Take Home Message
The decision to perform staged urethroplasty is influenced by factors such as stricture length and previous surgeries. Mentoring plays a crucial role in decision-making for reconstructive urology. Further research is needed to standardize practices and improve patient outcomes.
Keywords: Urethral stricture, Trends, Survey, Urethra, Staged, Grafts
Abstract
Background and objective
Anterior urethral strictures impact quality of life and often require surgical intervention. Urethroplasty is the definitive treatment, but consensus on the best approach or timing, particularly for staged procedures, is lacking. The aim of our study was to identify factors influencing the decision to perform staged versus one-stage urethroplasty and determine key factors for the timing of the second stage.
Methods
We conducted a cross-sectional survey to identify factors influencing surgical decision-making for urethral stricture treatment in adult patients. A survey designed for the study was distributed to 190 reconstructive urologists, of whom 187 returned complete responses. Responses were anonymous to minimize bias. The data were analyzed using STATA 18.0.
Key findings and limitations
Factors influencing staged urethroplasty included previous surgeries (74.3%), stricture length (67.9%), and etiology (65.7%). Timing of the second stage is determined by urethral plate characteristics and surgical plate length, with 56.7% of the respondents reporting that the second stage is performed within 6 mo. Notably, 37.4% do not use standardized symptom scales. Findings highlight the role of mentoring and training in surgical choices, which points to a need for standardized guidelines. Limitations include the use of a convenience sample and self-reported data, which may introduce bias.
Conclusions and clinical implications
Key factors influencing staged urethroplasty decisions include stricture length and prior surgeries. Most urologists schedule the second stage within 6 mo, guided by mentoring. Future research should develop international staging guidelines, standardize treatments, and assess long-term outcomes for consistent practices.
Patient summary
We carried out a survey to find out why urologists choose one- or two-stage surgery to repair narrowing of the urethra, and when they perform the second stage. Two-stage procedures are often used for complex cases and patients who have had previous surgeries, with the second stage mostly done within 6 months. Better tools to measure patient symptoms are needed to improve care.
1. Introduction
Urethral stricture (US) is an acquired permanent narrowing of the urethra for which urethroplasty is considered the gold standard for management [1]. A wide variety of urethroplasty techniques are currently used, all of which share specific goals for safety, efficacy, and long-lasting outcomes.
The two main approaches to anterior urethral reconstruction are one-stage and staged procedures. In a one-stage procedure, the stricture can be managed via anastomotic or augmentation techniques, whereby the affected segment is either excised or expanded using grafts [2]. By contrast, a staged procedure consists of stricture excision and gradual reconstruction of a neourethra requiring tissue integration, before final tubularization in a second or multiple stages [3].
Chapple and colleagues [4,5] conducted systematic reviews of urethroplasty outcomes and the factors influencing surgical technique selection. For one-stage urethroplasty, the success rate for symptomatic recurrence ranged from 30% to 88%, while the proportion of cases requiring further instrumentation ranged from 70% to 100%. For two-stage urethroplasty, the recurrence rate varied from 78% to 83%, with additional instrumentation required in 80–92% of cases. The authors concluded that one-stage urethral reconstruction is less successful than two-stage procedures, except in carefully selected cases (level of evidence 3; B) [5].
Multiple factors determine eligibility for surgery, including the duration, location, and etiology of the stricture, previous treatments, surgeon experience, comorbidities, and availability of penile skin or graft material, among others [6]. In determining the type of urethral reconstruction that is appropriate, urologists must consider the length of the stricture, its cause (particularly lichen sclerosus), and any previous surgery. The stricture etiology influences any decision, as inflammatory strictures and those associated with lichen sclerosus tend to be longer and recur because of the recrudescence of the underlying pathological process [7]. However, there is no consensus on the best approach or timing, particularly for staged procedures.
2. Materials and methods
We designed a cross-sectional study to determine the factors that influence the type of surgical procedure chosen for adult patients with urethral stricture at a multinational level.
