Determining the best treatment for urethral stricture disease should be a collaborative effort between the patient and the urologist. Before any urethral stricture treatment can be performed, informed consent is required. Regardless of the treatment type, be it dilation, forceful advancement of a cystoscope through a stricture (where the scope is used as a dilation tool rather than a diagnostic instrument), an internal urethrotomy, or another urethral stricture treatment option, the patient needs to fully understand the treatment. True informed consent can only be obtained when the patient is educated on all reasonable treatment options, the risks and benefits of each treatment, and the expected outcome of each option.
Unfortunately, this is rarely the case. Instead, it is very common for patients to be treated based only on the results of a urethroscopy, failing to complete all of the necessary imaging studies to get a comprehensive understanding of the length and location of the stricture. In addition, it is very common for patients to be treated without even being informed that urethral reconstruction, also called urethroplasty, is one of the most effective urethral stricture treatment options, with many urologists opting to instead only use dilation or urethrotomy, often repeatedly.
The Importance of Understanding All Urethral Stricture Treatment Options
To better understand the potential risks in taking these kinds of shortcuts, below is a typical history of a patient with urethral stricture disease. The patient will first report a slow urinary stream and possibly a urine infection. When the patient comes in for evaluation and treatment, the goal of most urologists is to simply confirm the presence of a stricture, possibly by performing a cystoscopy-urethroscopy (looking inside the urethra with a small telescope) so that the stricture can be observed. Instead of putting in the time and effort to determine the exact location and length of the stricture, they may rush to begin urethral stricture treatment. The patient will be informed that he “needs” to have the stricture dilated or a urethrotomy, without X-ray urethral imaging called a retrograde urethrogram and a voiding cystourethrogram (RUG-VCUG) being first performed.
However, when RUG-VCUG imaging is not performed, the exact stricture length is not known. While a urethrotomy is a reasonable option for the initial treatment of strictures less than 1.5 cm in length, it is not a suitable treatment for longer strictures. Therefore, if the stricture happens to be longer than anticipated, the patient is being treated with a procedure that is likely to fail, without even being informed that open reconstruction is the only option that offers the best possibility of a long-term cure.
Here is another example of the potential risks in not being informed of all urethral stricture treatment options. When patients are treated with dilations or incisions, usually the stricture can recur. If the stricture recurs, patients are often advised to have the procedure repeated or to use a catheter to dilate themselves on a regular basis to keep the stricture open. Many of these patients are under the false belief that they just “tend to form scar tissue” and have no other treatment options.
What patients often do not know is that definitive repair, the standard of care, offers up to a 98+ % cure rate at The Center for Reconstructive Urology. Patients are treated with short-term stopgaps without even knowing that they can be cured. We have successfully treated patients who have had literally hundreds of dilations and up to 31 operative incisions before learning that curative open repair was even an available option. These patients were never able to give proper informed consent, as they were not aware of all treatment options or the expected outcome of each option. For example, these patients were likely not aware that if they opt for a third incision, the treatment offers around a 0% cure rate. On the other hand, a properly performed open repair by a urologist with expertise in urethral reconstruction offers a very high cure rate.
A Modern Approach to Urethral Stricture Disease
The modern approach to urethral stricture disease requires a complete diagnostic evaluation with urethral imaging, with the evaluation allowing for a treatment decision that is based on the location and length of the stricture. In certain situations, a dilation or urethrotomy is a reasonable option, as they are the least invasive approaches. For example, these treatments are generally only a good choice when the stricture is very short and the goal is to obtain some improvement with a quick procedure, even if temporary. However, in many cases, these procedures are simply not good urethral stricture treatment options. This is especially true when strictures are not discreet or are recurrent, as the failure rate in these situations can approach 100%. Moreover, the trauma of dilation and urethrotomy can lead to the disease getting progressively worse.
Expert Open Urethral Reconstruction is Often the Best Treatment Option
A properly performed open urethral reconstruction is often the best option for initial stricture management and is usually the best option for the treatment of recurrent strictures. Excision and anastomosis performed by an expert with the necessary experience is associated with a cure rate of over 99% at the Center for Reconstructive Urology, with a cure being defined as a permanently unobstructed urethra, without the need for catheterization or other procedures. When a tissue transfer is needed to successfully complete urethral reconstruction, the success rate is less than with primary repair but still offers a short-term technical success rate of over 97% and a long-term success rate of 95%.
When Dr. Gelman joined the Faculty of the Department of Urology at the University of California, Irvine in 1998, he was the first Urologist in Southern California with this level of urethral reconstructive surgery expertise. In fact, Dr. Gelman is one of only 3 Urologists in the Western half of the United States with specialization and specific training in urethral reconstruction (urethroplasty). Over the past 5-10 years, there has been a substantial increase in the number of Urologists who include urethral stricture surgery as part of their practices without the necessary expertise or experience. This surge has resulted in a significant number of men who are coming to the Center for Reconstructive Urology after failed open surgery. However, if a urethroplasty is performed in the best possible way by an expert who exclusively specializes in male urethral-genital reconstructive surgery, there should be little risk of failure or recurrence, unless there is a more complex problem.
Modern surgical techniques performed by a urethral reconstruction specialist using dedicated instruments and equipment is associated with high cure rates and a low complication rate. In many cases, open urethral reconstruction is the best approach for the treatment of urethral stricture disease. However, urethral stricture treatment should be based on the findings obtained during a diagnostic evaluation and a detailed discussion of all treatment options, with treatment tailored to each individual patient.