Ultrasound imaging of male urethral stricture disease: a narrative review of the available evidence, focusing on selected prospective studies.

PURPOSE: To synthetize the current scientific knowledge on the use of ultrasound of the male urethra for evaluation of urethral stricture disease. This review aims to provide a detailed description of the technical aspects of ultrasonography, and provides some indications on clinical applications of it, based on the evidence available from the selected prospective studies. Advantages and limitations of the technique are also provided. METHODS: A comprehensive literature search was performed using the Medline and Cochrane databases on October 2022. The articles were searched using the keywords "sonourethrography", "urethral ultrasound", "urethral stricture" and "SUG". Only human studies and articles in English were included. Articles were screened by two reviewers (M.F. and K.M.). RESULTS: Our literature search reporting on the role of sonourethrography in evaluating urethral strictures resulted in selection of 17 studies, all prospective, even if of limited quality due to the small patients' number (varied from 28 to 113). Nine studies included patients with urethral stricture located in anterior urethra and eight studies included patients regardless of the stricture location. Final analysis was based on selected prospective studies, whose power was limited by the small patients' groups. CONCLUSION: Sonourethrography is a cost-effective and safe technique allowing for a dynamic and three-dimensional urethra assessment. Yet, because of its limited value in detecting posterior urethral strictures, the standard urethrography should remain the basic 'road-map' prior to surgery. It is an operator-dependent technique, which can provide detailed information on the length, location, and extent of spongiofibrosis without risks of exposure to ionizing radiation.

Multicentre, prospective study on local treatment of metastatic prostate cancer (LoMP study).

OBJECTIVES: To investigate the role of cytoreductive radical prostatectomy in addition to standard of care for patients with newly diagnosed metastatic prostate cancer. MATERIALS AND METHODS: This multicentre, prospective study included asymptomatic patients from 2014 to 2018 (NCT02138721). Cytoreductive radical prostatectomy was offered to all fit patients with resectable tumours, resulting in 40 patients. Standard of care was administered to 40 patients who were ineligible or unwilling to undergo surgery. The primary endpoint was castration resistant cancer-free survival at the time point of ≥50% events. The secondary endpoint was local event-free survival. Kaplan-Meier and Cox regression analyses with propensity-score analysis were applied. RESULTS: After a median (quartiles) follow-up of 35 (24-47) months, 42 patients became castration-resistant or died. The median castration resistant cancer-free survival was 53 (95% confidence interval [CI] 14-92) vs 21 (95% CI 15-27) months for cytoreductive radical prostatectomy compared to standard of care (P = 0.017). The 3-year estimates for local event-free survival were 83% (95% CI 71-95) vs 59% (95% CI 51-67) for cytoreductive radical prostatectomy compared to standard of care (P = 0.012). However, treatment group showed no significance in the multivariable models for castration resistant cancer-free survival (P = 0.5) or local event-free survival (P = 0.3), adjusted for propensity-score analysis. Complications were similar to the non-metastatic setting. Patients undergoing surgery were younger, with lower baseline prostate-specific antigen levels, alkaline phosphatase levels and metastatic burden. CONCLUSION: The present LoMP study was unable to show a difference between the two inclusion groups regarding castration resistant cancer-free survival for asymptomatic patients with newly diagnosed metastatic prostate cancer. These results validate previous evidence that, in well-selected and informed patients, cytoreductive radical prostatectomy is feasible and safe, with corresponding continence rates compared to the non-metastatic, high-risk setting. Whether cytoreductive radical prostatectomy could be a valuable option to achieve good local palliation needs to be further researched. Overall, the role of cytoreductive radical prostatectomy needs to be further explored in randomized studies to correct for potential bias.

POIROT trial: post-operative imaging after urethroplasty with peri-catheter retrograde urethrography or trial of voiding with voiding cysto-urethrography.

