Urethral Stricture Disease (2023)
Using AUA Guidelines
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(Published 2016; Amended 2023)
To cite this guideline:
Wessells H, Morey A, Vanni A, Rahimi L, Souter L. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71.
The Practice Guidelines Committee would like to acknowledge the contributions of Dr. Allen Morey, MD and Dr. Lesley Souter, Ph.D. to the 2023 Guideline Amendment.
Hunter Wessells, MD; Kenneth W. Angermeier, MD; Sean P. Elliott, MD; Christopher M. Gonzalez, MD; Ron T. Kodama, MD; Andrew C. Peterson, MD; James Reston, PhD; Keith Rourke, MD; John T. Stoffel, MD; Alex Vanni, MD; Bryan Voelzke, MD; Lee Zhao, MD; Richard A. Santucci, MD
The clinical guideline on urethral stricture provides a clinical framework for the diagnosis of urethral stricture and includes discussion of initial management, urethroplasty, reconstruction, contracture, stenosis, special circumstances, and post-operative follow-up care.
A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment used the Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases and was modified to included females and males (search dates 12/2015 – 10/2022 for males; 01/1990 – 10/2022 for females) and one new Key Question on sexual dysfunction outcomes in men with bulbar urethral strictures was added (search dates: 01/1990 – 10/2022). All searches yielded 11,752 citations; after inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty) and evidence-based statements of Strong, Moderate, or Conditional Recommendation based on risks and benefits were developed. Additional information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.
- Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection, and after rising post-void residual. (Moderate Recommendation; Evidence Level: Grade C)
- After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture. (Clinical Principle)
- Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)
- Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion)
- Surgeons may utilize urethral endoscopic management (e.g., urethral dilation, direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)
- Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence Level: Grade C)
- Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
- Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
- Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)
- In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain urethral patency. (Conditional Recommendation; Evidence Level: Grade C)
- a. Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level: Grade C)
b. Surgeons may offer urethral dilation or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)
- Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)
Anterior Urethral Reconstruction
- Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle)
- Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate Recommendation; Evidence Level: Grade C)
- Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)
- Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral strictures, given the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation; Evidence Level: Grade C)
- Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
- a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)
b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)
- a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)
b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation; Evidence Level: Grade A)
- Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion)
- Surgeons should not perform a single stage tubularized graft urethroplasty. (Expert Opinion)
- Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)
Pelvic Fracture Urethral Injury
- Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate Recommendation; Evidence Level: Grade C)
- Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)
- Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion)
Female Urethral Reconstruction
- Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
Bladder Neck Contracture/Vesicourethral Stenosis
- Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion)
- Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
- Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
- In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)
- Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle)
- In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Level: Grade B)
- Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy, or urethroplasty. (Expert Opinion)
Urethral stricture is chronic fibrosis and narrowing of the urethral lumen caused by acute injury, inflammatory conditions, and iatrogenic interventions including urethral instrumentation, surgery, and prostate cancer treatment. The symptoms of urethral stricture are non-specific and may overlap with other common conditions that confound timely diagnosis, including lower urinary tract symptoms (LUTS) and urinary tract infections (UTI). Urologists play a key role in the initial evaluation of urethral stricture and currently provide all accepted treatments. Thus, urologists must be familiar with the evaluation and diagnostic tests for urethral stricture as well as endoscopic and open surgical treatments. This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.
A systematic review for the 2016 guideline was conducted to identify published articles relevant to the diagnosis and treatment of urethral stricture in men. Literature searches were performed on English-language publications using the Pubmed, Embase, and Cochrane databases from 1/1/1990 to 12/1/2015 by the ECRI Institute and were included in a systematic review evidence report. Preclinical studies (e.g., animal models), commentary, editorials, non-English language publications, and meeting abstracts were excluded. Additional exclusion criteria were as follows: studies of females; studies of stricture prevention; patients with epispadias, congenital strictures, and duplicated urethra; trauma already covered under trauma guidelines including diagnosis and management of acute pelvic fracture urethral injury (PFUI) or pelvic fracture urethral disruption; urethral cancer not related to stricture; or voiding symptoms not related to stricture. Studies with less than 10 patients were generally excluded from further evaluation and thus data extraction given the unreliability of the statistical estimates and conclusions that could be derived from them. In rare instances, we have included studies with less than 10 patients or studies preceding the literature search date if no other evidence was identified. For certain key questions that had little or no evidence from comparative studies, we included case series with 50 or more patients. Review article references were checked to ensure inclusion of all possible relevant studies. Multiple reports on the same patient group were carefully examined to ensure inclusion of only non-redundant information. The systematic review yielded a total of 250 publications relevant to preparation of the guideline.
