Review – Reconstructive UrologyEuropean Association of Urology Guidelines on Urethral Stricture Disease (Part 2): Diagnosis, Perioperative Management, and Follow-up in Males
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
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Cited by (29)
Treatment Success After Urethroplasty: The Ongoing Quest for a Pragmatic and Universal Definition
2023, European Urology FocusSurgical complications in adult urology: Surgery of the external genitalia
2022, Progres en UrologieGraft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures
2022, European Urology Open ScienceCitation 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.
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These authors are joint first authors.