PURPOSE: This study directly compares peri-catheter retrograde urethrography (pcRUG) and voiding cysto-urethrography (VCUG) as early postoperative imaging after urethroplasty and aims to assess whether pcRUG is superior at avoiding catheter reinsertion. METHODS: This is a single-center, prospective, interventional study comparing pcRUG and VCUG after urethroplasty in a within-patient fashion. All participants were first evaluated with pcRUG and subsequently with VCUG, unless pcRUG revealed significant contrast extravasation warranting further catheter stay. The primary end-point was to assess whether pcRUG is superior at avoiding catheter reinsertion compared with VCUG. Secondary end-points included the amount of significant contrast extravasations missed on pcRUG and the differences in radiation exposure. RESULTS: 80 patients were included in this study. Median (IQR) interval between surgery and first postoperative imaging was 16 (9-16) days. In 14/80 (18%) patients, the pcRUG showed significant contrast extravasation and catheter reinsertion was avoided, while this percentage is 0 by default for VCUG (p < 0.001). In the other 66/80 (82%) patients, a VCUG was performed and 1/66 (1.5%) of these was considered as significant contrast extravasation. Notably, 9/66 (14%) of these patients could not void during the investigation. Median (IQR) dose of radiation exposure during pcRUG and VCUG was, respectively, 120 (84-161) mGy/cm2 and 241 (169-334) mGy/cm2 (p < 0.001). CONCLUSIONS: After urethroplasty, pcRUG is a valuable alternative for VCUG as early postoperative imaging. It has a comparable diagnostic yield, averts the risk of having to reinsert the catheter, avoids the problem of patients being unable to void during the examination and requires significantly less radiation.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review.

PURPOSE: The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS: To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS: Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS: The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery.

BACKGROUND: Possible options of genital gender affirming surgery in transmasculine are metoidioplasty or phalloplasty. As opposed to phalloplasty, no flapbased neophallic reconstruction is needed in metoidioplasty. Urethral lengthening is needed in metoidioplasty if the patient desires voiding at the tip of the neophallus. This urethral lengthening poses the patient at risk for urethral complications. AIM: Our primary goal was to describe the morbidity and specific the urethral complications related to metoidioplasty. Second, we sought for predictors of these urethral complications. METHODS: Our institutional database was retrospectively analyzed to identify transmasculine who underwent metoidioplasty between 2006 and 2020. This cohort was further evaluated for surgical morbidity, urethral complications and potential predictors for urethral complications. OUTCOMES: The rate of surgical morbidity and urethral complications (temporary/permanent fistula, stricture or fistula and stricture) was calculated. Potential predictors evaluated herein were BMI, concomitant vaginectomy, active smoking and additional urethral lengthening (AUL). They were tested with logistic regression analysis with calculation of Odds Ratio (OR). RESULTS: Seventy-four patients underwent metoidioplasty with a median follow-up of 44 months. Median age was 26 years. AUL was done in 36 (48.6%) patients and established by a transverse preputial skin island and labium minus flap in respectively 34 and 2 patients. Within 30 days after metoidioplasty, 3 (4.1%) high-grade complications were noted. Urethral complications of any kind were noted in 42 (56.8%) patients. All fistulas, permanent fistulas and strictures were seen in resp. 34 (45.9%), 27 (36.5%) and 14 (18.9%) patients. AUL is a significant predictor for all urethral complications (OR 15.5), strictures (OR 24.5), all fistula's (OR 6.07) and permanent fistulas (OR 3.83). In contrast, smoking is only a predictor for all fistulas (OR 6.54) and permanent fistulas (OR 3.76). CLINICAL IMPLICATIONS: Obtaining information about the risk of complications is important in preoperative patient counselling. Patient who desires AUL are at higher risk to develop urethral complications and patients who continue to smoke at the period of metoidioplasty have a higher risk of fistula formation. STRENGTH & LIMITATIONS: Sufficient events to calculate predictors for urethral complications. However, this is a retrospective study with still a small number of patients with a relative short follow-up. CONCLUSION: Urethral complications are frequent after metoidioplasty and approximately 50% needs corrective surgery. AUL is an independent risk factor for fistula and stricture formation, whereas smoking is a risk factor for fistula formation. Waterschoot M, Hoebeke P, Verla W, et al. Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery. J Sex Med 2021;18:1271-1279.

Implantation of the ZSI 475 FTM Erectile Device After Phalloplasty: A Prospective Analysis of Surgical Outcomes.

