Evidence
Alert

Men with urethral narrowing can be offered a choice of effective surgery

Urethral narrowing reduces the flow of urine from the bladder out of the body. The tube (called the urethra) may become narrowed because of injury or infection. Painful and potentially dangerous narrowing is more common in men and if it happens repeatedly, it is treated with surgery.

Initial treatment is usually a minimally invasive procedure called urethrotomy, in which the blockage is gently cut away. About half of the blockages recur within four years and the options then are to have either a further urethrotomy, or more invasive surgery to reconstruct the narrowed area of the urethra (urethroplasty).

The OPEN trial is the first direct comparison of these two common surgical approaches. It showed that both reduce symptoms for men with recurrent narrowing of the bulbar urethra (the U-shaped part of the urethra between penis and bladder).  However, the more invasive reconstruction had longer-lasting benefit and required fewer re-interventions.

The research gives surgeons and patients more information on which to base individual decisions. It concludes that both options can be considered.

What’s the issue?

Injury and infection can produce scar tissue in the urethra, which carries urine from the bladder to pass from the body. Scarring narrows the urethra, can make it difficult and painful to pass urine, and also raises the risk of further infections. Men have a longer urethra and are more susceptible to urethral narrowing than women.

In the UK, the first treatment is the minimally invasive urethrotomy, but for many men, the problem returns within a few years. The next step is uncertain: some surgeons prefer to perform another urethrotomy (and more if necessary). Much medical literature suggests that the more invasive urethroplasty would offer better results but it is a more complicated procedure, and more expensive.

Surgeons and patients find it difficult to choose between the two techniques because, before this study, there was no direct head-to-head comparison of their effectiveness.

What’s new?

This trial compared the two procedures – urethrotomy and urethroplasty – for men with recurrent urethral narrowing in the bulbar region. It recruited 222 men, all of whom had previously had at least one minimally invasive urethrotomy with problems recurring later. The men were randomly allocated to receive one of the two procedures.

The results showed that:

  • two years after surgery, both techniques improved urination-related symptoms
  • urinary flow rate was increased more by invasive urethroplasty
  • the number of serious adverse events such as infection, pain or re-admission to hospital was the same in both groups (11%)
  • the more invasive reconstruction had longer-lasting benefit and required fewer re-interventions.

Why is this important?

The results will allow patients and clinicians to directly compare the two types of surgery.

The data suggest that outcomes with the less invasive urethrotomy were slightly better than previous medical literature suggests, and slightly worse with the more invasive urethroplasty. Importantly, the study shows that both techniques – with appropriate after care – benefit patients, and both should therefore remain available. But overall, invasive urethroplasty performed slightly better over the study period.

Surgeons and patients can now make a final decision based on individual circumstances, the relative risks of the two procedures and a solid evidence base that compares outcomes.

What’s next?

These results have been included in a new set of British Association of Urological Surgeons guidelines on how to treat and manage urethral narrowing. The researchers say that both approaches are effective and can be considered by surgeons and patients.

The study team wants to follow patients for longer to check on their symptoms and whether they need further intervention within five years of surgery. They would like to explore so-called “patient regret”: whether patients would make a different choice of surgical procedure if offered the chance again. This could feed into the discussion about which of the two procedures is superior.

You may be interested to read

The full study: Goulao B, and others. Surgical Treatment for Recurrent Bulbar Urethral Stricture: A Randomised Open-label Superiority Trial of Open Urethroplasty Versus Endoscopic Urethrotomy (the OPEN Trial). European Urology. 2019;78:572-580

The new guidelines: Bugeja S, and others. The standard for the management of male urethral strictures in the UK: a consensus document. Journal of Clinical Urology. 2000. doi: 10.1177/2051415820933504

Editorial discussing this study: Osman NI and Chapple CR. Is Urethrotomy as Good as Urethroplasty in Men with Recurrent Bulbar Urethral Strictures? European Urology. 2020;78:581-582

 

Funding: This research was supported by the NIHR Health Technology Assessment Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

Our job now is to educate the British community that these data exist. But the overall message for patients is a positive one. Whatever technique they are given, they can be confident that it will relieve their symptoms. Now secondary care practitioners need to emphasise to patients that they have a choice.

I think there is a bias in the medical literature towards the more invasive urethroplasty. Surgeons tend to write up case studies when their patients do well. So it didn’t surprise me that urethroplasty didn’t perform quite as well as the literature suggests.

Nick Watkin, Professor of Urology and Consultant Urological Surgeon, St George’s University Hospitals

Surgeon

Patients considering surgery for urethral narrowing will be interested in this research, particularly those who have had initial treatment which has failed. The research will inform decision-making and should reassure patients and surgeons that both approaches are effective in addressing key symptoms.

The research could have implications for the provision of care as it could increase the need for urethroplasty surgeons.

Further exploration of the patient experience and health economics is a natural next step.”

Jaspal Phull, Consultant Urologist, Royal United Hospital, Bath

Clinician

This paper strengthens the evidence base on the pros and cons of open urethroplasty and urethrotomy to treat recurrent narrowing of the urethra. The research could help both surgeons and patients make informed decisions on the management of this condition. It will take robust investment in these specialist services, in both manpower and infrastructure, to provide patients with a balanced option.

Musliu Tolani, Consultant Urologist and Lecturer, Ahmadu Bello University Teaching Hospital, Nigeria