The 2016 AUA guidelines for urethral strictures attempted to streamline and simplify the treatment algorithm for patients and physicians alike. However, due to the wide range of etiologies leading to symptomatic strictures the “best” treatment is often an individualized approach dependent on the specific patient history and goals, and the experience of the surgeon. This seemingly à la carte approach to an ailment that every urologist will come across in their practice can be frustrating to those clinicians who have not subspecialized in genitourinary reconstruction. To cut through the infinite possibilities we’ve compiled a group of experts to show how there are common themes that any urologist can follow to turn unlimited options into an evidence-based treatment plan for the bulbar stricture in front of them.

Drs. Lindsay Hampson, Amanda Chang, Matthias Hofer and Cooper Benson will pull from their wealth of knowledge and clinical experience to work through example cases, and give clinical context to the 2016 guidelines starting with preoperative workup and factors thorough definitive surgical correction.

Increasingly, we recognize the importance of the patients’ perspective on the outcomes of urethral reconstruction. The first validated urethral stricture specific patient reported outcome measure (PROM) was the urethral stricture symptoms PROM (USS PROM) questionnaire.^1–3 Building on this, the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) group is validating a rigorously developed urethral stricture specific 32-item instrument called the USSIM (Urethral Stricture Symptoms and Impact Measure).⁴ The USSIM seeks to characterize urethroplasty outcomes across multiple domains in a single instrument. The use of PROMs supports the viewpoint of urethral stricture disease being viewed as a quality of life problem. However, urethral strictures may result in significant patient morbidity.⁵

How do we incorporate PROMs to aid our decision making both for initial treatment and with post-urethroplasty surveillance? The TURNS group demonstrated that nonurethral stricture PROMs were unable to differentiate patients with and without cystoscopic recurrence and also failed to correlate with reinterventions.^6,7 Similarly, up to 35%–42% of patients with cystoscopic recurrence may be asymptomatic.^7–9 Not surprisingly, Anderson et al found that urethroplasty success rates vary widely (37%–75% at 5 years) depending on the definition of success, and when defining success as reporting absence of weak stream on a PROM, this resulted in the lowest 5 year success at 37%.⁹ Thus, how do we define success and how do we use PROMs when there is a discrepancy between the PROM and objective outcomes? Future research will hopefully guide us in how to best utilize PROMs in clinical practice.

Urinary symptoms such as post-void dribbling (PVD), urgency and urge incontinence (UI) are noted to be common in men both before and after stricture surgery. It is important for urologists to understand the impact that urethral stricture surgery has on urinary symptoms in order to improve patient counseling and expectations. Regarding PVD, one study showed that among 331 men undergoing anterior urethroplasty 75% reported preoperative PVD (44% reported PVD “most of the time”).¹⁰ Among those with preoperative PVD, 60% reported improvement (with 8% reported worsening symptoms), while among those without preoperative PVD, 26% developed de novo PVD. Type of repair has not been found to be a significant predictor of PVD after urethroplasty.^10,11 With regard to urinary urgency, one study of 439 individuals undergoing anterior urethroplasty showed that 58% of men reported preoperative urgency compared to 40% postoperatively.¹² Among those with preoperative urgency, 37% noted improvement while 9% without preoperative urgency developed de novo urgency. Regarding UI, among 305 men undergoing urethroplasty, 31% reported preoperative urge incontinence; 74% with preoperative urge incontinence reported improvement and 5% developed de novo urge incontinence after surgery.¹² Overall, these studies show that the prevalence of PVD, urgency and UI is high among those presenting with anterior urethral strictures, and that the majority of those with preoperative symptoms will note stability or improvement following surgery, with few developing worsening or de novo symptoms.

Please join us for this informative panel discussion at the 2022 AUA to demystify treatment of urethral strictures.