A simplified protocol for evaluating and monitoring urethral stricture patients minimizes cost without compromising patient outcome

Male urethral stricture disease. Why management guidelines are challenging in low-income countries

Urethral stricture disease is one of the commonest urological pathologies in adult men in low or low-middle income countries, providing a significant work burden for the small number of specialist surgeons who are able to provide appropriate treatment. The underlying causes of anterior urethral stricture relate to urethral fibrosis from sexually transmitted infection, with posterior urethral disruption secondary to pelvic trauma being an equally common cause of stricture disease in many countries in sub-Saharan Africa. Anterior urethral strictures are often long, and multifocal, and bulbo-prostatic disruptions are usually due to relatively low-velocity pelvic trauma. The management options available in resource poor settings are often severely limited by the individual's ability to pay for care, the availability of a specialist surgeon and, importantly, a shortage of functioning endoscopic equipment for less-invasive treatments. Consequently, reconstructive surgery is often regarded by the patient, and surgeon, as the most cost-effective and, therefore, primary means of treating a urethral stricture once urethral dilatation has failed. Regional anaesthetic techniques have limited the adoption of free graft augmentation as an alternative to pedicled flaps of locally available skin for reconstruction, whilst an inability to provide tension-free bulbo-prostatic anastomoses has negatively impacted the outcome from the treatment of pelvic fracture disruption injuries in much of sub-Saharan Africa. Urolink has, however, found that local surgeons can be taught sustainable skills required for successful complex urethroplasty when supported by longitudinal mentorship in the management of difficult clinical issues. Evidence-based practice is known to improve the standard of care in specific conditions in high-income countries, including the management of male urethral stricture disease. However, guidelines developed in high-income countries aren't necessarily appropriate for stricture management in less well-resourced healthcare environments, but could be adapted to help improve the delivery of stricture care for men in low- or low-middle income countries.

Critical Analysis of the Use of Uroflowmetry for Urethral Stricture Disease Surveillance

OBJECTIVE

To critically evaluate the use of uroflowmetry (UF) in a large urethral stricture disease cohort as a means to monitor for stricture recurrence.

MATERIALS AND METHODS

This study included men that underwent anterior urethroplasty and completed a study-specific follow-up protocol. Pre- and postoperative UF studies of men found to have cystoscopic recurrence were compared to UF studies from successful repairs. UF components of interest included maximum flow rate (Qm), average flow rate (Qa), and voided volume, in addition to the novel post-UF calculated value of Qm minus Qa (Qm-Qa). Area under the receiver operating characteristic curves (AUC) of individual UF parameters was compared.

RESULTS

Qm-Qa had the highest AUC (0.8295) followed by Qm (0.8241). UF performed significantly better in men ≤40 with an AUC of 0.9324 and 0.9224 for Qm-Qa and Qm respectively, as compared to 0.7484 and 0.7661 in men >40. Importantly, of men found to have anatomic recurrences, only 41% had a Qm of ≤15 mL/s at time of diagnostic cystoscopy, whereas over 83% were found to have a Qm-Qa of ≤10 mL/s.

CONCLUSION

Qm rate alone may not be sensitive enough to replace cystoscopy when screening for stricture recurrence in all patients, especially in younger men where baseline flow rates are higher. Qm-Qa is a novel calculated UF measure that appears to be more sensitive than Qm when using UF to screen for recurrence, as it may be a better numerical representation of the shape of the voiding curve.

Modifying and increasing day-case procedures to solve local problems: Experience of a urology unit

BACKGROUND

Surgical ward congestion continues to be a problem across rural Africa. Day-case surgery has helped minimize this problem in most developed countries but remains underdeveloped across Africa. The objective of this study was to carefully expand day-case services within the framework of already existing hospital infrastructure.

MATERIALS AND METHODS

Seventy-one consecutive patients out of 149 mostly urologic patients that met the study criteria were treated and followed up on a daycase basis over a 15-month period. In the absence of a day surgery unit, these patients were prioritized and operated on urologic theater days while adequately utilizing the equipped preoperative holding area for patient recovery. Patients were all nonemergent, of American Society of Anesthesiologists' physical status (ASA-PS) classes 1 and 11 and accepting to undergo day-case procedure among other selection criteria. The main outcome measures were to determine the percentage reduction in admission rate and encountered complications.

RESULTS

Forty-nine (69%) of these 71 patients were treated using local anesthesia. The day-case surgery rate for the urology service was increased to 47.65% from a previous rate of 21.6%. Six patients (8.4%) felt that their postoperative pain was more significant than they had anticipated. Postoperative nausea and vomiting occurred in two patients (2.8%). There was one case of scrotal hematoma that resolved on observation. There was no mortality.

CONCLUSIONS

In the absence of a dedicated day-case service, individual specialists should develop or increase safe lists of cases in their respective fields that can be done on a day-case basis in order to reduce demand for in-patient beds.