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• W4328022897 abstract "Surgical treatment may be the only means of preventing chronic disability and mortality[1] in cases of traumatic injuries and numerous other conditions that significantly impact the quality of life, such as iatrogenic, inflammatory, or neoplastic injury. Despite effective prevention strategies, these conditions contribute significantly to the burden of disease in the population. In reality, timely access to essential surgery is not always readily available, despite being a human right.[2] In developing countries, where the most appropriate treatment for various diseases may not always be easily accessible;[2] there is a high incidence of complications resulting from delays in diagnosis or access to specialized centers. In Brazil, this is the context in which complex urethral stenosis in public university institutions affiliated with the Unified Health System is addressed. Urethral stenosis in males has a significant negative impact on patient quality of life. The pathophysiology of this condition is better understood, and differences between developed and developing countries must be taken into account. A recent study by Astolfi et al.,[3] involving 899 patients, found that in Brazil, the most common cause of urethral stenosis was iatrogenesis (43.2%), followed by idiopathic (21.7%) and traumatic (21.5%) causes. Of the inflammatory causes (13.7%), the majority were due to sclerotic lichen (66.7%), with the remaining 33.4% attributed to infectious urethritis. Palminteri et al.[4] found that in developed countries, stenosis predominantly occurs in the anterior urethra (92.2%), particularly in the bulbar segment (45.9%), with involvement of the posterior urethra in only 7.8% of cases.[5] The majority of trauma-related stenosis occurred in urethral injuries associated with pelvic fractures (62.7%), and 62.7% were associated with perineal trauma. Of iatrogenic causes, 59% were secondary to urethral instrumentation (catheterization and other procedures), 24.8% were due to procedures such as prostatectomy, radiotherapy, and postectomy, and 16.2% occurred following the failure to correct hypospadias. Such demographic data are useful in guiding the development of preventive and therapeutic population strategies, as well as being important for educational guidance in relation to manipulation of the urethra,[6] including vesicoureteral catheterization and instrumentation of the urethra in therapeutic procedures, particularly in learning different urethroplasty techniques. These strategies should be guided by the Unified Health System (SUS) as outlined in Article 5 of Law 8.080 of September 1990, and educational guidance is the responsibility of medical schools and specialized urology courses.[7] The SUS provides universal coverage and free access to all levels of health care for every individual within its jurisdiction, but there may be long waiting periods for examinations or surgery.[7] Tertiary care centers and the best health-care services are disproportionately concentrated in the wealthiest regions of the country, making access more difficult for the population residing in disadvantaged areas. To mitigate the impact of such inequality, out-of-home treatment was established by Ordinance No. 55 of the Ministry of Health, which aims to ensure medical treatment for patients with diseases that are untreatable in their municipality of origin due to a lack of technical facilities through the SUS.[7] Although SUS clinical care and treatment strategies are well-organized, with specific programs for different diseases, there is room for improvement in the case of urethral stenosis. Patients still encounter various challenges in accessing referral centers, resulting in delayed access to definitive treatment. This can worsen the prognosis due to episodes of urinary tract infection and secondary changes in the upper urinary tract. At the same time, doctors providing initial care and those at reference centers face their own challenges.[7] Not every urologist is proficient in performing surgical correction for various forms of urethral stenosis, in both adults and children. Referrals for classic techniques such as urethral dilatations and urethrotomies are now more selective, although they are still widely performed. Without the proper referral, these techniques only provide temporary resolution and often exacerbate the primary lesion.[8] In other countries, developed or otherwise, these techniques are still performed by the majority of practicing urologists,[9–12] even when excellent centers with modern modalities are available. Currently, urethroplasties require years of study to achieve the most durable results, and some authors consider proficiency to be achieved after approximately 100 surgeries.[13] Therefore, it is possible that urethroplasties are underutilized due to a lack of training or access to a trained colleague.[14,15] It is crucial to consider that training in reconstructive urology should be encouraged and offered by the various Medical Residency Services in Urology in Brazil.[16,17] Depending on the etiological factor or the extent of the urethral lesion,[18,19] some patients with urethral stenosis experience complications such as erectile dysfunction and/or urinary incontinence, requiring additional procedures such as implantation of penile prostheses and artificial sphincters, which are typically costly and may not always be widely available in public health-care services. We emphasize the importance of expediting the referral of patients to SUS Reference Centers where professionals trained in performing various types of urethroplasties are practicing, as there is a certain competition for slots available to municipalities in their jurisdiction.[7] The municipality schedules the consultation, but slot scheduling should not be handled by an administrative officer who is unaware of the functional implications of each disease. It should be performed by a physician who is able to differentiate more serious situations and use available slots appropriately.[7] In reference to public health-care centers, there are typically multiple specialties operating, each with a backlog of patients waiting for surgical treatment, and as a result, operating rooms have different schedules on weekdays.[7] In urology, there are other significant diseases such as tumors, urinary obstructions due to other causes, anomalies, lithiasis, etc., Therefore, in addition to the availability of slots for surgery, there is also internal competition for the use of operating rooms for more serious diseases. Another factor to consider is the lack of counter-referral for follow-up of complex cases after treatment; the inability to schedule outpatient visits at longer intervals reduces the number of places available for new patients.[7] Urological knowledge advances rapidly and requires ongoing updates, as well as careful analysis of international literature. National guidelines need to be updated to align with the current context of urological work in public centers in developing countries, with the aim of synthesizing information from the medical field and standardizing behavior that supports reasoning and decision-making, which must be evaluated and critically analyzed given the reality and clinical status of each patient.