Urethral stricture disease (USD) is a common cause of urological morbidity. When patients present for treatment, we have several approaches at our disposal. All urologists are proficient at endoscopic procedures to treat USD. These procedures are straightforward with low surgical risk and require no subspecialization. Urethral dilation and urethrotomy are equivalent. Unfortunately, the success rates of endoscopic management are very poor with progressive attempts failing 100% of the time.¹ These repetitive procedures increase medical costs and delay inevitable reconstruction, often causing more urethral trauma that lengthens the stricture and increases the complexity of the repair.²

On the other hand, urethroplasty is the gold standard for treating USD. While the surgeries can be technically demanding and have an associated learning curve,³ the success rates are superior. Straightforward bulbar USD can have success rates beyond 90%. The early use of urethroplasty has been shown to be cost-effective compared to repeated and futile endoscopic treatments.⁴

As a result, proceeding either directly to urethroplasty or after first recurrence following endoscopic treatment has been endorsed by the American Urological Association (AUA) as the standard of care. The recently updated AUA USD guideline recommends that “surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy (DVIU).”⁵ These recommendations were intended to change the practice pattern of USD that has been repeated endoscopic management as the mainstay of treatment for many years.⁶

A recent study of over 77,000 USD patients from the AUA Quality registry found that only 1.7% of patients who initially failed endoscopic treatment went on to have a urethroplasty, versus 98.3% of patients who underwent another endoscopic treatment. Almost 600 patients underwent 5 or more endoscopic treatments (fig. 1).⁷ The findings of this study show good concordance with other literature that also found urethroplasty utilization to be <1%.⁸

Figure 1. Findings from population study of how USD is managed. Most patients with recurrent stricture disease undergo >1 endoscopic procedure. Adapted and reprinted with permission.⁷

Figure 2. Practice heterogeneity showing distribution of practices recommending 2 or more endoscopic procedures for patients with USD. Adapted and reprinted with permission.⁷

When examining the patterns of individual practices, a wide range of heterogeneity amongst USD management was found, with some practices exclusively offering only repeat endoscopic procedures (fig. 2).⁷ Barriers for wide adoption of urethroplasty are multifactorial but have been found to include patient age, regional access to subspecialty care and comorbidity.⁹

Despite the established efficacy of urethroplasty, it remains underutilized. This is likely due to a lack of experience with reconstructive techniques that leads to a pattern of repeated endoscopic procedures over urethroplasty. While treatment heterogeneity exists, there is evidence that providers are more readily referring patients for urethroplasty, preventing repeated endoscopy management.¹⁰ Furthermore, there has been a dramatic expansion in Genitourinary Reconstructive Surgeon Fellowship trained surgeons across North America over the last decade. This expansion provides our patients and urologists with many more options to manage USD for the best outcomes and patient satisfaction possible. Given that urethroplasty has a superior efficacy to endoscopic management in the vast majority of cases, continued awareness and promotion of urethroplasty as a management option for our patients remains a critical undermet need.