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Male Urethral Stricture: American Urological Association Guideline

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Male Urethral Stricture: American Urological Association Guideline Male Urethral Stricture: 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 urethrotomy 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 retrograde urethrogram 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 infection 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 Urology . 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, urethra, penis 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 catheter. 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 cystoscopy 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 lichen sclerosus (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 antibiotic to reduce surgical site infections. Preoperative urine 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 hypospadias surgery 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 urinary tract infection (UTI), Complications epididymitis, rising post-void residual (PVR) urine Erectile dysfunction 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 urethroplasty with resolution of ing or dysuria. 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 kidney injury from manifested as pooling of semen, decreased ejacula- obstructive uropathy. 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 cystourethrography (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 Endoscopy 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
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