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Table of Contents
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 393-398  

Adult urethral stricture: Practice and expertise of urologists in Saudi Arabia

1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center; Division of Urology, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission14-Nov-2018
Date of Acceptance08-Apr-2019
Date of Web Publication9-Oct-2019

Correspondence Address:
Dr. Abdullah M Al Khayal
King Abdulaziz Medical City, Ministry of National Guard – Health Affairs, P.O. Box 22490, Mail Code: 1446, Riyadh 11426
Saudi Arabia
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DOI: 10.4103/UA.UA_159_18

PMID: 31649460

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Objective: The aim of this study is to determine the methods used to evaluate and manage urethral strictures by urologists practicing in Saudi Arabia.
Materials and Methods: This is a cross-sectional study based on a validated questionnaire directed to all urologists and senior residents practicing in Saudi Arabia. Categorical data reported as frequencies and percentages. A Chi-square test was used for inferential analysis. P < 0.05 was considered statistically significant.
Results: We received 112 responses, of which 78% were from board-certified urologists. The majority were working in government hospitals. The rate of endoscopic procedures performed exceeded open urethroplasty. Direct Vision Internal Urethrotomy was the most common procedure performed as stated by 85% of the responses. Uroflowmetry with postvoid residual was the most common investigation requested to assess strictures before and after the operation usually in adjunction with retrograde urethrogram and or cystoscopy. Most of the urologists believed in a step-wise approach in the management of strictures and that urethroplasty is indicated only after repeated trials of endoscopic management.
Conclusion: Our results revealed a preference, and perhaps misuse, of endoscopy which might raise a concern regarding patients' prognosis with repeated endoscopic management. Most of the urologists seem to be reluctant to proceed to a definitive treatment on the time of diagnosis either due to a lack of experience or knowledge. The results showed no difference between practice in government and private hospitals.

Keywords: Saudi Arabia, urethral stricture, urethroplasty, urethrotomy

How to cite this article:
Al Khayal AM, Bin Mosa MA, Alrabeeah KA, Abumelha SM. Adult urethral stricture: Practice and expertise of urologists in Saudi Arabia. Urol Ann 2019;11:393-8

How to cite this URL:
Al Khayal AM, Bin Mosa MA, Alrabeeah KA, Abumelha SM. Adult urethral stricture: Practice and expertise of urologists in Saudi Arabia. Urol Ann [serial online] 2019 [cited 2020 Jul 14];11:393-8. Available from: http://www.urologyannals.com/text.asp?2019/11/4/393/266966

   Introduction Top

Narrowing in the urethral lumen resulting from fibrosis of the spongeous subepithelial tissue is known as a urethral stricture.[1] Even though urethral strictures have been well-known since historic times, its management continues to pose a challenge.[2] Surgical options range from a minimally invasive intervention to a much more technically demanding but definitive surgery.

Endoscopic management such as urethrotomy and dilatation are easy, accessible, and can be performed multiple times for the same patient; however, on the long term, up to 40% will fail and strictures will recur.[1],[3] Urethroplasty can be effective in up to 90% of primary strictures, but its success rate decreases in cases previously treated through endoscopic management.[1],[4] In spite of overwhelming evidence that supports open urethroplasty as a more cost-effective solution, endoscopic procedures are primarily used even in patients considered as poor candidates with expected high failure rates.[5],[6],[7],[8]

Locally, experts suggest that there is a lack of experience in urethral reconstruction and misuse of endoscopic procedures in managing strictures. A single study has evaluated the management approach and opinions of urologists in Saudi Arabia. Results showed a predominance of performing endoscopic procedures to strictures even after a second recurrence. In addition, more than half the urologists denied performing urethroplasty.[9] Our aim was to determine the trend in the pre- and postoperative evaluation and stricture management by urologists practicing in government and private hospitals in Saudi Arabia.

   Materials and Methods Top

This descriptive cross-sectional study was conducted during the period February–June 2018 using a 23-item questionnaire [Appendix 1], which was created by combining questions from four reports in the literature.[3],[4],[7],[8] Before distribution, the questionnaire was validated through a focus group validation. It was distributed to all practicing urologists and all senior residents (namely, 4th- and 5th-year residents) in Saudi Arabia. A consent form was included, and responses were submitted anonymously. Data were entered and coded in an Excel spreadsheet and then incorporated into and analyzed using SAS version 9.4 (SAS institute, Cary, North Carolina, United States). Categorical variables were reported as frequencies and percentages. The Chi-square test was used for inferential statistics. Statistical significance was recognized when P < 0.05.

