List of Abbreviations
IOU – internal optical urethrotomy
UTI – urinary tract infection
ICD-10 – International Classification of Diseases 10th Revision
US – ultrasound examination
CBC – complete blood count
UA – urinalysis
BL – bladder
MRI – magnetic resonance imaging
AUR – acute urinary retention
LUTS – lower urinary tract symptoms
GR – grade of recommendation
LoD – level of evidence certainty
UFM – urine flow measurement (uroflowmetry)
PROM-USS – Patient-Reported Outcome Measures for Urethral Stricture Surgery
Terms and Definitions
Bougie dilatation of the urethra — a palliative method of treating urethral strictures by stretching, dilation, or increasing the diameter of the urethral lumen in the area of narrowing using various methods (bougies, catheters, balloon dilators).
Internal optical urethrotomy (IOU) — a minimally invasive palliative method for treating male urethral stricture, in which the urethral mucosa and the scar zone of the corpus spongiosum are incised under optical control using various energy sources.
Urinary diversion — diversion (drainage) of urine from the urinary system bypassing the natural urinary tract using a surgical procedure, often via an indwelling or catheterizable stoma.
Urethral distraction defect — partial or complete (obliteration) scar replacement of a membranous urethral defect as a result of its partial or complete rupture due to pelvic bone fracture.
Replacement (multi-stage) urethroplasty (urethral reconstruction) — a reconstructive-plastic surgery in which a new urethral segment is formed to replace the affected one, often requiring two or more surgical stages.
Urethral calibration – measurement of the urethral lumen diameter using various methods, typically with bougies or catheters.
Flap – a segment of tissue harvested from a donor site while preserving its own blood supply through a vascular pedicle, used for transplantation to another, typically relatively closely located anatomical zone.
Micturition cystourethrography – a method of X-ray examination of the urinary bladder and urethra by filling the bladder with a contrast agent and taking an X-ray image during the act of urination.
Urethral obliteration – complete absence of the urethral lumen due to spongiofibrosis and/or fibrosis of periurethral tissues.
Perineostomy (perineal urethrostomy) – the most common type of urethrostomy, in which the proximal segment of the bulbar urethra relative to the stricture is brought out to the skin of the perineum without correction of the affected part of the urethra.
Urethral resection with end-to-end anastomosis (anastomotic urethroplasty) – a reconstructive plastic surgery procedure involving complete excision of the narrowed, scar-transformed segment of the urethra along with the pathologically altered corpus spongiosum and surrounding tissues, followed by an anastomosis between the healthy ends of the urethra.
Retrograde (ascending) urethrography – a method of X-ray examination of the urethra in which a radiopaque contrast agent is injected into the urethra through its external meatus, and an image is taken under fluoroscopic guidance.
Urethral stricture – narrowing of the urethra due to scarring of the urethral wall.
Transplant (graft) – a segment of tissue harvested from a donor site without preserving its own blood supply and used for transplantation to another anatomical zone. The graft receives blood supply via neoangiogenesis from the recipient tissue bed, and its viability primarily depends on the quality of the supporting tissue bed.
Ultrasound examination of the urethra (ultrasound urethrography) – a method of ultrasound examination of the urethra in which the urethra is filled with sterile normal saline, the external meatus is occluded, and an ultrasound examination is performed using a linear probe with a frequency starting from 7 MHz.
Urethrostomy – an anastomosis between the healthy suprastenotic part of the urethra and the skin surface for urinary diversion when the anatomical integrity of the urethra cannot be restored.
Urethroplasty – various open plastic and reconstructive surgical interventions on the urethra aimed at eliminating its narrowing and restoring normal urine flow.
Urethrotomy – incision of a urethral segment (mucosa and underlying tissues) using an endoscopic or open approach.
