RECONSTRUCTIVE UROLOGY

Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture
Rourke KF, Jordan GH
Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
J Urol. 2005; 173: 1206-10

• Purpose: Treatment for urethral stricture disease often requires a choice between readily available direct vision internal urethrotomy (DVIU) and highly efficacious but more technically complex open urethral reconstruction. Using the short segment bulbous urethral stricture as a model, we determined which strategy is less costly.
• Materials and Methods: The costs of DVIU and open urethral reconstruction with stricture excision and primary anastomosis for a 2 cm bulbous urethral stricture were compared using a cost minimization decision analysis model. Clinical probability estimates for the DVIU treatment arm were the risk of bleeding, urinary tract infection and the risk of stricture recurrence. Estimates for the primary urethral reconstruction strategy were the risk of wound complications, complications of exaggerated lithotomy and the risk of treatment failure. Direct third party payer costs were determined in 2002 United States dollars.
• Results: The model predicted that treatment with DVIU was more costly (17,747 dollars per patient) than immediate open urethral reconstruction (16,444 dollars per patient). This yielded an incremental cost savings of $1,304 per patient, favoring urethral reconstruction. Sensitivity analysis revealed that primary treatment with urethroplasty was economically advantageous within the range of clinically relevant events. Treatment with DVIU became more favorable when the long-term risk of stricture recurrence after DVIU was less than 60%.
• Conclusions: Treatment for short segment bulbous urethral strictures with primary reconstruction is less costly than treatment with DVIU. From a fiscal standpoint urethral reconstruction should be considered over DVIU in the majority of clinical circumstances.
  
  
• Editorial Comment
  The decision how to treat today a bulbar urethral stricture is not only influenced the best long-term outcome but although the cost effectiveness.
  Patient, who are diagnosed with a urethral stricture, want to know what the best treatment might be. The urologist, who is the specialist in this field, will explain the patient where and how long this stricture is. In addition the surgeon will inform the patient about treatment options. An bulbous urethral stricture, first diagnosed, with a length of 2 cm offers two ways to be treated; through direct vision internal urethromy (DVIU) or excision and primary anastomosis (EPA). Probably the patient will prefer the DVIU because of the endoscopic approach, but the long-term data gives a different argument to prefer the open procedure. In a Medline literature research several articles about the long-term outcome of both treatment options were reviewed by Rourke et al. For each approach they reviewed 7- 8 articles, which demonstrated with a comparable follow-up of more than 58 months that the EPA does have a success rate of 93 - 100% (mean 96%) whereas the DVIU succeeded in 18 – 49% (mean 28%) for the treatment of urethral strictures of 2 cm.
  It is almost impossible to predict the outcome of an individual case especially by knowing only the length of the stricture. Regarding to the literature, which was reviewed, the long-term can be predicted by the results of the single mentioned publication. The decision to treat a stricture should be related to the published data and the state of health of the patient. The authors helped to give a further argument for strictures of 2 cm to be treated by the open procedure, which is superior and even less expensive in the long term because of success rate over 95%. We suggest to proceed those urethral strictures by DVIU, which are short and uncomplicated without dens, deep spongiofibroses or in those patients who are not suitable for the open procedure because of their co-morbidities and refuse a suprapubic catheter although the risk of recurrence is high, as recommended in the Campbell’s Urology (1). Hinman (2) pined it down to the following: “The internal uretherotomy in anticipation of urethral regeneration is simple to perform, but the recurrence is high. The most straightforward method is the excision and reanastomosis method, which has the greatest success”.

References
1. Jordan GH, Schlossberg SM: Surgery of the Penis and Urethra. Treatment of Urethral Stricture Disease. In: Walsh PC (ed.), Campbell’s Urology, 8th ed. Philadelphia, Saunders. 2002; pp. 3918-3921.
2. Hinman Jr F: Strictures of the Bulbar Urethra. Atlas of Urologic Surgery, 2nd ed. Philadelphia, Saunders. 2002.

Dr. Karl-Dietrich Sievert, Dr. Udo Nagele
Dr. Joerg Seibold & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany