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Home , Cystoscopy, Retrograde urethrogram, Urethral stricture, Urethroplasty, Urethrotomy

Male : American Urological Association Guideline

Hunter Wessells, Keith W. Angermeier, Sean Elliott, Christopher M. Gonzalez, Ron Kodama, Andrew C. Peterson, James Reston, Keith Rourke, John T. Stoffel, Alex J. Vanni, Bryan B. Voelzke, Lee Zhao and Richard A. Santucci

From the American Urological Association Education and Research, Inc., Linthicum, Maryland

Purpose: The purpose of this Guideline is to provide a clinical framework for the Abbreviations and diagnosis and treatment of male urethral stricture. Acronyms Materials and Methods: A systematic review of the literature using the Pubmed, DVIU ¼ direct visual internal Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was con- ducted to identify peer-reviewed publications relevant to the diagnosis and LS ¼ lichen sclerosis treatment of urethral stricture. The review yielded an evidence base of 250 ar- PFUI ¼ pelvic fracture urethral ticles after application of inclusion/exclusion criteria. These publications were injury used to create the Guideline statements. Evidence-based statements of Strong, PVR ¼ post-void residual Moderate, or Conditional Recommendation were developed based on benefits and RUG ¼ risks/burdens to patients. Additional guidance is provided as Clinical Principles SP ¼ suprapubic and Expert Opinion when insufficient evidence existed. UTI ¼ urinary tract Results: The Panel identified the most common scenarios seen in clinical practice VCUG ¼ voiding cystourethrogram related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of

Accepted for publication July 19, 2016. patients presenting with urethral strictures. The complete guideline is available at http:// Conclusions: Successful treatment of male urethral stricture requires selection www.auanet.org/education/guidelines/male- urethral-stricture.cfm. of the appropriate endoscopic or surgical procedure based on anatomic location, This document is being printed as submitted length of stricture, and prior interventions. Routine use of imaging to assess independent of editorial or peer review by the stricture characteristics will be required to apply evidence based recommenda- Ò editors of The Journal of . tions, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Key Words: urethral stricture, ,

PURPOSE stricture, carry out appropriate testing Urologists must be familiar with the to determine the location and severity evaluation and diagnostic tests for of the stricture, and recommend the urethral stricture as well as endo- best options for treatment and follow- scopic and open surgical treatments. up. The most effective approach for a This Guideline provides evidence- particular patient is best determined based guidance to clinicians and by the individual clinician and patient patients regarding how to recognize in the context of that patient’s history, symptoms and signs of a urethral values, and goals for treatment.

0022-5347/17/1971-0182/0 http://dx.doi.org/10.1016/j.juro.2016.07.087 THE JOURNAL OF UROLOGY® Vol. 197, 182-190, January 2017 182 j www.jurology.com Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. MALE URETHRAL STRICTURE 183

