Guidelines on Urethral Stricture Disease: European Association of Urology updates 2021

In a recent development, a panel of experts aimed to present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

The guidelines as has been provided are summerised below.

Aetiology and guidelines on prevention

• Urethritis due to sexually transmitted infection, inflammation due to lichen sclerosus (LS), External trauma to the urethra, Iatrogenic injury to the urethra , Urethral catheterization, Transurethral prostate surgery, Radical prostatectomy , Prostate radiation and ablative treatments, are some of the common causes of urethral stricture disease.

Guidelines for prevention of urethral stricture disease

· Advise safe sexual practices, recognise symptoms of sexually transmitted infections, and provide access to prompt investigation and treatment for men with urethritis.

· Avoid unnecessary urethral catheterisation.

· Implement training programmes for physicians and nurses performing urinary catheterisation.

· Do not use catheters larger than 18 Fr if urinary drainage only is the purpose.

· Avoid using noncoated latex catheters.

· Do not perform urethrotomy routinely when there is no pre-existent urethral stricture.

Guidelines on conservative management

• not intervene in patients with asymptomatic incidental (>16 Fr) strictures
• Consider long-term suprapubic catheter in patients with radiation-induced bulbomembranous strictures and/or poor performance status.

Guidelines on urethroplasty for meatal stenosis, fossa navicularis, and penile strictures

Recommendations	Strength rating
Offer open meatoplasty or distal urethroplasty to patients with meatal stenosis or fossa navicularis/distal urethral strictures.	Weak
Offer men with penile urethral stricture disease augmentation urethroplasty by either a single-stage or a staged approach, taking into consideration previous interventions and stricture characteristics.	Strong
Proceed to the second stage of the procedure after an interval of at least 4–6 mo and provided that outcome of the first stage is satisfactory.	Weak
Do not offer anastomotic urethroplasty to patients with penile strictures >1 cm due to the risk of penile chordee postoperatively.	Strong
Counsel patients with penile strictures that single-stage procedures might be converted to staged ones in case of adverse intraoperative findings.	Strong
Perform single-stage oral mucosa graft urethroplasty in the absence of adverse local conditions in men with lichen sclerosus–related strictures.	WeakG

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• Guidelines on urethroplasty for bulbar strictures

  Use transecting excision and primary anastomosis (tEPA) for short post-traumatic bulbar strictures with (nearly) complete obliteration of the lumen and full-thickness spongiofibrosis. Strong

• Use nontransecting excision and primary anastomosis or free graft urethroplasty (FGU) instead of tEPA for short bulbar strictures not related to straddle injury. Weak
• Use FGU for bulbar strictures not amendable to excision and primary anastomosis (EPA). Strong
• Use augmented anastomotic repair for bulbar strictures not amenable to EPA, but with a short, nearly obliterative segment within the whole strictured segment. Weak
• Use the dorsal, dorsal-lateral, or ventral approach according to surgical practice, expertise, and intraoperative findings. Strong
• Offer staged urethroplasty to men with complex anterior urethral stricture disease not suitable for single-stage urethroplasty and those who are fit for reconstruction. Weak
• Do not perform staged bulbar urethroplasty for lichen sclerosis if single-stage urethroplasty is possible. Weak
• Consider staged procedure in patients unsure about perineal urethrostomy versus urethral reconstruction. Weak
• Warn men that staged urethroplasty may comprise more than two stages. Weak

Guidelines on urethroplasty for penobulbar/panurethral strictures

Recommendations	Strength rating
Offer panurethral urethroplasties in specialised centres because different techniques and materials might be needed.	Weak
Combine techniques to treat panurethral strictures if one technique is not able to treat the whole extent of the stricture.	Weak

Guidelines on perineal urethrostomy

Recommendations	Strength rating
Offer perineal urethrostomy as a management option to men with complex anterior urethral stricture disease.	Strong
Offer perineal urethrostomy to men with anterior urethral stricture disease who are not fit or not willing to undergo formal reconstruction.	Weak
Choose the type of perineal urethrostomy based on personal experience and patient characteristics.	Weak
Consider augmented Gil-Vernet Blandy perineal urethrostomy or "7-flap" perineal urethrostomy in men with proximal bulbar or membranous urethral stricture disease.	Weak
Consider "7-flap" urethroplasty in obese men.	Weak

