Trends in urethral stricture management over two
decades
Stephen McGeorge*†, Amanda Chung**†† and Devang J. Desai*†
*Department of Urology, Toowoomba Hospital, Toowoomba, †Faculty of Medicine, University of Queensland, Brisbane,
QLD, Australia, **Department of Urology, Royal North Shore Hospital, University of Sydney, and ††Department of
Urology, Macquarie University Hospital, Sydney, NSW, Australia
Objectives
To identify trends in the management of urethral stricture
disease in Australia, assess changes in the standard of care,
and examine the availability of genitourinary reconstructive
surgery.
Methods
Data on eight stricture management procedures were
collected online via Medicare Item Reports from the
Australian Government Department of Human Services, and
then matched to population data from the Australian Bureau
of Statistics. A survey was disseminated via the Urological
Society of Australia and New Zealand (USANZ) asking
whether active members performed urethroplasty and
whether this was done in a rural, regional or metropolitan
setting.
Results
Over a 22-year period, there were 140 540 endoscopic
procedures and 5136 urethroplasties, with 27.4 endoscopic
procedures per urethroplasty. From 1994 to 2016, the per
Introduction
The prevalence of urethral stricture is estimated to be ~0.9%
in developed countries [1]. Patients with urethral stricture
disease experience bothersome LUTS, recurrent infections and
haematuria and often undergo multiple endourological
procedures [2].
The burden of disease from urethral strictures is expected to
increase with time. Contributory factors include a rising incidence
of prostate cancer in an ageing population, with use of radiotherapy
and increasing utilisation of endoscopic vs open urological
procedures for large-volume BPH and urolithiasis [3–6].
Strictures can be treated via repetitive endoscopic means,
such as urethral dilatation or optical urethrotomy, or by
definitive reconstruction with urethroplasty.
The aim of the present study was to identify trends in the
management of urethral stricture disease across Australia in
© 2019 The Authors
BJU International © 2019 BJU International | doi:10.1111/bju.14875
Published by John Wiley & Sons Ltd. www.bjui.org
capita number of passage of sounds and dilatation procedures
decreased by 74% and 75%, respectively, with increases in use
of optical urethrotomy of 70% and in single-stage
urethroplasty of 144%. Overall, the ratio of all endoscopic
procedures vs urethroplasty decreased from 58.9 to 16.8.
There were as few as 16 surgeons in the USANZ performing
urethroplasty, with seven providing this service in regional
areas. Seven had formal fellowship training.
Conclusion
There has been a clear shift from repetitive endoscopic
procedures towards urethroplasty, but the former still make
up the majority of interventions. This may be explained by
patients not being referred for urethroplasty earlier in the
course of disease and there appears to be a gap in
genitourinary reconstructive expertise in regional and rural
areas.
Keywords
urethral stricture, urethroplasty, genitourinary reconstruction
order to assess changes in the standard of care, and to assess
the availability of genitourinary reconstructive subspecialty
expertise.
Methods
Data pertaining to eight Medicare Benefits Schedule (MBS)
codes for stricture management procedures were collected via
Medicare Item Reports available online from the Australian
Government Department of Human Services. The number of
procedures performed in 1994 and 2016 was collected for the
procedure codes listed in Table 1, as well as the total number
of procedures across this 22-year period. These data do not
include procedures performed in public hospitals and do not
distinguish among the underlying aetiologies of strictures.
The number of procedures per capita was calculated by
matching this against population data from the Australian
Bureau of Statistics as at 30 June of each year.
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McGeorge et al.