Cystoscopy and urethroscopy (urethrocystoscopy) – a method of endoscopic (transurethral) examination of the mucosal lumen of the urethra and urinary bladder.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Currently, there is no single consensus definition of urethral stricture. In modern literature, the term "urethral stricture" encompasses a polymorphic group of diseases characterized by narrowing of the lumen of the urethra, surrounded by the corpus spongiosum, with impaired patency (complete or partial). Based on this, the term "urethral stricture" can be used to describe a process localized in the anterior urethra.
To describe processes localized in the posterior urethra (membranous and prostatic parts), it is advisable to use the term urethral stenosis. Urethral stenosis is a narrowing of the posterior urethra not surrounded by the corpus spongiosum, due to partial or complete replacement of the posterior urethra and surrounding tissues by scar tissue. For the membranous part, the term "distraction defect of the urethra" is recommended, as its occurrence is associated with partial or complete rupture of the urethra due to pelvic bone fractures [1, 2].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Etiology of urethral strictures in children: iatrogenic (48%) (conditions associated with hypospadias [35%] and not associated with hypospadias [13%]) and traumatic (34%) strictures are most frequently identified in children, whereas congenital (13%), inflammatory (4%), and post-infectious strictures (1%) are relatively rare [3, 4].
iatrogenic
traumatic
inflammatory
post-infectious
congenital
idiopathic
Traumatic strictures of the anterior urethra by mechanism of injury:
Blunt perineal trauma. Injuries to the bulbar urethra occur when tissues are crushed between the pubic bones and the traumatic force.
Blunt trauma to the scrotum and/or penis. Injuries to the penile urethra.
Open (penetrating) trauma (foreign body). Injuries involving the corpus spongiosum [5].
Iatrogenic trauma to the anterior urethra, resulting from:
Intraurethral manipulations (catheterization, bougienage, endoscopic surgery, and urethroscopy);
Unsuccessful outcomes of open urethral surgery for the correction of hypospadias and epispadias;
Chemical burns of the urethra following the introduction of acid or alkaline solutions into its lumen: subtotal or total scarring of the corpus spongiosum.
Etiology of traumatic distraction injuries of the membranous segment:
Blunt trauma with injury to the pelvic ring (fractures of the pubic and ischial bones, ruptures of the pubic symphysis and sacroiliac joints).
Open trauma with injury to the pelvic ring (fractures of the pubic and ischial bones, ruptures of the pubic symphysis and sacroiliac joints).
Iatrogenic trauma to the posterior urethra, resulting from:
Intraurethral manipulations (catheterization, bougienage, urethroscopy, endoscopic interventions);
Open (penetrating) trauma.
Etiology of traumatic stenoses and obliterations of the prostatic segment:
Iatrogenic trauma. Injuries resulting from open urethral surgery.
Blunt or open trauma to the pelvic bones.
Posterior urethral distraction defects are associated with pelvic bone fractures in the vast majority of cases in children. Pelvic bone fractures are accompanied by posterior urethral injuries in 1–5% of cases. Complex injuries include posterior urethral distraction defects exceeding 3 cm in length, surrounded by pronounced fibrotic perifocal tissue changes in combination with paraurethral diverticula, false passages, fistulas, rectal tears, or concurrent damage to the bladder neck [6,7].
Posterior urethral distraction defects in children have the following features that distinguish them from adult patients: defects are generally longer than in adults due to more pronounced upward displacement of the urinary bladder and prostate caused by the trauma, and combined injuries to the bladder neck and membranous urethra are more frequently observed [9, 10].
Inflammatory strictures
Urethral catheter as a factor provoking the development of urethritis via the invasion of nosocomial infection. Biofilms with persistent microflora can form on the catheter; additionally, the catheter can cause ischemia of the urethral wall;
Xerotic obliterans balanitis (balanitis xerotica obliterans, BXO). A non-venereal infection with an unclear etiological factor. The scleroatrophic process initially affects either the skin of the glans or the inner preputial layer, and can subsequently spread to the meatus and further proximally. In lichen sclerosus, the extent of the pathological process and urethral narrowing can reach 4–6 cm;
Congenital strictures
Urethral meatus, particularly common in hypospadias (narrowing limited to 1–2 mm in length);
Junction of the bulbar and membranous urethra, at the site of their embryonic fusion.
