Adult urologyWhat is the most cost-effective treatment for 1 to 2-cm bulbar urethral strictures: Societal approach using decision analysis
Section snippets
Model
The decision tree constructed (Fig. 1) graphically represents the components of the problem. It consisted of four types of nodes: a decision node (squares) at which the treatment strategy was chosen; chance nodes (circles), at which an event was out of the decision maker’s control and requires the probability of outcomes to be estimated; label nodes (bowties), which are placeholders marking the progression of patients from one surgical procedure to the next; and terminal nodes (triangles),
Results
In the base case of a 1 to 2-cm bulbar urethral stricture with an estimated success rate of 95% for urethroplasty, 50% for a first DVIU and 20% for a second DVIU, the strategy of one DVIU before proceeding to urethroplasty was the least costly ($8575) and three DVIUs before urethroplasty had the greatest cost ($10,466; Table II). The average cost per successfully voiding patient of the “one DVIU before urethroplasty” strategy was $8795, and it achieved a 97.5% success rate. The ICERs for the
Comment
Using decision analysis, we found that across a wide range of success rates for DVIU, and assuming a very high success rate for urethroplasty, an approach of endoscopic therapy first is more cost-effective for strictures less than 1 to 2 cm in length.
Disagreement exists on the appropriate management algorithm for short urethral strictures. Urethroplasty has been advocated as a primary therapy16 after one failed DVIU6, 13 or after multiple failed DVIUs.3 A recent survey reported that 74% of
Conclusions
The most cost-effective strategy for the management of short urethral stricture disease is to reserve urethroplasty for patients in whom one attempt at DVIU fails. Urethroplasty, as the primary therapy, is only cost-effective if the expected success of a first DVIU is less than 27% to 35%. Two endoscopic treatments before urethroplasty would be the most cost-effective if the expected success rate of a second DVIU were greater than 28% to 34%. Future prospective, multicenter studies of DVIU and
References (22)
- et al.
Long-term results of internal urethrotomy
J Urol
(1996) - et al.
Internal urethrotomy versus dilation as treatment for male urethral stricturesa prospective, randomized comparison
J Urol
(1997) - et al.
Newly diagnosed bulbar urethral stricturesetiology and outcome of various treatments
J Urol
(1993) - et al.
Internal urethrotomy in the management of anterior urethral strictureslong-term followup
J Urol
(1996) - et al.
Long-term outcome of urethroplasty after failed urethrotomy versus primary repair
J Urol
(2001) - et al.
Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction
J Urol
(2003) - et al.
Urethroplasty for refractory anterior urethral stricture
J Urol
(2002) - et al.
Anastomotic urethroplasty for bulbar urethral strictureanalysis of 168 patients
J Urol
(2002) - et al.
The long-term results of urethroplasty
J Urol
(2003) - et al.
Treatment of male urethral stricturesis repeated dilation or internal urethrotomy useful?
J Urol
(1998)
Excisional repair of urethral stricturefollow-up of 90 patients
Urology
Cited by (91)
Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which Technique Is Best? A Systematic Review
2021, European UrologyCitation Excerpt :The anterior urethra is most frequently affected, predominantly in the bulbar segment [2]. Urethroplasty provides the highest chance of long-term patency and is considered the gold standard treatment for bulbar urethral strictures, despite the ease and widespread availability of endoscopic procedures [3,4]. Various techniques for bulbar urethroplasty have been described [4].
Management of male anterior urethral strictures in adults. Results from a national survey among urologists in Spain
2020, Actas Urologicas EspanolasA brief review on anterior urethral strictures
2018, Asian Journal of UrologyCitation Excerpt :Various new articles on intralesional treatment of these strictures have shown good results [16,17]. Moreover, there is consensus that repeated DVIU for early recurrence has a far less curative effect than expected [18], thus, for patients with early stricture recurrence, reconstructive urethroplasty is likely to be a more appropriate choice rather than repeated DVIU. In the bulbar urethra, the choice of surgical techniques depends on the stricture length.
This study was supported by grant R49-CE000197 from the Centers for Disease Control.