METHODOLOGY Diagnosis The quality of individual studies that were either ran- In the initial evaluation of patients suspected of domized controlled trials or clinical controlled trials having a urethral stricture, a combination of patient 1 was assessed using the Cochrane Risk of Bias tool. reported outcome measures to assess symptoms, Observational cohort studies with a comparison of inter- uroflowmetry to determine severity of obstruction, est were evaluated with the Drug Effectiveness Review 2 and ultrasound PVR volume to identify urinary Project instrument. Conventional diagnostic cohort retention, may be used. In patients in whom urethral studies, diagnostic case-control studies, or diagnostic case stricture is suspected, stricture must be diagnosed series that presented data on diagnostic test characteris- tics were evaluated using the QUADAS 2 tool, which by urethro-cystostoscopy, retrograde urethrogram evaluates the quality of diagnostic accuracy studies.3 (RUG)/ voiding cystourethrogram (VCUG) or even The AUA categorizes body of evidence strength as by the passage of a urethral . Once urethral Grade A, B, or C based on both individual study quality stricture is confirmed, delineation of stricture length and consideration of study design, consistency of findings and location is required, usually by RUG, augmented across studies, adequacy of sample sizes, and generaliz- by VCUG or antegrade through a supra- ability of samples, settings, and treatments for the pur- pubic (SP) tube site, if present. poses of the Guideline.4 Evidence-based statements are provided as Strong, Patient Selection Moderate, and Conditional Recommendations with addi- Patient selection and proper choice of surgical pro- tional statements provided in the form of Clinical cedure are paramount to maximize the chance of Principles or Expert Opinion. successful outcome in the treatment of urethral stricture. The main factors to consider in decision making include stricture etiology, location, and BACKGROUND severity; prior treatment; comorbidity; presence of A urethral stricture is any abnormal narrowing of (LS); and patient preference. the anterior and posterior urethra. The anterior urethra, which runs from the bulbar urethra to the meatus, is surrounded by the corpus spongiosum OPERATIVE CONSIDERATIONS and thus anterior urethral strictures are associated Before proceeding with surgical management of a with varying degrees of spongiofibrosis. urethral stricture, the physician should provide an appropriate to reduce surgical site . Preoperative cultures are recom- EPIDEMIOLOGY mended to guide antibiotic choice, and active UTIs In developed countries, the most common etiology of must be treated before urethral stricture inter- urethral stricture is idiopathic, followed by iatro- vention. Prophylactic antibiotic choice and dura- genic. Late failure of and tion should follow the AUA Best Practice Policy stricture resultant from endoscopic manipulation Statement.7 (e.g. transurethral resection) are common iatrogenic reasons. In comparison, trauma is the most common Postoperative Care cause in developing countries, reflecting higher A urinary catheter should be placed following ure- rates of road traffic injuries, less developed trauma thral stricture intervention to divert urine from the systems, inadequate roadway systems and conceiv- site of intervention and prevent urinary extravasa- ably socioeconomic factors.5 tion. Either urethral catheter or SP cystostomy is a viable option; a urethral catheter is thought to be optimal. Urethral dilation and direct visual internal EVALUATION urethrotomy (DVIU) require only a short period of catheterization. RUG or VCUG is typically per- Presentation formed two to three weeks following open urethral Patients with urethral stricture most commonly reconstruction to assess for complete urethral present with decreased urinary stream and incom- healing. plete bladder emptying but other signs and symp- toms include (UTI), Complications epididymitis, rising post-void residual (PVR) urine as measured by the Interna- volume or decreased force of ejaculation.6 Addi- tional Index of Erectile Function (IIEF) may occur tionally, patients may present with urinary spray- transiently after with resolution of ing or . Rare sequelae of untreated stricture nearly all reported symptoms approximately six may include bladder calculi, urethral abscess, ure- months postoperatively.8 Ejaculatory dysfunction thral carcinoma, and chronic injury from manifested as pooling of semen, decreased ejacula- . tory force, ejaculatory discomfort, and decreased 184 MALE URETHRAL STRICTURE