Quality of Individual Studies and Determination of Evidence Strength
The quality of individual studies that were either randomized controlled trials (RCTs) or clinical controlled trials was assessed using the Cochrane Risk of Bias tool.1 Observational cohort studies with a comparison of interest were evaluated with the Drug Effectiveness Review Project instrument.2 Conventional diagnostic cohort studies, diagnostic case-control studies, or diagnostic case series that presented data on diagnostic test characteristics were evaluated using the QUADAS 2 tool, which evaluates the quality of diagnostic accuracy studies.3
The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but also consideration of study design, consistency of findings across studies, adequacy of sample sizes, and generalizability of samples, settings, and treatments for the purposes of the guideline. The American Urological Association (AUA) categorizes the level of a body of evidence as Grade A (well-conducted and highly-generalizable RCTs or exceptionally strong observational studies with consistent findings); Grade B (RCTs with some weaknesses of procedure or generalizability or moderately strong observational studies with consistent findings); or Grade C (RCTs with serious deficiencies of procedure, generalizability, or extremely small sample sizes or observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.4
The 2016 guideline search strategy was modified to include females in addition to males and was used to systematically search Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases for new evidence published between December 2015 and October 2022. A second search was designed to only identify female urethral stricture studies published between January 1990 and December 2015, the timeframe covered in the original guideline for male patients. Finally, a third search (January 1990 – October 2022) was developed to address a new Key Question comparing sexual dysfunction outcomes in men with bulbar urethral strictures receiving either non-transecting anastomotic urethroplasty procedures or transecting procedures. Titles and abstracts of studies identified by all searches were reviewed in a two-stage process. During the first stage, studies were reviewed to determine if they assessed urethral stricture in males or females, and if they met the study selection criteria of prespecified study type, minimum allowable sample size, and if published in English. Allowable study types included systematic reviews, RCTs, diagnostic accuracy studies, cohort studies with and without comparison group, case-control studies, and case series. All other study types were excluded. Only studies that enrolled at least 10 patients were considered for inclusion in the evidence base. During the second stage of title and abstract review, abstracts were compared to the PICO criteria (Appendix 1). Additionally, studies were assessed to determine if they either directly informed the Key Questions or if they presented data that could reaffirm or refute the original guideline statements.
In the original ECRI evidence report that underpinned the male urethral stricture guideline,5 single-arm observational studies that evaluated urethroplasty or bulbar urethral strictures were excluded, and the evidence base was comprised of RCTs and comparative cohort studies. This exclusion criterion was retained in the amendment when evaluating studies that enrolled male or both male and female populations. However, based on a paucity of data, single-arm studies that enrolled a solely female population were retained. Following study selection, 81 studies were included in the amendment evidence base (Appendix 2).
Individual Study Quality and Potential for Bias
Quality assessment for all retained studies was conducted. Using this method, studies deemed to be of low quality would not be excluded from the systematic review, but would be retained, and their methodological strengths and weaknesses discussed where relevant. To define an overall study quality rating for each included study, risk of bias as determined by validated study-type specific tools was paired with additional important quality features. AMSTAR-2 was used for assessment of systematic review with and without meta-analyses.6 To evaluate the risk of bias within the identified RCTs, the Cochrane Risk of Bias Tool7 was employed, while for observational studies, a Risk of Bias in Non-Randomized Studies – of Intervention (ROBINS-I) tool8 was used. Additional important quality features, such as study design, comparison type, power of statistical analysis, and sources of funding were extracted for each study.
Certainty of Evidence by GRADE
The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to determine the aggregate evidence quality for each recommendation statement.9 GRADE defines a body of evidence in relation to how confident guideline developers can be that the estimate of effects as reported by that body of evidence is correct. Evidence is categorized as high, moderate, low, and very low, and assessment is based on the aggregate risk of bias for the evidence base, plus limitations introduced as a consequence of inconsistency, indirectness, imprecision and publication bias across the studies.10 Upgrading of evidence is possible if the body of evidence indicates a large effect or if confounding would suggest either spurious effects or would reduce the demonstrated effect.