[7] Regarding trauma, in particular, Brazilian urologists in public hospitals often do not have access to instruments that would enable them to provide the best emergency care; rigid cystoscopes are generally not available in SUS emergency cases, and flexible cystoscopes are not even available in private hospitals. Retrograde urethrocystography, a low-cost, easy-to-perform, and accurate test that allows for better treatment planning,[20] is often not an option. Traumatic urethral injuries are not uncommon, particularly in severely injured patients.[18,19] Suprapubic urinary diversion is often performed in trauma in critically ill patients to allow for accurate monitoring of urine output and resuscitation. Immediate surgical repair can be technically challenging and should be restricted to patients with penetrating urethral trauma who are hemodynamically stable. Injuries to the posterior urethra are often accompanied by significant abdominal trauma or pelvic fractures that are life-threatening and require immediate attention and resuscitation. Anterior urethral injuries are usually caused by direct trauma to the urethra, with fewer associated and less extensive injuries.[6] Incomplete posterior urethral lesions can be treated with bladder catheterization, however, there is a risk of it becoming a complete lesion; in which case, treatment options include immediate primary surgical reconstruction (currently avoided due to high rates of erectile dysfunction, incontinence, stenosis, and intraoperative bleeding), primary realignment in stable patients (which reduces rates of stenosis and incontinence and is the preferred option in several referral services), or suprapubic urinary diversion and late reconstruction (the classic and often necessary management due to the clinical instability of polytrauma patients),[6,13] with urethral stenosis being common in the latter case. Late posterior perineal urethral repair has high success rates and avoids the need for multiple procedures.[18,19] Erectile dysfunction which occurs in approximately 50% of patients and has a multifactorial etiology (resulting from trauma rather than treatment) is a common complication in patients undergoing posterior urethral repair. Between 5% and 15% of these patients will develop recurrent stenosis, and about 4%–10% will develop urinary incontinence.[17,18] These complications and functional sequelae are also treated by the SUS, but not always in proportion to their occurrence. This sphere presents the greatest challenges for professionals working in reconstructive urology in the public health-care service, more so than those related to the techniques of urethral repair themselves. Access to penile prostheses and artificial sphincters is limited to a few services in Brazil.[7] In addition, the functional impact of delayed treatment affects surgical procedures and referrals. Narrowing in the penile urethra is less common, but tends to be longer than those in the bulbar urethra. Due to the narrow cancellous body and, therefore, higher spongiofibrosis, endoscopic treatment has lower success rates and should not be routinely used, being reserved only for ring stenoses.[8,9] Excision techniques and primary anastomosis of the penile urethra can result in penile curvature or shortening due to contact with the corpora cavernosa. Therefore, the treatment of choice is substituted urethral repair (graft or flap) or staged urethral repair in more complex cases. Using foreskin flaps should be considered, as they are more easily accessible in the penile urethra, reducing morbidity and surgical time, although success rates are lower than those for oral mucosa, which is widely used due to its excellent success rates. The graft is preferably positioned on the dorsal surface of the urethra.[6] Stenosis of the bulbar urethra, particularly when it is short (up to 2 cm) and of idiopathic origin with little spongiofibrosis, can be treated with endoscopic urethrotomy under direct vision.[9,20] More modern methods using lasers for internal urethrotomy have good success rates (70%–80%), but they are limited to a single approach in patients who have not received prior treatment and to short lesions due to the high rate of recurrence.[20,21] Narrowing of the bulbar urethra, especially if it is caused by trauma or inflammation, often results in extensive spongiofibrosis. The initial plan for treatment typically involves removing as much spongiofibrosis as possible and performing a wide spatulated anastomosis between two healthy stumps. However, due to the risk of penile curvature or shortening, excision and primary anastomosis are typically only used for impairments up to 3 cm in length.[6,9] In cases of significant narrowing of the bulbar urethra, with involvement exceeding 3 cm and of nontraumatic etiology, substitute techniques such as oral mucosa grafting can be utilized. The graft can be positioned on the dorsal or ventral region of the urethra or in both regions, with similar results. For more complex cases, enlarged urethroplasty techniques that involve resection and mucosa grafting may also be used.[6] Treatment of complex urethral stenosis in public centers in developing countries in the 21st century remains a challenge due to the lack of access to specialized care and appropriate equipment.[7] While the SUS aims to provide universal and free access to health care for all individuals within its territory, long waiting periods for examinations and surgery and a lack of resources in certain regions can impede timely treatment. In addition, urological knowledge and techniques continue to advance rapidly, requiring constant updates and access to international literature. National guidelines for the management of urethral stenosis in the SUS context, therefore, need to be updated to reflect the current practices and to ensure standardization of care.[7] The provision of reconstructive urology care, particularly in the case of traumatic injuries, can be hindered by a lack of access to necessary equipment and specialized personnel, as well as limited availability of penile prostheses and artificial sphincters. It is crucial to address these issues to improve the quality of care and outcomes for patients with urethral stenosis in developing countries.[7] The treatment of urethral stenosis in public health-care centers presents numerous challenges in the current context. Teaching hospitals have a responsibility beyond providing continuing education, as they also shape the conduct and doctor–patient relationship of practitioners. It is crucial for urologists working in reconstructive surgery to prioritize the well-being of their patients and remain motivated to provide comfort, relief, and treatment, despite the difficulties they may face.[7] Despite these challenges, the complexity of these cases can also be a source of motivation for urologists. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4328022897 date "2023-01-01" @default.
• W4328022897 modified "2023-10-06" @default.
• W4328022897 title "Management of complex urethral stricture in public health facilities in developing nations in the 21^st century" @default.
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