Male Urethral Strictures: A National Survey Among Urologists in Italy

Enzo Palminteri 1, Serena Maruccia 2, Di Pierro Giovanni Battista 3, Elisa Berdondini 1, Omid Sedigh 4, Francesco Rocco 5
  • 1 Centro di Chirurgia Uretrale (Arezzo)
  • 2 Ospedale San Donato - Dipartimento di Urologia (Milano)
  • 3 Università "La Sapienza" - Dipartimento di Urologia (Roma)
  • 4 Ospedale Le Molinette - Dipartimento di Urologia (Torino)
  • 5 Clinica Urologica I, Università degli Studi di Milano (Milano)

Objective

Urethral stricture disease is one of the most difficult pathologies to treat in urology. Its management has undergone significant changes in the last decades, passing from various minimally invasive but often unsuccessful procedures to definitive open urethroplasty as procedure of choice. Although urethroplasty surgery can be technically demanding and time-consuming, evidence suggests that it is more successful than minimally invasive procedures. However, no consensus exists for the treatment of urethral stricture disease. The number and types of procedures performed nationwide in different nations has yet to be ascertained. We determined national practice patterns in the management of male urethral strictures among Italian urologists.

Methods and results

A nationwide survey of practising Italian urologists was performed by mailed questionnaires.
The Questionnaire was designed based on a nationwide survey performed in the United States first and in the Netherlands subsequently. The survey elicited information on respondent demographics, number of urethral strictures managed yearly, diagnosis, treatment and follow-up strategy of male urethral stricture disease. The questionnaire was mailed to 700 urologists (randomly selected from each of the 3 wide areas of Italy: Northern, Central and Southern Italy) and could be returned anonymously. A total of 523 (74.7%) urologists completed and mailed back the questionnaire.
Upon receipt of the completed questionnaires, data were entered into a computer database and extensively evaluated. Analysis was performed using SAS statistical software. Statistical significance was defined as p≤0.05.
A total of 523 (74.7%) urologists completed the questionnaire. Internal urethrotomy and dilatation were the most frequently used procedures (practiced by 81.8% and 62.5% of responders, respectively), even if most urologists (71.5%) considered internal urethrotomy appropriate only for strictures no longer than 1.5 cm; 12% of urologists declared to use stents. Overall, minimally invasive techniques were performed more frequently that any open urethroplasty (P . .012). Particularly, 60.8% of urologists did not perform urethroplasty surgery, 30.8% performed 1-5 urethroplasties yearly, and only 8.4% performed >5 urethroplasty surgeries yearly. The most common urethroplasty surgery was one-stage graft technique, particularly using oral mucosa and ventrally placed. Diagnostic workup and outcome assessment varied greatly.

Discussion

Our survey describes the current management of male urethral stricture disease in Italy.
Analysis shows the lack of uniformity among the responders in what concerns diagnostic procedures. Indeed, only 16% of the responders declared to perform urethrography which, on the contrary, should represent the fundamental test for a right diagnostic evaluation. Most Italian urologists treat few cases (<10) per year. Minimally invasive methods confirmed to be performed more frequently than any open urethroplasty technique (p = 0.012). Indeed, the most practised treatment was IU: specifically, 65.8% of urologists use the traditional cold knife (Sachse), 42.4% the blind internal urethrotomy (Otis) and 14.3% the modern laser.
A high percentage of responders admitted performing UI even in cases where the literature has clearly demonstrated the uselessness of this treatment and, on the contrary, the efficacy of urethroplasty surgery. However, most urologists (71.5%) considered appropriate IU only for short (6 urethroplasty per year. The most preferred techniques were not the traditional anastomotic procedures (8.6%) but graft urethroplasties using buccal mucosa (16.8% vs 4.4% for skin graft; p < 0.001), ventrally placed on the urethra (11.3% vs 4.2% for dorsal location).
The above cited data confirm the persistence of an old philosophy in the management of urethral stricture disease, characterized by the repeated use of minimally invasive and unsuccessful procedures. The cases treated by any urologist per year are few; this hinders acquiring an adequate surgical experience and raises the ethical dilemma whether it is proper to perform urethroplasty in non-specialized centers. In conclusion, In Italy, minimally invasive procedures are the most commonly used treatment for urethral stricture disease. Only a minimal part of urologists perform urethroplasty surgery and only few cases per year. The most preferred techniques are not traditional anastomotic procedures but graft urethroplasties using oral mucosa; the graft is preferably ventrally placed rather than dorsally. There is no uniformity in the methods used to evaluate urethral stricture before and after treatment.

References

1- Bullock TL, Brandes SB. Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States. J Urol 2007;177:685–90.
2- Van Leeuwen MA, Brandenburg JJ, Kok ET, et al. Management of Adult Anterior Urethral Stricture Disease: Nationwide Survey Among Urologists in The Netherlands. Eur Urol, 2011;60:159-166.
3- Palminteri E, Gacci M, Berdondini E, et al. Management of Urethral Stent Failure for Recurrent Anterior Urethral Strictures. Eur Urol 2010;57:615-621.

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