semen volume has been reported by up to 21% of stricture, therefore indicating definitive evaluation, men following bulbar urethroplasty.9 such as urethro-cystoscopy, RUG, or ultrasound urethrography. Follow-Up 3. Clinicians should use urethro-cystoscopy, Successful treatment for urethral stricture (endo- retrograde urethrography (RUG), voiding scopic or surgical) is most commonly defined as no (VCUG), or ultrasound further need for surgical intervention or instru- urethography to make a diagnosis of urethral mentation. Consensus has not been reached on the stricture. (Moderate Recommendation; Evi- optimal postoperative surveillance protocol to iden- dence Strength: Grade C) tify stricture recurrence following urethral stricture and/or radiological imaging of the treatment. Some centers use a flexible cystoscope to urethra is essential for confirmation of the diag- confirm lack of recurrence, while others rely on nosis, assessment of stricture severity (e.g. staging), absence of lower urinary tract symptoms, low PVR, and procedure selection. Urethroscopy identifies a non-flattened urinary flow pattern on uroflow, and and localizes urethral stricture and allows evalua- > peak urine flow 15 ml/second to define patients tion of the distal caliber, but the length of the free from clinically significant stricture recurrence. stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases. RUG, with or without VCUG, remains the study of choice GUIDELINE STATEMENTS for delineation of stricture length, location, and Diagnosis severity.12 1. Clinicians should include urethral stricture Ultrasound urethrography may serve to diagnose in the differential diagnosis of men who pre- the presence of urethral stricture as well as describe sent with decreased urinary stream, incom- the location, length, and severity of narrowing of plete emptying, dysuria, urinary tract strictures. It has a high sensitivity and specificity in infection (UTI), and rising post-void residual the anterior urethra but requires a skilled ultraso- (PVR). (Moderate Recommendation; Evidence nographer and shares with other modalities the Strength: Grade C) drawback of patient discomfort.13 Differences in stricture characteristics (e.g. 4. Clinicians planning non-urgent inter- location, length, luminal diameter), duration of vention for a known stricture should deter- obstruction, and other factors create a heteroge- mine the length and location of the urethral neous combination of subjective complaints related stricture. (Expert Opinion) to a symptomatic urethral stricture. Other urologic Determination of urethral stricture length and conditions, such as benign enlargement location allows the patient and urologist to engage (with or without bladder outlet obstruction), bladder in an informed discussion about treatment options, outlet obstruction, and abnormal detrusor function, perioperative expectations, and expected outcomes can present with similar subjective findings, mak- following urethral stricture therapy. In addition, ing diagnosis challenging. Young men do not preoperative planning permits operative and anes- commonly present with voiding urinary symptoms; thetic planning. therefore, a urethral stricture should be considered 5. Surgeons may utilize urethral endoscopic in the differential diagnosis. management (e.g., urethral dilation or direct 2. After performing a history, physical ex- visual internal urethrotomy [DVIU]) or im- amination, and urinalysis, clinicians may use mediate suprapubic (SP) cystostomy for ur- a combination of patient reported measures, gent management of urethral stricture, such uroflowmetry, and ultrasound post-void re- as discovery of symptomatic sidual (PVR) assessment in the initial evalua- or need for catheterization prior to another tion of suspected urethral stricture. (Clinical surgical procedure. (Expert Opinion) Principle) When urethral strictures are identified at the If symptoms and signs suggest the presence of a time of catheter placement for another surgical stricture, noninvasive measures, such as uro- procedure, assessment of the need for catheteriza- flowmetry, may then definitively delineate low flow, tion should be made. Urethral strictures may be which is typically considered to be less than 12 mL dilated in this setting to allow catheter insertion, per second and may indicate obstruction from the and dilation over a guidewire is recommended to stricture.10,11 Similarly, ultrasonographic PVR prevent false passage formation or rectal injury. measurement may detect poor bladder emptying. Alternatively, DVIU may be performed, particularly The presence of voiding symptoms as described if the stricture is too dense to be adequately dilated. above in combination with reduced peak flow rate SP cystotomy may also be performed to provide place patients at higher probability for urethral urinary drainage at the time of surgery if these MALE URETHRAL STRICTURE 185

