To determine national practice patterns in the management of male urethral strictures among Italian urologists.
We conducted a survey using a nonvalidated questionnaire mailed to 700 randomly selected Italian urologists. Data were registered into a database and extensively evaluated. Analysis was performed using SAS statistical software (version 9.2). Statistical significance was defined as P _.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 ¼ .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.
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. UROLOGY 83: 477e484, 2014. _ 2014 Published by Elsevier Inc.
Urethral stricture disease is one of the oldest pathologies known in urology.1-3 In the last decades, its management has undergone significant changes, passing from various minimally invasive but often unsuccessful procedures to definitive open urethroplasty as the procedure of choice.1,4
Although long-term results are excellent, urethroplasty can be technically demanding and time-consuming. Thus, the decision on how to treat urethral stricture often remains midway between a highly efficacious but complex surgical procedure and a minimally invasive but less effective approach. Despite the fact that multiple studies have demonstrated the long-term inefficacy of internal urethrotomy (IU) and urethral dilatations, these procedures remain by far, the most commonly performed treatments, probably because of their simplicity, ease of repetition, and lack of familiarity with the open urethroplasty. 5-9
Currently, no consensus exists for the treatment of urethral stricture disease. Moreover, the number and types of procedures performed nationwide are yet to be ascertained in different countries.
Two interesting surveys among urologists in the Netherlands and the United States revealed that most of them have little experience with urethroplasty, and despite predictable failure minimally invasive techniques are often performed.3,10
We performed a similar survey in Italy to obtain information on the current strategies in the management of urethral stricture disease and to ascertain if there were any significant differences between Italy and other nations.
MATERIAL & METHODS
A nationwide survey of practicing Italian urologists was performed by mailed questionnaires.
The nonvalidated questionnaire (see Appendix) was based on a nationwide survey first performed in the United States and subsequently in the Netherlands.3,10 The survey elicited information on respondent demographics, number of urethral strictures managed yearly, diagnosis, treatment, and follow-up strategy of male urethral stricture disease. A total of 700 board-certified, practicing urologists from the Italian Urological Association directory were randomly selected from each of the 3 wide areas of Italy (Northern, Central, and Southern Italy).
The questionnaire was mailed to all of them in June 2009, and a total of 523 of 700 (74.7%) completed the questionnaire. On receipt of the completed questionnaires, data were entered into a computer database and extensively evaluated. Analysis was performed on all completed and partially completed surveys using SAS statistical software (version 9.2). Statistical significance was defined as P .05.
Responding urologists were classified by age group, geographic distribution, practice type, and field of interest.
Responders were divided into 4 groups according to their age: 102 of 523 (19.5%) in group 30-39 years, 155 of 523 (29.6%) in group 40-49 years, 210 of 523 (40.1%) in group 50-59 years, and 56 of 523 (10.8%) in group >60 years. The geographic distribution was as follows: 197 of 523 (37.7%) urologists in Northern Italy, 161 of 523 (30.8%) in Central Italy, and 165 of 523 (31.5%) in Southern Italy.
The practice type was private in 43 of 523 (8.2%) urologists, government 432 of 523 (82.6%), and academic 48 of 523 (9.2%). The field of interest was endourology in 196 of 523 (37.5%) urologists, andrology 86 of 523 (16.4%), general urology 79 of 523 (15.1%), lithiasis 53 of 523 (10.2%), oncology 49 of 523 (9.4%), reconstructive surgery 22 of 523 (4.2%), pediatric urology 7 of 523 (1.3%), and others 31 of 523 (5.9%).
Table 1 lists the number of urethral strictures treated annually and also the type and number of procedures performed in the last year. Table 2 lists the management of bulbar urethral strictures: when presented with a long (3.5 cm) primary bulbar urethral stricture (case 1) or a short (1 cm) bulbar urethral stricture refractory to IU (case 2), 53.3% and 26% of urologists, respectively, would continue to manage the stricture by repeated endoscopic and minimally invasive procedures, despite predictable failure.
Almost 68.8% and 83.5%, respectively, would perform some type of urethroplasty. Table 3 lists details on maximum stricture length, which IU is considered appropriate for and the duration of transurethral catheter after IU: most of urologists (374 of 523; 71.5%) considered IU to be recommended only for strictures no longer than 1.5 cm. According to the published data, 342 of 523 (65.4%) of the responders thought that urethroplasty is the best option only after failed minimally invasive treatments.
Only 177 of 523 (33.8%) would also consider urethroplasty as a primary treatment option. The method to evaluate a urethral stricture before performing surgery varied widely, and most urologists use many options: uroflowmetry was performed by 274/ 523 (52.4%) of responders, urethroscopy by 116/523 (22.2%) (particularly, 11.3% declared to use a rigid urethroscope and 10.9% a flexible urethroscope), retrograde urethrography and voiding cystourethrography by 85 of 523 (16.3%), ultrasonography by 57 of 523 (10.9%), urography by 11 of 523 (2.1%), urethral calibration by 11 of 523 (2.1%), and undeclared by 3 of 523 (0.6%).
