BERKELEY, CA (UroToday Inc.) - Optical urethrotomy and urethral dilation are simple endoscopic procedures that are currently the most common procedures performed for the management of new and recurrent urethral strictures. Each, however, has a success rate that hovers around 50%, making experts wonder if endoscopic stricture management is being excessively used. Some defenders point to the simplicity and ease of repetition of the procedure, while others question whether it is done because of the lack of familiarity with more major urethral reconstruction techniques.

Therefore, T.J. Greenwell and colleagues from London examined the cost-effectiveness and clinical appropriateness of stricture management, and their study is published in the July 2004 issue of The Journal of Urology. The study group consisted of 126 new patients who were treated endoscopically for urethral stricture disease in a general urology practice over an 8-year period. Clinical outcomes as well as medical and hospital costs associated with treatment were analyzed. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention. The mean age of the patients was 57.7 years, and the mean follow-up duration was 25 months.

The most common anatomical sites of stricture were bulbar (48.47% of cases), penile (25.4%) and mixed (16.6%). A total of 25 patients had posterior urethral strictures and 101 had anterior strictures. The most common etiologies were iatrogenic and traumatic. The cost, determined using private medical insurance reimbursements in the UK for each intervention was as follows: urethrotomy/dilation ($3,375), simple one-stage urethroplasty ($7,522.50), complex one-stage urethroplasty ($8,002.50), and a two-stage urethroplasty ($15,555.00).

Their analysis showed that of the 126 patients assessed, 60 (47.6%) required one or more endoscopic retreatments (for a total of 194 further operations, a mean of 3.23 per patient). Overall, endoscopic treatment was deemed successful in 66 patients (52.4%) although 19 of them (28.8% of the group) still performed bi-weekly self-catherization to maintain a patent urethral lumen. Stricture length was significant in predicting failures in the penile urethra, with failures having a mean stricture length of 3.9 cm vs. 1.5 cm in the successes. Stricture length was not predictive of failure in the bulbar urethra (mean 1.1 cm for both successes and failures).

The total cost per patient for urethral stricture treatment during the study period was $9,169.50. For those patients managed only endoscopically, the cost was $9,174. The total cost per patient employing a strategy of initial urethrotomy or urethral dilation followed by urethroplasty for stricture recurrence was $8,799.

The authors suggest that while primary endoscopic management of urethral strictures remains simple and safe, it yields a high failure rate with recurrence in 47.6% of their patients. A strategy of initial urethrotomy or urethral dilation followed by urethroplasty for stricture recurrence is more cost-effective and clinically effective. In light of this finding, the authors suggest that repeat endoscopic management for recurrent urethral stricture can be no longer justified.

J Urol. 2004; 172(1):275-7