Stages of urethral stricture pathogenesis
Primary infectious inflammation → epithelial metaplasia → disruption of mucosal integrity → urinary extravasation → microabscesses → proliferation → granulation tissue formation → stricture.
Primary urothelial injury → disruption of mucosal integrity → urinary extravasation → microabscesses → proliferation → granulation tissue formation → stricture.
Primary urethral trauma → urinary extravasation → microabscesses → proliferation → granulation tissue formation → stricture.
Stricture → bougienage → urethral trauma → stricture progression.
1.3 Epidemiology of the Disease or Condition
There are no exact data on the prevalence of urethral strictures in children. When assessing the disease frequency in children, data obtained from adults are projected. Results from 10 US databases from 1992 to 2000 indicate that this condition occurs in approximately 0.6% of patients with suspected urological problems, and urethral stricture was the reason for 1.5 million doctor visits. In a follow-up study by Anger J.T. et al., data are presented showing a decrease in the number of individuals receiving disability benefits due to urethral stricture from 1.4% in 1992 to 0.9% in 2001 [11].
1.4 Features of Coding the Disease or Condition
N35.0 Post-traumatic urethral stricture
N35.1 Post-infective urethral stricture, not elsewhere classified
N35.8 Other urethral stricture
N35.9 Urethral stricture, unspecified
N99.1 Postprocedural urethral stricture
Q64.3 Other atresia and stenosis of urethra and bladder neck
1.5 Classification of the disease or condition
There is currently no unified classification of urethral strictures.
Urethral strictures are generally classified according to:
Etiology:
Traumatic origin
Developed as a result of inflammation
Congenital urethral strictures
Anatomical location:
Anterior urethral strictures
Meatal strictures
Navicular fossa strictures
Penile urethral strictures
Bulbar urethral strictures
Strictures of the anterior urethra account for up to 62% of all urethral strictures and obliterations in children.
Stenoses, obliterations, and distraction defects of the posterior urethra
Membranous part
Prostatic part [4].
Comment: In the male posterior urethra, spongy tissue is absent, therefore for narrowing in this location, it is preferable to use the term "stenosis" [11, 12]. Meatostenosis is a short narrowing at the meatal level without involvement of the navicular fossa [12]. There is no precise definition of urethral stricture in women in the literature. Most authors understand stricture as "a fixed anatomical narrowing of the urethra" leading to a reduction in its lumen [13, 14]. The threshold diameter for diagnosing stricture varies from <10 to <20 Ch [15, 16]. In most publications, a size of <14 Ch is used as the criterion for urethral stricture, while the normal diameter is 18–30 Ch.
1.6 Clinical presentation of the disease or condition
Urethral stricture is a disease characterized by diverse symptoms that depend on the cause, location, and severity of the stricture. Symptoms in patients with traumatic and inflammatory urethral strictures differ. Traumatic strictures are accompanied by symptoms of associated injuries (skeletal system, rectum, other organs and systems) and their complications (chronic pelvic pain syndrome, gait disturbances, etc.).
With the gradual development of a stricture (traumatic or inflammatory), a symptom complex is also gradually formed, which is characterized by three components:
1. Voiding (micturition) symptoms:
weak stream
spraying
intermittency
hesitancy
straining, terminal dribbling
absence of urethral urination
2. Post-micturition symptoms
post-micturition dribbling
3. Storage symptoms:
increased urinary frequency
urgency
nocturia
incontinence
sensation of incomplete bladder emptying
A specific feature of urethral stricture symptomatology is the initial predominance of voiding symptoms, which are subsequently joined by post-micturition symptoms and later by storage symptoms.
