The Urological Society of India Guidelines for the management of urethral stricture (Executive Summary)

Abstract

These guidelines have been drafted by the Urological Society of India (USI) urethral stricture guidelines panel for the use of urologists. The recommendations are updated till August 2020 and will remain valid till the next update or a maximum period of 5 years. This executive statement represents the best evidence and expert opinion and are not intended to replace clinical judgement. The complete guidelines document can be accessed from the USI website at http://www.usi.org.in. METHODOLOGY The majority of evidence for the management of urethral stricture is from retrospective case series. Randomized controlled trials for urethral reconstructive procedures are rare. The panel recognizes that certain aspects of urethral reconstructive surgery present unique challenges for randomized trials. Literature search was conducted on PubMed, Cochrane Central Register of Controlled Trials, Embase, Mendeley, and Directory of Open Access Journals. The available articles were reviewed by the panelists and evidence was extracted. The articles published from India and pertaining to the Asian subpopulation were analyzed along with the world literature. Levels of evidence (LE) was based on the Centre for Evidence-Based Medicine guidelines.[1] RECOMMENDATIONS The guidelines panel based its final recommendations on the best available Indian data and global evidence. Grades of recommendation (GR) (strong/moderate/weak) are the strength of mandate based on the extent of risk-benefit ratio of either taking or not taking an action. The Clinical Principle is a statement that is widely agreed upon by clinicians, for which there may or may not be evidence in the medical literature. An Expert Opinion is a statement agreed on by the guidelines panel in the absence of evidence. In atypical circumstances, the clinician should carefully consider the benefits, risks, and patient preferences carefully before arriving at a decision.[1] The burden of urethral stricture disease in India has not been reported, but the etiology patterns have been reported in limited studies from men undergoing urethroplasty. A study of over 400 patients in eastern India has reported iatrogenic injury as the most frequent cause. Urethral catheterization was a more frequent cause than transurethral surgery in this population.[2] A study comparing characteristics of strictures in men undergoing urethroplasty at leading centers in India and the West suggested that trauma-related strictures were much more common in India (36% vs. 15.8%), whereas the iatrogenic were lesser (16% vs. 35%). The incidence of Lichen Sclerosus (LS)-associated strictures were three times as compared to the western data (21.5% vs. 6.9%). Similarly, the number of pan-urethral strictures were almost two times that in West (18% vs. 8.9%), whereas strictures involving only the penile urethra were four times less common (5.3% vs. 27%). Regarding iatrogenic strictures, post-transurethral resection of prostate (TURP) strictures were three times more common than in the Western population.[3] The unique socioeconomic condition and the lack of easily accessible health care results in late presentations. Widespread tobacco chewing and abuse is a unique problem to the Indian subcontinent and certain other developing countries. Panurethral and long strictures are more common[4] The long-term outcomes of buccal mucosal graft in this population are inferior as compared to nonusers as was reported in two Indian studies, whereas the outcomes with lingual mucosa remain unaffected by tobacco.[5] GUIDELINE STATEMENTS Meatal/fossa navicularis strictures[67] Meatal dilatation is palliative (LE-4, GR moderate) Meatotomy (Ventral) is the first line of treatment when possible (LE-4, GR moderate) Meatoplasty. Meatoplasty can be performed with dorsal inlay Buccal Mucosa graft as first choice (LE-4, GR moderate) Ventral preputial skin graft as alternative (LE-5, GR-strong) Local skin flaps can be used for meatoplasty (LE-4, GR moderate). P