The AUA employs a 3-tiered strength of evidence system to underpin evidence-based guideline statements. Table 1 summarizes the GRADE categories, definitions, and how these categories translate to the AUA strength of evidence categories. In short, high certainty by GRADE translates to AUA A-category strength of evidence, moderate to B, and both low and very low to C.
AUA Nomenclature: Linking Statement Type to Evidence Level
The AUA nomenclature system explicitly links statement type to body of evidence level, degree of certainty, magnitude of benefit or risk/burdens, and the Panel's judgment regarding the balance between benefits and risks/burdens (Table 2). Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. Moderate Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is moderate. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burden is unclear. All three statement types may be supported by any body of evidence grade. Grade A evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances and that future research is unlikely to change confidence. Grade B evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but that better evidence could change confidence. Grade C evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but that better evidence is likely to change confidence. Grade C evidence is only rarely used in support of a Strong Recommendation. Conditional Recommendations also can be supported by Grade A, B, or C evidence. When Grade A is used, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. When Grade B evidence is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances and better evidence could change confidence. When Grade C evidence is used, there is uncertainty regarding the balance between benefits and risks/burdens, alternative strategies may be equally reasonable, and better evidence is likely to change confidence.
For some clinical issues, particularly diagnosis, there was little or no evidence from which to construct evidence-based statements. Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinion with consensus achieved using a modified Delphi technique if differences of opinion emerged.11 A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there is no evidence.
Table 1: Strength of Evidence Definitions
Table 2: AUA Nomenclature Linking Statement Type to Level of Certainty, Magnitude of Benefit or Risk/Burden, and Body of Evidence Strength
The Urethral Stricture Panel was created in 2013 by the American Urological Association Education and Research, Inc. The Practice Guidelines Committee (PGC) of the AUA selected the Panel Co-Chairs who in turn appointed the additional panel members with specific expertise in this area. The AUA conducted a thorough peer review process. The draft guidelines document was distributed to 90 peer reviewers. The panel reviewed and discussed all submitted comments and revised the draft as needed. Once finalized, the guideline was submitted for approval to the PGC and the AUA Science and Quality Council. Then it was submitted to the AUA Board of Directors for final approval. Funding of the panel was provided by the AUA; panel members received no remuneration for their work.
The Urethral Stricture Amendment Panel was created in 2020 by the AUA. The Chair of the original guideline was appointed Chair of the amendment panel. The balance of the panel was composed of one member of the original panel and one content expert who was not a member of the original guideline panel. The outside expert was approved by the PGC Chairs. The AUA conducted a thorough peer review process and the draft guideline document was distributed to 50 peer reviewers, 21 of whom submitted a total of 67 comments. The Amendment Panel reviewed and discussed all submitted comments and revised the draft as needed. Once finalized, the guideline was submitted for approval to the PGC and Science and Quality Council. It was then submitted to AUA Board of Directors for final approval. Panel members received no renumeration for their work.
The urethra extends from the bladder neck, which is composed of smooth muscle circular fibers, to the meatus, with varying histological features and stromal support based on anatomical location. The components of the posterior urethra are lined with transitional epithelium, whereas the male anterior urethra is lined with pseudostratified columnar epithelium that changes to stratified squamous epithelium in the fossa navicularis. The posterior urethra includes both the prostatic and membranous urethra in men whereas in women it consists solely of the membranous urethra. The prostatic urethra extends from the distal bladder neck to the distal end of the veru montanum. The distal external sphincter mechanism surrounds the membranous urethra and is comprised of both intrinsic smooth muscle and rhabdosphincter. The anterior urethra includes the bulbar urethra, penile urethra, and fossa navicularis. This portion of the urethra is surrounded by the corpus spongiosum, which in the bulbar urethra is surrounded by the bulbocavernosus muscle. The fossa navicularis is located entirely within the glans penis.