The most characteristic symptoms of urethral strictures are a weakened urinary stream and intermittency, accompanied by terminal dribbling. As the urethral lumen narrows, these symptoms intensify. When the cross-sectional area of the lumen decreases to 25%, symptoms of chronic urinary retention are invariably present.
Another important symptom is pain. It begins with the onset of micturition and ends with it, and pain is always accompanied by a weakened stream. Furthermore, pain does not occur as the sole symptom of a urethral stricture. As a rule, micturitional pain is absent in traumatic strictures and occurs in inflammatory strictures. Pain arising after intraurethral procedures may serve as the first symptom of urethral stricture formation.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The objectives of evaluating a patient with obstructive voiding disorders include: determining the form and exact localization of the obstruction, diagnosing local complications and secondary changes in the urogenital organs, and identifying comorbid conditions [12].
Diagnostic criteria according to the European Association of Urology (2022) guidelines for low- and high-grade strictures remain controversial. With a urethral diameter of less than 3 mm, a diagnosis of high-grade stricture, or "dense" stricture, can be established. In a normally functioning bladder, the urinary flow rate does not decrease until the urethral lumen size is <10 Ch. The table presents the classification of urethral strictures with a normally functioning bladder, developed by the working group upon reaching a consensus.
Category | Description | Urethral lumen, Ch |
|---|---|---|
0 | No changes upon diagnosis | - |
1 | Subclinical stricture | Lumen narrowed, but size ≥16 Ch |
2 | Low-grade stricture | 11–15 Ch |
3 | High-grade stricture or significantly affecting urination | 4–10 Ch |
4 | Practically complete obliteration | 1–3 Ch |
5 | Obliteration | No lumen (0 Ch) |
The purpose of taking the medical history is to assess symptoms, including their severity and duration, potential etiology of the stricture, previous treatment, complications, as well as comorbid issues and factors that may affect the efficacy of surgical treatment (see the "Clinical Presentation" section).
The clinical presentation of urethral strictures varies. Common clinical manifestations include lower urinary tract symptoms, acute urinary retention, urinary tract infection, catheterization difficulties, a weak urinary stream, a feeling of incomplete bladder emptying, urinary frequency, post-micturition dribbling, and pain in the urogenital organs is a frequent symptom. The pain may be localized in the projection of the bladder and/or urethra and is associated with more pronounced lower urinary tract symptoms.
Other complaints include spraying of the urinary stream, gross hematuria, urethral abscess/necrotizing fasciitis, urgency, and urinary incontinence.
To assess the etiology of the stricture, information should be clarified regarding pelvic, genital, or perineal trauma, surgeries or instrumental manipulations, radiation or focal therapy, and urethritis. It is important to consider previous approaches and the timing of the last intervention (e.g., dilation), as this may affect the timing of radiological imaging or surgical treatment.
Diagnostic Methods
History taking and anamnesis
Physical examination
Laboratory diagnostics
Instrumental diagnostics
Supplementary Diagnostics
Maintaining a frequency volume chart (if spontaneous urination is preserved)
Uroflowmetry (measurement of urinary flow rate) A12.28.006
Comprehensive ultrasound examination of the urogenital system A04.28.002.001- A04.28.002.006
Retrograde urethrography A06.28.011, voiding cystourethrography, combined (antegrade-retrograde) urethrography for urethral obliteration (voiding cystography combined with retrograde urethrography) A06.28.010
Urethrocystoscopy A03.28.002 and A03.28.001.
Additional diagnostic methods (indicated clinically: excretory urography A06.28.002, voiding spiral computed tomography A05.28.003, magnetic resonance urethrography and pelvic MRI, etc. A05.28.003.001)
2.1 Complaints and Anamnesis
are described in detail in the "Clinical Presentation" section. When taking the patient's history, efforts should be made to determine the etiology of the disease or identify potential precipitating factors. The most common cause of stricture formation is trauma or iatrogenic urethral injury. In the majority of patients injured in traffic accidents, posterior urethral rupture is associated with pelvic bone and organ injuries. A history of instillation of caustic and cytotoxic compounds into the urethra may indicate multiple strictures throughout the spongy urethra in boys. The leading symptom of urethral stricture is lower urinary tract symptoms, manifested by prolonged voiding and decreased urinary flow rate. Pain in patients with urethral stricture generally indicates secondary urogenital changes and the development of complications [13, 14, 15].
