60% success rate at 12 months for short (1 to 2 cm) strictures of the bulbar urethra treated with DVIU, whereas outcomes were significantly worse for longer strictures.2 In fact, Cox regression analysis showed that for each 1 cm increase in stricture length the risk of recurrence increased by 1.22 (95% confidence interval 1.05 to 1.43). Although to my knowledge no studies have directly compared DVIU and anastomotic urethroplasty for short strictures, success rates in excess of 95% for urethroplasty have been reported from experienced surgeons at recognized centers of excellence.3 The question remains whether all short strictures should be treated with primary urethroplasty. Thus, timely performance of urethroplasty instead of DVIU will reduce ineffective procedures for patients with recurrent strictures. Health care costs related to the treatment of urethral stricture disease were estimated at $200 million in 2002,4 and consist
predominantly of ambulatory surgery and office procedures. These figures underestimate the true economic burden of strictures because they fail to account for lost wages, decreased worker productivity or loss of quality of life associated with the disease and its treatments. When considering the choice of treatment for short bulbar urethral strictures, important considerations include stricture length, prior treatments, surgical expertise of the treating urologist and perspective from which the analysis is being framed. For example, a third party payer perspective of lost work, actual cost and deferred costs is different than a societal perspective. A societal perspective, taking into account lost worker productivity and wages, is recommended by the Public Health Service Task Force on Cost Effectiveness. A critical factor in deciding between urethroplasty and DVIU is the expected success of the options. We based a cost-effectiveness model on success rates of DVIU and urethroplasty of 50% and 95%, respectively.5 The widespread use of DVIU to treat a broad range of strictures reflects a level of proficiency and penetration of this technology that are not true for urethroplasty. Advocates of primary urethroplasty for all bulbar strictures will need to consider the lower rates of success that will be likely with diffusion of the technique away from selected
Urethral Stricture is Now an Open Surgical Disease URETHRAL reconstructive surgical techniques have advanced dramatically in safety, variety and effectiveness during the last 3 decades. Dilation and incision of urethral stricture, traditionally considered prerequisites for open urethroplasty, are now regarded as neither cost-effective nor efficacious as a long-term strategy.1 Endoscopic treatment should now only be viewed as a viable short-term solution in selected instances.
THE CASE AGAINST ENDOSCOPIC TREATMENT Like every pathological entity in our specialty, urethral stricture disease is actually a family of diseases, manifesting across a broad spectrum of severity. In general, minimally invasive treatments are best reserved for appropriate patients for whom safety and clinical success are anticipated, and not as a compulsory first step on the road to failure. Accordingly, urethral strictures should be managed on the basis of careful radiographic and/or endoscopic evaluation to establish the length, severity and location of the obstruction. Only when success is probable should dilation or incision be offered. Strictures of the bulbar urethra less than 1 cm long and less than 15Fr in caliber have been proposed as the group most amenable to a trial of incision or dilation.2 The problem is that symptomatic strictures are nearly always much longer and much more severe. Endoscopic treatment is nearly always futile for complex and distal strictures, with success rates in the range of 10%, a rate similar to the reported complication rate.3 Many reports of endoscopic treatment are further clouded by adjunctive use of self-catheterization as a strategy for prolonging the interval between interventions. Self-catheterization is a traumatic maneuver that most patients view with considerable disdain as a painful, time-consuming, embarrassing, difficult and unnatural practice they would gladly abandon if given the choice. False passages will develop in most cases over time, further complicating the problem. Today we can and must do better. 0022-5347/09/1813-0953/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Emerging evidence suggests that urethral dilation is often counterproductive, extending fibrosis into the periurethral tissues, thus complicating repair.3 Previous endoscopic manipulation has repeatedly been associated with higher failure rates following open urethroplasty. Undoubtedly, many men with intermediate length strictures (longer than 3 cm) requiring complex methods of repair such as flaps or grafts would have been cured initially with a simple anastomotic procedure performed in a 23hour hospital stay. Office dilations are psychologically traumatic and should only be performed as a temporizing maneuver in select instances. Office dilations may be more commonly performed in elderly men who have become accustomed to the practice, although men older than 65 years enjoy the same excellent outcomes as younger men after open urethral reconstruction (95% success rate).4 Endoscopic urethrotomy, performed with the patient under anesthesia using a Sachse urethrotome, is no more effective than dilation. Suprapubic urinary diversion is often a better approach. Urethral margins, analyzed histologically at the time of anastomotic urethroplasty, have been associated with reduced fibrosis after suprapubic diversion compared to similar tissues obtained in men who have not undergone diversion.5 Urethral rest is a sound principle for “preparing the battlefield” before undertaking open urethroplasty. A period of at least 2 months free of any instrumentation is advised prior to urethral reconstruction. If the stricture is severe, a suprapubic tube should be placed promptly, thus providing peace of mind for the patient and adequate time to allow the periurethral tissues to stabilize, optimizing conditions for repair.