A survey was created using Google Forms and disseminated via e-mail to urologists specializing in reconstructive urology, including members of the Society of Genitourinary Reconstructive Surgeons, at three different opportunities. The survey, which is included in the Supplementary material, consisted of three sections: demographic information, factors influencing decision-making, and staged surgery. These three domains were assessed via 15 questions with multiple-choice or drop-down responses specifically designed for the study. No patient data were collected; all responses reflect surgeon-reported practices and preferences. No additional scales or validated instruments were used. A pilot test was conducted with urologists from the Urology Members of Pontificia Universidad Javeriana to correct accuracy errors in the wording of the questions and responses.
To address potential biases, responses were anonymous. The questionnaire was structured to minimize leading questions. The data were tabulated in a Microsoft Excel spreadsheet and statistical analysis was conducted using absolute values in STATA v18.0.
The inclusion criteria were urologists dedicated to urethral reconstruction, with or without formal training, who agreed to share information about their practice. Individuals who did not consent to participation were excluded.
3. Results
The survey was sent to 190 urologists, 187 of whom agreed to share information regarding their practice and answered the full survey. The majority were aged 30–50 yr (66.5%). The respondents practiced in 26 different countries, the main ones being Colombia (38.2%), Argentina (23.4%), and the USA (15.4%). Some 77.1% of those surveyed reported a fellowship, subspecialty, or training course in reconstructive urology, and 44.7% had been practicing reconstructive urology for more than 10 yr. Table 1 lists the demographic data.
Table 1.
Demographic data for the survey respondents
| Parameter | Respondents,n (%) |
|---|---|
| Age | |
| 20–30 yr | 1 (0.5) |
| 31–40 yr | 63 (33.6) |
| 41–50 yr | 61 (32.6) |
| 51–60 yr | 37 (19.7) |
| 61–70 yr | 22 (11.7) |
| >70 yr | 3 (1.6) |
| Fellowship/subspecialty | |
| Yes | 145 (77.5) |
| No | 42 (22.5) |
| Time practicing reconstructive urology | |
| 0–3 yr | 48 (25.5) |
| 4–5 yr | 24 (12.8) |
| 6–10 yr | 32 (17.0) |
| >10 yr | 84 (44.7) |
| Average urethroplasties per year | |
| 0–10 | 55 (29.3) |
| 11–20 | 26 (13.8) |
| 21–30 | 30 (16.0) |
| 31–40 | 21 (11.2) |
| 41–50 | 13 (6.9) |
| >50 | 43 (22.9) |
Among the most influential factors when deciding between staged and single-stage urethroplasty were a history of previous surgery (74.3%), stricture length (67.9%), and stricture etiology (65.8%). Some 37% of respondents reported that they do not use any type of scales to assess the success of the surgery. Among those who reported that they use scales, patient-reported outcome measures (PROMs) were preferred by 32% of the urologists. Table 2 lists the factors considered in urethroplasty decisions.
Table 2.
Factors considered by respondents in urethroplasty decisions
| Factor | Respondents,n (%) |
|---|---|
| Important factors for choosing a single or staged procedure | |
| Previous surgeries | 139 (74.33) |
| Stricture length | 127 (67.91) |
| Etiology | 123 (65.78) |
| Location of the stricture | 110 (58.82) |
| Lichen | 96 (51.34) |
| Age | 75 (40.11) |
| Panurethral | 64 (34.22) |
| Comorbidities | 63 (33.69) |
| Surgeon experience | 62 (33.16) |
| Previous radiotherapy | 60 (32.09) |
| Endoscopic surgery | 30 (16.04) |
| Scales used during evaluation | |
| None | 70 (37.43) |
| Patient-reported outcome measures | 59 (31.55) |
| Charlson comorbidity index | 40 (21.39) |
| Clinical Frailty Scale | 17 (9.09) |
| FRAIL | 12 (6.42) |
| PRISMA 7 quiz | 9 (4.81) |
| Other | 5 (2.67) |
As shown in Table 3, the majority of the respondents reported that the most decisive factors when choosing the timing of the next surgical approach are the characteristics of the urethral plate and the stricture length. Some 56% of the respondents prefer to perform the second stage within 3 mo, with the main criteria being the training received and recommendations from mentors/professors.