2.2 Physical Examination
It is recommended to perform an examination of all external genitalia and the perineum to assess the condition of the genital tissues, pathological discharge, and anatomical features:
Of the penis
Of the external urethral meatus
Of the presence or absence of foreskin abnormalities
To assess the condition of the perineum
To perform palpation of the urethra and scrotal contents
To assess for the presence of postoperative scars and urethrocutaneous fistulas
To determine the presence of urethral discharge
Comment: Physical examination allows for the assessment of the etiological factor of the urethral stricture, previous surgeries, tissue quality for subsequent reconstructions, and complications of urethral stricture disease [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.3 Laboratory Diagnostics
It is not recommended for confirming the diagnosis of urethral stricture:
General clinical blood tests (Complete blood count [CBC] B03.016.002 / Differential white blood cell count B03.016.003) and urinalysis (Urinalysis B03.016.006) (to determine the presence and severity of the microbial-inflammatory process)
General biochemical blood test B03.016.004 (including to determine the presence and severity of renal impairment)
Microbiological (culture) urine test for aerobic and facultatively anaerobic opportunistic pathogens A26.28.003 (to confirm urinary tract infection and select antibacterial therapy, including the prevention of infectious complications in the postoperative period) [16, 42].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
Following the examination and laboratory tests, all patients are recommended to undergo ultrasound examination of the kidneys and bladder (A04.28.002.001- A04.28.002.006) to determine post-void residual urine volume. The amount of residual urine provides insight into detrusor contractility and the degree of functional decompensation [16].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
The next step is to evaluate the rhythm of spontaneous micturition (if urination is preserved). This is done by completing a frequency volume chart. It is recommended that patients with urethral stricture complete a frequency volume chart to assess spontaneous voiding patterns [1, 2].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: The frequency volume chart – in patients with preserved spontaneous micturition, is a non-invasive and informative diagnostic tool of great importance not only in the diagnosis of strictures but also in postoperative follow-up.
In patients whose dysfunctional voiding can be evaluated, it is recommended to measure the urinary flow rate (uroflowmetry) to assess the severity of obstruction in urethral stricture [84, 85].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: Uroflowmetry (Measurement of urinary flow rate [uroflowmetry] A12.28.006) is a non-invasive urodynamic test that allows for an objective assessment of the severity of bladder outlet obstruction in patients with preserved ability to urinate. The test should be performed when the patient has a natural urge to urinate, twice for each patient. Urethral stricture is typically characterized by a plateau-shaped or box-shaped uroflowmetry curve, where the maximum flow rate and average flow rate are approximately equal [2, 26].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: Uroflowmetry can reveal an obstructive flow pattern, but the flow rate may be normal despite the presence of a stricture; therefore, uroflowmetry cannot be relied upon to rule out a stricture [18, 19, 20].
It is recommended to use radiological diagnostic methods (in all patients capable of undergoing the procedure) to clarify the localization, length, and degree of narrowing or obliteration of the urethra: ascending urethrography A06.28.011, voiding cystourethrography A06.28.010 [2, 34, 37, 41].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comments: To date, retrograde urethrography (ascending urethrography A06.28.011) is considered the primary diagnostic method for urethral patency disorders. The main disadvantages of X-ray urethrography include: static and projection-dependent imaging, radiation exposure to the patient and physician, limited capability in diagnosing local complications and periurethral tissue changes, and the necessity of using a contrast agent [2, 34, 37, 41].
