Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes

Proximal Urethrostomy Versus Urethroplasty for Complex Urethral Strictures

Background

The optimal treatment for complex urethral stricture (CUS) is yet to be determined. Comparisons of methods based on validated questionnaires or objective outcome measures are lacking.

Objective

To compare proximal urethrostomy and urethroplasty for CUS using objective measures and validated questionnaires, and to evaluate trends in subgroups of patients who underwent proximal urethrostomy as the intended definitive treatment versus first-stage urethroplasty.

Design setting and participants

We identified all patients who underwent proximal urethrostomy at our center from 2004 to 2021. The control group comprised patients who underwent urethroplasty for CUS (strictures >6 cm, recurrent posturethroplasty strictures, or CUS due to lichen sclerosus or past hypospadias surgery).

Outcome measurements and statistical analysis

The primary outcome was a recurrent stricture at a minimal follow-up of 1 yr. The secondary outcomes included validated questionnaires, uroflowmetry, and residual urine volume. Survival was compared by a Kaplan-Meier analysis.

Results and limitations

The study included 57 proximal urethrostomy and 75 urethroplasty patients. Results for these two groups were as follows: the cumulative incidence of stricture recurrence over a median follow-up of 46 mo was 22.6% for proximal urethrostomy versus 36.2% for urethroplasty (p = 0.106); no statistically significant differences were observed between groups in terms of postoperative quality of urination or life, satisfaction with outcome, and erectile function. Both groups had a significant improvement in urinary flow after surgery (19.65 vs 20.29 ml/s), with no difference between the groups (p = 0.796); the proximal urethrostomy group had a significant improvement in postvoid residual after surgery, but there was no difference between the groups in the last follow-up visit (79.16 vs 52.03 ml; p = 0.245). A subgroup analysis of the proximal urethrostomy group showed no significant differences in cumulative primary or secondary outcomes. Limitations included the retrospective design and the relatively small study population.

Conclusions

Comparisons of the two groups revealed no significant differences in stricture recurrence, results of validated questionnaires, or objective measures of urination.

Patient summary

Proximal urethrostomy is equivalent to urethral reconstruction, and it should be offered as a viable solution for complex urethral stricture.

Algorithmic Midline Approach to Perineal Urethrostomy is Associated With Long-term Success and High Patient Satisfaction

OBJECTIVE

To assess surgical success and patient-reported outcomes of perineal urethrostomy via midline approach.

MATERIALS AND METHODS

Charts of patients undergoing primary perineal urethrostomy between May 2008 and June 2022 were reviewed. Background characteristics were assessed; success was defined as freedom from re-intervention. Patient-reported outcome measures were assessed using a cross-sectional phone survey. Several validated questionnaires were used to assess lower urinary tract symptoms, quality of life, and erectile dysfunction.

RESULTS

Among 1768 urethroplasties performed over the study period, 103 patients (5.8%) underwent midline perineal urethrostomy. Surgery was successful in 95.1% of cases (98/103); 5 patients (4.9%) required re-intervention at a median of 8.7 months. Post-operative complications occurred in 5.8% of cases (6/103) and were both mild and self-limited. Forty-nine patients (47.6%) were reached via phone survey at a median of 61 months post-operatively. Some questions were not answered by all patients. Most patients (42/49, 86%) were satisfied or very satisfied with surgical results, and 82% (40/49) reported an improvement in their overall health. Most patients (31/41, 76%) were unbothered by sitting to urinate. Although 20% of patients (10/49) reported post-operative urinary symptoms that interfered "a lot" with their daily life, only 3 (6%) of these patients reported dissatisfaction with the outcome. Regarding sexual function, 64% (27/42) reported indifference to or increased satisfaction with sexual encounters vs before surgery. The rate of de novo erectile dysfunction was 24% (12/49).

CONCLUSION

The midline approach to perineal urethrostomy provides excellent, durable success rates with high levels of patient satisfaction.

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults

OBJECTIVES

We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes.

METHODS

Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied".

RESULTS

The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction.

CONCLUSIONS

Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

Pedicled dorsal penile skin tube as neourethra in total penectomy for primary male urethral carcinoma

Background:

The aim of this article is to present our experience of pedicled dorsal penile skin tube as neourethra after radical penectomy due to invasive primary male carcinoma of anterior urethra.

Methods:

This is an observational descriptive study including seven men with primary urethral carcinoma who underwent radical penectomy between 2018 and 2021. Instead of urinary derivation with suprapubic catheter, perineal urethrostomy, or bladder orthotopic/heterotopic reconstruction, patients underwent reconstruction of the anterior urethra with a pedicled dorsal penile skin tube. In brief, before corpora amputation and radical urethrectomy, the dorsal penile skin is preserved to reconstruct the neourethra. The distal end of the skin is anastomosed with the proximal urethral stump (usually membranous urethra) to assure continuity of the urinary tract, without jeopardising urinary continence. Finally, the flap is tubularized with two layers of watertight running sutures.

Results:

Median age was 50 (35–70) years. Histology revealed squamous cell carcinoma in all patients. Almost 100% of patients presented locally advanced (pT3–4, G3) disease and received perioperative chemotherapy (MVAC). The median follow-up was 10 (5–24) months. Median operative time was 230 min (190–315). There were not severe (Clavien–Dindo III–IV) perioperative complications. All patients were able to void in standing position through the reconstructed neourethra. No patients reported post-operative incontinence. Two patients died after 8 and 11 months from surgery.

Conclusion:

This new technique of using the dartos-based dorsal penile skin tube urethroplasty offers the possibility to void in standing position after radical penectomy with no need of urinary derivations.

Level of evidence:

Not applicable.