initial maneuvers are unsuccessful, or when subse- uncomplicated dilation or direct visual inter- quent definitive treatment for urethral stricture is nal urethrotomy (DVIU). (Conditional Recom- planned in the near future. mendation; Evidence Strength: Grade C) 6. Surgeons may place a suprapubic (SP) The reported length of catheterization after cystostomy prior to definitive urethroplasty dilation or DVIU is highly variable in the literature, in patients dependent on an indwelling ure- ranging from one to eight days.17,19,21 There is no thral catheter or intermittent self-dilation. evidence that leaving the catheter longer than 72 (Expert Opinion) hours improves safety or outcome, and Men with a urethral stricture who have been may be removed after 24-72 hours. Catheters may managed with either an indwelling urethral cath- be left in longer for patient convenience or if in the eter or intermittent self-dilation require a period surgeon’s judgment early removal will increase the free of catheterization before treatment. This allows risk of complications. the full length of the stricture to develop, permitting 10. In patients who are not candidates for accurate determination of definitive treatment op- urethroplasty, clinicians may recommend self- tions. When voiding is not possible, the patient catheterization after direct visual internal should undergo SP cystostomy placement prior to urethrotomy (DVIU) to maintain temporary imaging. urethral patency. (Conditional Recommenda- tion; Evidence Strength: Grade C) Dilation/Internal Urethrotomy/Urethroplasty Studies using varying self-catheterization sched- 7. Surgeons may offer urethral dilation, direct ules after DVIU, ranging from daily to weekly, have visual internal urethrotomy (DVIU), or ure- demonstrated that stricture recurrence rates were throplasty for the initial treatment of a short significantly lower among patients performing self- (< 2 cm) bulbar urethral stricture. (Condi- catheterization (risk ratio 0.51, 95% CI 0.32 to tional Recommendation; Evidence Strength: 0.81, p ¼ 0.004).18 Data suggests that performing Grade C) self-catheterization for greater than four months Short bulbar urethral strictures may be treated after DVIU reduced recurrence rates compared to by dilation, DVIU, or urethroplasty. Urethral dila- performing self-catheterization for less than three tion and DVIU have similar long-term outcomes in months.18 short strictures, with success ranging from 35- 11. Surgeons should offer urethroplasty, 70%.14e16 The success of endoscopic treatment de- instead of repeated endoscopic management pends on the location and length of the stricture, for recurrent anterior urethral strictures with the highest success rates found in those with following failed dilation or direct visual in- bulbar strictures less than 1 cm. Conversely, suc- ternal urethrotomy (DVIU). (Moderate cess rates for dilation or DVIU of strictures longer Recommendation; Evidence Strength: than 2cm are very low.17 Grade C) Excision and primary anastomosis of bulbar Urethral strictures that have been previously urethral stricture has a higher long-term success treated with dilation or DVIU are unlikely to be rate than endoscopic treatment, ranging from 90- successfully treated with another endoscopic pro- 95%.18 Urethroplasty may be offered as the initial cedure.22 Repeated endoscopic treatment may cause treatment for a short bulbar urethral stricture, but longer strictures, and may increase the complexity the higher success rate of this treatment compared of subsequent urethroplasty.23 to endoscopic treatment must be weighed against 12. Surgeons who do not perform ure- the increased requirement, cost, and throplasty should offer patients referral to higher morbidity of urethroplasty. surgeons with expertise. (Expert Opinion) 8. Surgeons may perform either dilation or When evaluating a patient with a recurrent direct visual internal urethrotomy (DVIU) urethral stricture, a physician who does not perform when performing endoscopic treatment of a urethroplasty should consider referral to a surgeon urethral stricture. (Conditional Recommen- with experience in this technique due to the higher dation; Evidence Strength: Grade C) rate of successful treatment compared to repeat Dilation and DVIU have similar success and endoscopic management. complication rates and can be used interchangeably. Few studies exist that compare different methods of Anterior Urethral Reconstruction performing DVIU, but cold knife and incision 13. Surgeons may initially treat meatal or of the stricture scar appear to have similar success fossa navicularis strictures with either dila- rates and may be used interchangeably.19,20 tion or meatotomy. (Clinical Principle) 9. Surgeons may safely remove the urethral First time presentation of an uncomplicated catheter within 72 hours following urethral stricture confined to the meatus or fossa 186 MALE URETHRAL STRICTURE