Performing voiding cystourethrography A06.28.010 is indicated. If urethral patency to the contrast agent is preserved, voiding cystourethrography allows visualization of the entire urethra, determination of the localization, degree, and length of the stricture, and represents the most physiological radiological method when performed as the final stage of intravenous urography. Retrograde urethrography (ascending urethrography) in the 3/4 oblique view is the "gold standard" in diagnosing anterior urethral strictures. In cases of obliteration, contrast opacification of the urethra visualizes only the distal border of the stricture.
In patients with complex stricture and urethral obliteration, the most informative radiological diagnostic method is combined (antegrade-retrograde, total) urethrocystography, which combines voiding and retrograde techniques. In this case, contrast medium is injected through a suprapubic cystostomy / urinary bladder fistula, and after filling the bladder, during an attempted urination, the contrast agent fills the proximal segment of the urethra up to the stricture [2, 34, 37, 41].
It is recommended to perform a radiological examination (voiding cystourethrography A06.28.010) in the diagnosis of local stricture complications (fistula, false passage, periurethral abscess) [2, 34, 37, 41].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
In cases of inconclusive results of retrograde urethrography and antegrade cystourethrography regarding the presence or absence of a stricture and its parameters, it is recommended to perform urethroscopy А03.28.002. [2, 34, 37, 41].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
2.5 Other Procedures
Magnetic resonance imaging of the urethra is recommended for additional preoperative evaluation of the urethral stricture and the condition of periurethral tissues [5, 29, 28].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Ultrasound examination of the urethra is recommended for additional evaluation of the urethral stricture and the degree of spongiofibrosis [16].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Diagnosis examples
When formulating the diagnosis, it is necessary to indicate: etiology (traumatic, inflammatory, congenital), localization (prostatic, membranous, bulbar, penile, glanular: navicular fossa; external urethral meatus), and length of the stricture (short [<2 cm], long [>2 cm], subtotal spongy [involvement of 75-90% of the spongy urethra], total spongy [involvement of the entire spongy urethra], total [involvement of the entire urethra]).
For example:
Inflammatory subtotal stricture of the spongy urethra
Traumatic (iatrogenic) stricture of the glanular urethra
Idiopathic long stricture of the bulbar urethra
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1. Surgical treatment of urethral stricture
Urethral dilation A16.28.040, as an independent treatment method, has relatively low efficacy, requires repeated procedures, and is not recommended when urethroplasty can be performed [25, 27].
Urethrotomy A16.28.035 (Urethral meatotomy) – incision of a narrowed urethral segment, effective for short distal urethral strictures [27,30].
Internal optical urethrotomy (Internal (transurethral) urethrotomy A16.28.060 )– internal incision of a stricture under endoscopic control. Internal optical urethrotomy, regardless of the tissue incision technique (cold knife or laser energy), is effective in approximately one-third of cases and should not be used as first-line surgery in children [28-33].
Internal optical urethrotomy can be performed for strictures of the bulbar urethra with a length of no more than 1 cm; in this case, it is advisable to incise the tissues at the 12 o'clock position of the conditional clock face [34, 35, 36].
In the treatment of stenosis after previously performed anastomotic urethroplasties localized in the prostatic urethra, internal optical urethrotomy provides success in 90% of cases [38-40].
Anastomotic urethroplasty (Urethral reconstruction A16.28.038 ) – a method of treating urethral stricture in which complete excision of the scarred lesion of the urethral mucosa and the zone of spongiofibrosis is performed, followed by the restoration of urethral patency by creating an end-to-end anastomosis of healthy urethral edges. For strictures less than 1 cm in length, the success rate of anastomotic urethroplasty in children is over 80%.
Anastomotic urethroplasty is the main surgical technique used in the treatment of posterior urethral distraction defects. Perineal and perineo-transpubic approaches are mainly used to perform anastomotic urethroplasty in children. A limitation for its use is associated anterior urethral diseases that prevent the latter from being used after mobilization to bridge the defect [40, 41].