Table 1 Medicare Benefits Schedule procedure codes.
MBS code Procedure
37300 URETHRAL SOUNDS, passage of, as an independent procedure
37303 URETHRAL STRICTURE, dilatation of
37324 URETHROTOMY OR URETHROSTOMY, internal or external
37327 URETHROTOMY, optical, for urethral stricture
37342 URETHROPLASTY, single-stage operation
37345 URETHROPLASTY, two-stage operation – first stage
37348 URETHROPLASTY, two-stage operation – second stage
37351 URETHROPLASTY, not being a service to which
another item in this Group applies
MBS, Medicare Benefits Schedule.
A survey was also disseminated amongst 485 active members
of the Urological Society of Australia and New Zealand
(USANZ), of whom 438 were in Australia and 47 were in
New Zealand. The survey asked whether they performed
urethroplasty and, if so, whether this was in a rural, regional
or metropolitan setting.
Results
Table 2 lists the total number of procedures performed for
the period 1994–2016 inclusive. There were 140 540
endoscopic procedures, approximately half of which (69 390)
were dilatations, and 5136 urethroplasties, which were
predominantly single-stage. This gave an overall ratio of 27.4
endoscopic procedures per urethroplasty.
In 1994, the national resident population was 17 843 300
people [7]. There were 11 514 procedures recorded, including
2215 passage of sounds procedures, 6490 dilatations of
urethral strictures and 1263 urethrotomies/urethrostomies,
and 1347 optical urethrotomies. Per capita procedures are
listed in Table 3. There were 95 single-stage urethroplasties,
20 two-stage urethroplasties and 61 other urethroplasties.
Three two-stage urethroplasties only underwent the first
stage, but the reasons for this were not clear. A large
proportion of the procedures performed was made up by
passage of sounds procedures, forming 19.24%, and urethral
dilatation, forming 56.37% of all procedures.
The national resident population in 2016 was 24 127 159 [8].
Per capita procedures are listed in Table 4. There was an 57%
decrease in total procedures performed, down to 6694. This
was due in large part to a decrease in endoscopic procedures,
with only 776 passage of sounds procedures, 2158 dilatations,
and 280 urethrotomies/urethrostomies recorded. There was,
however, a large increase in optical urethrotomies, to 3104.
Single-stage urethroplasties also rose to 314 recorded
procedures. There were also 13 completed two-stage
urethroplasties, with another 12 patients only undergoing the
first of two stages, and 24 other urethroplasties.
Table 5 shows the percentage change in per capita procedures
in 1994 compared to 2016. Adjusted for population, the
number of passage of sounds and dilatation procedures had
decreased by 74% and 75%, respectively. There was a 70%
increase in per capita performance of optical urethrotomies
and a per capita increase of 144% in single-stage
urethroplasties. This trend was seen in all regions, to varying
degrees. Overall, the ratio of all endoscopic procedures to
urethroplasties decreased from 58.9 to 16.8.
Northern Territory data are not included in Table 5 as there
were only two procedures of any kind recorded in 1994, thus
not providing a meaningful comparison point.
Responses to the USANZ survey of members who conduct
male urethral reconstructive surgery included 13 surgeons
who performed this only on adult patients, with two surgeons
who performed this only on paediatric patients, and one
surgeon who performed urethroplasty on both adult and
paediatric patients. Data on formal fellowship training are
shown in Table 6. Three surgeons said they had not received
formal fellowship training in either adult or paediatric
reconstructive urology.
Only one urologist performed >50 cases in a year, with seven
performing 10–50 cases annually, and the remainder
performing <10 cases. Importantly, nine respondents were
working exclusively in metropolitan areas, with three working
in metropolitan areas with regional outreach, four working
exclusively in regional areas, and no respondent reported
working in rural areas.

Table 2 Total number of procedures performed. Discussion

MBS code: procedure Total procedures Causes of urethral stricture include infection, instrumentation,
1994–2016 radiation, surgery, trauma and lichen sclerosus, but ~30% are
37300: passage of sounds 19 618
idiopathic [1]. Important contributors to an expected growth
37303: urethral dilatation 69 390 in stricture prevalence are instrumentation attributable to the
37324: urethrotomy or urethrostomy 5447 increasing use of endoscopic methods for treatment of
37327: optical urethrotomy 46 085
urolithiasis and large-volume BPH, and treatment for prostate
37342: single-stage urethroplasty 3732
37345: two-stage urethroplasty – first stage 389 cancer in the context of an ageing population with greater
37348: two-stage urethroplasty – second stage 282 comorbidity [3,9–11]. One tertiary centre reported that
37351: other urethroplasty 733
urethral stricture comprised 7.7% of urological radiotherapy
MBS, Medicare Benefits Schedule. complications, leading to acute admission [12]. Reported rates

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 Trends in urethral stricture management

Table 3 Procedures performed per 100 000 people in 1994.

