Urethral stricture disease is an uncommon urologic disorder but carries significant morbidity.
Direct vision urethrotomy (DVIU) is the procedure of choice for most urethral strictures in the United States. DVIU is an inexpensive, outpatient procedure with few complications and success rates of 39% to 73% have been reported for short strictures. DVIU has a low long-term success rate for longer strictures. Urethroplasty is the reference standard, but it is a complex operation requiring hospitalization, and many patients undergo multiple DVIU's before urethroplasty is considered. Urethroplasty is indicated for long, densely fibrotic strictures, but debate exists as to the optimal management of short strictures of the bulbar urethra.
A recent study by J. L. Wright, Hunter Wessels and colleagues from the University of Washington in Seattle, examined the cost-effectiveness of the treatments for bulbar strictures between 1 and 2 cm. The study is published in the May, 2006 issue of Urology. A decision tree was constructed that applied the statistical technique of decision analysis which applies a systematic framework for decision making between competing options in the face of uncertainty.
In the base case of a 1 to 2 cm bulbar urethral stricture with an estimated success rate of 95% for urethroplasty, 50% for a first DVIU and 20% for a second DVIU, the strategy of one DVIU before proceeding to urethroplasty was the least costly ($8575) and three DVIU's before urethroplasty had the greatest cost ($10,466). The average cost per successful voiding patient of "one DVIU before urethroplasty" strategy was $8795, and it achieved a 97.5% success rate. The incremental cost of performing a second DVIU before attempting urethroplasty was $141,962 for each additional successfully voiding patient. In the sensitivity analysis, urethroplasty as the primary therapy was cost-effective only when the expected success rate of the first DVIU was less than 35%.
The authors conclude that while future studies may be necessary to validate these findings, the most cost-effective strategy for the management of short bulbar strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails. For longer strictures for which the success rate of DVIU is expected to be less than 35%, urethroplasty as primary therapy is cost-effective.
Written by Michael J. Metro, MD - UroToday
Urology. 2006 May; 67(5):889-93