4. Discussion
Male US disease is a common and challenging health problem, increasing with the ageing of the population [
11]. The estimated prevalence ranges between 229 and 627 cases per 100,000 adults [
16]. Minimally invasive endoscopic treatments are the most common options for US, in both primary and recurrent setting [
17]. They proved only to be curative for selected cases, with limited chances for definitive success when repeated more than two times [
18,
19,
20]. These repetitions are not cost effective [
20,
21], but do not seem to affect the outcome of further urethral repairs [
22,
23]. Urethroplasty is the definitive treatment for most anterior US, with excellent outcomes in long-term follow-up [
1,
24], and should be offered as a first option when indicated [
1,
25]. A wide variety of techniques have been described for urethral repair, depending on strictures and patient characteristics [
1,
26].
Evaluation of practice patterns in US management started in 2005, with a mailed survey designed to assess pelvic fracture-related urethral injuries treatment among those practicing in the United Kingdom and Ireland [
5]. Another mailed survey was conducted but focused on anterior US management among board certified urologists in the USA [
6]. In both studies, an excess of endoscopic management was evidenced, proposing the non-familiarity with urethral surgery and limited knowledge of the literature on this topic as the reasons. Based on the original questionnaire used in the American study [
6,
7], national surveys on anterior US practices were conducted in the Netherlands [
13], Italy [
12] and Germany [
27]. Recently, a most complete non-validated questionnaire was also used in Spain [
14].
ESGURS group intends to bring together senior experts in the field of reconstructive urology and young urologists interested in reconstructive urological surgery. All members had their application form reviewed by ESGURS Board, requiring for acceptance a minimum of two peer-reviewed publications in the field of genitourinary reconstructive surgery, along with the written support of at least two ESGURS board members -certifying that ESGURS candidates are involved in clinical and academic activities within the area of genitourinary reconstructive surgery.
The response rate tends to be variable, depending on the targeted population. The original USA study, performed on a randomly selected sample of board-certified urologists, had a 34% response rate [
6], in Spain was 21.7% with all members of the Spanish Urological Association being targeted [
14], and in German response rate was 14.6% [
27]. The highest response rate to date was achieved by Dutch and Italian studies (74% and 74.7%, respectively), but the first survey was conducted over all the urologists in the Netherlands—which has a small population—while the second was distributed between a randomly selected group of Italian urologists, with no information about how the authors selected them. We targeted all members of ESGURS group with an acceptable response rate (55.6%). Most of ESGURS responders work in academic/teaching hospitals (77.6%), similar to the Spanish survey (70%), and higher than in Italy (9.2%), the USA (10.7%), the Netherlands (18%) and Germany (20%).
The number of strictures managed by ESGURS urologists per year (73.5% > 20) is also higher when compared to other surveys: 38.7% in Spain, 30.1% in the Netherlands, 20% in Germany, 13.7% in the USA and 5.9% in Italy. Clearly this is because ESGURS members are all specialized in US. Likewise, the percentage of ESGURS urologists performing urethroplasties per year is higher (91.8%). Conversely, only 22.1% stated not performing urethroplasties in Spain, 77% in Netherland, 73.2% in Germany, 60.8% in Italy and 57.8% in the USA.
RUG and UF are the most common diagnostic tools, very similar to previous surveys, except in Italy where they use more frequently urethroscopy than RUG. For follow-up, the UF is the most routinely performed, as in all previous surveys, and according to recommended practices [
2].
In previous surveys, the DVIU and UD were the most widespread treatment options, but among ESGURS members urethroplasties are the commonest techniques used. This is probably due to specialized characteristics of ESGURS members—working in academic high-volume centres where patients would be referred after endoscopic attempts—ESGURS members have preference for dorsal grafts (36.4%) versus ventral ones (29.6%) for bulbar strictures, which is similar to Spain. In other countries, the ventral location is the most widespread for graft augmentation. In line with previously published data, use of flaps is almost anecdotic for bulbar location.
The selection of patients suitable for endoscopic therapies seems adequate among ESGURS members, with 65.31% of responders using them on strictures <1.5 cm compared to Spain (84.4%), Italy (71.5%), the Netherlands (50.2%) or the USA (44.1%). ESGURS practitioners tend to use a guidewire during DVIU and leave a urethral catheter (14–18F) in place < 3 days (81.64%) as advocated by current evidence [
28], which is opposite to Spain (13.8%). Conversely, 2% of ESGURS members keep urethral catheter after endoscopic procedures for 1–3 weeks, in line with 1.6% in Germany, but different from 8.2% in the USA and 38% in Spain.