MBS code: procedure State/territory, % Total, %

NSW VIC QLD SA WA TAS ACT NT

37300: passage of sounds 4.61 22.21 4.88 40.82 10.22 2.33 0.33 0.00 12.41
37303: dilatation 40.30 57.08 15.67 41.43 10.46 29.21 23.26 0.00 36.37
37324: urethrotomy or urethrostomy 8.20 1.76 9.04 26.47 0.35 0.21 0.66 0.58 7.08
37327: optical urethrotomy 6.74 8.65 6.19 9.59 6.76 9.95 16.62 0.58 7.55
37342: single-stage urethroplasty 0.46 0.65 0.56 0.48 0.59 0.64 0.00 0.00 0.53
37345 two-stage urethroplasty – first 0.18 0.16 0.03 0.00 0.06 0.42 0.33 0.00 0.13
37348 two-stage urethroplasty – second stage 0.12 0.16 0.00 0.07 0.00 1.06 0.00 0.00 0.11
37351: other urethroplasty 0.48 0.22 0.19 0.54 0.29 0.64 0.00 0.00 0.34
Total 61.09 90.88 36.57 119.4 28.73 44.45 41.21 1.17 64.53

MBS, Medicare Benefits Schedule.

Table 4 Procedures performed per 100 000 people in 2016.

MBS code: procedure State/territory, % Total, %

NSW VIC QLD SA WA TAS ACT NT

37300: passage of sounds 0.38 4.42 0.35 21.84 2.64 0.96 0.00 6.13 3.22
37303: dilatation 7.17 11.73 4.52 31.85 2.64 3.85 9.09 1.63 8.94
37324: urethrotomy or urethrostomy 0.65 0.46 2.35 3.45 0.19 0.00 4.80 2.04 1.16
37327: optical urethrotomy 13.67 13.17 8.96 17.33 12.65 30.63 5.55 2.86 12.87
37342: single-stage urethroplasty 0.71 1.68 1.07 1.58 2.48 1.73 0.76 0.41 1.30
37345: two-stage urethroplasty – first stage 0.01 0.23 0.10 0.00 0.19 0.00 0.00 0.00 0.10
37348: two-stage urethroplasty –second stage 0.00 0.08 0.06 0.00 0.19 0.00 0.00 0.00 0.05
37351: other urethroplasty 0.13 0.12 0.06 0.06 0.04 0.00 0.50 0.00 0.10
Total 22.72 31.89 17.48 76.10 21.02 37.18 20.70 13.07 27.74

MBS, Medicare Benefits Schedule.

Table 5 Percentage change in per capita procedures, 1994 compared to 2016.

Code: procedure State/territory, % Total, %

NSW VIC QLD SA WA TAS ACT

37300: passage of sounds 92 80 93 47 74 59 100 74

37303: dilatation 82 79 71 23 75 87 61 75
37324: urethrotomy or urethrostomy 92 74 74 87 46 100 622 84
37327: optical urethrotomy 103 52 45 81 87 208 67 70
37342: single-stage urethroplasty 54 159 91 232 323 173 144
37345: two-stage urethroplasty – first stage 93 48 230 225 100 100 20
37348: two-stage urethroplasty –second stage 100 47 100 100 52
37351: other urethroplasty 73 48 67 89 87 100 71
Total 63 65 52 36 27 16 50 57

MBS, Medicare Benefits Schedule.

of urethral stricture are also higher with brachytherapy
techniques, but the use of brachytherapy is declining in
Australia according to MBS data over the past 10 years,
despite evidence regarding its efficacy [13].
It was previously thought that approximately half of patients
with an isolated short bulbar stricture could be cured by
optical urethrotomy [14]; however, newer data show that the
cure rate from optical urethrotomy is as low as 8% for a
single attempt [15]. Additionally, men with recurrence of a
stricture after their first urethrotomy or urethral dilatation are
generally expected to have further recurrence [2,15]. It should
therefore not be surprising that there has been a large
increase in performance of urethroplasty in Australia, as has
been demonstrated above. Similar trends in decreasing use of
repetitious endoscopic procedures and more urethroplasties
have also been seen in the USA [16].
Recurrence rates after urethroplasty, including all methods
and stricture locations, vary from 8.3% to 18.7%, much
lower than those for optical urethrotomy, for example [17].
Cure rates are particularly favourable for bulbar strictures,
being achieved in >85% of patients with bulbar
urethroplasty [14].