BACKGROUND: Until recently, all available erectile devices were manufactured in accordance with the anatomy of a native penis and led to high explantation rates when implanted in the neophallus. AIM: The aim of this study was to investigate surgical outcomes after implantation of the ZSI 475 FTM in the neophallus; this is the first erectile device specifically manufactured for implantation after phalloplasty. METHODS: This is a prospective observational study of patients undergoing implantation of the ZSI 475 FTM in the neophallus at a tertiary referral center since September 2017. Patients with a follow-up < 3 months were excluded from this analysis. OUTCOMES: Intraoperative and postoperative complications were analyzed with descriptive statistics and explantation-free survival was assessed using a Kaplan-Meier survival analysis. RESULTS: In total, 57 patients were included with a median (IQR) follow-up of 16 (10-21) months. No intraoperative complications occurred. Postoperative complications were seen in 18 of 57 (32%) patients and included cylinder protrusion (1/57, 1.8%), infection (8/57, 14%), malpositioning (4/57, 7.0%), mechanical failure (4/57, 7.0%), and urinary retention (1/57, 1.8%). A total of 13 of 57 (23%) devices were explanted which corresponds with an estimated explantation-free survival rate (SD) of 84% (4.9), 80% (5.6), and 80% (5.6) after, respectively, 6, 12, and 18 months of follow-up. CLINICAL IMPLICATIONS: By better addressing the specific needs after phalloplasty, this innovative erectile device might lead to improved cylinder protrusion, malpositioning, and mechanical failure rates, but device infection remains common. STRENGTHS & LIMITATIONS: This is the largest study on this topic to date and the first to report prospective data. Main limitations involve the relatively small sample size and the limited follow-up. CONCLUSION: Short-term cylinder protrusion, malpositioning, and mechanical failure rates are encouraging, although device infection remains a common problem. These complications resulted in a device explantation rate of 23%. Verla W, Goedertier W, Lumen N, et al. Implantation of the ZSI 475 FTM Erectile Device After Phalloplasty: A Prospective Analysis of Surgical Outcomes. J Sex Med 2021;18:615-622.

Update on the management of complex strictures of the bulbar urethra.

PURPOSE OF REVIEW: This narrative review summarizes the most relevant literature published in 2019-2020 regarding urethroplasty for bulbar strictures. RECENT FINDINGS: We identified relevant papers focussing on new insights in the field of excision and primary anastomosis, graft augmentation urethroplasty and perineostomy for bulbar strictures and bulbomembranous strictures after radiotherapy or surgery for benign prostatic hyperplasia. SUMMARY: Respecting the vascularity of the anterior urethra and maintaining the integrity of surrounding structures during bulbar urethroplasty does not appear to deteriorate surgical outcomes and might be associated with improved functional outcomes.

Primary care providers' knowledge about the therapeutic management of refractory pelvic floor dysfunctions in Flanders, Belgium: a cross-sectional study.

BACKGROUND: Pelvic floor dysfunctions (PFD) are prevalent conditions in primary care practice. Basic knowledge of second-line therapies among primary care providers (PCPs) is indispensable to well-inform refractory patients and improve their access to specialized care. OBJECTIVES: Getting insight into the extent of knowledge about second-line therapies for refractory PFD among PCPs in Flanders, Belgium. METHODS: From January to March 2019 Flemish PCPs participated in the OptiLUTS trial - Part A (EC/2018/0244), by the completion of a 22-item online Dutch questionnaire. Prevalence of PCPs having awareness about sacral neuromodulation (SNM), intradetrusor botulinum toxin injections (BTX) and percutaneous tibial nerve stimulation (PTNS) was explored. Descriptive statistics, univariate analyses, and multiple logistic regression analyses were performed. RESULTS: Sixty PCPs, 55% GPs, 45% GP trainees, median age 29 years, participated. Respectively, 90, 73 and 5% had ever heard about BTX, SNM and PTNS. The profession was an independent predictive factor for never having heard of SNM therapy, GPs being more likely to have a lack of knowledge than trainees (OR = 29, 95%CI [1.9-442.5]). Ninety-three percent want to learn more about these therapies. CONCLUSION: There is a margin for improvement in the knowledge of PCPs regarding therapies for refractory PFD. Awareness among PCPs should be increased for the optimization of patient care.