   Results Top

Of 363 questionnaires distributed, 112 responses were received (30.8% response rate). Details of the responses are shown in [Table 1], [Table 2], [Table 3], [Table 4] and [Figure 1], [Figure 2], [Figure 3]. About 78% of the responses were from attending physicians and 21% were from senior residents. Among the former, 55% practiced in government hospitals, 16% in private hospitals, and 27% in both. Over the past year, most (68%) treated no more than 10 patients for stricture [Table 2]. Half of the respondents performed no open urethroplasties in the past year, 31% performed at least one and 13% performed >5 [Table 2]. The rate of urethroplasty in private hospitals was statistically the same as that in government hospitals. Endoscopic procedures were by far more common than urethroplasty. Direct vision internal urethrotomy (DVIU) was the most common procedure performed (85% of respondents) followed by urethral dilatation (67%). Excision and primary anastomosis (EPA) was the most frequent urethroplasty performed (33%) followed by dorsal buccal mucosa graft (BMG; 20%) and ventral BMG [15%; [Figure 1]. Contrary to expectations, private hospitals were comparable to government hospitals in their rates of endoscopy (86% and 94%, respectively) and open urethroplasty (43% and 44%, respectively). Uroflowmetry and postvoid residual volume (UFM/PVR) was used by the majority (84%) for preoperative evaluation followed by Retrograde urethrogram (RUG; 78%) and cystoscopy [64%; [Figure 2]. To evaluate the urethral patency after surgery, UFM/PVR was used by 83% of the respondents, RUG by 36%, international prostate symptom score by 20%, and cystoscopy by 19% [Figure 2].
Table 1: Respondent characteristics

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Table 2: Responses to questions 9, 16, 17

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Table 3: Responses to questions 11, 12, and 13

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Table 4: Answers to Q15, 19, 20, and 22

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Figure 1: Procedures performed last year

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Figure 2: Methods used to evaluate urethral strictures before surgery and lumen patency after surgery

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Figure 3: Answers to Q23 A and B

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Over half of the respondents (57%) managed urethral stricture disease via a reconstructive surgical ladder. Among senior residents, 70% believed that starting with endoscopy is a mainstay in managing strictures, whereas among attending physicians, 53% believed this. Surprisingly, urologists who treated >10 patients and had more experience with strictures also believed more in the step-wise approach. Compared to those practicing in government hospitals, those practicing in private hospitals were more likely to follow the surgical ladder approach (69% vs. 54%); however, it was not statistically significant. Surgeons who practiced in government hospitals were more likely to direct patients to definitive surgery after failure of the first attempt at endoscopic management. Yet many who practiced in government hospitals (42%) and most who practiced in private hospitals (69%) believed that urethroplasty is indicated after the second failure of endoscopic management.

A great majority of participants (95%) believed that stricture length and location were primary reasons for opting to perform open urethroplasty [Table 4]. A lack of experience with open urethroplasty was the primary reason for a low rate of performing this procedure as stated by 75% [Table 4]. Other reasons were patient preference, lack of interest in urethroplasty by the surgeon, a reasonable success rate and comparatively low morbidity with endoscopy, revenue pursuits of the surgeon, and a lack of training, given that the specialized training required for urethroplasty is absent from urology training programs. Urologists practicing in private hospitals were considerably more likely to believe that urethroplasty is a difficult procedure (46% vs. 26%).

Finally, participants were asked how they would manage each of two scenarios: a 3.5-cm primary stricture and a 1-cm recurrent stricture with two failed attempts at endoscopic management. In the former, 73 (66%) would refer the case to a reconstructive urologist. Of the 37 who chose not to refer, 15 (41%) would perform a dorsal BMG [Figure 3]. In the latter, respondents predominantly chose to refer to a reconstructive urologist. Of the 51 remaining respondents, 34 (67%) chose EPA [Figure 3]. Differences between private and government practices were not found. Likewise, differences between nonreconstructive and reconstructive urologists were not found when rates of referral were ignored.

   Discussion Top

These results indicate that UFM, RUG, and cystoscopy are the most commonly used preoperative investigations used to plan stricture management. These are also the most common investigations performed in the Netherlands, Italy, and Turkey. In particular, UFM is performed by more than half the urologists in these countries.[3],[7],[8] On the other hand, RUG is preferred by 78% of our respondents compared to only 16% of Italian urologists. This is attributed to the invasive nature of RUG.[7] Among urologists in the Netherlands, Italy, and our sample, UFM remained the preferred method for evaluating urethral patency after surgery.[3],[7] However, the preference for RUG and cystourethroscopy dropped from 78% and 64% to 36% and 19%, respectively. Likewise, Dutch and Italian urologists opted for less invasive methods postoperatively.[3],[7] According to the current guidelines, a postoperative evaluation for stricture recurrence must be carried out; however, recommendations for the diagnostic methods are not given, indicating that follow-up plans must be individualized.[10] It is reasonable that patients with high risks for recurrence (for example, those with prior management with endoscopy, a long stricture, or a penile stricture)[11],[12] be evaluated using invasive modalities that are highly sensitive and specific (for example, urethrocystoscopy or RUG).