Table 3.
Factors taken into account in timing decisions for staged urethroplasty
| Factor | Respondents,n (%) |
|---|---|
| Main patient factors influencing the time of the next intervention | |
| Characteristics of the urethral plaque | 152 (81.28) |
| Stricture length in mm | 61 (32.62) |
| Previous surgeries | 59 (31.55) |
| Etiology | 54 (28.88) |
| Comorbidities | 50 (26.74) |
| Age | 31 (16.58) |
| Other | 27 (14.44) |
| Previous endoscopic surgery | 7 (3.74) |
| Time range for scheduling of the next surgical step | |
| 3–6 mo | 106 (56.68) |
| 6–9 mo | 65 (34.76) |
| 9–12 mo | 17 (9.09) |
| >12 mo | 0 (0.00) |
| Surgeon factors that influence the timing of the next stage | |
| Recommendations from mentors/teachers | 75 (40.10) |
| Knowledge from training received | 63 (33.68) |
| Personal experience | 49 (26.20) |
| Other patient factors influencing the decision | |
| Previous surgeries | 72 (38.50) |
| Origin of the urethral lesion | 58 (31.01) |
| Smoking | 21 (11.22) |
| Age | 19 (10.16) |
| Diabetes | 11 (5.88) |
| Frailty scores | 5 (2.67) |
| Hypertension | 1 (0.53) |
4. Discussion
Our survey results show that one of the most influential factors in decisions on staged urethroplasty is the presence and number of previous surgeries, in agreement with the literature. Yalçınkaya and Kartal [8] identified two factors as predictors of poor urethroplasty outcomes: the number of prior direct vision internal urethrotomy (DVIU) procedures, particularly in cases with two or more DVIUs, and a large urethral stricture. Likewise, a review by Secrest [3] highlighted the need to choose a staged approach in patients with complex urethral pathology such as severe hypospadias and those who have undergone multiple unsuccessful surgeries. This suggests that prior endoscopic interventions are an independent risk factor for urethroplasty failure [[9], [10], [11]].
Success rates for staged urethroplasty have improved in comparison to earlier techniques. However, the presence of comorbidities—regardless of whether they are well controlled or not—was identified as a key factor influencing the decision to opt for a two-stage procedure. Some relevant conditions include those that impair healing, such as metabolic syndrome, previous collagen diseases, and chronic kidney disease, among others, along with a history of anticoagulant use.
Armstrong and colleagues [12] identified predictors of complications occurring within 30 days after urethroplasty and developed a model to assess patients at higher risk. The authors found that patients who experienced complications often had comorbidities such as diabetes mellitus, low preoperative albumin and hematocrit levels, prolonged surgical duration, wound contamination, and a history of preoperative transfusion. An analysis by Breyer et al [13] suggested that a body mass index of 25–30 kg/m2 (overweight) or 30–35 kg/m2 (obese) was associated with a higher risk of stricture recurrence in comparison to 0–25 kg/m2 (normal) and >35 kg/m2 (severe/morbid obesity). A study by Chapman et al [14] showed that patients with greater overall comorbidity and obesity, among other factors, had a higher risk of treatment failure. While the study does not establish a direct link between these factors and postoperative complications, it suggests potential associations that warrant further investigation.
Stricture length and location were identified as key factors with a similar impact on outcomes. Supporting this, Kinnaird et al [15] concluded that long segment strictures (≥5 cm) and those caused by lichen sclerosus, infection, or iatrogenic injury are associated with a higher risk of recurrence.
The timing of the second stage of urethroplasty, which often relies on the surgeon’s experience, has been a topic of debate. A study conducted in Senegal revealed a success rate of 81% for patients treated by experienced reconstructive urologists, versus 53.7% for those managed by less experienced surgeons [16]. Because of this variability, some authors recommend that two-stage urethroplasty should be performed exclusively by surgeons with at least 3 yr of training in reconstructive urology [17,18].