Independent risk factors for failure after anterior urethroplasty: a multivariate analysis on prospective data.

PURPOSE: To identify independent risk factors for urethroplasty failure in a prospective dataset. METHODS: Since 2008, data of all male patients undergoing urethroplasty at Ghent University Hospital have been prospectively recorded and maintained. This analysis excluded: posterior strictures, strictures of the perineostomy, urethral malignancy-related strictures, age < 18 years and follow-up < 1 year. Postoperatively, a voiding cysto-urethrography (VCUG) was performed after 2 weeks and in absence of significant contrast extravasation, the transurethral catheter was removed. Patients were followed after 3 m, 12 m and annually thereafter. Failure was defined as stricture recurrence requiring additional urethral intervention(s). Uni- and multivariate Cox regression analyses were performed on the entire patient cohort and for one-stage urethroplasty (OSU) at specific locations. RESULTS: In total, 474 patients were included. Median follow-up was 62 m (IQR 35-91). Significant extravasation was present in 6.9%. Bulbar stricture location was identified as independent protective factor for urethroplasty failure (HR 0.44; p = 0.046) and significant extravasation at first VCUG was identified as independent risk factor for urethroplasty failure (HR 2.86; p = 0.005). Cox regression analyses for OSU at specific locations could not identify other risk factors. All but one (89%) of the failures preceded by significant extravasation at first VCUG occurred within 2 years of follow-up whereas 44% of the failures with no or insignificant extravasation at first VCUG occurred after 2 years of follow-up (p = 0.03). CONCLUSIONS: Bulbar stricture location is an independent protective factor for urethroplasty failure. Significant extravasation at first urethrography is an independent risk factor for urethroplasty failure and is associated with earlier stricture recurrence than other failed cases.

Importance of metastatic volume in prognostic models to predict survival in newly diagnosed metastatic prostate cancer.

PURPOSE: To explore the prognostic importance of metastatic volume in a contemporary daily practice cohort of patients with newly diagnosed metastatic hormone-naive prostate cancer (mHNPC) and to develop a pragmatic prognostic model to predict survival for these patients. METHODS: Since 2014, 113 patients with newly diagnosed mHNPC were prospectively registered. Statistical analysis was performed using SPSS 25.0™ with two-sided p value < 0.05 indicating statistical significance. Univariate and multivariate cox regression analyses were performed to identify prognostic risk factors. Kaplan-Meier method with log-rank statistics was constructed to analyze difference in survival in the prognostic groups. Model performance was assessed using the Concordance-index (C-index) and cross-validated in R v3.4.1. High-volume mHNPC (HVD) was defined as the presence of visceral metastasis or ≥ 4 bone metastases with ≥ 1 appendicular lesion. RESULTS: Multivariate analysis identified HVD (p = 0.047) and elevated alkaline phosphatase (ALP) (p = 0.018) as independent prognostic risk factors for overall survival (OS). Consequently, three prognostic groups were created: a good (no risk factors), intermediate (1 risk factor) and poor prognosis group (2 risk factors). Median OS for the good, intermediate and poor prognosis group was not reached, 73 and 20 months (95% CI 9-31 months with p < 0.001 and Correspondence-index of 0.78), respectively. CONCLUSIONS: We developed a pragmatic and qualitative prognostic model consisting of three prognostic risk groups for OS in a daily practice cohort of patients with newly diagnosed mHNPC. Independent prognostic risk factors included in the model were HVD and abnormal ALP.

Urethroplasty and Quality of Life: Psychometric Validation of a Dutch Version of the Urethral Stricture Surgery Patient Reported Outcome Measures.

