The road to evidence-based urethral stricture management
Three associations differ on their approach.
Clinical guidelines are the roadmaps to patient care. They are designed to show the best route for reaching the desired destination. The road to optimal treatment of urethral stricture management, however, has included some twists and turns with differing opinions on the best approach.
The guidelines for managing urethral strictures, for the most part, provide a straightforward approach and consensus among the American Urological Association (AUA), the European Association of Urology (EAU) and the Urological Society of India (USI). Each has published and often updated its guidelines for evidence-based urethral stricture management.
Yet, there are some differences and debate among them. Kenneth Angermeier, MD, a professor of urology at the Cleveland Clinic in Ohio, is among the speakers sorting out the differences at today’s session, “Crossfire: Controversies in Urology: Battle of the Guidelines: Examining Key Differences in Evidence-Based Urethral Stricture Management,” 8-8:30 a.m. in the Venetian Ballroom.
“There are a few major differences, controversies or opposing views among the three published sets of guidelines, including AUA [published in 2016 and updated in 2023], EAU [published in 2021 with a limited update in 2023] and USI [published in 2020],” Dr. Angermeier said. “The recommendations in the guidelines are based on level of evidence in the available literature and overall grade, based on level of evidence or expert opinion and well-established clinical principles. All methods of stricture treatment are included, and options for various types of stricture/stenosis, including urethroplasty and endoscopic treatments, are reviewed.”
Managing urethral strictures often involves a choice between urethral dilation/internal urethrotomy and urethroplasty. The discussion about the optimal approach for different stricture lengths, locations and patient characteristics is ongoing, Dr. Angermeier said, as well as the use of flaps versus grafts, perineal urethrostomy and the role of staged versus single-stage urethroplasty.
As for some key differences, Dr. Angermeier noted that the EAU guidelines include a discussion and recommendations for preventing stricture formation and strictures in transgender patients, whereas the AUA and USI guidelines do not.
Additionally, Dr. Angermeier said EAU guidelines state that Optilume balloon dilation for recurrent bulbar strictures should be done only in patients for whom urethroplasty is not an option. Conversely, AUA recommendations are “more liberal for use of Optilume in this setting,” and USI guidelines do not mention Optilume because they were published prior to its availability.
“EAU guidelines specifically address bulbomembranous strictures and posterior urethral stenosis related to prior radiation therapy for prostate cancer,” he said. “USI guidelines mention this topic with a few limited recommendations. AUA mentions the impact of radiation in the discussion, but it is not included in the actual guideline statements. EAU also has more discussion and guidelines with respect to options for urinary diversion in this patient population.”
Dr. Angermeier also reminds colleagues that an accurate diagnosis is critical when planning treatment for anterior urethral strictures and posterior urethral stenosis. The importance of this is addressed in EAU and AUA guidelines; however, not much attention is given to it in the USI guidelines, he said.
Finally, Dr. Angermeier said the USI guidelines have clear recommendations for urethroplasty and stricture management in patients with end-stage renal disease who may be considering or already have a renal transplant. However, this is not specifically addressed in the AUA and EAU guidelines.
“These guidelines are very helpful in patient management, and their use is highly recommended,” Dr. Angermeier said. “The majority of the recommendations that would be used by general urologists are quite similar among them, with the differences being somewhat esoteric and perhaps more limited to use by those treating complex strictures and performing larger numbers of urethroplasty procedures.”
