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Making The Right Choice for Urethral Stricture Treatment

A very important point is that before any stricture treatment is performed, such as dilation, forceful advancement of a cystoscope through a stricture (where the scope is used as a dilation tool rather than a diagnostic instrument), or an internal urethrotomy, informed consent is required. Proper informed consent can only be obtained when the patient is informed of all reasonable treatment options and the risks and benefits and expected outcome of each option.

Unfortunately it is very common for patients to be treated for their strictures with dilation or incision based only on the observation of a stricture during urethroscopy without first having complete properly performed imaging studies. In addition, it is very common for patients to be treated with dilation or a urethrotomy or multiple dilations or urethrotomies without being informed of the option of urethral reconstruction.

For example, a typical history is when a patient reports developing a slow urinary stream and/or urine infections. A cystoscopy is performed and a stricture is seen. The patient is then informed, without a RUG-VCUG being first performed, that he needs to have the stricture dilated or urethrotomy. However, when imaging is not performed, the stricture length is not known. It has been clearly established that a single incision is a reasonable option for the initial treatment of strictures less than 1.5 cm in length, but not for longer strictures. Therefore, if the stricture happens to be long and dense, the patient is being treated with a procedure very likely to fail without knowing that open reconstruction is the current standard of care and the option that best offers the possibility of a cure.

As another example, when patients are treated with dilations and/or incisions and the stricture recurs, they 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 choice than to be managed this way even though definitive repair, the standard of care, offers up to a 98+ % cure rate at our Center. Patients are managed without even knowing that they can be cured. We have seen and successfully reconstructed patients who have had literally hundreds of dilations and up to 31 operative incisions before learning that curative open repair was the best option or even an option at all. Patients managed this way are not giving proper informed consent, as they are not aware of all options and the expected outcome of each option. They are not aware that the third incision offers around a 0% cure rate where a properly performed open repair by a urologist with expertise in urethral reconstruction offers a very high cure rate.

The modern approach to urethral stricture disease requires a full evaluation with urethral imaging, and a treatment decision that is based on the location and length of the stricture. A dilation or urethrotomy is an option, especially when the stricture is very short without significant scarring of the surrounding tissue or when the goal is to obtain some improvement, even if temporary, with the least invasive approach. In many cases, these procedures are not good options. This is especially true when strictures are not discreet or are recurrent as the failure rate approaches 100%. Moreover, the trauma of dilation and urethrotomy can be lead to progression of the disease. A metallic urethral stent is an option, and the technique has the advantage of being “minimally invasive”. However, this procedure is only suited to certain strictures.

The outcomes are very inferior to open surgery. We have successfully reconstructed patients who suffered complications from urethral stents (outcomes published in the Journal of Urology), but these patients presented with problems far more complex than they had prior to the stent placement and the reconstructive surgery was very difficult. Therefore, we mention but do not recommend this option to the vast majority of our patients. Alternatively, a properly performed open urethral reconstruction may be the best option for initial management in many cases and is usually the best option for the treatment of recurrent strictures. When properly performed, excision and anastomosis is associated with a cure rate of over 98%, where cure is defined as the permanent maintenance of a widely patent urethra without the need for catheterization or other procedures to maintain patency. When tissue transfer is needed, the success rate is less than with primary repair, but is often well over 85-95%.

Modern surgical techniques performed by a specialist in urethral reconstruction using dedicated instruments and equipment is associated with high cure rates and a low complication rate. In many cases, open urethral reconstruction is the approach of choice for the treatment of urethral stricture disease. However, the treatment should be based on the findings obtained during a diagnostic evaluation, and a detailed discussion of all options with treatment tailored to the individual patient.

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