Shyam S. Sukumar, MD

Shyam S. Sukumar, MD, Assistant Professor of Urology at Baylor College of Medicine in Houston, Texas, poses the question, “What is the most accurate modality to diagnose an anterior urethral stricture?” He discusses studies that conclude that a retrograde urethrogram (RUG) is recommended over urethral ultrasonography (sono-urethrography, or SUG) or magnetic resonance urography (MRU) due to its widespread availability, familiarity, and ability to evaluate the entire urethra. Dr. Sukumar outlines treatments including endoscopic and reconstructive options. He homes in on the question of optimal initial treatment for short (1-2cm) bulbar urethral strictures, sharing data that emphasize the low success rate of direct visual internal urethrotomy (DVIU) and points out that successive DVIUs also negatively impact subsequent urethroplasty. He concludes that DVIU and dilation have similarly poor efficacy, that urethroplasty is more cost effective and clinically effective than endoscopic management, and that a single attempt at endoscopic management is appropriate for select patients but practitioners should avoid further attempts. Dr. Sukumar then turns to anastomotic urethroplasty, illustrating methods to shorten the distance in anastomotic urethroplasty and concluding the procedure has an 86-95 percent success rate at five years and an 86 percent success rate at 15 years. He explains non-transecting anastomotic urethroplasty and substitution urethroplasty, pointing out that buccal grafts are now considered standard of care. He shares data on substitution urethroplasty, noting that it is not as successful as anastomotic urethroplasty. Dr. Sukumar poses the question of whether ventral versus dorsal graft placement is desirable, citing a review concluding that the success rates are comparable, thereby recommendations take into consideration surgeon experience and that dorsal placement is preferable for distal bulbar or penile urethra. He also discusses synchronous urethral strictures, post-hypospadias recurrences for staged urethroplasty, perineal urethrostomy, and augmented perineal urethrostomy. Dr. Sukumar addresses failed prior urethroplasty, recommends one attempt at a DVIU over a dilation, and describes recommended procedures. Dr. Sukumar concludes that urethroplasty provides patients with the best outcomes, that practitioners should be prepared to adapt since no single type of repair can be presumed to be optimal preoperatively, and that evidence-based management of urethral stricture disease will benefit from better-quality studies.