navicularis may be treated with simple dilation or long urethral strictures. Urethroplasty may be meatotomy, with or without guidewire placement. performed using a variety of techniques based on Most patients with previous hypospadias repair, the experience of the surgeon, most often through prior failed endoscopic manipulation, previous ure- substitution or augmentation of the narrowed throplasty, or LS should be offered urethroplasty. segment of the urethra. 14. Surgeons should offer urethroplasty to 17. Surgeons may reconstruct long multi- patients with recurrent meatal or fossa navi- segment strictures with one stage or multi- cularis strictures. (Moderate Recommenda- stage techniques using oral mucosal grafts, tion; Evidence Strength: Grade C) penile fasciocutaneous flaps or a combination Meatal and fossa navicularis strictures refractory of these techniques. (Moderate Recommenda- to endoscopic procedures are unlikely to respond to tion; Evidence Strength: Grade C) further endoscopic treatments.15 Furthermore, Multi-segment strictures (frequently referred to as urethroplasty is the best option for completely panurethral strictures) are most commonly defined obliterated strictures or strictures associated with as strictures over 10 cm in length spanning long hypospadias or LS. Patients who opt for repeat segments of both the penile and bulbar urethra. endoscopic treatments or intermittent self-dilation in Reconstruction of panurethral strictures should be lieu of more definitive treatment, such as ure- addressed with all of the tools in the reconstructive throplasty should be advised that success of a sub- armamentarium, including fasciocutaneous flaps, sequent reconstructive procedure may be lower when oral mucosal grafts or other ancillary tissue following a plan of repeated endoscopic surgery and/ sources, and may require a combination of these or intermittent self-dilation. Similar to other types of techniques.29e31 Regardless of technique and combi- stricture, exact delineation of length and etiology is nations, success rates appear similar in all of these important for guiding treatment. small series. 15. Surgeons should offer urethroplasty to 18. Surgeons may offer perineal ure- patients with penile urethral strictures throstomy as a long-term treatment option to because of the expected high recurrence rates patients as an alternative to urethroplasty. with endoscopic treatments. (Moderate (Conditional Recommendation; Evidence Recommendation; Evidence Strength: Strength: Grade C) Grade C) Perineal urethrostomy can be used as a staged or Strictures involving the penile urethra are more permanent option for patients with anterior ure- likely to be related to hypospadias, LS, or iatrogenic thral strictures in order to establish unobstructed etiologies when compared to strictures of the bulbar voiding and improve quality of life. Reasons to urethra, and are thus unlikely to respond to dilation perform perineal urethrostomy include recurrent or or urethrotomy, except in select cases of previously primary complex anterior stricture, advanced age, untreated, short strictures.22 Given the low likeli- medical co-morbidities precluding extended opera- hood of success with endoscopic treatments, most tive time, extensive LS, numerous failed attempts at patients with penile urethral strictures should be urethroplasty, and/or patient choice. offered urethroplasty at the time of diagnosis, 19. Surgeons should use oral mucosa as the avoiding repeated endoscopic treatments. When first choice when using grafts for ure- compared to bulbar strictures, penile urethral throplasty. (Expert Opinion) strictures are more likely to require tissue transfer Patient satisfaction is higher for oral mucosa and/or a staged approach.24,25 urethroplasty compared to skin flaps and skin grafts 16. Surgeons should offer urethroplasty as due to less post-void dribbling and fewer penile skin the initial treatment for patients with long problems.32 (‡2cm) bulbar urethral strictures, given the 20. Surgeons should not perform substitu- low success rate of direct visual internal ure- tion urethroplasty with allograft, xenograft, throtomy (DVIU) or dilation. (Moderate or synthetic materials, except under experi- Recommendation; Evidence Strength: mental protocols. (Expert Opinion) Grade C) Use of non-autologous grafts may be indicated Longer strictures are less responsive to endo- in the patient who has failed a prior urethroplasty scopic treatment, with success rates of only 20% for and has no tissue available for reoperative substi- strictures longer than 4cm in the bulbar urethra.14 tution urethroplasty. However, experience to date The success rate for buccal mucosa graft ure- is limited and the long-term success rates are throplasty for strictures of this length is greater unknown. than 80%.26e28 21. Surgeons should not perform a single- Given the low efficacy of endoscopic treatment, stage tubularized graft urethroplasty. urethroplasty should be offered to patients with (Expert Opinion) MALE URETHRAL STRICTURE 187

