Preface
Based on international evidence and the Delphi expert consensus method, the Japan Urological Association's (JUA) Subcommittee on Trauma, Emergency Medicine and Reconstruction has developed the 2024 edition of the clinical practice guidelines for urethral strictures, in order to provide reference and guidance for standardized treatment regimens for urethral strictures suitable for the clinical setting in Japan.
Q1 Is urethroplasty better than transurethral treatment [urethral dilation or direct optic intraurethrotomy (DVIU)]? Testimonials
Transurethral treatment may be preferred for urethral strictures that meet all of the following criteria: strictures unrelated to trauma, lichen sclerosus (LS), or hypospadias surgery; stenosis without a history of treatment; The length of the stenosis is less than 2 cm, and the lumen is open; isolated stenosis; and the stricture is confined to the bulbar urethra. In all other cases, urethroplasty is recommended. (Weak recommendation; Quality of Evidence: C)
Fig.1 Treatment flow of urethral stricture
Q2Is urethroplasty better than repeated transurethral treatment for recurrent urethral strictures after transurethral therapy? Testimonials
Urethroplasty should be considered as a first-line treatment option for recurrent urethral strictures after transurethral therapy. Repeat transurethral therapy is not recommended. (Strongly recommended; Quality of Evidence B)
Q3 Is cold knife DVIU better than hot knife or laser DVIU for urethral stricture? Testimonials
The success rate and complications of a cold knife DVIU are comparable to those of a hot knife or laser DVIU. The choice of equipment should be based on the surgeon's experience and the availability of the equipment. (No recommendation; Quality of Evidence: C)
Q4 In the transurethral treatment of urethral strictures, is DVIU or urethral dilation preferred? Testimonials
The success rate and complication rate of DVIU and urethral dilation are almost identical. Treatment options can be chosen based on the availability of equipment and the doctor's experience and preferences. (No recommendation; Quality of Evidence: C)
Q5Is intermittent self-dilation (ISD) recommended after transurethral treatment of urethral strictures? Testimonials
ISD is indicated only for patients who are not candidates for urethroplasty to reduce the rate of stricture recurrence. (Weak recommendation; Quality of Evidence: C)
Q6 What type of institution should urethral stricture be performed and by whom will urethroplasty be performed? Testimonials
Clinicians with limited experience with urethroplasty should refer patients to facilities that include urethroplasty as part of routine clinical practice, or seek support from experienced reconstructive urologists. (Weak recommendation; Quality of Evidence: C)
Fig.2 Success rate of urethroplasty performed by surgeons with or without urethroplasty experience (forest chart)
Q7 For short-segmented bulbar urethral strictures, is non-discrete end-to-end urethral anastomosis (ntEPA) better than end-to-end urethral anastomosis (EPA)? Testimonials
Although EPA is associated with a higher incidence of sexual dysfunction, a high success rate in the treatment of short-segmented bulbar urethral strictures can be achieved regardless of the surgical modality. (No recommendation; Quality of Evidence: C)
Q8 Is the oral mucosa better than foreskin tissue as an alternative tissue for urethroplasty? Testimonials
The oral mucosa and penile foreskin are also recommended as alternative tissues for urethroplasty. However, the use of the oral mucosa is recommended for cases where there is no excess foreskin to provide or where LS causes stricture. (Strongly recommended; Quality of Evidence: C)
Fig.3 Success rate of oral mucosal mesh and foreskin mesh for urethroplasty (forest diagram)
Bibliography:
[1] Horiguchi A, Shinchi M, Hirano Y, et al. Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures. Int J Urol. Published online June 14, 2024.
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