There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Interpretation of this finding however must be guarded as it seems to be a downward trend consistent with an overall change in practice patterns over the observed time period. Admittedly, previous reports have demonstrated a downward trend in the use of endoscopic management accompanied by an increase in urethroplasties [11, 12], and therefore the lack of a significant inflection point at time of guideline release in our cohort suggests the guideline is not a unique influence.
The results from this study still suggest that urethral dilation and DVIU remain the most common treatment modalities for USD management, even in areas where patients have local access to fellowship trained reconstructive surgeons. The observed number of patients with at least one endoscopic procedure in our study (69.8%) was consistent with the 65.5% rate found in a large review of Veterans Affairs data from 1999 to 2013 [13]. However, inconsistent with prior studies was our observation that significantly fewer men reported ≥2 endoscopic procedures prior to urethroplasty (37.7%) than previously reported series, where close to 70% of patients fell into this category [9, 14]. While this change may also be related to publication of the guidelines, alternative explanations include the expansion of fellowship trained reconstructive surgeons who can now support high volume urethroplasty practices, literature published prior to the release of the AUA guidelines demonstrating the cost-effective benefit of primary reconstruction over endoscopic management [15, 16], and studies emphasizing the futility of repeated endoscopic treatments [17].
Our pre-May 2016 cohort finding of an average of 2.3 pre-urethroplasty treatments for all urethroplasties and 2.6 pre-urethroplasty treatments for anterior strictures is consistent with previous studies performed during the time period [18]. Altogether, we did find a decrease in average number of pre-urethroplasty endoscopic treatments after publication of the AUA guidelines both for overall urethroplasties and anterior urethroplasties. As mentioned, in addition to the AUA guidelines, the decrease in multiple endoscopic treatments may be due to the presence of a fellowship trained reconstructive surgeon available for tertiary referral for urologists who would otherwise treat USD by endoscopic means. More reconstructive urologists are graduating from fellowships, and both younger urologists and those academically affiliated are more likely to manage strictures with urethroplasty than endoscopic treatments [19]. Admittedly, the reconstructive surgeons in our study group have been present in their geographic region for years and thus the decrease in endoscopic treatments seen after May 2016 would not be due to a new expert in the region, but rather could be explained by community urologists referring patients for urethroplasty earlier than in the past in response to the AUA guideline. We additionally note that our conclusions are limited secondary to the shorter follow up of patients after the 2016 AUA guidelines for the time period investigated in our study.
We considered urethral stricture length and stricture etiology as potential confounders of our study. However, there was no significant difference in average stricture length or in patients with lichen sclerosus for all urethroplasties between the two cohorts under investigation, which further strengthens our findings. Our results further demonstrate that the two cohort groups are fairly similar with regard to stricture etiology and therefore etiology is not likely the underlying reason for a difference in endoscopic treatments.
There are several strengths of this study that make it uniquely informative. For example, this is the largest study to look specifically at this trend with a granularity regarding patient, operative, and stricture characteristics not available in many national database sample studies since the publication of the AUA guidelines, which thereby serves to make the results more informative. A Nationwide Inpatient Sample by Buckley et al. in 2016 corroborated a similar trend to what we have shown, however our prospective database gives particular insights into these findings that can serve to tailor future research and guide more accurate conclusions [20]. The granularity of our study demonstrates that even in areas served with fellowship trained reconstructive urologists, endoscopic management of USD continues to be the dominant treatment, and thus continued research is needed to determine the barriers to earlier urethroplasty. Though, even with the new AUA guideline and trends among graduating urologists, we would be remiss not to note the significant geographic disparity in urologic reconstructive expertise that influences USD management that our study does not accurately capture [21].
Endoscopic treatments such as dilation and DVIU remain a mainstay of initial treatment for short urethral strictures. Our study demonstrates a change in practice patterns over the observed time period that progressively favor urethroplasty as an intervention with a higher long-term success rate that should be integrated earlier into USD management. The lack of a clear inflection point at the time of AUA USD guidelines release date does not necessarily infer a lack of impact, but rather suggests that guidelines continue to provide further evidence of the success of earlier referral for urethroplasty that we have shown is serving to propagate a change in contemporary practice patterns and contribute to increased utilization of urethroplasty.
