Management of Adult Anterior Urethral Stricture Disease: Nationwide Survey Among Urologists in The Netherlands

Abstract

Background

Adult anterior urethral stricture disease is most often treated with dilatation or direct vision internal urethrotomy (DVIU). Although evidence suggests that anastomotic urethroplasty for short bulbar strictures is more efficient and cost effective in the long term, no consensus exists. It is unclear by whom and how often urethroplasties are performed in The Netherlands and how results are being evaluated.

Objective

To determine national practice patterns on management of anterior urethral strictures among Dutch urologists. This information will help to define the nationwide need for training in urethral surgery.

Design, setting, and participants

We conducted a 16-question survey among all 323 Dutch urologists.

Results and limitations

The response rate was 74%. DVIU was practised by 97% of urologists. Urethroplasty was performed at least once yearly by 23%, with 6% performing more than five urethroplasties annually. In the group of urologists younger than 50 yr of age, 13% performed urethroplasty, with 3% of those performing more than five annually. In the case of a 3.5-cm-long bulbar stricture, DVIU was preferred by 49% of responders. Even after two recurrences, 20% continued to manage a 1-cm-long bulbar stricture endoscopically. Of responders, 79% believed that urethroplasty should be proposed only after a failed endoscopic attempt. Diagnostic workup and evaluation of success varied greatly.

Conclusions

Most Dutch urologists believe that urethroplasty is an option only after failed DVIU. Endoscopic procedures are widely used, even when the risk of recurrence is virtually 100%. The definition of success is hampered by nonstandardised methods of follow-up. Only a small group of mainly older urologists frequently performs urethroplasties. Training programmes seem necessary to guarantee a high standard of care for stricture disease in The Netherlands. A pan-European practice survey might be interesting to clarify the need for centralised fellowship programmes.

Introduction

Urethral stricture disease is common; in The Netherlands, 2193 clinical admissions were registered in 2008 for surgical treatment of the disease in males older than 14 yr of age (80% of national hospitals participate in this registry) [1]. In everyday practice, direct vision internal urethrotomy (DVIU) is the most popular procedure [2].

In 2008 in The Netherlands, which has a population of 16.5 million people, 1915 endoscopic urethral procedures were registered in males older than 14 yr of age in contrast to only 175 open urethroplasties in this age group. In the United Kingdom, which has 61.5 million citizens, similar proportions are seen: About 700 urethroplasties and as many as 16 000 endoscopic procedures are performed yearly [3]. However, long-term efficacy of DVIU is moderate, with 60% success 4 yr after a first procedure, but with a 50–94% and 91–100% recurrence rate after a second and third DVIU, respectively [4], [5], [6]. Reconstructive surgery, either with excision and primary anastomosis (EPA) in short bulbar strictures or substitution urethroplasty in longer strictures, has a high success rate in experienced hands [7], [8], [9], [10], [11]. Nevertheless, its use is substantially less frequent, perhaps because of overestimation of the efficacy of DVIU or lack of experience with technically demanding urethroplasty.

To optimise treatment in urethral stricture disease, familiarity with indications and state-of-the-art performance of these newer procedures seem to be of utmost importance. A national survey on practice patterns among urologists in the United States showed little experience with urethroplasty, and often, minimally invasive techniques were continued despite predictable failure [12]. This result prompted us to design a similar survey for Dutch urologists. Knowledge of the number and type of procedures performed by urologists nationwide is important baseline information needed before one could argue that management strategies should be modernised. The data will be used for further studies on optimal treatment of urethral stricture disease in The Netherlands and to define nationwide training needs in urethral surgery.