The success rate of anastomotic urethroplasty in the treatment of posterior urethral distraction defects is 75-95% [42, 43, 44].
Comments: among children who underwent urethroplasty, anastomotic urethroplasty was used in more than half of the cases.
Augmentation urethroplasty (Urethral reconstruction using a skin flap and Urethral reconstruction using oral mucosa A16.28.038.001, A16.28.038.003) – a reconstructive plastic surgery in which the lumen (diameter) of a stricture-affected urethra is increased by longitudinally incising its urethral wall and inserting a graft or a flap of healthy tissue harvested from another anatomical region into the defect. A graft is understood as a free tissue site without a blood supply. The success rate of augmentation urethroplasty in children is 95% [45, 46, 47, 48].
Flap urethroplasty (Urethral reconstruction using a revascularized free flap) A16.28.038.002 - is used for long urethral strictures. Unlike a graft, a flap has its own preserved blood supply. A cutaneous-fascial flap is used in the treatment of urethral strictures in children. This type of intervention is advisable for long urethral strictures when performing anastomotic urethroplasty is impossible or difficult. The success rate of this urethroplasty option is 68-86% [49, 50, 51, 52].
3.2. Evaluation of urethroplasty outcomes
Currently, there are no agreed unified criteria for the success of urethroplasty. For a long time, it was believed that the absence of the need for reoperations is sufficient to determine the success of urethroplasty.
The first year after surgery is considered the most dangerous in terms of recurrence development.
Measurement of urine flow rate (uroflowmetry) is an objective method for recording the dynamics of urination speed parameters in the postoperative period. To assess efficacy, the maximum urine flow rate is evaluated. A decrease in the latter below 15 ml/s should be regarded as an indicator of stricture recurrence and dictate the need for further examination to rule out recurrence. An even more sensitive indicator of stricture recurrence is a decrease in the difference between the average and maximum urine flow rates below 10 ml/s [53].
When evaluating uroflowmetry curves to determine the success of urethroplasty, it is possible to assess the curve shape. The presence of a bell-shaped uroflowmetry curve can be regarded as an indicator of surgical success [54].
The study of residual urine volume combined with uroflowmetry data is an important diagnostic criterion for diagnosing stricture recurrence.
To confirm urethral stricture recurrence, urethroscopy should be considered the most informative.
In case of failure to restore adequate urination, it is recommended to preserve the existing cystostomy, and if absent, trocar cystostomy is recommended [4, 16].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
In the formation of fistulous tracts or infectious complications (acute prostatitis, orchiepididymitis, wound suppuration), patients are recommended to undergo trocar cystostomy and removal of the urethral catheter [5, 23; 33].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
3.3. Prognosis
With timely and appropriate treatment, the prognosis is relatively favorable. After surgical treatment, long-term follow-up is indicated due to rare cases of recurrence 1 year after surgery. In general, the outcome of the disease with adequately performed surgery and adherence to postoperative recommendations is positive in approximately 90% of cases with single-stage treatment.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
None.
5. Prevention and Dispensary Observation
It is recommended to maintain continuous follow-up (until coming of age) for children operated on for urethral stricture [22].
Level of Evidence CGrade of Recommendation 5Level of recommendation validity C (level of evidence reliability – 5)
Comment: Postoperative follow-up is listed in Table 1.
