Elsevier

European Urology

Volume 80, Issue 2, August 2021, Pages 201-212
European Urology

Review – Reconstructive Urology
European Association of Urology Guidelines on Urethral Stricture Disease (Part 2): Diagnosis, Perioperative Management, and Follow-up in Males

https://doi.org/10.1016/j.eururo.2021.05.032Get rights and content

Abstract

Context

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.

Objective

To present a summary of the 2021 European Association of Urology (EAU) guidelines on diagnosis, classification, perioperative management, and follow-up of male urethral stricture disease.

Evidence acquisition

The panel performed a literature review on the topics covering a time frame between 2008 and 2018, and using predefined inclusion and exclusion criteria for the literature. Key papers beyond this time period could be included if panel consensus was reached. A strength rating for each recommendation was added based on a review of the available literature after panel discussion.

Evidence synthesis

Routine diagnostic evaluation encompasses history, patient-reported outcome measures, examination, uroflowmetry, postvoid residual measurement, endoscopy, and urethrography. Ancillary techniques that provide a three-dimensional assessment and may demonstrate associated abnormalities include sonourethrography and magnetic resonance urethrogram, although these are not utilised routinely. The classification of strictures should include stricture location and calibre. Urethral rest after urethral manipulations is advised prior to offering urethroplasty. An assessment for urinary extravasation after urethroplasty is beneficial before catheter removal. The optimal time of catheterisation after urethrotomy is <72 h, but is unclear following urethroplasty and depends on various factors. Patients undergoing urethroplasty should be followed up for at least 1 yr. Objective and subjective outcomes should be assessed after urethral surgeries, including patient satisfaction and sexual function.

Conclusions

Accurate diagnosis and categorisation is important in determining management. Adequate perioperative care and follow-up is essential for achieving successful outcomes. The EAU guidelines provide relevant evidence-based recommendations to optimise patient work-up and follow-up.

Patient summary

Urethral strictures have to be assessed adequately before planning treatment. Before surgery, urethral rest and infection prevention are advised. After urethral surgery, x-ray dye tests are advised before removing catheters to ensure that healing has occurred. Routine follow-up is required, including patient-reported outcomes. These guidelines aim to guide doctors in the diagnosis, care, and follow-up of patients with urethral stricture.

Section snippets

Patient history

This should assess symptomatology, identify possible aetiology, note prior treatments and complications, and identify associated factors that could influence surgical outcome (Fig. 1 and Table 1).

Male urethral stricture disease (MUSD) presents in a variety of ways. A retrospective series (n = 611) revealed that lower urinary tract symptoms (LUTS) were the main mode of presentation (54.3%). Other less common modes were urinary retention (22.3%), urinary tract infection (UTI; 6.1%), and

According to stricture location

Classification according to stricture location is important as this will affect further management (Table 2) [28].

Strictures extending towards the membranous urethra are termed bulbomembranous strictures.

Penobulbar strictures should be differentiated from multifocal strictures, defined by two or more narrowed segments—either in the same urethral segment or in different segments—but preserving healthy urethral areas between them.

According to stricture tightness

It has been demonstrated that men usually do not experience

Urethral rest

After any form of urethral manipulation (urethral catheter, ISC, dilation, and DVIU), a period of urethral rest is necessary in order to allow tissue recovery and stricture “maturation” before considering urethroplasty (Table 4). This improves the ability to identify the true extent of the fibrotic segments during subsequent surgery. If the patient develops incapacitating obstructive symptoms or urinary retention, an SPC should be inserted. Terlecki et al [30] proposed a diagnostic evaluation

Rationale for follow-up after urethral surgery

The rationale is to detect and manage any complication or recurrence (Table 5). Up to 54% of patients after anterior urethroplasty [41] would present with complications with short to medium follow-up. Though urethroplasty provides the highest chances for patency, some patients will experience recurrence [42].

Definition of success after urethroplasty surgery

The “traditional academic” definition of success after urethroplasty has been considered as the lack of any postoperative intervention for restricture [43]. This definition is problematic

Calibration

The difference between calibration and urethral dilation is usually subjective as soft strictures may be dilated during calibration [46]. Therefore, urethral calibration should be used with caution for follow-up after urethroplasty.

Urethrocystoscopy

Flexible urethrocystoscopy has been considered the most useful tool to confirm the presence or absence of a recurrent stricture [47], [48]. In addition, it could be a measure to calibrate the lumen, bearing in mind the most commonly used endoscopes: 15.7F (5 mm

Ideal interval and length of follow-up

The optimal follow-up strategy must allow for an objective determination of anatomic and functional outcomes to assess surgical success, whilst avoiding excessive invasive testing that leads to unnecessary cost, discomfort, anxiety, and risk [43].

