Practice Patterns in the Treatment of Urethral Stricture among American Urologists: A Paradigm Change?

Objective To examine surgical case volume characteristics among certifying urologists associated with treatment of urethral stricture to compare practice patterns of recent graduates to recertifying attending urologists and trends over time. Materials and Methods Six-month case log data of certifying and recertifying urologists (2003-2013) were obtained from the American Board of Urology. Cases specifying a CPT code for urethral dilation, direct vision internal urethrotomy (DVIU), urethroplasty, and graft harvest in males ≥18 years were analyzed for surgeon-specific variables. Results Among 6320 urologists logging at least one reconstructive urology procedure, 95,747 (86.2%) urethral dilations, 10,986 (10.0%) DVIU, and 4349 (3.9%) urethroplasties were identified, with 99 (0.9%) using graft and 405 (9.3%) staged procedures. Overall ratio of urethral dilation/DVIU to urethroplasty was 24.5:1. More recent log year and new certification correlated with a decrease in ratio of dilation/DVIU to urethroplasty, but stable use of graft. The ratio of dilation/DVIU to urethroplasty for new certification was much lower (7.9:1), compared to first (24.4:1), second (63.3:1), and third recertification cycles (99.5:1), wherein urethroplasty was increasingly rare. Newly certifying urologists performed urethroplasty 4.5 times more often than those recertifying. Academically affiliated urologists were 8 times more likely to perform urethroplasty. Conclusion Most urethral strictures are treated with dilation/DVIU, but a changing paradigm favoring urethroplasty is evident. Most urethroplasties are performed by a small number of urologists with high volume, academic affiliation, recent residency graduation, and residence in a state with a reconstructive urology fellowship.