Shyam S. Sukumar, MD, presented “Evidence-Based Approach to Management of Urethral Strictures” during the 25th Annual Innovations in Urologic Practice on September 24th, 2021, in Santa Fe, New Mexico.
How to cite: Sukumar, Shyam S. “Evidence-Based Approach to Management of Urethral Strictures.” September 24th, 2021. Accessed Nov 2024. https://grandroundsinurology.com/evidence-based-approach-to-management-of-urethral-strictures/
Evidence-Based Approach to Management of Urethral Strictures – Summary
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.
About The 25th Annual Innovations in Urologic Practice:
Presented by co-chairs Mohit Khera, MD, MBA, MPH, and Michael Coburn, MD, FACS, the Innovations in Urologic Practice conference provides a detailed review and commentary on multiple genitourinary and urologic diseases. Among the featured oncological topics are bladder cancer and immunotherapies, as well as upper tract cancer management, prostate cancer, including state-of-the-art imaging, focal therapy, and MRI. Experts also discuss new tools and techniques for nephrectomy and treating advanced renal cell carcinoma. In terms of general urological approaches, the conference also includes pelvic reconstruction and trauma, men’s health topics like male infertility and sexual dysfunction, and ways to diagnose and treat infections in the urology patient. Dr. Sukumar presented this talk at the 2021 conference.
For further educational activities from this conference, visit our collection page.
ABOUT THE AUTHOR
Shyam S. Sukumar, MD, is an associate professor in the Scott Department of Urology at the Baylor College of Medicine in Houston, Texas. Dr. Sukumar graduated from Kilpauk Medical College in Chennai, India, in 2009. He completed his urology residency at the University of Minnesota in Minneapolis and his fellowship in genitourinary reconstruction at Columbia University in New York, under the leadership of Dr. Steven Brandes. Dr. Sukumar’s clinical and research interests are centered on reconstructive urology including urethral stricture disease, male voiding dysfunction and urinary incontinence, genitourinary fistula, and upper tract reconstruction.