Endoscopic management was by far more frequently performed on urethral strictures in our sample, and this agrees with observations in the US, the Netherlands, Italy, and Turkey. In our sample, DVIU was performed by 85% of the urologists, matching the rates in the other countries (≥80%). The most common urethroplastic procedures performed were EPAs and dorsal and ventral BMGs, and this is similar to findings in other countries.[3],[4],[7],[8] In the Netherlands, nearly half of the urologists stated they do not obtain images; however, only two of our respondents stated this.[3] Among our respondents, 59% stated they would use endoscopy to treat strictures as long as 2 cm, but in Italy, 72% used 1.5 cm as the cutoff.[7] In the Netherlands, however, nearly half the urologists would perform endoscopic procedures on strictures as long as 3 cm.[3] The management of urethral strictures is largely believed by urologist in the US, the Netherlands, and Italy to follow a reconstructive surgical ladder, and urethroplasty is considered a last resort.[3],[4],[7] Our findings were the same: 57% believed this.

When presented with a 3.5-cm stricture, of those who would treat rather than refer the patient to a reconstructive surgeon, 41% of our sample would perform a dorsal BMG. This differs from urologists in other countries. Some form of endoscopy would be performed by 33% of the urologists in the US, 49% of those in the Netherlands, and 53% of those in Italy.[3],[4],[7] If a patient had a short stricture with repeated failed attempts at endoscopic management, 67% of our sample chose to perform an EPA, and 12% would continue management through urethrotomy. In Italy, US, and the Netherlands, EPA was also chosen by 43%, 38%, and 25% of the urologists, respectively. A considerable percentage (>20%) of urologists in these countries would continue management using an endoscopic procedure.[3],[4],[7] This raises concern because the literature provides ample evidence that with each endoscopic intervention, the success rate drops significantly, reaching 0% after the third attempt.[1]

   Conclusion Top

These results demonstrate an evident predilection for endoscopic procedures when managing urethral strictures either because it is an effortless application or lack of knowledge. Evaluating and managing strictures in Saudi Arabia is quite similar to that reported in other countries. Moreover, while many claim that practices differ between government and private sectors, our results show that, within the limits of our sample size, variations are not significant.


The authors would like to thank Dr. Husam Ardah for his assistance with analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011;107:6-26.  Back to cited text no. 1
Webster GD, Koefoot RB, Sihelnik SA. Urethroplasty management in 100 cases of urethral stricture: A rationale for procedure selection. J Urol 1985;134:892-8.  Back to cited text no. 2
van Leeuwen MA, Brandenburg JJ, Kok ET, Vijverberg PL, Bosch JL. Management of adult anterior urethral stricture disease: Nationwide survey among urologists in the Netherlands. Eur Urol 2011;60:159-66.  Back to cited text no. 3
Bullock TL, Brandes SB. Adult anterior urethral strictures: A national practice patterns survey of board certified urologists in the United States. J Urol 2007;177:685-90.  Back to cited text no. 4
Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment of male urethral strictures: Is repeated dilation or internal urethrotomy useful? J Urol 1998;160:356-8.  Back to cited text no. 5
Andrich DE, O'Malley KJ, Greenwell TJ, Mundy T. Does urethrotomy jeopardize the outcome of urethroplasty? BJU Int 2003;91:89-92.  Back to cited text no. 6
Palminteri E, Maruccia S, Berdondini E, Di Pierro GB, Sedigh O, Rocco F. Male urethral strictures: A national survey among urologists in Italy. Urology 2014;83:477-84.  Back to cited text no. 7
Akyuz M, Sertkaya Z, Koca O, Caliskan S, Kutluhan MA, Karaman MI. Adult urethral stricture: Practice of Turkish urologists. Int Braz J Urol 2016;42:339-45.  Back to cited text no. 8
Almannie RM, Alkhamis WH, Alshabibi AI. Management of urethral strictures: A nationwide survey of urologists in the Kingdom of Saudi Arabia. Urol Ann 2018;10:363-8.  Back to cited text no. 9
[PUBMED]  [Full text]  
Wessells H, Angermeier KW, Elliott S, Gonzalez CM, Kodama R, Peterson AC, et al. Male urethral stricture: American urological association guideline. J Urol 2017;197:182-90.  Back to cited text no. 10
Liu JS, Dong C, Gonzalez CM. Risk factors and timing of early stricture recurrence after urethroplasty. Urology 2016;95:202-7.  Back to cited text no. 11
Spilotros M, Sihra N, Malde S, Pakzad MH, Hamid R, Ockrim JL, et al. Buccal mucosal graft urethroplasty in men-risk factors for recurrence and complications: A third referral centre experience in anterior urethroplasty using buccal mucosal graft. Transl Androl Urol 2017;6:510-6.  Back to cited text no. 12


  [Figure 1], [Figure 3], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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