As in previous surveys, two clinical cases were asked about the management of different situations. In a long (3.5 cm) bulbar stricture in a young patient, ESGURS responders would perform a graft augmentation, preferably dorsal, with only 14.9% offering endoscopic options. In other surveys, the minimally invasive treatment was chosen for a case like this by between 20.5 and 43.8% of responders. A second case asked about a young male with a short bulbar stricture, presented after two failed DVIUs. End-to-end anastomotic urethroplasty would be offered by most of responders (30.4%), as previously reported in another surveys, but the non-transecting technique was the first option for the 23.9%.
Most of ESGURS responders (74.5%) acknowledge that urethroplasty could be the first line therapy according to current evidence [
28], instead of climbing a “therapeutic ladder” and performing open repairs only after endoscopic attempts. This is similar to the recent survey in Spain (70.9%), but in previous studies the commonest opinion was different, with only 21.3% supporting an urethroplasty as initial treatment in the USA (survey performed in 2002), 21% in the Netherlands, 26.2% in German and 33.8% in Italy. These data evidence that an appropriate management requires adequate education of the urological community, exposing the poor outcome of repeated endoscopic manoeuvres and current non-justification of “therapeutic ladder” theory, as a primary urethroplasty would lead to the best prognosis in certain patients and strictures [
6,
7,
8,
9,
10,
11,
12,
13,
14,
15,
16,
17,
18,
19,
20,
21,
22,
23,
24,
25,
26,
27,
28].
Depending on the number of urethroplasties performed annually, the answers showed significant differences. Urologists performing a higher number of procedures are more prone to choosing urethroplasty as the first option in selected patients. This conclusion was also achieved in the American survey [
6,
7], and supports the need for high volume specialized centres. Teaching hospitals have urethral disease units more frequently than non-teaching, and in the German survey they are more likely to select open reconstructive treatments, instead of endoscopic therapies. Likewise, high volume surgeons use better diagnostic and follow-up tools, such as PROM questionnaires, and more accurate imaging studies in previously published studies. According to their specialization, ESGURS surgeons are also using new urethroplasty techniques (as non-transecting ones) in a significantly higher percentage than in other surveys. Most of ESGURS responders (95.7%) agreed with the need for referral centres for treatment of male anterior US disease. This was also suggested for both anterior [
12,
13] and posterior urethral injuries [
5], but not asked directly in previous surveys, except in Spain (88.4%).
Many ESGURS urologists performed control images before or immediately after removing the urethral catheter in urethroplasties, some routinely (68.2%), others depending on the specific case (18.2%). It seems to be important to assess for urinary extravasation to avoid ensuing complications including peri-urethral inflammation, abscess formation and fistulation [
2,
3,
4,
5,
6,
7,
8,
9,
10,
11,
12,
13,
14,
15,
16,
17,
18,
19,
20,
21,
22,
23,
24,
25,
26,
27,
28].
This survey could present some possible limitations that should be discussed. One could be related to different access to email and to a computer between members, leading to age bias. Another source of bias could be related with differences in time between the responders’ training and our study period, as certainly these years of practice may be important to correlate with diagnostic and therapeutic choices. Such information—years of practice since completing training—is not available, but as the distribution of ages of responders is uniform, it is unlikely that more young urologists were selectively targeted and therefore biased the obtained results. Another limitation could be the response rate (55.6%), but this is among the higher range for internet-based surveys. As we have mentioned before, the reply rate to surveys tends to be variable, depending on targeted population. In this one, all members of ESGURS are surgeons specialized in US, so our results are not from all European urologists but from those devoted to this challenging pathology. This selection bias should add strength to our results, helping to describe current practice in most of the specialized centres in Europe. In addition, we can learn about use of most recent techniques (i.e., non-transecting) which are not very common among previously surveyed urologists. We used the same questionnaire as previously published to increase comparability, even when some surgical options are not currently of choice, as using skin grafts. Again, we believe genitourinary reconstructive surgeons working in referral centres should be able to offer different techniques for managing complex and difficult cases where standard options are not suitable.