Regarding the methods to evaluate stricture treatment outcomes, uroflowmetry was performed by325 of 523 (62.1%) of responders, retrograde urethrography and voiding cystourethrography by 91 of 523 (17.4%), urethroscopy by 66 of 523 (13%) (particularly, 4.6% declared to use a rigid urethroscope and 8.4% a flexible urethroscope), ultrasonography by 15 of 523 (2.9%), urography by 8 of 523 (1.5%), urethral calibration by 14 of 523 (2.7%), and undeclared by 2 of 523 (0.4%).
Our survey describes the current management of male urethral stricture disease in Italy. The response rate (74.7%) was very similar to the Dutch study (74%)10; of the 523 responders, 467 (89%) were aged
Only 16% of the urologists stated that they perform urethrography, which is considered the fundamental test/investigation for correct diagnostic evaluation. In contrast, 72% of Dutch urologists reported using urethrography.10 We were very surprised by the low use of radiography: probably it is because the method is considered invasive and not well accepted by Italian patients.
However, the fact that methods for the evaluation of urethral strictures vary greatly has been shown in published data.11 Even the methods to assess postoperative outcomes have shown to vary greatly. Most (81.5%) Italian urologists treat few cases (10) per year (Table 1), similar to the American responders and slightly inferior to the number of cases treated by Dutch urologists.
Similar to the US and the Netherlands, minimally invasive methods (dilatation, IU, and endourethral stent) confirmed to be performed more frequently than any open urethroplasty technique (P ¼ .012). Indeed, the most practiced treatment was IU (81.8% of urologists): specifically, 65.8% of urologists use the traditional cold knife (Sachse), 42.4% the blind IU (Otis), and 14.3% the modern laser.
A high percentage of responders admitted performing IU even in cases (Table 2) in which the published data has clearly demonstrated the uselessness of this treatment and, on the contrary, the efficacy of urethroplasty surgery. However, in this study, 374/523 (71.5%) of respondents considered IU appropriate only for short (
Surprisingly, 12% of urologists still uses stents (Table 1), which have been shown not only to have no long-term efficacy, but also on the contrary to worsen the urethral stricture and compromise the result of further treatments.12-15 Dutch urologists showed to reduce considerably the use of stents (1.3%), whereas the American ones seem to maintain an inexplicably frequent use of them (23.4%).
Interestingly, most urologists believe that the best evidence-based treatment strategy is reconstructive surgery, but only after a failed minimally invasive procedure: this belief has always generated many debates and partly explains why many cases (ie, long or panurethral strictures, lichen sclerosus strictures, strictures after failed hypospadia repair, and so forth) are still managed by procedures that have a predictable failure.
Overall, 318 of 523 (60.8%) of Italian responders did not perform urethroplasty surgery, 161 of 523 (30.8%) performed 1-5 cases yearly, and only 44 of 523 (8.4%) performed >6 urethroplasty per year (Table 1). The most preferred techniques were not traditional anastomotic procedures (45 of 523; 8.6%) but graft urethroplasties (111 of 523; 21.2%) more often by using oral mucosa than skin graft (16.8% vs 4.4%; P <.001); surgeons preferred ventral graft location compared with dorsal location (11.3% vs 4.2%; P ¼ .014). In the Netherlands and the US, the frequency of use of anastomotic procedures (16.4% and 15.3%, respectively)3,10 is similar to that of graft techniques, and ventral grafting seems to be slightly more practiced than dorsal grafting.
The aforementioned data seem to 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. In our personal opinion, the cases treated by any urologist per year are few: this hinders acquiring an adequate surgical experience and raises the ethical and debated dilemma whether it is proper to perform urethroplasty in nonspecialized centers.1,3 To optimize the management of urethral stricture disease, familiarity with indications and state-of-the-art performance of the procedures seem to be of utmost importance. Our and other national surveys3,10 on practice patterns among urologists revealed little experience with urethroplasty and the repeated use of unsuccessful maneuvers.
Knowledge of the number and type of procedures performed nationwide represents important baseline information, extremely precious in determining what should be changed in urethral stricture disease management strategies. Our study has some limitations. It was based on a questionnaire mailed to selected urologists, with a response rate of 75%. This study design always has the possibility that people who are more interested in the subject are more likely to complete the questionnaire; the 25% who did not respond might not be interested in urethral strictures at all, so the findings might not be representative, and might even overestimate the proportion of urologists who treat strictures or who perform urethroplasty. However, in general, 523 urologists represent a sufficiently large sample.
The questionnaire has some shortcomings. For example, it would be interesting to know the mean age of the stricture patients treated by the various respondents, because the choice of management might be influenced by patient age and comorbidities. At the same time, it would be interesting to know what type of exposure to urethroplasty the respondents had during their urology training or additional training in reconstructive urology. However, our data might be used for further studies on optimal treatment of urethral strictures in Italy and to define nationwide training needs in urethral surgery.
In Italy, despite predictable failure confirmed by the published data, minimally invasive procedures remain the most commonly performed treatment for urethral stricture disease. Only a minor number 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. In addition, diagnostic workup and outcome assessment varied greatly.
The authors thank Pierre Fabre for supporting and funding the study.