Table 1. Management scheme for children with urethral stricture in the postoperative period
6. Organization of Medical Care
Emergency hospitalization in cases of traumatic urethral injury or acute urinary retention
Elective hospitalization for surgical treatment with additional instrumental examinations and surgical treatment in the absence of contraindications
Discharge from the medical institution for outpatient and dispensary follow-up according to recommendations
7. Additional Information
Not applicable
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1 | Completion of urination diaries | Yes/No |
2 | Performance of retrograde urethrography | Yes/No |
3 | A general (clinical) urinalysis was performed | Yes/No |
4 | Measurement of urine flow rate (uroflowmetry) | Yes/No |
5 | Ultrasound examination of the kidneys, ultrasound examination of the bladder with determination of residual urine | Yes/No |
6 | Performance of urethroscopy | Yes/No |
7 | Performance of ascending urethrography | Yes/No |
8 | Measurement of urine flow rate (uroflowmetry) to assess treatment efficacy | Yes/No |
References
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Appendix A1. Working Group Composition
Sergey N. Zorkin – MD, Professor, Head of the Research Institute of Pediatric Nephrourology, Head of the Urology Department with Groups of Reproductology and Transplantation, National Medical Research Center for Children's Health of the Russian Ministry of Health
Yuri E. Rudin – MD, Professor, Head of the Pediatric Urology Group, Lopatkin Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Center of Radiology of the Russian Ministry of Health
Nail R. Akramov – MD, Professor, Head of the Department of Urology, Nephrology and Transplantology, Kazan State Medical Academy – branch of the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health
Vladimir V. Sizonov – MD, Professor, Professor of the Department of Urology and Human Reproductive Health with a Course of Pediatric Urology-Andrology, Rostov State Medical University of the Russian Ministry of Health
Sergey G. Bondarenko – PhD in Medicine, Head of the Pediatric Urology Department, Clinical Emergency Hospital No. 7, Volgograd
Kagantsov Ilya Markovich – MD, Associate Professor, Head of the Research Laboratory of Surgery for Congenital and Hereditary Pathology, Almazov National Medical Research Centre of the Russian Ministry of Health
Conflict of Interest: All Working Group members have confirmed no financial support/conflict of interest to disclose.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines
Pediatric surgeon
Pediatric urologist-androlgist;
Pediatrician;
District pediatrician;
Municipal (district) pediatrician
General practitioner (family physician);
Obstetrician-gynecologist;
Neonatologist;
Anesthesiologist-resuscitator;
Surgeon;
Urologist;
General practitioner (internist);
Adolescent therapist
District general practitioner;
Functional diagnostics physician.
Methods used for collecting/selecting evidence: searching electronic databases.
Description of methods used to evaluate the quality and strength of evidence: publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed databases served as the evidence base for the recommendations. Search depth – 7 years.
Methods used to assess the quality and strength of evidence:
expert consensus;
assessment of significance in accordance with the rating scheme.
Methods used for evidence analysis:
reviews of published meta-analyses;
systematic reviews with evidence tables.
Description of methods used for evidence analysis
When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations.
To minimize potential bias, each study was evaluated independently. Any discrepancies in evaluations were discussed by the full panel of authors. If a consensus could not be reached, an independent expert was involved.
Evidence tables: compiled by the authors of the clinical guidelines.
Methods used for formulating recommendations: expert consensus.
Good Practice Points (GPPs)
Recommended good clinical practice is based on the clinical experience of the authors of these guidelines.
Economic analysis
Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.
Recommendation validation method
External expert review.
Internal expert review.
Description of the recommendation validation method
The draft of these recommendations was reviewed by independent experts who were primarily asked to comment on how comprehensible the interpretation of the evidence underlying the recommendations is.
All comments received from the experts were thoroughly systematized and discussed by the members of the working group (authors of the recommendations). Each item was discussed individually.
Consultation and peer review
The draft recommendations were reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.
Working Group
For the final revision and quality control, the recommendations were re-evaluated by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account and the risk of bias in the development of the recommendations was minimized.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading the levels of recommendation evidence (LRE) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
Clinical Guidelines of the Russian Society of Urology, 2021
European Association of Urology Clinical Guidelines, 2022
American Urological Association Clinical Guidelines 2016.
Order of the Russian Ministry of Health No. 561n dated October 31, 2012, “On approval of the procedure for providing medical care to the pediatric population in the profile ‘pediatric urology-andrology’”
Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, “On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard template of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in clinical guidelines”
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable within the scope of these clinical practice guidelines.