The standard for the management of male urethral strictures in the UK: a consensus document

Abstract

Objective: The aim of this study was to establish an evidence-based best clinical practice consensus for the management of urethral stricture disease in the UK. Methods: A systematic review of optimal management of urethral stricture generated a base document which was endorsed by the British Association of Urological Surgeons (BAUS) section of Andrology and Genito-Urinary Reconstructive Surgeons (AGUS). A two-round electronic mail modified Delphi survey of 43 consultant reconstructive urologists, members of the British Association of Genito-Urinary Reconstructive Surgeons (BAGURS), was then performed. The panel’s views about the base document was sought in seven domains: definition, diagnosis, investigation, conservative, endoscopic and reconstructive treatments, and follow up. Responses were collated and used to modify the base to achieve a consensus statement. Results: In round one of the Delphi process four panel members commented on the base document and seven in round two. Consensus was thereby reached on 38 statements regarding definition (one), diagnosis (three), investigation (two), conservative/endoscopic (five) and reconstructive (24) treatments and follow up (three) for the management of urethral stricture disease. Conclusion: This consensus statement will help standardise care, provide guidance on the management of urethral stricture disease, and assist in clinical decision-making for healthcare professionals of all grades.

Male urethral stricture disease: why management guidelines are challenging in low‐income countries

“…The 2020 British Association of Genito‐Urethral Reconstructive Surgeons (BAGURS) consensus on the management of urethral strictures [10] suggests that the diagnosis should be made after clinical evaluation, supplemented by patient‐reported outcome measures (PROMs) [50], to determine symptoms, severity and bother, and assessments of lifestyle impacts of the symptoms using validated questionnaires such as the IPSS [51] and five‐item version of the International Index of Erectile Function (IIEF‐5) [52]. In addition, it is recommended that initial documentation should include information about the aetiology of the stricture, the patient's symptoms, initial flow rate result, post‐void ultrasound residual and urine analysis [10]. Subsequently, the presence of a stricture should be confirmed either by urethrography or endoscopically.…”

“…There is general acceptance that the operative management of USD depends upon the length, location, aetiology and number of strictures, the type, number and timing of previous interventions, symptom severity and the presence of complications, patient factors, including comorbidities, patient preference and the expertise available [10]. The less‐invasive techniques available, UD, CISD, DVIU are often applied in a stepwise manner in HICs with urethroplasty often being the ‘gold standard’ treatment of choice when these have not provided a durable result [11,12].…”

“…In HICs the consensus is that documentation of patient's postoperative symptoms, PROMs, IIEF, flow rate and post‐void residual should be undertaken to give some subjective evaluation of the patient's outcome from intervention, and to determine stricture recurrence [10]. It is often not even practical to see patients for follow‐up in the resource‐poor setting and many patients will simply re‐appear if they have ongoing problems with their urinary flow.…”

“…However, USD's importance as a clinical presentation demanding treatment makes it an omnipresent challenge to specialist surgeons in SSA [8,9], as well as other resource-poor healthcare environments globally [5]. Whilst HICs manage most strictures, at least initially, with less invasive measures such as urethral dilatation (UD) or endoscopic techniques such as hot or cold knife direct visual internal urethrotomy (DVIU), with or without postoperative clean intermittent self-dilatation (CISD) [10][11][12], these options, apart from UD, are not always available to specialists in LMICs [5,8]. Additionally, the aetiology of strictures, and their complexity, is often fundamentally different to that seen in many HICs [5,13].…”

“…In this article, the eighth in this BJUI series, we aim to describe the experience Urolink, a charitable nongovernmental organisation associated with the BAUS, has had with the management of USD in a number of different countries in SSA. We will outline the differences in the aetiology, investigative and operative management of urethral strictures in these countries and explore the reasons why guidelines and consensus statements generated in HICs, with and without universal healthcare provision [10][11][12], have limited usefulness in a resource-poor environment.…”