LIMITED ROLE FOR ENDOSCOPIC TREATMENT When is dilation/incision appropriate for urethral strictures? First and foremost is the category of patients who have already undergone open urethral surgery, including those with bladder neck contracVol. 181, 953-955, March 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.12.026
www.jurology.com
953
954
OPPOSING VIEWS
tures after radical prostatectomy. Open reconstruction of the vesicourethral anastomosis, while often successful, is a formidable undertaking that should be reserved for specialized centers and as a last resort after multiple bladder neck endoscopic procedures have proven fruitless. Focal strictures appearing after open urethroplasty are nearly always amenable to early endoscopic treatment because the fibrotic tissues have been excised and replaced by healthier tissues. Recurrent stenoses after urethroplasty tend to be thin, soft and web-like, malleable enough to be reshaped
into a stable, patent configuration by either a balloon dilation or urethrotome. Finally, although the current armamentarium of urethral reconstruction techniques is varied and highly effective, many communities do not have this expertise readily available. Urethral dilation may be appropriate for stabilizing patients with acute obstructive symptoms when better alternatives are not practical. Allen Morey Department of Urology University of Texas Southwestern Medical Center Dallas, Texas
REFERENCES 1. Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL and Mundy AR: Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004; 172: 275.
3. Culty T and Boccon-Gibod L: Anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final outcome. J Urol 2007; 177: 1376.
2. Pansadoro V and Emiliozzi P: Internal urethrostomy in the management of anterior urethral strictures: long-term followup. J Urol 1996; 156: 74.
4. Santucci RA, McAninch JW, Mario LA, Fajpurkar A, Chopra AK, Miller KS et al: Urethroplasty in patients older than 65 years: indications, results,
outcomes and suggested treatment modifications. J Urol 2004; 172: 202. 5. DaSilvo EA, Schiavini JL, Santos JBP and Damiao R: Histological characterization of the urethral edges in patients who underwent bulbar anastomotic urethroplasty. J Urol 2008; 180: 2077.
Cost-Effective Approach to Short Bulbar Urethral Strictures Supports Single Internal Urethrotomy Before Urethroplasty THE appropriate treatment of anterior urethral strictures remains ill-defined, with the majority of board certified urologists in the United States choosing to perform repeated endoscopic procedures before proceeding to urethroplasty.1 Fortunately, a randomized controlled trial of direct vision internal urethrotomy (DVIU) vs dilation offers level I evidence on which to base important medical and health policy decisions. Steenkamp et al reported a 60% success rate at 12 months for short (1 to 2 cm) strictures of the bulbar urethra treated with DVIU, whereas outcomes were significantly worse for longer strictures.2 In fact, Cox regression analysis showed that for each 1 cm increase in stricture length the risk of recurrence increased by 1.22 (95% confidence interval 1.05 to 1.43). Although to my knowledge no studies have directly compared DVIU and anastomotic urethroplasty for short strictures, success rates in excess of 95% for urethroplasty have been reported from experienced surgeons at recognized centers of excellence.3 The question remains whether all short strictures should be treated with primary urethroplasty. Thus, timely performance of urethroplasty instead of DVIU will reduce ineffective procedures for patients with recurrent strictures. Health care costs related to the treatment of urethral stricture disease were estimated at $200 million in 2002,4 and consist
predominantly of ambulatory surgery and office procedures. These figures underestimate the true economic burden of strictures because they fail to account for lost wages, decreased worker productivity or loss of quality of life associated with the disease and its treatments. When considering the choice of treatment for short bulbar urethral strictures, important considerations include stricture length, prior treatments, surgical expertise of the treating urologist and perspective from which the analysis is being framed. For example, a third party payer perspective of lost work, actual cost and deferred costs is different than a societal perspective. A societal perspective, taking into account lost worker productivity and wages, is recommended by the Public Health Service Task Force on Cost Effectiveness. A critical factor in deciding between urethroplasty and DVIU is the expected success of the options. We based a cost-effectiveness model on success rates of DVIU and urethroplasty of 50% and 95%, respectively.5 The widespread use of DVIU to treat a broad range of strictures reflects a level of proficiency and penetration of this technology that are not true for urethroplasty. Advocates of primary urethroplasty for all bulbar strictures will need to consider the lower rates of success that will be likely with diffusion of the technique away from selected