AUA guideline positively impacts stricture management

Dr. Erickson is associate professor of urology and surgery, and Dr. Cotter is a reconstructive urology fellow, University of Iowa Carver College of Medicine, Iowa City.

A recent survey conducted by Urology Times asked readers about their practice’s utilization and understanding of the 2016 AUA urethral stricture disease guidelines and the impact the guidelines have had on their clinical management of urethral strictures. In addition, given the rise in popularity of careers in reconstructive urology among graduating urology residents (17 Genitourinary Reconstruction Society fellowship programs now participate in the match, with a resident match rate of only 58% in 2017), we surveyed urologists about their individual comfort with urethral reconstruction, the presence of a urethral “specialist” within their group, and their referral patterns for complicated urethral reconstruction.

Overall, the survey results suggest that the AUA urethral stricture guidelines have made a positive impact and the management of urethral stricture disease continues to shift from endoscopic treatment to open surgical repairs.

The majority of readers (72%) have read the AUA urethral stricture guidelines (bit.ly/2HR5Z8q), with only 8% being unaware of their existence. When asked how the guidelines have changed their clinical management, 18% said they are doing more urethroplasties and 38% are referring more cases to centers of expertise.

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In a case-based question, readers were asked how they would manage a 1.5-cm bulbar urethral stricture that has failed multiple urethrotomies, the last being 18 months ago. The guidelines would suggest here that urethroplasty is the most appropriate choice for this patient. Encouragingly, over 40% of the respondents would either perform an anastomotic urethroplasty (31%) or a urethroplasty utilizing a buccal graft (13%). An additional 43% would refer the patient to a center that routinely performs urethroplasties, while only 13% would repeat the urethrotomy.

When asked about a pelvic fracture urethral distraction defect case, 73% indicated that they are comfortable in the initial trauma management, of whom 42% would initially attempt retrograde catheter placement, 38% would immediately place a suprapubic tube, and 39% would only place a suprapubic tube after initially failing retrograde catheter placement. A much smaller percentage (6%) would attempt open realignment.

A multitude of recent studies have shown that experience matters when it comes to urethroplasty outcomes (Urology 2016; 89:137-42; Eur Urol 2016; 69:686-90; Transl Androl Urol 2017; 6:1132-7), with one study showing that acceptable outcomes may not be achieved until 100 cases (Urology 2016; 89:137-42) and another showing that results may continue to improve even after 500 cases (Eur Urol 2016; 69:686-90). The survey responses suggest that most urologists understand that not all urologists should be doing urethral reconstruction. Indeed, when asked specifically how they manage urethral strictures in their practice, only 32% of urologists stated they manage all the male stricture cases in their practice, with the vast majority either referring to a provider inside (16%) or outside (47%) of their practice.

Compared to those in other practice settings, urologists in academic practice were more likely to manage all cases of urethral stricture themselves (70%). Similarly, although only 43% of respondents stated they had a urologist in their practice who “specialized” in urethral reconstruction, specialization was much more common in academic/government practices (73%) and in larger practices with 10-19 urologists (70%) and 20+ urologists (69%), as compared to practices with fewer than seven physicians (24%).

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Interestingly, regardless of practice type, those with less overall experience were significantly more likely to manage all urethral strictures themselves, with 91% of respondents 1-4 years out of residency saying they do all their own urethroplasties, compared to only 23% who were 20-29 years out. We suspect that this is related to an increase in surgical exposure during residencies, likely the direct result of greater penetrance of reconstructive urologic specialists within training programs.

In general, it appears that the effect of the AUA urethral stricture guidelines has been positive and that the condition’s clinical management is evolving from endoscopic to open surgical repairs. This finding is supported by recent data looking at overall trends in urethral stricture management (Urology 2015; 86:830-4; Urology 2014; 84:1506-9), which show a practice shift away from repeat endoscopic management, as reported in a survey of urologists published a decade ago (J Urol 2007; 177:685-90).

Specialization in urethral reconstruction is no longer just found in academics, with many larger private practice groups having a designated urethral expert. With more reconstructive faculty in training programs nationwide, comfort with urethroplasties will continue to improve, which we believe represents a positive impact in our overall management of urethral stricture disease.