Urethral stricture is the preferred term for any abnormal narrowing of the anterior urethra, which runs from the bulbar urethra to the meatus and is surrounded by the corpus spongiosum. Urethral strictures are associated with varying degrees of spongiofibrosis. Narrowing of the posterior urethra, which lacks surrounding spongiosum, is thus referred to as a "stenosis." PFUI typically creates a distraction defect with resulting obstruction or obliteration.12
Urethral strictures or stenoses are treated endoscopically or with urethroplasty. Endoscopic management is performed by either urethral dilation or direct vision internal urethrotomy (DVIU). There are a multitude of different urethroplasty techniques that can be generally divided into tissue transfer-involved procedures and non-tissue transfer-involved procedures. Anastomotic urethroplasty does not involve tissue transfer and can be performed in both a transecting and non-transecting manner. Excision and primary anastomosis urethroplasty involve transection and removal of the narrowed segment of urethra and corresponding spongiofibrosis with anastomosis of the two healthy ends of the urethra and corpus spongiosum. Non-transecting anastomotic urethroplasty preserves the corpus spongiosum, thus allowing the strictured urethra to be excised and reanastomosed or incised longitudinally through the narrowed segment of the urethra and closed in a Heineke-Mikulicz fashion.
Techniques that involve tissue transfer can be categorized into single-stage and multi-stage procedures. In single-stage procedures, the urethra is augmented in caliber by transferring tissue in the form of a graft or flap. Multi-stage procedures use a graft as a urethral substitute for future tubularization.
Geographic setting, socioeconomic factors, and access to healthcare can affect stricture etiology. In high income countries, the most common etiology of urethral stricture is idiopathic (41%) followed by iatrogenic (35%). Late failure of hypospadias surgery and stricture resultant from endoscopic manipulation (e.g., transurethral resection) are common iatrogenic reasons. In comparison, trauma (36%) is the most common cause in low- and middle-income countries, reflecting higher rates of road traffic injuries, less developed trauma systems, inadequate roadway systems, and conceivably socioeconomic factors leading to a higher prevalence of trauma-related strictures.13-15
Strictures in the bulbar urethra are more common than other anatomic locations in males; however, certain etiologies are closely associated with an anatomic segment of the urethra.13 For example, strictures related to hypospadias and lichen sclerosus ([LS]; previously termed balanitis xerotica obliterans) are generally located in the penile urethra, while traumatic strictures and stenoses tend to be located in the bulbar and posterior urethra.
Patients with urethral stricture most commonly present with decreased urinary stream and incomplete bladder emptying but may also demonstrate UTI, epididymitis, rising post-void residual (PVR), or decreased force of ejaculation. Additionally, patients may present with urinary spraying or dysuria.16
Patient Reported Outcomes Measures
Patient reported measures (PRMs) help elucidate the presence and severity of patient symptoms and bother and thus may serve as an important component of urethral stricture diagnosis and management. While the American Urological Association Symptom Index (AUASI) includes items assessing decreased urinary stream and incomplete bladder emptying, it does not identify other symptoms seen in patients with a urethral stricture, such as urinary spraying and dysuria.16 Therefore, there is a need for development of a standardized urethral stricture PRM that can be used to assess symptoms, degree of bother, and quality of life (QoL) impact. A more disease specific standardized PRM will also allow for comparison of patient outcomes across research studies. Several have been developed in more recent years.17, 18
All patients being evaluated for LUTS should have a complete history and physical examination and urinalysis at a minimum. Decreased urinary stream, incomplete emptying, and other findings such as UTI should alert clinicians to include urethral stricture in the differential diagnosis. In the initial assessment of patients suspected of having a urethral stricture, a combination of PRMs to assess symptoms, uroflowmetry to determine severity of obstruction, and ultrasound PVR volume to identify urinary retention may be used. Patients with symptomatic urethral stricture typically have a reduced peak flow rate.19, 20 Confirmation of a urethral stricture diagnosis is made with urethroscopy, retrograde urethrography (RUG), or ultrasound urethrography. In women, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG).21, 22 Urethroscopy readily identifies a urethral stricture but does not delineate the location and length of strictures. RUG, with or without VCUG, allows for identification of stricture location in the urethra, length of the stricture, and degree of lumen narrowing.23, 24 All of these stricture characteristics are important for subsequent treatment planning. Ultrasound urethrography can be used to identify the location, length, and severity of male urethral stricture.25 While ultrasound urethrography is a promising technique, further studies are needed to validate its value in clinical practice.
Preoperative assessment for definitive reconstruction should elicit details of the etiology, diagnostic information about length and location of the stricture, and prior treatments. In the case of PFUI, a detailed history should document all associated injuries and angiographic embolization of any pelvic vessels. The history should assess preoperative sexual function and urinary continence. Physical examination should include an abdominal and genital exam, digital rectal exam, and assessment of lower extremity mobility for operative positioning.