In addition to surgical experience, plaque characteristics have been identified as a significant factor that influences outcomes. One-third of the respondents in our study reported that they consider plaque features when determining the timing for the second stage. These findings align with results reported by Claassen et al [19], who highlighted that the extent, position, and degree of lumen obliteration can significantly affect urethroplasty outcomes. Kinnaird et al [15] identified long strictures (≥5 cm) and etiologies such as lichen sclerosus, infection, and iatrogenic causes as key risk factors for recurrence. Furr et al [20] also found that stricture length was associated with the risk of stricture recurrence.
Comorbidities also play an important role in surgical outcomes. Chapman et al [14] reported that patients with greater comorbidity and obesity face a higher risk of failure. Similarly, Armstrong et al [12] identified factors such as diabetes mellitus, low preoperative albumin and hematocrit, prolonged surgical duration, and wound contamination as predictors of postoperative complications.
Recent studies have underscored the importance of waiting periods between surgical stages. In line with these findings, recent evidence suggests that longer waiting periods between surgical stages may improve outcomes in patients with complex strictures, particularly those with penile strictures caused by lichen sclerosus. A longer interval allows better tissue maturation and stability and thus reduces the risk of recurrence [21].
Various scales for evaluating urethroplasty success have been proposed, with increasing emphasis on PROMs for assessment. As a result, traditional methods such as uroflowmetry and serial cystoscopy and urethrocystography are being used less frequently.
PROMs are questionnaires that patients fill out before and after an intervention to determine if there has been a change in their symptoms, functionality, and quality of life. PROMs are the main method used to evaluate urethroplasty success by our survey respondents. Research by Baradaran et al [22] highlighted the need for PROMs to comprehensively evaluate the success of urethroplasty, as traditional methods such as uroflowmetry and serial cystoscopy and urethrocystography fail to capture patient satisfaction and symptom relief. Historically, urethroplasty success was defined solely by the absence of recurrence. However, this definition overlooks potential complications such as urinary obstructive or irritative symptoms. PROMs are particularly valuable because in addition to the absence of recurrence, they assess patient satisfaction and provide a more comprehensive evaluation of treatment outcomes.
The Charlson comorbidity index (CCI) is an instrument that seeks to predict complications, such as the ability function at discharge and mortality, using the sum of certain comorbid conditions. According to the literature, patients with more comorbidities, previous surgery, and preoperative bacteriuria have a higher risk of complications after urethroplasty. Dornbier et al [23] identified lower CCI as one of the factors favoring urethroplasty, along with younger age, higher income, private insurance, prior endoscopic treatment, and academic hospital settings. Likewise, in a study by Noble et al [24] to identify patient factors associated with complications 90 d after urethroplasty, multivariable analysis revealed that higher CCI, prior urethroplasty, and preoperative bacteriuria were associated with complications [23].
4.1. Strengths and limitations
Strengths of our study include a substantial sample size encompassing a significant number of urologists, including those with specialization in reconstructive surgery. Limitations include the use of self-reported, convenience-sampled data and limited regional representation, which precluded geographic comparisons.
5. Conclusions
Key factors influencing the decision to perform staged urethroplasty include stricture length and a history of prior surgeries. Most urologists reported that they schedule the second surgical procedure within 6 mo, with timing decisions shaped by mentoring and specialized training. The survey results highlight the crucial role of mentoring in decision-making, as it significantly influences surgical choices and practice patterns. Further research should focus on developing international guidelines for staged urethroplasty via a consensus on standardized treatment approaches, and on evaluating long-term outcomes to ensure consistent, evidence-based practice across the field.
Author contributions: German Patino had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Breyer, Patino, Arenas, Perez.
Acquisition of data: Saaibi, Nino Alarcón, Arenas.
Analysis and interpretation of data: Saaibi, Nino Alarcón, Arenas, Patino.
Drafting of the manuscript: Saaibi, Nino Alarcón, Arenas, Patino.
Critical revision of the manuscript for important intellectual content: Breyer, Patino, Arenas.
Statistical analysis: Saaibi, Nino Alarcón, Arenas, Patino.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Breyer, Patino.
Other: None.
Financial disclosures: German Patino certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Associate Editor: Véronique Phé
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.euros.2025.07.007.
Appendix A. Supplementary material
The following are the Supplementary data to this article:
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