Study: Urethroplasty use on the rise

March 6, 2020
John Schieszer

Volume 48, Issue 03

A significant trend is occurring in the management of urethral stricture, with increased utilization of urethroplasty and decreased utilization of repeat endoscopic procedures, researchers at the University of Washington in Seattle report.

A significant trend is occurring in the management of urethral stricture, with increased utilization of urethroplasty and decreased utilization of repeat endoscopic procedures, researchers at the University of Washington in Seattle report.

Investigators examined a national sample of patients with employer-based health insurance and found a drastic change in national practice patterns for management of urethral stricture patients, favoring more definitive management in accordance with recently published guidelines.

“The actual AUA guidelines about urethral stricture management weren’t published until 2017, so it’s too early to specifically evaluate the impact of these guidelines on management,” said study investigator Niels V. Johnsen, MD, who was a male genitourinary trauma and reconstruction fellow at the University of Washington at the time of the study. The findings from the current study were presented at the 2019 AUA annual meeting in Chicago.

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Dr. Johnsen and his co-authors examined national trends in urethral stricture management over time utilizing MarketScan, which is a database of employed individuals and their dependents with employer-sponsored health insurance in the U.S. For this investigation, the authors defined repeat endoscopic management as two or more endoscopic procedures per patient. They used the published AUA guidelines as a framework to evaluate what they defined as appropriate surgical management of urethral strictures (a single endoscopic procedure, a single endoscopic procedure followed by urethroplasty if needed, or upfront urethroplasty) compared to inappropriate surgical management (multiple endoscopic procedures).

From 2008 to 2016, which included data on more than 15 million eligible male beneficiaries per year on average, the crude urethroplasty rates per stricture diagnosis had significantly increased by about 44% over the study period, the researchers found.

Next: Increase in ‘appropriate care’ seenIncrease in ‘appropriate care’ seen

“More importantly, when we looked at what we defined as ‘appropriate care,’ there has been an 87% increase in appropriate care during the period as well. After adjusting for age and comorbidity status, there was an approximately 18% increased odds of receiving ‘appropriate care’ for each additional year in the study, while older and sicker men remained more likely to undergo endoscopic management as would be assumed,” said Dr. Johnsen, currently assistant professor of urology at Vanderbilt University Medical Center, Nashville, TN.

He said the impetus for this study was that there had been signs within the urology community and some previously published works that the tides were beginning to turn and more urologists were feeling more comfortable performing basic urethroplasty techniques. Over the past decade, a growing body of literature has shown that repeat endoscopic procedures are unlikely to provide good long-term success, resulting in the latest AUA guidelines in 2017.

Dr. Johnsen noted there are some limitations to the current study, including the fact that the authors did not have information as to why patients/providers choose to undergo one management or another.

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“We also do not know if certain individuals were offered a urethroplasty and then opted to undergo repeat endoscopic treatment,” said Dr. Johnsen.

Another limitation is that the definitions of “appropriate” and “inappropriate” care are based on the current guidelines, but not necessarily a reflection of adherence to the guidelines prior to 2017.

This study is important because it shows that nationwide it is becoming less likely that patients will undergo repeat endoscopic management of urethral strictures, suggesting a better understanding by urologists of the low long-term success rates of endoscopic management and relatively higher success rates of urethroplasty, according to Dr. Johnsen.

However, what is driving this evolution is not entirely clear. He said it appears to be due in part to both better data on the relative success rates, as well as increased comfort and distribution of urethroplasty surgical techniques through changes in resident training.

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