Patient selection and proper surgical procedure choice are paramount to maximize the chance of successful outcome in the treatment of urethral stricture. The main factors to consider in decision making include stricture etiology, location, and severity; prior treatment; comorbidity; and patient preference. As with any operation, surgeons should consider a patient's goals, preferences, comorbidities, and fitness for surgery prior to performing urethroplasty.26
Before proceeding with surgical management of a urethral stricture, the physician should provide an appropriate antibiotic to reduce surgical site infections. Preoperative urine cultures are recommended to guide antibiotic choice, and active UTIs must be treated before urethral stricture intervention. Prophylactic antibiotic choice and duration should follow AUA Best Practice Policy Statement.27 To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours. Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter.27 In the setting of endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins.27 Antimicrobial prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors.27
Positioning of the extremities should be careful to avoid pressure on the calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position. Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries. Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.
A urinary catheter should be placed following urethral stricture intervention to divert urine from the site of intervention and prevent urinary extravasation. Either urethral catheter or suprapubic (SP) cystostomy is a viable option; a urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal. The length of urinary catheterization is widely variable, with a shorter recommended time for endoscopic interventions than open urethral reconstruction.28
Urethrography or voiding cystography is typically performed two to three weeks following open urethral reconstruction to assess for complete urethral healing. Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula. A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.29, 30
Erectile dysfunction (ED), as measured by the International Index of Erectile Function (IIEF) may occur transiently after male urethroplasty with resolution of nearly all reported symptoms approximately six months postoperatively.31-35 Meta-analysis has demonstrated the risk of new onset ED following anterior urethroplasty to be ~1%.36 Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of surgery. ED in this cohort may be related to the initial pelvic trauma rather that the subsequent urethral reconstruction.37
Ejaculatory dysfunction manifested as pooling of semen, decreased ejaculatory force, ejaculatory discomfort, and decreased semen volume has been reported by up to 21% of men following bulbar urethroplasty.38 Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction but the exact etiology remains uncertain.39-41 Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.38 Data on ejaculatory function in men undergoing penile urethroplasty or urethroplasty for PFUI is limited.
Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.42-54 Some studies use the absence of postoperative or post-procedural patient reported obstructive voiding symptoms and/or peak uroflow >15m/sec as a benchmark for successful treatment.55-60 Additional measures of success that have been used alone or in combination include urethral patency assessed by urethro-cystoscopy, absence of recurrent stricture on urethrography, PVR urine <100mL, "unobstructed" flow curve shape on uroflowmetry, absence of UTI, ability to pass a urethral catheter, and patient-reported improvement in LUTS.61-65 Consensus has not been reached on the optimal postoperative surveillance protocol to identify stricture recurrence following urethral stricture treatment.
Guideline Statement 1
Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection, and rising post-void residual. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 2
After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture. (Clinical Principle)
Guideline Statement 3
Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 4
Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion)
Guideline Statement 5
Surgeons may utilize urethral endoscopic management (e.g., urethral dilation or direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)
Guideline Statement 6
Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 7
Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 8
Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 9
Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 10
In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain temporary urethral patency. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 11
11a. Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level: Grade C)
11b. Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)
Guideline Statement 12
Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)
Anterior Urethral Reconstruction
Guideline Statement 13
Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle)
Guideline Statement 14
Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 15
Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 16
Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral strictures given the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 17
Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 18
18a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)
18b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)
Guideline Statement 19
19a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)
19b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation; Evidence Level: Grade A)
Guideline Statement 20
Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion)
Guideline Statement 21
Surgeons should not perform a single-stage tubularized graft urethroplasty. (Expert Opinion)
Guideline Statement 22
Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)
Urethral Reconstruction after Pelvic Fracture Urethral Injury
Guideline Statement 23
Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate Recommendation; Evidence Level: Grade C)
Guideline Statement 24
Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)
Guideline Statement 25
Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion)
Female Urethral Reconstruction
Guideline Statement 26
Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
Bladder Neck Contracture/Vesicourethral Stenosis
Guideline Statement 27
Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion)
Guideline Statement 28
Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 29
Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
Guideline Statement 30
In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)
Guideline Statement 31
Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle)
Guideline Statement 32
In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Level: Grade B)
Guideline Statement 33
Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy or urethroplasty. (Expert Opinion)
Much of the literature on the topic urethral strictures consists of single surgeon or single institution case series with inconsistent definitions of stricture length, location, and etiology; success of treatment; and follow up. These inconsistencies make comparisons between studies difficult, while also providing ample opportunities for future research. To improve the quality of research, the Panel recommends the following:
- Standardize research terms to allow comparison between centers; specifically, the International Consultation on Urological Diseases nomenclature should be used. For example, the term "urethral stricture" should be applied to a narrowing of the anterior urethra that restrict the flow of urine.