After anterior urethroplasty, 21% of recurrences are clinically evident, and cystoscopically confirmed, after 3 mo [57] and 96% after 1 yr [49]. Of bulbar stricture recurrences, 23% would be detected during the 2nd year of follow-up and the percentage

Risk-stratified proposals

As the risk of recurrence and side effects are related to the type of stricture and urethroplasty, a different follow-up schedule was proposed based upon risk stratification. This was shown to be cost effective, potentially saving up to 85% of costs at 5 yr [59]. If evidence of good anatomical outcome is obtained using cystourethroscopy or RUG/VCUG at 3–6 mo postoperatively, flowmetry and questionnaires should be considered as the new baseline. Thereafter, follow-up could be performed safely

References (61)

  • A. Horiguchi et al.

    Pubourethral stump angle measured on preoperative magnetic resonance imaging predicts urethroplasty type for pelvic fracture urethral injury repair

    Urology

    (2018)
  • R.S. Purohit et al.

    Natural history of low-stage urethral strictures

    Urology

    (2017)
  • R.P. Terlecki et al.

    Urethral rest: role and rationale in preparation for anterior urethroplasty

    Urology

    (2011)
  • M.L. McDonald et al.

    Antimicrobial practice patterns for urethroplasty: opportunity for improved stewardship

    Urology

    (2016)
  • B.A. Erickson et al.

    A prospective, randomized trial evaluating the use of hydrogel coated latex versus all silicone urethral catheters after urethral reconstructive surgery

    J Urol

    (2008)
  • LL Yeung et al.

    Urethroplasty practice and surveillance patterns: a survey of reconstructive urologists

    Urology

    (2013)
  • M.A. Granieri et al.

    A critical evaluation of the utility of imaging after urethroplasty for bulbar urethral stricture disease

    Urology

    (2016)
  • E.T. Grossgold et al.

    Routine urethrography after buccal graft bulbar urethroplasty: the impact of initial urethral leak on surgical success

    Urology

    (2017)
  • BA Erickson et al.

    Definition of successful treatment and optimal follow-up after urethral reconstruction for urethral stricture disease

    Urol Clin North Am

    (2017)
  • M.J. Jackson et al.

    A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure

    Eur Urol

    (2013)
  • TM Kessler et al.

    Patient satisfaction with the outcome of surgery for urethral stricture

    J Urol

    (2002)
  • J.J. Meeks et al.

    Stricture recurrence after urethroplasty: a systematic review

    J Urol

    (2009)
  • S.K. Goonesinghe et al.

    Flexible cystourethroscopy in the follow-up of posturethroplasty patients and characterisation of recurrences

    Eur Urol

    (2015)
  • J. Seibold et al.

    Urethral ultrasound as a screening tool for stricture recurrence after oral mucosa graft urethroplasty

    Urology

    (2011)
  • B.A. Erickson et al.

    Changes in uroflowmetry maximum flow rates after urethral reconstructive surgery as a means to predict for stricture recurrence

    J Urol

    (2011)
  • E. Palminteri et al.

    Two-sided dorsal plus ventral oral graft bulbar urethroplasty: long-term results and predictive factors

    Urology

    (2015)
  • J. DeLong et al.

    Patient-reported outcomes combined with objective data to evaluate outcomes after urethral reconstruction

    Urology

    (2013)
  • B.A. Erickson et al.

    The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery

    J Urol

    (2010)
  • CC Maciejewski et al.

    Chordee and penile shortening rather than voiding function are associated with patient dissatisfaction after urethroplasty

    Urology

    (2017)
  • CF Heyns et al.

    Prospective evaluation of the American Urological Association symptom index and peak urinary flow rate for the followup of men with known urethral stricture disease

    J Urol

    (2002)
  • Cited by (29)

    • Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures

      2022, European Urology Open Science
      Citation Excerpt :

      Indeed, erectile function scores and penile Doppler findings were not assessed in our patients. Lastly, we acknowledge that no routine retrograde urethrogram were performed 12 mo after surgery, as it is now recommended by guidelines in these complex cases [23]. In summary, our study joins previous publications on single-stage graft plus flap urethroplasty expanding our knowledge on this challenging reconstructive surgery.

    View all citing articles on Scopus

    These authors are joint first authors.

    View full text