Treatment of complex urethral stenosis in public centers from developing countries in 21st century

Access to surgical treatment may be the only solution for preventing chronic disabilities and mortality (1) in cases of traumatic injuries and countless other situations that significantly affect quality of life such as iatrogenic, inflammatory or neoplastic injury. Notwithstanding successful prevention strategies, these conditions are responsible for a significant portion of disease burden in the population. In practice, speedy access to essential surgery is not always widely guaranteed (2), although it is part of the human right to health. In developing countries, where the most appropriate treatment for various diseases is not always readily available (2), there is a high incidence of complications from delays in diagnosis or access to specialized centers. In Brazil, this is the context in which complex urethral stenosis in public university institutions linked to the Unified Health System is approached. Male urethral stenosis has significant negative impact on patients’ quality of life. Its pathophysiology is better known and differences between developed and developing countries must be considered. The recent study by Astolfi et al, (3) evaluating 899 patients, shows that in Brazil iatrogenesis was the most frequent cause (43.2%), followed by idiopathic (21.7%) and traumatic (21.5%). Of the inflammatory causes (13.7%), the largest part was due to scleroatrophic lichen (66.7%), and 33.4% to infectious urethritis. Regarding the stenosis site, Palminteri et al. (4) showed that in developed countries, stenosis occurs mainly 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). Most trauma-related stenosis occurred in urethral lesions 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% due to procedures such as prostatectomy, radiotherapy and postectomy, and 16.2% following 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), from vesicoureteral catheterization to instrumentation of the urethra in therapeutic procedures and, above all, to learn the different urethroplasty techniques. Strategies must be guided by the Unified Health System (SUS) as set forth in Article 5 of Law 8.080 of September 1990, and educational guidance is an obligation of medical schools and specific courses in Urology as a specialty. The SUS offers universal coverage and free access to all levels of health care for each person Treatment of complex urethral stenosis in public centers from developing countries in 21st century _______________________________________________