- Utilization of an urethral stricture classification system that organizes the disease process, allows for improved patient counseling on expected outcomes, and better facilitates comparison of similar strictures across research studies.237, 238 Future urethroplasty research should include classification systems to better evaluate and compare uniform strictures.
- In studies of the treatment of urethral strictures, multiple criteria for success should be reported. When data is available, studies should report success based on several criteria: PRMs, symptoms, uroflowmetry, radiography, cystoscopy, and need for subsequent procedures. This would facilitate comparison between multiple studies. A consensus primary outcome measure should be considered for future RCT and registry studies.
- The duration of follow-up based on time of last clinic visit, telephone contact, or absence of known treatment for recurrence should be reported in all studies of urethral stricture treatment. Time-to-event analysis (Kaplan-Meier curves) should be reported.
- Multi-institutional collaboration should be formed to evaluate management of uncommon diagnoses such as PFUI, hypospadias, panurethral strictures, and LS.
- Urethral stricture remains a subject of active investigation. The Panel suggests the following issues in future investigations:
- Basic science and epidemiological research into the etiology of urethral strictures.
- Continued evaluation of robotic techniques to treat posterior urethral strictures and those extending into the proximal bulbar urethra.
- Prevention of catheter associated urethral injury and traumatic strictures through educational efforts on proper technique of catheter insertion and management after insertion.
- Studies on the effectiveness of early diagnosis and treatment of LS toward prevention of disease progression and urethral stricture formation.
- Basic science and animal studies using novel graft materials for urethral reconstruction (i.e., stem cells, tissue-engineered scaffolds).
- Long-term follow-up for adults in patients who have been treated as children, such as urethral stricture in adults after hypospadias repair.
- Further evaluation of alternative sources of autologous graft material.
- The efficacy of injection or balloon-coated anti-proliferative or other pharmacological agents at time of endoscopic treatment for penile urethral stricture, previous failed urethroplasty, posterior urethral stenosis, and bladder neck contracture.
- The relationship between of urethroplasty and ED.
- Role of urethral transection in urethroplasty regarding morbidity and outcomes.
- Dissemination and implementation of optimal perioperative antibiotic strategies for urethrotomy and urethroplasty.239, 240
- Determination of the ideal tissue for substitution urethroplasty.
- The optimal tissue and urethroplasty technique for urethral stricture following phalloplasty.
|AUA||American Urological Association|
|AUSAI||American Urological Association Symptom Index|
|CIC||Clean intermittent catheritization|
|DVIU||Direct visual internal urethrotomy|
|IIEF||International index of erectile function|
|LUTS||Lower urinary tract symptoms|
|PFUI||Pelvic fracture urethral injury|
|PGC||Practice Guidelines Commitee|
|PRM||Patient reported measures|
|QoL||Quality of life|
|RCT||Randomized controlled trial|
|UTI||Urinary tract infection|
|VUAS||Vesicourethral anastomotic stenosis|
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This document was written by the Male Urethral Stricture Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2015. The Practice Guidelines Committee (PGC) of the AUA selected the committee chair. Panel members were selected by the chair. Membership of the panel included specialists in urology with specific expertise on this disorder. The mission of the panel was to develop recommendations that are analysis-based or consensus-based, depending on panel processes and available data, for optimal clinical practices in the treatment of male urethral strictures. Funding of the panel was provided by the AUA. Panel members received no remuneration for their work. Each member of the panel provides an ongoing conflict of interest disclosure to the AUA. While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to encourage compliance by practitioners with current best practices related to the condition being treated. As medical knowledge expands and technology advances, the guidelines will change. Today these evidence-based guidelines statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual cases. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Conformance with any clinical guideline does not guarantee a successful outcome. The guideline text may include information or recommendations about certain drug uses ('off label') that are not approved by the Food and Drug Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings. These guidelines and best practice statements are not in-tended to provide legal advice about use and misuse of these substances. Although guidelines are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices. For this reason, the AUA does not regard technologies or management which are too new to be addressed by this guideline as necessarily experimental or investigational.