Blind stretching or telescopic cutting versus open surgery for urethral narrowing in men

Narrowing of the urine pipe (urethral stricture) is a common cause of problems in passing water for younger men. Standard treatment consists of widening the strictured segment using instruments passed down the urethra (called urethral dilatation or urethrotomy). Alternatively, a urethroplasty operation can be performed whereby the narrowed area is removed or replaced by graft material. The uncertainty as to which option is best prompted this review of the current evidence. We found very little good quality evidence and were unable to achieve all our objectives for this review. The results of a single study suggest that dilatation and urethrotomy offer equivalent outcomes, but they are associated with a high rate of recurrence of the stricture requiring repeated procedures over a relatively short period of time. Preliminary data reported in abstract form suggested that urethroplasty was more effective than urethrotomy for the specific circumstance of urethral trauma following fracture of the pelvic bones. We found no data concerning well-being or the quality of life amongst men treated for urethral stricture disease. The main conclusion of the review is that the current lack of quality evidence means that further trials are needed to establish which intervention is most effective and most cost-effective for treatment of urethral stricture disease in men. 

Authors' conclusions: 

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

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Background: 

Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised. The extent and quality of evidence guiding treatment choice for this condition are uncertain.  

Objectives: 

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.  

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles.

Selection criteria: 

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

Data collection and analysis: 

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5).

Main results: 

Two randomised trials were identified. One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size.

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