PURPOSE: The study aimed to translate the Urethral Stricture Surgery Patient Reported Outcome Measures (USS-PROM) questionnaire in Dutch. To validate this translated questionnaire, the study evaluates its psychometric properties in a different population, a different environment, and a different health care system. Questions about urinary incontinence and sexual functioning were added. MATERIALS AND METHODS: Between December 2014 and January 2017, Dutch-speaking adult men scheduled for urethroplasty at Ghent University Hospital were prospectively enrolled in this study. Patients completed the USS-PROM before surgery, 3-6 months after surgery, and 1 year after surgery. Psychometric criteria included content validity, criterion validity, internal consistency, reproducibility, responsiveness, and floor and ceiling effects. (EC/2014/0438). RESULTS: A total of 100 patients were included, 39 patients completed both the preoperative and the postoperative questionnaire, and 30 patients completed the USS-PROM twice within a short period of time in order to evaluate test-retest reliability. Pearson correlation coefficients showed no statistical significant correlation between lower urinary tract symptoms (LUTS) scores and maximum flow rates. Cronbach's α was 0.81 and 0.89, respectively, for the LUTS score and the summative Male Sexual Health Questionnaire Ejaculatory Dysfunction short form (MSHQ-EjD short form) score. The intraclass correlation coefficients ranged from 0.72 to 0.94. Significant changes were observed in all items except the MSHQ-EjD short form scores. All values exceeded the predefined thresholds. CONCLUSIONS: The Dutch version of the USS-PROM has adequate psychometric properties and is a valid instrument to assess patient-reported outcome measures in men undergoing urethroplasty.

Robot-assisted T-plasty for recalcitrant bladder neck stenosis: description of technique and initial results.

BACKGROUND: The aim of this study was to describe the technique and initial outcomes of robot-assisted T-plasty for recalcitrant bladder neck stenosis. METHODS: Patients who underwent robot-assisted T-plasty for recalcitrant bladder neck stenosis in a single center were included. Presence of bladder neck stenosis was preoperatively confirmed by the combination of retrograde urethrography with voiding cysto-urethrography and flexible urethroscopy. Follow-up visits were performed with history taking, uroflowmetry and echographic residual urine measurement. Complications were graded according to the Clavien-Dindo classification. Patients without urinary symptoms and with a maximum uroflow of no less than 15mL/s were considered as successfully treated. Otherwise, cystoscopy would be performed, and recurrence was defined as the inability to pass a 14 French cystoscope through the bladder neck. RESULTS: Since 2018, seven patients were treated. The etiologies were transurethral resection of the prostate and simple prostatectomy in respectively 6 patients and 1 patient. Cystoscopy was able to diagnose bladder neck stenosis in all cases whereas urethrography was equivocal in 3 out of 7 cases. Median (range) age at surgery was 60 (54-75) years, and median number of prior endoscopic treatment for bladder neck stenosis was 3 (1-16). The median operative time was 123 (110-159) minutes. No intraoperative complications were reported. Three patients suffered a grade 2 complication. After a median follow-up of 27 (4-74) months, the recurrence-free rate was 100% with no evidence of de-novo incontinence or erectile dysfunction. CONCLUSIONS: In our series, robot-assisted T-plasty suggests positive and safe outcomes in treating recalcitrant bladder neck stenosis with a good patency rate and low incontinence rate. Additionally, cystoscopy is reliable in the diagnosis of patients with inconclusive urethrography results.

Treatment Success After Urethroplasty: The Ongoing Quest for a Pragmatic and Universal Definition.

There is no consensus on the ideal definition of success after urethroplasty, which makes research, quality control, and comparisons challenging. Ongoing research endeavors are focused on achieving consensus regarding the optimal battery of outcomes for evaluation of patients after urethroplasty.

Urethral management after artificial urinary sphincter explantation due to cuff erosion.

Introduction: The artificial urethral sphincter (AUS) is the gold standard treatment in cases of moderate-to-severe stress urinary incontinence in males. Cuff erosions are one of the most important distant complications of AUS implantation. The optimal urethral management has still not been established. Material and methods: Search terms related to 'urethral stricture', 'artificial urinary sphincter', and 'cuff erosion' were used in the PubMed database to identify relevant articles. Results: In this mini review we identified 6 original articles that assessed the urethral management after AUS explantation due to cuff erosion and included urinary diversion by transurethral and/or suprapubic catheterization, urethrorrhaphy, and in situ urethroplasty. We summarized the results of different management methods and their efficacy in terms of preventing urethral stricture formation. We highlight the need for better-quality evidence on this topic. Conclusions: The available data do not provide a clear answer to the question of optimal urethral management during AUS explantation. There is a great need to provide higher-quality evidence on this topic.