© 2019 The Authors

BJU International © 2019 BJU International 39
McGeorge et al.
Table 6 Responses to survey of USANZ members asking ‘Have you had a
formal fellowship training in reconstructive urology?’
Recognized fellowship training – adult
Unrecognized fellowship training – adult
Recognized fellowship training – paediatric
Unrecognized fellowship training – paediatric
No formal fellowship training
MBS, Medicare Benefits Schedule.
It is debateable as to whether urethroplasty should be
performed as a first-line intervention or if it is more cost-
effective only after recurrence after urethrotomy or dilatation,
but it seems either approach is not unreasonable [18].
Endoscopic procedures, however, can make urethroplasty
more difficult, and therefore early urethroplasty has a major
role to play in modern stricture management.
Although the number of endoscopic procedures per
urethroplasty did decrease from 58.9 to 16.8 in 2016, this
should ideally continue to decrease as multiple endoscopic
procedures can make subsequent urethroplasty more difficult
and thereby negatively impact postoperative outcomes.
Performing higher volumes of urethroplasty cases has been
unsurprisingly correlated with subspecialty training, with
43.1% of urethroplasties in the USA recorded in the period
between 2003 and 2013 being performed in the 11 states with
genitourinary reconstructive surgery fellowship programmes
[16]. Working in academic centres was also associated with
an eightfold increase in likelihood of performing
urethroplasty [16].
As seen in our survey data, there are as few as 16 surgeons
performing urethroplasty, and only seven had formally
recognized fellowship training. Given the connection to
academic centres seen in the US setting, this may imply a
greater need for subspecialty fellowship training programmes;
however, in the Australian setting, consolidation of expertise
into tertiary metropolitan centres would not necessarily be
the best model for providing this service to all patients, as
very large geographical distances are involved for rural and
regional populations.
Current availability of patient access to urethroplasty,
especially in regional and rural areas, may be restricted for
two reasons. Firstly, no respondent to our survey identified as
working in a rural area, and only four were working in
regional areas. Three surgeons also provided a regional
outreach service but in-depth information such as the
frequency of outreach or the area covered was not collected.
Research directly quantifying the availability of urethroplasty
in the Australian setting would be beneficial in clarifying
surgical workforce shortfalls, particularly for those outside
metropolitan areas, and identifying measures for
improvement. One area to address may be the gender balance
© 2019 The Authors
40 BJU International © 2019 BJU International
in urology. In a 2016 survey of female urologists and urology
trainees in Australia, 25.6% were practising outside a
5 metropolitan setting, as opposed to 15.4% of urologists
6 overall, and 12.5% identified their practice as being
2
reconstructive urology [19]. An increase in the number of
2
3 female surgeons may therefore improve availability outside
metropolitan areas. Secondly, whilst the number of
urethroplasties has increased, there is still a persistently high
volume of endoscopic procedures, so it may be that patients
are not being referred for urethroplasty. Early referral for
definitive reconstruction is preferable, as repetitive endoscopic
procedures can increase the difficulty of urethroplasty,
thereby impacting on long-term success rates.
In conclusion, there has been a clear shift from repetitive
temporizing procedures, such as passage of sounds and
urethral dilatation procedures, towards more definitively
curative treatments for urethral stricture, such as
urethroplasty. Given that offering urethroplasty early is the
standard of care, there is a concomitant growing need for
genitourinary reconstructive expertise across all regions in
Australia. More research is warranted to ensure availability of
urethroplasty as a management option, particularly in
regional and rural areas, and to explore the best service
model for the Australian setting. This is especially important
as the age-old practice of repeated endoscopic procedures can
make subsequent urethroplasty more difficult and negatively
impact long-term outcomes for patients.
Conflict of Interest
No conflicts of interest to declare.
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Correspondence: Devang J. Desai, Consultant Urologist,
Toowoomba Urology, 14/9 Scott St., Toowoomba, Qld 4350,
Australia.
e-mail: ddesai@toowoombaurology.com.au
Abbreviations: MBS, Medicare Benefits Schedule; USANZ,
Urological Society of Australia and New Zealand.
© 2019 The Authors
BJU International © 2019 BJU International 41