A Systematic Review and Meta-analysis of Adjuncts to Minimally Invasive Treatment of Urethral Stricture in Men.

Abstract

CONTEXT:

Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates.

OBJECTIVE:

To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD.

EVIDENCE ACQUISITION:

A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist.

EVIDENCE SYNTHESIS:

A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.50; p <  0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11-0.48; p <  0.001; intraluminal injection: OR 0.11, 95% CI 0.02-0.61; p =  0.01). Urinary tract infection (2.9-14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen.

CONCLUSIONS:

Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence.

PATIENT SUMMARY:

We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.

• Authors: Karl H Pang, Christopher R Chapple, Robin Chatters, Alison P Downey, Christopher K Harding, Daniel Hind, Nick Watkin, Nadir I Osman
• Journal: European urology (Eur Urol) Vol. 80 Issue 4 Pg. 467-479 (10 2021) ISSN: 1873-7560 [Electronic] Switzerland
• PMID: 34275660 (Publication Type: Journal Article, Meta-Analysis, Systematic Review)
• Copyright: Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Chemical References

• Tamoxifen
• Triamcinolone
• Mitomycin
• Captopril

Topics

• Captopril
• Humans
• Injections, Intralesional
• Male
• Mitomycin
• Recurrence
• Tamoxifen
• Triamcinolone
• Urethra
• Urethral Stricture (surgery)