Tubularized urethroplasty consists of a technique wide range of times from six weeks to four years. in which a graft or flap is rolled into a tube over a Reconstruction should occur when patient factors catheter to completely replace a segment of urethra. allow the surgery to be performed (usually within This approach, when attempted in a single stage, three to six months after the trauma). has a high risk of restenosis and should be avoided. 22. Surgeons should not use hair-bearing Bladder Neck Contracture/Vesicourethral Stenosis skin for substitution urethroplasty. (Clinical 26. Surgeons may perform a dilation, bladder Principle) neck incision or transurethral resection for The use of hair-bearing skin for substitution bladder neck contracture after endoscopic urethroplasty may result in urethral calculi, recur- prostate procedure. (Expert Opinion) rent UTI, and a restricted urinary stream due to Treatment of bladder neck contractures following hair obstructing the lumen. endoscopic prostate procedures can be performed depending on surgeon preference, with comparable Urethral Reconstruction after Pelvic Fracture outcomes expected. Urethral Injury (PFUI) 27. Surgeons may perform a dilation, ves- 23. Clinicians should use retrograde ure- icourethral incision, or transurethral resec- thrography (RUG) with voiding cystourethro- tion for post-prostatectomy vesicourethral gram (VCUG) and/or retrograde D antegrade anastomotic stenosis. (Conditional Recom- cystoscopy for preoperative planning of mendation; Evidence Strength: Grade C) delayed urethroplasty after pelvic fracture Treatment of first time vesicourethral anasto- urethral injury (PFUI). (Moderate Recom- motic stenosis is successful in about 50-80% of cases, mendation; Evidence Strength: Grade C) with all techniques having similar success Preoperative evaluation of the defect after PFUI rates.33e37 Success appears to be lower in cases with should include RUG, VCUG and/or retrograde ure- prior pelvic radiation; however, prospective cohort throscopy. The VCUG may include a static cysto- studies including radiated and non-radiated pa- gram to determine the competency of the bladder tients are lacking. Repeat endoscopic treatment neck mechanism and the level of the bladder neck in may be necessary for successful treatment. There is relation to the symphysis pubis. Other adjunctive conflicting data about the utility of mitomycin C for studies may include antegrade cystoscopy (with or the treatment of recurrent vesicourethral stenosis; without fluoroscopy) and pelvic CT or MRI to assess further study is necessary to validate its use.38,39 the proximal extent of the injury, degree of mala- Patients should be made aware of the risk of in- lignment of the urethra, and length of the defect. continence after any of these procedures. 24. Surgeons should perform delayed ure- 28. Surgeons may perform open recon- throplasty instead of delayed endoscopic pro- struction for recalcitrant stenosis of the cedures after urethral obstruction/ bladder neck or post-prostatectomy ves- obliteration due to pelvic fracture urethral icourethral anastomotic stenosis. (Condi- injury (PFUI). (Expert Opinion) tional Recommendation; Evidence Strength: Repeated endoscopic maneuvers, including inter- Grade C) mittent catheterization, should be avoided because The treatment of recalcitrant vesicourethral they are not successful in the majority of PFUI, in- anastomotic stenosis must be tailored to the pref- crease patient morbidity, and may delay the time to erences of the patient, taking into consideration anastomotic reconstruction. Anastomotic recon- prior radiotherapy and the degree of urinary in- struction is performed through a perineal approach. continence. Urethral reconstruction is challenging Excision of the scar tissue and wide spatulation of and may cause significant the anastomosis is required. Several methods to gain requiring subsequent artificial urinary sphincter urethral length and reduce tension can be employed implantation but offers success rates of approxi- when necessary, including mobilization of the bulbar mately 66-80%.40,41 Success rates are lower after urethra, crural separation, inferior pubectomy and radiation. For the patient who does not desire ure- supracrural rerouting, but in most cases the latter throplasty, repeat urethral dilation, incision or two maneuvers are not required. resection of the stenosis is appropriate. Intermittent 25. Definitive urethral reconstruction for self-dilation with a catheter may be used to prolong pelvic fracture urethral injury (PFUI) should the time between operative interventions. Supra- be planned only after major injuries stabilize vesical diversion is an alternative. and patients can be safely positioned for ure- throplasty. (Expert Opinion) Special Circumstances No optimal time to perform urethral reconstruc- 29. In men who require chronic self- tion has been established, with studies reporting a catheterization (e.g. neurogenic bladder), 188 MALE URETHRAL STRICTURE