Guidelines on endoluminal management of posterior urethral stenosis

• Perform visually controlled dilatation or direct vision internal urethrotomy (DVIU) as first-line treatment for a nonobliterative vesicourethral anastomosis stricture (VUAS) or radiation-induced bulbomembranous stricture (BMS) Weak
• Do not perform deep incisions at the 6 and 12 o'clock position during DVIU for VUAS or radiation-induced BMS. Strong
• Perform transurethral resection or hot-knife DVIU as first-line treatment for patients with nonobliterative bladder neck stenosis (BNS) after surgery for benign prostatic obstruction. Strong
• Perform repetitive endoluminal treatments in nonobliterative VUAS or BNS in an attempt to stabilise the stricture. Weak
• Warn patients about the risk of de novo urinary incontinence (UI) or exacerbation of existing UI after endoluminal treatment. Weak
• Do not use stents for strictures at the posterior urethra. Weak
• Do not perform endoscopic treatment for an obliterative stenosis. Strong
• Perform one attempt at endoluminal treatment for a short, nonobliterative post-traumatic stenosis. Weak
• Do not perform more than two DVIUs and/or dilatations for a short and nonobliterative recurrence after excision and primary anastomosis for a traumatic posterior stenosis if long-term urethral patency is the desired intent.

Guidelines on urethroplasty and reconstructive surgery for posterior urethral stenosis

• Perform repeat (ReDo) vesicourethral anastomosis (VUA) in nonirradiated patients and irradiated patients with adequate bladder function with obliterative VUA stricture or VUA stricture refractory to endoluminal treatment. Weak
• Warn patients that urinary incontinence (UI) is inevitable after transperineal ReDo VUA and that subsequent anti-UI surgery might be needed in a next stage after at least 3–6 mo. Strong
• Offer ReDo VUA by retropubic approach if the patient is preoperatively continent. Weak
• Perform bladder neck reconstruction with Y-V or T-plasty for treatment refractory bladder neck stenosis (BNS). Weak
• Warn patients about de novo UI after reconstruction for BNS or bulbomembranous stricture (BMS) with previous benign prostatic obstruction surgery as aetiology. Strong
• Use either excision and primary anastomosis (EPA) or augmentation urethroplasty for short (<2.5 cm) radiation-induced BMS refractory to endoscopic treatment depending on surgeon's experience. Weak
• Perform augmentation urethroplasty for long (>2.5 cm) radiation-induced BMS. Weak
• Warn patients about the risk of de novo incontinence and new-onset erectile dysfunction after urethroplasty for radiation-induced BMS. Strong
• Offer salvage prostatectomy in motivated and fit patients with adequate bladder function in case of a prostatic stricture due to irradiation or high-energy treatment. Weak
• Perform urinary diversion in recurrent or complex cases with loss of bladder capacity and/or incapacitating local symptoms. Weak

Perform cystectomy during urinary diversion in case of intractable bladder pain, spasms, and/or haematuria. Weak

• Perform open reconstruction for post-traumatic posterior stenosis only in high-volume centres. Weak
• Perform progressive perineal excision and EPA for obliterative stenosis. Strong
• Perform progressive perineal EPA for nonobliterative stenosis after failed endoluminal treatment. Strong
• Perform a midline perineal incision to gain access to the posterior urethra. Strong
• Do not perform total pubectomy during abdominoperineal reconstruction. Strong
• Reserve abdominoperineal reconstruction for complicated situations including very long distraction defect, paraurethral bladder base fistula, trauma-related rectourethral fistula, and bladder neck injury. Weak
• Perform another urethroplasty after the first failed urethroplasty in motivated patients not willing to accept palliative endoluminal treatments or urinary diversion. Weak
• Use a local tissue flap to fill up excessive dead space or after correction of a concomitant rectourethral fistula. Weak

Guidelines on tissue transfer in urethroplasty

Recommendations	Strength rating
Use a graft above a flap when both options are equally indicated.	Strong
Do not use grafts in a tubularised fashion in a single-stage approach.	Strong
Use flaps in case of poor vascularisation of the urethral bed.	Weak
Do not use hair-bearing perineal or scrotal flaps unless no other option is feasible.	Strong
Use buccal or lingual mucosa if a graft is needed and these grafts are available.	Weak
Inform the patient about the potential complications of the different types of oral grafting (buccal vs lingual vs lower lip) when an oral graft is proposed.	Strong
Use penile skin if buccal/lingual mucosa is not available, suitable, or accepted by the patient for reconstruction.	Weak
Do not use genital skin graft in case of lichen sclerosus.	Strong
Do not use cell-free tissue-engineered grafts in case of extensive spongiofibrosis, after failed previous urethroplasty, or in case of stricture length >4 cm.	Weak
Do not use autologous tissue-engineered oral mucosa grafts outside the frame of a clinical trial.	Strong

"Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations." The experts concluded.

For full article follow the link: 10.1016/j.eururo.2021.05.022

Source:European Urology