Is a Course of Intermittent Self-dilatation with Topical Corticosteroids Superior at Stabilising Urethral Stricture Disease in Men and Improving Functional Outcomes over a Course of Intermittent Self-dilatation Alone? A Systematic Review and Meta-analysis.

Context: Intermittent self-dilatation (ISD) is a therapeutic strategy used to stabilise a urethral stricture and postpone or avoid further treatment. Adding corticosteroids to this mode of management might further enhance its outcomes by downregulation of collagen deposition and excessive scar tissue formation. Objective: To explore whether a course of ISD with topical corticosteroids is superior at stabilising urethral stricture disease in men and improving functional outcomes over a course of ISD alone. Evidence acquisition: This systematic review and meta-analysis was undertaken by the European Association of Urology Urethral Strictures Guideline Panel according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (CRD42021256744). The primary benefit outcome was successful stabilisation of the urethral stricture. Treatment-related complications were the primary harm outcome. Evidence synthesis: In total, 978 records were screened for eligibility, ultimately leading to five included studies, all randomised controlled trials, comprising 250 patients, of whom 124 underwent a course of ISD with corticosteroids and 126 underwent a course of ISD alone, all after direct vision internal urethrotomy (DVIU). Successful stabilisation of the stricture was achieved in 77% and 64% of patients in the group with and without corticosteroids, respectively (p = 0.04). No extra complications related to the addition of corticosteroids to the ISD regimen were reported. The risk of bias of the included studies was generally unclear to high. Conclusions: Based on the currently available data, a course of ISD with topical corticosteroids appears to be safe and superior at stabilising a urethral stricture after DVIU in the short term to a course of ISD alone. However, given the unclear to high risk of bias in the included studies, further high-quality studies are needed to fully underpin this. Patient summary: This study shows that addition of topical corticosteroids to intermittent self-dilatation after direct vision internal urethrotomy can better stabilise the stricture in the short term.

Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria.

Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.

European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients.

CONTEXT: Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice. OBJECTIVE: To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients. EVIDENCE ACQUISITION: The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion. EVIDENCE SYNTHESIS: Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates. CONCLUSIONS: Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations. PATIENT SUMMARY: Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. TAKE HOME MESSAGE: Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

Contemporary Management of Male Anterior Urethral Strictures by Reconstructive Urology Experts-Results from an International Survey among ESGURS Members.

Assessment of anterior urethral stricture (US) management of European urology experts is relevant to evaluate the quality of care given to the patients and plan future educational interventions. We assessed the practice patterns of the management of adult male anterior US among reconstructive urology experts from European countries. A 23-question online survey was conducted among European Association of Urology Section of Genito-Urinary Reconstructive Surgeons (ESGURS) members. A total of 88 invitations were sent by email at two different times (May and October 2019). Data were prospectively collected from May 2019 to December 2019. The response rate was 55.6%. Most of the responders were between 50 and 59 y.o. and mainly from University Public Teaching/Academic Hospitals. A total of 73.5% treated ≥20 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool, followed by uroflowmetry (UF) +/− post-void residual (PVR). Urethroplasty using grafts was the most frequent treatment (91.8%). Of responders, 55.3% performed >20 urethroplasties/year. Anastomotic urethroplasties were performed by 83.7%, skin flap repairs by 61.2%, perineal urethrostomy by 77.6% and non-transecting techniques by 63.3%. UF was the most common follow-up tool. Most of the responders considered urethroplasty as the primary option when indicated. Male anterior US among ESGURS members are treated mainly using urethroplasty graft procedures. RUG is preferred for diagnosis, and UF for follow-up.

Current Management of Membranous Urethral Strictures Due to Radiation.

Radiotherapy is a frequently used treatment for prostate cancer. It does not only causes the intended damage to cancer cells, but also affects healthy surrounding tissue. As a result radiation-induced urethral strictures occur in 2.2% of prostate cancer patients. Management of urethral strictures is challenging due to the presence of poor vascularized tissue for reconstruction and the proximity of the sphincter, which can impair the functional outcome. This review provides a literature overview of risk factors, diagnostics and management of radiation-induced urethral strictures.