surgeons may offer urethroplasty as a treat- Research terms should be standardized to allow ment option for urethral stricture causing dif- comparison between centers, with this Panel rec- ficulty with intermittent self-catheterization. ommending adoption of International Consultation (Expert Opinion) on Urological Diseases nomenclature. In studies of There is some evidence to suggest that urethral the treatment of urethral strictures multiple mea- reconstruction, if offered at an early stage in men sures of successful outcome should be reported to with stricture and neurogenic bladder, can achieve facilitate comparison between studies. Multi- outcomes comparable to men without neurogenic institutional collaboratives should be formed to bladder.42 evaluate management of uncommon diagnoses, 30. Clinicians may perform for sus- such as PFUI, hypospadias, panurethral strictures, pected lichen sclerosus (LS), and must and LS. In addition, multi-centered randomized perform biopsy if urethral is sus- clinical trials, pragmatic trials, or registries should pected. (Clinical Principle) be created for evaluation of important research The rate of squamous cell carcinoma in male questions. patients with LS has been reported to be 2-8%, highlighting the need for biopsy in selected cases both to confirm the diagnosis as well as to exclude ACKNOWLEDGMENT malignant or premalignant changes.43e46 The Panel Chairs would like to recognize Drs. 31. In lichen sclerosus (LS) proven urethral Vanni, Voelzke and Zhao for contributing additional stricture, surgeons should not use genital skin sections to the manuscript. Erin Kirkby assisted for reconstruction. (Strong Recommendation; with writing this article. Evidence Strength: Grade B) Reconstruction of anterior urethral strictures associated with LS should proceed according to the DISCLAIMER principles outlined in Guidelines 15-20, with the This document was written by the Male Urethral caveat that genital skin flaps and grafts should be Stricture Guideline Panel of the American Urologi- avoided due to very high long-term failure rates.18 cal Association Education and Research, Inc., which was created in 2013. The Practice Guidelines Com- Postoperative Follow-Up mittee (PGC) of the AUA selected the committee 32. Clinicians should monitor urethral stric- chair. Panel members were selected by the chair. ture patients to identify symptomatic recur- Membership of the panel included specialists in rence following dilation, direct visual internal urology with specific expertise on this disorder. The urethrotomy (DVIU) or urethroplasty. (Expert mission of the panel was to develop recommenda- Opinion) tions that are analysis-based or consensus-based, Urethral stricture recurrence following endo- depending on panel processes and available data, scopic treatment or urethroplasty can occur at any for optimal clinical practices in the treatment of time in the postoperative period, and, because of male urethral strictures. this, a specific regimen for postoperative follow-up Funding of the panel was provided by the AUA. cannot be reliably determined. A number of diag- Panel members received no remuneration for their nostic tests can be used to detect or screen for work. Each member of the panel provides an stricture recurrence following open or endoscopic ongoing conflict of interest disclosure to the AUA. treatment (see guideline statements 1 and 2). The While these guidelines do not necessarily estab- use of, or combination of, urethrocystoscopy, ultra- lish the standard of care, AUA seeks to recommend sound urethrography, or RUG appears to provide and to encourage compliance by practitioners with the most definitive confirmation of stricture current best practices related to the condition being recurrence.18 treated. As medical knowledge expands and tech- nology advances, the guidelines will change. Today these evidence-based guidelines statements repre- RESEARCH NEEDS AND FUTURE sent not absolute mandates but provisional pro- DIRECTIONS posals for treatment under the specific conditions Urethral stricture remains a subject of active described in each document. For all these reasons, investigation. Areas of focus should include basic the guidelines do not pre-empt physician judgment science and epidemiological research into the in individual cases. mechanisms and risk factors for urethral strictures. Treating physicians must take into account var- Educational efforts should be undertaken to aid in iations in resources, and patient tolerances, needs, the prevention of traumatic strictures following and preferences. Conformance with any clinical catheter insertion and endoscopic surgery. guideline does not guarantee a successful outcome. MALE URETHRAL STRICTURE 189

The guideline text may include information or rec- CONFLICT OF INTEREST DISCLOSURES ommendations about certain drug uses (‘off label’) All panel members completed COI disclosures. that are not approved by the Food and Drug Those marked with (C) indicate that compensation Administration (FDA), or about medications or was received. Disclosures listed include both topice substances not subject to the FDA approval process. and non-topic-related relationships. AUA urges strict compliance with all government Consultant/Advisor: Sean Elliott, American regulations and protocols for prescription and use of Medical Systems (C), GT Urological (C) these substances. The physician is encouraged to Meeting Participant or Lecturer: Kenneth carefully follow all available prescribing informa- Angermeier, American Medical Systems (C); Sean tion about indications, contraindications, pre- Elliott, American Medical Systems (C); Ron cautions and warnings. These guidelines and best Kodama, Journal of Urology/GURS; Andrew practice statements are not intended to provide Peterson, American Medical Systems, Inc. (C); legal advice about use and misuse of these Hunter Wessells, National Institutes of Health substances. Scientific Study or Trial: Ron Kodama, Although guidelines are intended to encourage Journal of Urology/GURS; Andrew Peterson, best practices and potentially encompass available American Medical Systems, Inc. (C); John Stoffel, technologies with sufficient data as of close of Uroplasty; Hunter Wessells, National Institutes of the literature review, they are necessarily time- Health limited. Guidelines cannot include evaluation of Leadership Position: Sean Elliott, Percuvi- all data on emerging technologies or management, sion (C); Ron Kodama, Journal of Urology/GURS; including those that are FDA-approved, which may Andrew Peterson, Society of Government Service immediately come to represent accepted clinical Urologists, Southeastern Sectiond AUA Board of practices. Directors, GURS Board of Directors; Hunter For this reason, the AUA does not regard tech- Wessells, American Board of Urology nologies or management which are too new to be Other: Christopher Gonzalez, American addressed by this guideline as necessarily experi- Medical Systems; Hunter Wessells, National In- mental or investigational. stitutes of Health

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