The initial treatment of urethral strictures: simple dilatation or urethrotomy?: “Bougie urethral dilators: revival or survival?” – pros

The study presented by A.A. Katib and A.Al-Adawi " Bougie urethral dilators; revival or survival? " in this issue of Central European Journal of Urology has a very interesting and promising title [1]. We know that there is still a place for less invasive interventions such as urethral dilatation and internal urethrotomy in the initial management of urethral strictures in selected patients [2,3]. Simple dilata-tion or urethrotomy are standard treatment options, but these procedures are associated with a high failure rate and very often require repeated treatment. The authors present the technique of bougie dilata-tion, reintroduced after years in their department. This old procedure is well–known by urologists, but the precise description of the technique and detailed protocol of urethral dilatation showed by the authors can be used successfully for teaching purposes (e.g. for students, young urologists). The strength of the study is the high number of patients analysed, but the results should be interpreted with caution due to the retrospective design of the study. The high recurrence rate does not seem very surprising, as the poor effectiveness of simple dilata-tion in the treatment of urethral stricture disease is well–known. The main concern is the high complication rate (with 6.6% cases of perforation!). Bougie dilatation is routinely used in the authors' department and has replaced internal urethrotomy. Should it really be the first–step procedure for the majority of cases? This is difficult to answer because of a lack of evi-dence–based data on that topic. According to the authors', bougie dilatation is above– all simple, low–cost and time–saving. Furthermore, it can also be performed as an office procedure with no need for operating room equipment and staff. The benefits of internal urethrotomy, which offers better visual assessment of all anatomic conditions than urethrography alone, are not mentioned. Visual evaluation of the stricture can be helpful in decision making after the failure of initial treatment. Moreover, placement of the guide wire makes the procedure safer and helps to avoid false passage and perforation. Attempts were made to establish which surgical method is the most effective and cost–effective in the treatment of male urethral strictures, but as the clinical data is very limited, a meta–analysis was not feasible [4]. There is only one randomised, prospective trial comparing the efficacy of dilatation versus internal urethrotomy as initial treatment for urethral strictures. The study revealed that both methods offer equivalent outcomes, but their effectiveness is …